Effect of daily cleaning with chlorhexidine on the incidence of contamination of blood cultures in the critical patient

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Garrido-Benedicto, P. Cueto-Quintana, E. Farré-Termens, M. Mariné-Cabré, J. Riba-Reig, R. Molina-Chueca" "autores" => array:6 [ 0 => array:3 [ "preGrado" => "PHD" "nombre" => "P." "apellidos" => "Garrido-Benedicto" ] 1 => array:3 [ "preGrado" => "MD" "nombre" => "P." "apellidos" => "Cueto-Quintana" ] 2 => array:5 [ "preGrado" => "MSN" "nombre" => "E." "apellidos" => "Farré-Termens" "email" => array:1 [ 0 => "mixtligf@yahoo.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 3 => array:3 [ "preGrado" => "MSN" "nombre" => "M." "apellidos" => "Mariné-Cabré" ] 4 => array:3 [ "preGrado" => "MSN" "nombre" => "J." "apellidos" => "Riba-Reig" ] 5 => array:3 [ "preGrado" => "MSN" "nombre" => "R." "apellidos" => "Molina-Chueca" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Medicina Intensiva, Hospital Universitari Sant Joan de Reus, Reus, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Efecto de la higiene diaria con clorhexidina sobre la incidencia de contaminaciones de hemocultivos en el paciente crítico" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1911 "Ancho" => 2507 "Tamanyo" => 194592 ] ] "descripcion" => array:1 [ "en" => "The probability of blood culture non-contamination." ] ] ] "textoCompleto" => "<elsevierMultimedia ident="tb0005"></elsevierMultimedia>IntroductionBacteraemia is a severe condition with a high rate of morbimortality. Blood cultures are a very useful diagnostic and prognostic tool for doctors. Nevertheless, false positive results due to contamination of blood samples by patient skin flora organisms, chiefly coagulase negative staphylococcus,<a class="elsevierStyleCrossRef" href="#bib0130">1</a> give rise to an increase in diagnostic tests and unnecessary treatment<a class="elsevierStyleCrossRef" href="#bib0135">2</a> with the subsequent increase in healthcare costs.<a class="elsevierStyleCrossRef" href="#bib0140">3</a> The most frequent causes of contamination are inadequate preparation of the skin and poor sample extraction technique.Actions to reduce contamination are based on minimising skin bacteria by using disinfectants and optimising sample extraction protocols.There are studies which show that washing with antiseptic solutions prior to surgery is effective in reducing the number of microorganisms on the skin,<a class="elsevierStyleCrossRef" href="#bib0145">4</a> and that this also reduces the incidence of surgical wound infection in orthopaedic surgery.<a class="elsevierStyleCrossRefs" href="#bib0150">5–7</a>Patients in the ICU are especially liable to suffer infections caused by skin flora and nosocomial germs. This is due to the use of invasive devices, antibiotic therapy, immunodeficiencies and comorbidity. Preventative measures based on hand washing, the use of disposable materials and even patient isolation are fundamental to prevent crossed contamination by germs that often colonise the skin.Chlorhexidine gluconate is a biguanide-type cationic antiseptic with broad spectrum action against several microorganisms including S. aureus and enterococcos species. It has prolonged residual activity<a class="elsevierStyleCrossRef" href="#bib0165">8</a> and low toxicity.<a class="elsevierStyleCrossRef" href="#bib0170">9</a>Quality standards propose a level of blood culture contamination below 3%.<a class="elsevierStyleCrossRef" href="#bib0175">10</a> This margin is considered to be tolerable and, when it is surpassed in practice it shows that there is a problem. The strict application of protocols with an emphasis of the use of sterile techniques to extract blood cultures leads to a reduction in contamination.<a class="elsevierStyleCrossRef" href="#bib0180">11</a> However, it sometimes may be necessary to adopt other additional measures such as changing the antiseptic used to decontaminate the skin or daily washing with antiseptic products. This will occur if in spite of careful compliance with blood culture extraction protocols no improvement is detected in the results.This work aims to evaluate the efficacy of daily hygiene using 4% chlorhexidine digluconate soap-impregnated sponges to reduce blood culture contamination down to the level set by quality standards in ICU patients. A water-based 2% chlorhexidine antiseptic solution was used to decontaminate the skin for the extraction of blood cultures according to our protocol.Material and methodsA quasi-experimental non-randomised prospective study with a pre-post design, longitudinal and in single hospital. Study period: 24 months from April 2013 to March 2015. It took place in a 12-bed medical-surgical intensive care unit in the Hospital Universitari Sant Joan de Reus.Population selectionThe inclusion criteria were: age>18 years old, admission to the ICU>48h, and the exclusion criteria were: skin disruption >20% (for example, burns),<a class="elsevierStyleCrossRef" href="#bib0185">12</a> pregnancy and allergy to chlorhexidine.Sample sizeThe sample size was determined on the basis of our proportion of contaminated blood cultures prior to the study (16%) and the accepted quality standards (3%). To detect a reduction of 13% in the proportion of contaminated blood cultures (from 16% to 3%) with a type I error of 5% and a power of 80% 70 blood cultures per group were necessary. The Domenech–Granero macro ¡NSize for SPSS was used for calculations.How the intervention was dividedThe study included 3 periods and 2 groups of patients:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">(a)First period—control group. During this period patient hygiene was performed daily with warm water and CR-32 antiseptic-free dermatological soap (José Collado S.A., Barcelona, Spain). This period lasted for 11 months.</li><li class="elsevierStyleListItem" id="lsti0010">(b)Second period—rest. This period lasted for one month, and its function was to prevent the overlap between patients in both study groups. During this time the patients in the control group were discharged and no intervention group patients were included. Additionally, we reinforced training in blood culture hygiene and extraction protocols. During this period patient hygiene was undertaken using antiseptic-free soap.</li><li class="elsevierStyleListItem" id="lsti0015">(c)Third period—intervention group. During this period hygiene was undertaken using body sponges impregnated with 4% chlorhexidine digluconate (Dispomedic sponge C, CV Médica, Tarragona, Spain), applied on the patient's skin until the whole skin surface apart from the face was covered, to prevent contact with oral mucus membranes and eyes (following the manufacturer's recommendations). The solution was left to act during 3min., after which the skin was rinsed using water before being dried with clean towels. The hair was washed every 3 days. This period lasted for 11 months.</li></ul>Prior to commencing periods 1 and 3 patient bathing technique was protocolised with the nursing and auxiliary staff. This technique emphasised sequential washing from clean zones to dirty ones. The stools of incontinent patients were washed off using soap and water or chlorhexidine, depending on the study group. The skin was hydrated using solutions that do not give rise to interference with the bactericide activity of chlorhexidine. Strict compliance with the hand hygiene protocol was recommended before and after contract with patients. Likewise, before periods 1 and 3 we implemented continuous training programs, emphasising the blood culture extraction and processing protocol (<a class="elsevierStyleCrossRef" href="#sec0095">Appendix A</a>: blood culture extraction and processing technique).Data gathering<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0020">(a)Basic level. On the admission to the ICU of each patient we recorded their age, sex, height, weight, disease type (medical, surgical or cardiological), degree of severity (APACHE II, SAPS II). All non-cardiological patients whose disease did not require surgery were considered to be medical.</li><li class="elsevierStyleListItem" id="lsti0025">(b)Follow-up. We recorded the date and time of each blood culture, the data and time of body washing, the location of blood culture extraction, days of admission in the ICU and hospital mortality. We also recorded the presence of central venous catheter, a bladder catheter, the need for mechanical ventilation, renal replacement therapy, antibiotic therapy and the presence of multiresistant germs (colonisation or infection).</li></ul>Every day the nursing staff evaluated patient skin integrity using a SCORAD<a class="elsevierStyleCrossRef" href="#bib0190">13</a> grading scale, a clinical tool used to evaluate the extension and severity of eczema in atypical dermatitis. If skin alterations were detected as a side effect of the chlorhexidine the patient's doctor or Dermatology Department proposed a therapeutic intervention.Blood cultures were requested under medical criterion when there was a suspicion of infection and body temperature above 38°C. Blood cultures were always requested in sets of 2.It is difficult to distinguish between contaminated blood cultures and a true infection without a “gold standard”. The initial independent evaluation was undertaken by the doctors in charge of the patient blood cultures had been extracted from. They were subsequently reviewed by 2 doctors involved in the study, based on the type of germ isolated, the number of jars with growth, the use of empirical antibodies following the extraction of blood cultures and the clinical evolution of the patient. All blood cultures were defined as cases of contamination when, after being extracted in the ICU on the order of a doctor due to the suspicion of infection, the Microbiology Laboratory reported the growth of germs in at least two blood cultures and these were interpreted by 2 doctors to be a caused by a germ with a low probability of being the cause of the suspected infection.The study was simple blind: the patients did not know which study group they belonged to. The medical staff was aware of the product used in the daily hygiene of each patient taking part in the study.Data analysisThe normal distribution of the groups was checked using the Shapiro–Wilk test.The comparison between groups of continuous variables was undertaken using the Student t-test or the non-parametric Mann–Whitney test according to correspondence and the categorical variables test using χ2.To graphically compare the time to appearance of blood culture contaminations following the daily bodily washing between group we made Kaplan–Meier curves and calculated the log-rank for each one. In survival analysis each contaminated blood culture was considered to be an event.The difference between blood culture contamination incidence density rates between groups was determined using Cox regression controlled for confusion variables. We considered previous antibiotic treatment and the presence of multiresistant germs to be confusion variables. We also controlled regression according to level of severity and days of admission in the ICU, assuming that more severe patients and those with prolonged admission are at greater risk of colonisation.We used the IBM SPSS 20 (Chicago, USA) statistics program for statistical analysis. Differences with a value of P<.05 were considered to be statistically significant.Ethical aspectsThis study was carried out according to the ethical principles of the Helsinki Declaration and it was approved by the Hospital Ethics Committee, which considered that it was necessary to obtain informed consent. The patients or their legal representatives were asked to give their informed consent after the purpose and nature of the study had been explained. Checks were made to ensure that the patient or their family members had understood the risks and benefits of taking part. A simple answer was given to all of the questions that arose.To ensure the confidentiality of the data of each individual, as a guarantee of the protection of personal information and to prevent divulgation of the same without their consent, alphanumerical identification codes were used to identify them computerised analysis. Access to these codes was restricted to the authors, and printed records were kept in a locked and protected place.Results1061 patients were admitted during the period from April 2013 to March 2015; of these, 237 patients fulfilled the inclusion criteria and agreed to take part in the study. They were then distributed as follows: 118 in the control group and 119 in the intervention group.Patient characteristics were similar in both groups in terms of age, sex, degree of severity in the first 24h (APACHE II, SAPS II), BMI, central venous catheter, bladder catheter, the need for assisted respiration or renal replacement therapy, the presence of multiresistant germs (colonisation or infection) and antibiotic treatment, days of admission in the ICU and hospitalisation (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>), as well as intra-ICU and hospital mortality (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). Respecting the type of disease a higher proportion of medical patients were included in the control group, and there were more surgical patients in the intervention group. Nevertheless, the differences were not statistically significant (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>). No skin alterations were detected that were considered to be side effects of the chlorhexidine. We found no differences in the SCORAD score between the two groups studied.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia>259 blood cultures were extracted, 148 in the control group and 111 in the intervention group, of which 30 were considered to be contaminated (23 and 7, respectively) (<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>). This showed that there was a higher proportion of contaminated blood cultures during the control group period than was the case during the intervention group period (15.5% and 6.3%, respectively). The difference between these proportions amounted to 9.23% (95% CI: 1.34–16.7%). This is a statistically significant difference, with an odds ratio of 2.73 (95% CI: 1.13–6.63) (<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>).<elsevierMultimedia ident="tbl0020"></elsevierMultimedia><elsevierMultimedia ident="tbl0025"></elsevierMultimedia>Survival analysis considered blood culture contamination to be an event and showed a statistically significant difference in favour of the intervention group. We found the probability of blood culture contamination was lower up to 18h after bathing in the group bathed using chlorhexidine, after which both curves become closer (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).<elsevierMultimedia ident="fig0005"></elsevierMultimedia>Cox regression study, taking the presence of multiresistant germs, previous antibiotic treatment, degree of severity and days of admission in the ICU to be confusion variables, showed that bathing without chlorhexidine increased the risk of blood culture contamination: HR 3.05 (95% CI: 1.14–8.12; P<.05).DiscussionThere is now increasing interest in improving the quality of healthcare while also restricting the cost of the same. In the context of patients admitted to critical care units, actions such as daily bathing with chlorhexidine has the aim of improving both aspects.Some studies show that daily hygiene using chlorhexidine in ICU patients gives rise to a decontamination effect that prevents infections from developing<a class="elsevierStyleCrossRefs" href="#bib0195">14–18</a> and reduces the possibility of crossed transmission.<a class="elsevierStyleCrossRef" href="#bib0220">19</a>Bleasdale et al.<a class="elsevierStyleCrossRef" href="#bib0185">12</a> show a significant reduction in cases of bacteraemia as well as a tendency to reduce the incidence of contaminated blood cultures. Popovich et al.<a class="elsevierStyleCrossRef" href="#bib0215">18</a> found that as well as reducing catheter bacteraemia, bathing with chlorhexidine also reduced the possibility of blood culture contamination in critical medical patients. Nevertheless, in a subsequent publication<a class="elsevierStyleCrossRef" href="#bib0225">20</a> these authors once again show a significant reduction in the incidence of contaminated blood cultures in surgical patients admitted to the UCI who were bathed daily using chlorhexidine, although they did not find a fall in catheter bacteraemia. A recent study by Noto et al.<a class="elsevierStyleCrossRef" href="#bib0230">21</a> does not show a reduction in the incidence of infections associated with healthcare procedures or a fall in contaminated blood cultures in patients bathed every day with chlorhexidine. Among other weak points this work did not monitor adherence to protocols and provides weak evidence of the effect of chlorhexidine on the incidence of nosocomial infections.Septimus et al.,<a class="elsevierStyleCrossRef" href="#bib0235">22</a> in another recent study that includes a large sample of patients admitted to an ICU, but without ensuring that a skin disinfection protocol was followed or that a uniform blood sample extraction technique was used, conclude that daily bathing using chlorhexidine and the use of nasal mupirocin is effective in reducing bacteraemia and blood culture contamination. This work does not discriminate the individual benefits of mupirocin and chlorhexidine.The published studies which show that daily washing with chlorhexidine leads to a reduction in blood culture contamination use wipes with 2% chlorhexidine. In our work we used sponges with 4% chlorhexidine digluconate, leading to a drastic reduction in the contamination rate, the effect of which persisted for up to 18h after washing. Although our study did not aim to compare the different commercial preparations of chlorhexidine at different concentrations, it may be thought that higher concentrations may have a greater protective effect against blood culture contamination.The study by Popovich et al.<a class="elsevierStyleCrossRef" href="#bib0240">23</a> showed the importance of chlorhexidine concentration. This study used colorimetric techniques to analyse the concentration of the said antiseptic on specific zones of the skin of patients in a medical ICU and made quantitative microbiological cultures of germs from the same zones of the skin. They thereby established that an inverse relationship exists between microbial density and chlorhexidine concentration, the activity of which persists for up to 24h after it is applied.The results of our study show a high incidence of blood culture contamination in our ICU in spite of the revision and diffusion of the blood culture extraction protocols. The use of daily washing with chlorhexidine has a good cost-efficacy ratio, given the reduction in costs arising due to blood culture contamination.Nevertheless, our study has methodological limitations. One of these is the fact that it took place in a single hospital with a small sample and a before and after design which may inappropriately attribute the effect studied to the intervention. We also started with an unacceptably high blood culture contamination rate, even though the extraction protocols had been revised and training programs had been implemented. Although these factors may weaken the results by introducing distortions, we believe that this is the most practical type of study.No development of resistant microorganisms or allergic reactions to the use of chlorhexidine were detected.<a class="elsevierStyleCrossRef" href="#bib0220">19</a> In our case, nor were any cutaneous reactions observed due to the use of this antiseptic.There is ongoing debate about the efficacy of different antiseptics in preventing the contamination of blood cultures. Alcohol solutions are more effective decontaminants than water-based ones.<a class="elsevierStyleCrossRefs" href="#bib0245">24,25</a> Although alcohol-free 2% chlorhexidine antiseptic solution was used to decontaminate the skin in our blood culture extraction protocol, we believe that the results are due to the use of chlorhexidine soap in daily washing, which reduced blood culture contamination. Studies in the future will be needed to evaluate the effect of alcohol-based antiseptic as skin decontaminants in patients washed every day with chlorhexidine.ConclusionsThe use of 4% chlorhexidine soap in the daily washing of critical patients reduces the incidence of blood culture contamination, and its effect lasts over time. A low rate of blood culture contamination is a quality of care marker. It gives rise to cost savings due to the use of diagnostic tests and unnecessary treatments, as well as aiding the clinical management of patients.Ethical disclosuresProtection of human and animal subjectsThe authors declare that the procedures followed are in accordance with the ethical norms of the responsible human experimentation ethical committee, the World Medical Association and the Helsinki Declaration.Confidentiality of dataThe authors declare that they followed the protocols of their centre of work regarding the publication of patient data.Right to privacy and informed consentThe authors declare that they obtained the informed consent of the patients or subjects included in the paper. This document is held by the corresponding author.Conflict of interestsThe authors have no conflict of interests to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:13 [ 0 => array:3 [ "identificador" => "xres881353" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec868336" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres881354" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y método" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec868337" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0015" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0020" "titulo" => "Material and methods" "secciones" => array:6 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Population selection" ] 1 => array:2 [ "identificador" => "sec0030" "titulo" => "Sample size" ] 2 => array:2 [ "identificador" => "sec0035" "titulo" => "How the intervention was divided" ] 3 => array:2 [ "identificador" => "sec0040" "titulo" => "Data gathering" ] 4 => array:2 [ "identificador" => "sec0045" "titulo" => "Data analysis" ] 5 => array:2 [ "identificador" => "sec0050" "titulo" => "Ethical aspects" ] ] ] 6 => array:2 [ "identificador" => "sec0055" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0060" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0065" "titulo" => "Conclusions" ] 9 => array:3 [ "identificador" => "sec0070" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0075" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0080" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0085" "titulo" => "Right to privacy and informed consent" ] ] ] 10 => array:2 [ "identificador" => "sec0090" "titulo" => "Conflict of interests" ] 11 => array:2 [ "identificador" => "xack294270" "titulo" => "Acknowledgements" ] 12 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-04-06" "fechaAceptado" => "2016-10-19" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec868336" "palabras" => array:3 [ 0 => "Chlorhexidine bathing" 1 => "Contaminated blood cultures" 2 => "Critically-ill patient" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec868337" "palabras" => array:3 [ 0 => "Baño con clorhexidina" 1 => "Hemocultivos contaminados" 2 => "Paciente crítico" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "ObjectiveTo evaluate the efficacy of daily cleaning with 4% chlorhexidine-impregnated sponges in decreasing contamination of blood cultures in critically-ill patients. Material and methodsProspective, quasi-experimental, longitudinal, single-centre trial. During 24 months (April 2013 to March 2015), we analysed 237 patients who fulfilled the inclusion criteria, divided into 2 groups: one underwent daily cleaning with common soap (control group, n=108), and the other with chlorhexidine (intervention group, n=109). Demographic variables, pathology group, severity scores, ICU and hospital length of stay and mortality, and time passed since cleaning to blood culture extraction were included. ResultsStatistical analysis showed a higher proportion of contaminated blood cultures during the control group period in contrast with the intervention group period (15 vs. 6.3%), with a significant difference: 9.23% (CI 95%: 1.34–16.7%), with an odds ratio of 2.73 (CI 95%: 1.13–6.63). Surveillance analysis showed lower probability of blood culture contamination within the 18h following daily cleaning. Cleaning without chlorhexidine increased contamination of blood cultures (HR: 3.05; CI 95%: 1.14–8.12). ConclusionsThe use of 4% chlorhexidine-impregnated sponges for daily cleaning of critically-ill patients decreases blood culture contamination incidence and its protection lasts for almost 18h." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "ObjetivoEvaluar la eficacia de la higiene diaria con esponjas impregnadas con clorhexidina al 4% para disminuir la contaminación de hemocultivos en pacientes ingresados en UCI. Material y métodoEstudio prospectivo, cuasi experimental, longitudinal, unicéntrico. Durante 24 meses (de abril de 2013 a marzo de 2015) fueron analizados 237 pacientes que cumplieron los criterios de inclusión, y fueron divididos en 2grupos: uno recibió higiene corporal diaria con jabón común (grupo control, n=118) y el otro con clorhexidina (grupo intervención, n=119). Fueron incluidas variables demográficas, tipo de enfermedad, nivel de gravedad, estancia y mortalidad en UCI y hospitalaria, y tiempo trascurrido (minutos) desde el baño hasta la extracción de los hemocultivos. ResultadosEl análisis estadístico mostró una mayor proporción de contaminación de los hemocultivos durante el período control con respecto al de intervención (15,5 vs. 6,3%); con una diferencia significativa: 9,23% (IC 95%: 1,34-16,7%), odds ratio de 2,73 (IC 95%: 1,13-6,63). El análisis de supervivencia mostró una menor probabilidad de contaminación de los hemocultivos hasta las 18 h desde el baño. El baño sin clorhexidina aumentó el riesgo de contaminación de los hemocultivos (HR: 3,05; IC 95%: 1,14-8,12). ConclusionesEl empleo de jabón con clorhexidina al 4% en la higiene diaria de los pacientes críticos disminuyó la incidencia de contaminaciones de hemocultivos y su efecto perduró al menos 18 h." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y método" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Garrido-Benedicto P, Cueto-Quintana P, Farré-Termens E, Mariné-Cabré M, Riba-Reig J, Molina-Chueca R. Efecto de la higiene diaria con clorhexidina sobre la incidencia de contaminaciones de hemocultivos en el paciente crítico. Enferm Intensiva. 2017;28:97–104." ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "etiqueta" => "Appendix A" "titulo" => "Blood culture extraction and processing technique" "identificador" => "sec0095" "apendiceSeccion" => array:2 [ 0 => array:4 [ "apendice" => "<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0030">2% water-based chlorhexidine</li><li class="elsevierStyleListItem" id="lsti0035">Vein compressor</li><li class="elsevierStyleListItem" id="lsti0040">Gauze</li><li class="elsevierStyleListItem" id="lsti0045">Sterile wipe</li><li class="elsevierStyleListItem" id="lsti0050">70° alcohol</li><li class="elsevierStyleListItem" id="lsti0055">Sterile latex gloves</li><li class="elsevierStyleListItem" id="lsti0060">Surgical mask</li><li class="elsevierStyleListItem" id="lsti0065">IV needle</li><li class="elsevierStyleListItem" id="lsti0070">20ml syringe or needle+holder</li><li class="elsevierStyleListItem" id="lsti0075">Blood culture flasks (anaerobic/aerobic)</li></ul>" "etiqueta" => "A.1" "titulo" => "Material" "identificador" => "sec0100" ] 1 => array:4 [ "etiqueta" => "A.2" "titulo" => "Procedure" "identificador" => "sec0105" "apendiceSeccion" => array:3 [ 0 => array:4 [ "apendice" => "<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0080">Hygienic hand washing. Putting on a surgical mask.</li><li class="elsevierStyleListItem" id="lsti0085">Select extraction site.</li><li class="elsevierStyleListItem" id="lsti0090">Disinfect the selected extraction zone with 2% water-based chlorhexidine and let it dry. Once disinfected the puncture point must not be touched, unless this is done in a sterile way. Put the sterile cover into place and put on sterile gloves.</li></ul>" "etiqueta" => "A.2.1" "titulo" => "Skin preparation" "identificador" => "sec0110" ] 1 => array:4 [ "apendice" => "<ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0095">Remove the plastic caps from the flasks.</li><li class="elsevierStyleListItem" id="lsti0100">The rubber cap is not sterile and must be disinfected.</li><li class="elsevierStyleListItem" id="lsti0105">Disinfect the rubber cap using 70° alcohol.</li><li class="elsevierStyleListItem" id="lsti0110">Let it dry.</li></ul>" "etiqueta" => "A.2.2" "titulo" => "Preparation of blood culture flasks" "identificador" => "sec0115" ] 2 => array:4 [ "apendice" => "<ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0115">Extract 20ml blood and inoculate 10ml in the anaerobic flask and 10ml in the aerobic flask.</li><li class="elsevierStyleListItem" id="lsti0120">Blood is extracted by direct puncture of a vein or artery.</li><li class="elsevierStyleListItem" id="lsti0125">The gauze must not touch the needle when it is withdrawn.</li><li class="elsevierStyleListItem" id="lsti0130">The needle of the syringe does not have to be changed to inoculate the flasks.</li><li class="elsevierStyleListItem" id="lsti0135">Do not touch the flask cap membrane after it has been disinfected with 70° alcohol.</li><li class="elsevierStyleListItem" id="lsti0140">Record patient data on the flasks (request label) without covering the barcode or batch number.</li></ul> Send the flasks to the laboratory as soon as possible, where they will be incubated in a stove within a blood culture processing automatic system (BacT/ALERT)." "etiqueta" => "A.2.3" "titulo" => "Blood extraction and flask inoculation" "identificador" => "sec0120" ] ] ] ] ] ] ] ] "multimedia" => array:7 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1911 "Ancho" => 2507 "Tamanyo" => 194592 ] ] "descripcion" => array:1 [ "en" => "The probability of blood culture non-contamination." ] ] 1 => 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" => "APACHE II: Acute Physiology And Chronic Health Evaluation II; C: control; Hosp days: days of admission to hospital; ICU days: days of admission in the intensive care unit; MRG: multiresistant germs; I: intervention; BMI: body mass index; SAPS II: Simplified Acute Physiology Score II; BC: bladder catheter; CRRT: continuous renal replacement therapy; CVC: central venous catheter; MV: mechanical ventilation." "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="table-head ; entry_with_role_rowhead " align="left" valign="top" scope="col">Characteristics \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Study period</th><th class="td" title="table-head " colspan="4" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Statistical tests</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Control group \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Intervention group \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Shapiro–Wilk<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> (C/I) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">t-Test<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mann–Whitney<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">χ2<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " colspan="7" align="left" valign="top">Categorical variable, percentage</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sex M/F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">56.8/43.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">60.5/39.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">>0.05 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">MV yes/no \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">56.8/43.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">66.4/33.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">>0.05 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">BC yes/no \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">90.7/9.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">90.8/9.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">>0.05 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">CVC yes/no \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">78.8/21.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">79.8/20.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">>0.05 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">CRRT yes/no \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12.7/87.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12.6/87.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">>0.05 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">MRG yes/no \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">18.6/81.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">15.1/84.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">>0.05 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">ATB yes/no \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">93.4/6.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">91.1/8.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">>0.05 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="7" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="7" align="left" valign="top">Continuous variables, median (RIC25–75)</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">65.6 (53.9–75.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">63.9 (51.6–73.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><0.05/<0.05 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">>0.05 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">APACHE II \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">16 (11–21) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">16 (11.5–21.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.4/0.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">>0.05 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">SASP II \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">36 (28–47) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">34 (27–45.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.86/0.31 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">>0.05 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">ICU days \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8 (5–15.25) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8 (4–16) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><0.05/<0.05 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">>0.05 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hosp days \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">20 (12–36.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">24 (14–41) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><0.05/<0.05 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">>0.05 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">BMI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">26.4 (23.3–31.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">26.6 (23.1–31.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.2/<0.05 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">>0.05 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1487672.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "Differences where P<.05 are considered significant." ] ] ] "descripcion" => array:1 [ "en" => "Comparison of patient characteristics in the study groups." ] ] 2 => 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" => "ICU: intensive care unit." "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="table-head ; entry_with_role_rowhead " align="left" valign="top" scope="col">Characteristics \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Study period</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Statistical tests</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Control group \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Intervention group \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">OR (95% CI) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">P<a class="elsevierStyleCrossRef" href="#tblfn0010">a</a> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " colspan="5" align="left" valign="top">Categorical variable: percentage</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">ICU mortality \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.75 (0.36–1.56) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">>0.05 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hospital mortality \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">25.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.59 (0.31–1.12) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">>0.05 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1487673.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "a" "nota" => "The χ2 test was used for the calculation, and differences where P<.05 were considered to be significant." ] ] ] "descripcion" => array:1 [ "en" => "Comparison between the mortality of patients in both study groups." ] ] 3 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "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="table-head ; entry_with_role_rowhead " align="left" valign="top" scope="col">Characteristics \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Study period</th><th class="td" title="table-head " align="left" valign="top" scope="col">Statistical tests \t\t\t\t\t\t\n \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Control group \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Intervention group \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">P<a class="elsevierStyleCrossRef" href="#tblfn0015">a</a> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top">Categorical variable: percentage</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Medical \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">77.1<a class="elsevierStyleCrossRef" href="#tblfn0020">b</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">65.5<a class="elsevierStyleCrossRef" href="#tblfn0020">b</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">>0.05 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cardiological \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Surgical \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">18.6<a class="elsevierStyleCrossRef" href="#tblfn0020">b</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">29.4<a class="elsevierStyleCrossRef" href="#tblfn0020">b</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1487670.png" ] ] ] "notaPie" => array:2 [ 0 => array:3 [ "identificador" => "tblfn0015" "etiqueta" => "a" "nota" => "The χ2 test (3×2 table) was used for the calculation, and differences where P<.05 were considered to be significant." ] 1 => array:3 [ "identificador" => "tblfn0020" "etiqueta" => "b" "nota" => "In the comparison between ‘Medical’ and ‘Non-medical’ (Cardiological+Surgical) a significant difference was detected between the distribution within the groups." ] ] ] "descripcion" => array:1 [ "en" => "Comparison between the study groups respecting pathologies on admission." ] ] 4 => array:8 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at4" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Study period</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Control group \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Intervention group \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top">Isolated germs; number (%)</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Staphylococcus coag. neg. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20 (76.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 (100) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Staphylococcus epidermidis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (15.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Corynebacterium sp. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (7.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1487671.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Comparison of contaminant pathogens between the study groups." ] ] 5 => array:8 [ "identificador" => "tbl0025" "etiqueta" => "Table 5" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at5" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Study period</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Statistical tests</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Control group \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Intervention group \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">P<a class="elsevierStyleCrossRef" href="#tblfn0025">a</a> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">OR (95% CI) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " colspan="5" align="left" valign="top">Contaminated blood cultures; number (%)</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Contaminated \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">23 (15.5)<a class="elsevierStyleCrossRef" href="#tblfn0030">b</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 (6.3)<a class="elsevierStyleCrossRef" href="#tblfn0030">b</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><0.05 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.73 (1.13–6.63) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Not contaminated \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">125 (84.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">104 (93.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1487669.png" ] ] ] "notaPie" => array:2 [ 0 => array:3 [ "identificador" => "tblfn0025" "etiqueta" => "a" "nota" => "The χ2 test (2×2 table) was used for the calculation, and differences where P<.05 were considered to be significant." ] 1 => array:3 [ "identificador" => "tblfn0030" "etiqueta" => "b" "nota" => "The difference between the proportions of contaminated blood cultures is 9.23%, with a 95% CI: 1.34–16.7% (Newcombe method)." ] ] ] "descripcion" => array:1 [ "en" => "Comparison of blood culture contamination between the study groups." ] ] 6 => array:5 [ "identificador" => "tb0005" "tipo" => "MULTIMEDIATEXTO" "mostrarFloat" => false "mostrarDisplay" => true "texto" => array:1 [ "textoCompleto" => "What is known/what is the contribution of this?A high rate of false positives in critically-ill patient blood cultures leads to increased healthcare costs. The use of aseptic techniques to extract blood cultures gives rise to a reduction in the number of contaminations, which are often due to germs that colonise the skin. Nevertheless, it may sometimes be necessary to adopt additional measures if, in spite of compliance with blood culture extraction protocols the aim of maintaining a less than 3% level of contamination is unmet. Daily chlorhexidine bathing of patients in the ICU may reduce the possibility of blood culture contamination.This study demonstrates the efficacy of daily chlorhexidine bathing in reducing the incidence of blood culture contamination in critically ill patients, and it may be especially useful in units with a high contamination rate.Implications of the studyThe use of sponges with 4% chlorhexidine digluconate in the daily hygiene of critically ill patients helps to maintain a low rate of blood culture contamination. It is also a care quality indicator and leads to a reduction in healthcare costs due to diagnostic tests and unnecessary treatments." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:25 [ 0 => array:3 [ "identificador" => "bib0130" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Peripheral blood culture contamination in adults and venepuncture technique: prospective cohort study" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "A. Qamruddin" 1 => "N. Khanna" 2 => "D. Orr" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1136/jcp.2007.047647" "Revista" => array:7 [ "tituloSerie" => "J Clin Pathol" "fecha" => "2007" "volumen" => "61" "paginaInicial" => "509" "paginaFinal" => "513" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17761739" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0302283812004034" "estado" => "S300" "issn" => "03022838" ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0135" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Contaminant blood cultures and resource utilization. The true consequences of false-positive results" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "D.W. Bates" 1 => "L. Goldman" 2 => "T.H. Lee" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "JAMA" "fecha" => "2005" "volumen" => "265" "paginaInicial" => "365" "paginaFinal" => "369" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/1984535" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0140" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clinical impact of blood cultures contaminated with coagulase-negative staphylococci at an academic medical center" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "Y.F. Van der Heijden" 1 => "G. Miller" 2 => "P.W. Wright" 3 => "B.E. Shepherd" 4 => "T.L. Daniels" 5 => "T.R. Talbot" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1086/660096" "Revista" => array:7 [ "tituloSerie" => "Infect Control Hosp Epidemiol" "fecha" => "2011" "volumen" => "32" "paginaInicial" => "623" "paginaFinal" => "625" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21558778" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S1078143914002920" "estado" => "S300" "issn" => "10781439" ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0145" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Comparative of a new and innovative 2% chlorhexidine gluconate-impregnated cloth with 4 antiseptic for preparation of the skin prior to surgery" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "C.E. Edmiston Jr." 1 => "G.R. Seabrook" 2 => "C.P. Johnson" 3 => "D.S. Paulson" 4 => "C.M. Beausoleil" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.ajic.2006.06.012" "Revista" => array:6 [ "tituloSerie" => "Am J Infect Control" "fecha" => "2007" "volumen" => "35" "paginaInicial" => "89" "paginaFinal" => "96" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17327187" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0150" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Presurgical skin preparation with a novel 2% chlorhexidine gluconate cloth reduces rates of surgical site infection in orthopaedic surgical patients" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "D. Eiselt" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/NOR.0b013e3181a469db" "Revista" => array:7 [ "tituloSerie" => "Orthop Nurs" "fecha" => "2009" "volumen" => "28" "paginaInicial" => "141" "paginaFinal" => "145" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19494763" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0302283813002583" "estado" => "S300" "issn" => "03022838" ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0155" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Advance pre-operative chlorhexidine reduces the incidence of surgical site infections in knee arthroplasty" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "M.G. Zywiel" 1 => "J.A. Daley" 2 => "R.E. Delanois" 3 => "Q. Naziri" 4 => "A.J. Johnson" 5 => "M.A. Mont" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00264-010-1078-5" "Revista" => array:6 [ "tituloSerie" => "Int Orthop" "fecha" => "2011" "volumen" => "35" "paginaInicial" => "1001" "paginaFinal" => "1006" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20563806" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0160" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Preoperative chlorhexidine preparation and the incidence of surgical site infections after hip arthroplasty" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "A.J. Johnson" 1 => "J.A. Daley" 2 => "M.G. Zywiel" 3 => "R.E. Delanois" 4 => "M.A. Mont" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.arth.2010.04.012" "Revista" => array:7 [ "tituloSerie" => "J Arthroplasty" "fecha" => "2012" "volumen" => "25" "numero" => "Suppl." "paginaInicial" => "98" "paginaFinal" => "102" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20570089" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0165" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Use of 4 per cent chlorhexidine detergent solution (hibiscrub) and other methods of skin disinfection" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "E.J. Lowbury" 1 => "H.A. Lilly" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:7 [ "tituloSerie" => "Br Med J" "fecha" => "1973" "volumen" => "1" "paginaInicial" => "510" "paginaFinal" => "515" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/626868" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0302283815006077" "estado" => "S300" "issn" => "03022838" ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0170" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Agents and techniques for disinfection of the skin" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "A.F. Kaul" 1 => "J.F. Jewett" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:7 [ "tituloSerie" => "Surg Gynecol Obstet" "fecha" => "1981" "volumen" => "152" "paginaInicial" => "677" "paginaFinal" => "685" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7013126" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0302283815000767" "estado" => "S300" "issn" => "03022838" ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0175" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:3 [ "comentario" => "M47-A,27(17). Available from: http://shop.clsi.org/site/Sample_pdf/M47A_sample.pdf" "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Principles and procedures for blood cultures; approved guideline. Clinical and Laboratory Standards Institute Document" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M.L. Wilson" 1 => "M. Mitchell" 2 => "A.J. Morris" 3 => "P.R. Murray" 4 => "L.G. Reimer" 5 => "L.B. Reller" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:1 [ "fecha" => "2007" ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0180" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Reducing blood culture contamination in community hospital emergency departments: a multicenter evaluation of a quality improvement intervention" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "W.H. Self" 1 => "J. Mickanin" 2 => "C.G. Grijalva" 3 => "F.H. Grant" 4 => "M.C. Henderson" 5 => "G. Corley" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/acem.12337" "Revista" => array:7 [ "tituloSerie" => "Acad Emerg Med" "fecha" => "2014" "volumen" => "21" "paginaInicial" => "274" "paginaFinal" => "282" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24628752" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0090429515011887" "estado" => "S300" "issn" => "00904295" ] ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib0185" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Effectiveness of chlorhexidine bathing to reduce catheter-associated bloodstream infections in medical intensive care unit patients" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "S.C. Bleasdale" 1 => "W.E. Trick" 2 => "I.M. Gonzalez" 3 => "R.D. Lyles" 4 => "M.K. Hayden" 5 => "R.A. 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Bernard" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1001/jama.2014.18400" "Revista" => array:6 [ "tituloSerie" => "JAMA" "fecha" => "2015" "volumen" => "313" "paginaInicial" => "369" "paginaFinal" => "378" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25602496" "web" => "Medline" ] ] ] ] ] ] ] ] 21 => array:3 [ "identificador" => "bib0235" "etiqueta" => "22" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Does chlorhexidine bathing in adult intensive care units reduce blood culture contamination? A pragmatic cluster-randomized trial" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "E.J. Septimus" 1 => "M.K. Hayden" 2 => "K. Kleinman" 3 => "T.R. Avery" 4 => "J. Moody" 5 => "R.A. 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Effect of daily cleaning with chlorhexidine on the incidence of contamination of blood cultures in the critical patient

Efecto de la higiene diaria con clorhexidina sobre la incidencia de contaminaciones de hemocultivos en el paciente crítico

P. Garrido-Benedicto, P. Cueto-Quintana, E. Farré-Termens

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mixtligf@yahoo.es

Corresponding author.

, M. Mariné-Cabré, J. Riba-Reig, R. Molina-Chueca

Servicio de Medicina Intensiva, Hospital Universitari Sant Joan de Reus, Reus, Spain

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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="tb0005"></elsevierMultimedia></p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Introduction</span><p id="par0025" class="elsevierStylePara elsevierViewall">Bacteraemia is a severe condition with a high rate of morbimortality&#46; Blood cultures are a very useful diagnostic and prognostic tool for doctors&#46; Nevertheless&#44; false positive results due to contamination of blood samples by patient skin flora organisms&#44; chiefly coagulase negative staphylococcus&#44;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">1</span></a> give rise to an increase in diagnostic tests and unnecessary treatment<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">2</span></a> with the subsequent increase in healthcare costs&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">3</span></a> The most frequent causes of contamination are inadequate preparation of the skin and poor sample extraction technique&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Actions to reduce contamination are based on minimising skin bacteria by using disinfectants and optimising sample extraction protocols&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">There are studies which show that washing with antiseptic solutions prior to surgery is effective in reducing the number of microorganisms on the skin&#44;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">4</span></a> and that this also reduces the incidence of surgical wound infection in orthopaedic surgery&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">5&#8211;7</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Patients in the ICU are especially liable to suffer infections caused by skin flora and nosocomial germs&#46; This is due to the use of invasive devices&#44; antibiotic therapy&#44; immunodeficiencies and comorbidity&#46; Preventative measures based on hand washing&#44; the use of disposable materials and even patient isolation are fundamental to prevent crossed contamination by germs that often colonise the skin&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Chlorhexidine gluconate is a biguanide-type cationic antiseptic with broad spectrum action against several microorganisms including <span class="elsevierStyleItalic">S&#46; aureus</span> and enterococcos species&#46; It has prolonged residual activity<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">8</span></a> and low toxicity&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">9</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Quality standards propose a level of blood culture contamination below 3&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">10</span></a> This margin is considered to be tolerable and&#44; when it is surpassed in practice it shows that there is a problem&#46; The strict application of protocols with an emphasis of the use of sterile techniques to extract blood cultures leads to a reduction in contamination&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">11</span></a> However&#44; it sometimes may be necessary to adopt other additional measures such as changing the antiseptic used to decontaminate the skin or daily washing with antiseptic products&#46; This will occur if in spite of careful compliance with blood culture extraction protocols no improvement is detected in the results&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">This work aims to evaluate the efficacy of daily hygiene using 4&#37; chlorhexidine digluconate soap-impregnated sponges to reduce blood culture contamination down to the level set by quality standards in ICU patients&#46; A water-based 2&#37; chlorhexidine antiseptic solution was used to decontaminate the skin for the extraction of blood cultures according to our protocol&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Material and methods</span><p id="par0060" class="elsevierStylePara elsevierViewall">A quasi-experimental non-randomised prospective study with a pre-post design&#44; longitudinal and in single hospital&#46; Study period&#58; 24 months from April 2013 to March 2015&#46; It took place in a 12-bed medical-surgical intensive care unit in the Hospital Universitari Sant Joan de Reus&#46;</p><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Population selection</span><p id="par0065" class="elsevierStylePara elsevierViewall">The inclusion criteria were&#58; age<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>18 years old&#44; admission to the ICU<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>48<span class="elsevierStyleHsp" style=""></span>h&#44; and the exclusion criteria were&#58; skin disruption &#62;20&#37; &#40;for example&#44; burns&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">12</span></a> pregnancy and allergy to chlorhexidine&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Sample size</span><p id="par0070" class="elsevierStylePara elsevierViewall">The sample size was determined on the basis of our proportion of contaminated blood cultures prior to the study &#40;16&#37;&#41; and the accepted quality standards &#40;3&#37;&#41;&#46; To detect a reduction of 13&#37; in the proportion of contaminated blood cultures &#40;from 16&#37; to 3&#37;&#41; with a type I error of 5&#37; and a power of 80&#37; 70 blood cultures per group were necessary&#46; The Domenech&#8211;Granero macro &#161;NSize for SPSS was used for calculations&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">How the intervention was divided</span><p id="par0075" class="elsevierStylePara elsevierViewall">The study included 3 periods and 2 groups of patients&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#40;a&#41;</span><p id="par0080" class="elsevierStylePara elsevierViewall">First period&#8212;control group&#46; During this period patient hygiene was performed daily with warm water and CR-32 antiseptic-free dermatological soap &#40;Jos&#233; Collado S&#46;A&#46;&#44; Barcelona&#44; Spain&#41;&#46; This period lasted for 11 months&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#40;b&#41;</span><p id="par0085" class="elsevierStylePara elsevierViewall">Second period&#8212;rest&#46; This period lasted for one month&#44; and its function was to prevent the overlap between patients in both study groups&#46; During this time the patients in the control group were discharged and no intervention group patients were included&#46; Additionally&#44; we reinforced training in blood culture hygiene and extraction protocols&#46; During this period patient hygiene was undertaken using antiseptic-free soap&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#40;c&#41;</span><p id="par0090" class="elsevierStylePara elsevierViewall">Third period&#8212;intervention group&#46; During this period hygiene was undertaken using body sponges impregnated with 4&#37; chlorhexidine digluconate &#40;Dispomedic sponge C&#44; CV M&#233;dica&#44; Tarragona&#44; Spain&#41;&#44; applied on the patient&#39;s skin until the whole skin surface apart from the face was covered&#44; to prevent contact with oral mucus membranes and eyes &#40;following the manufacturer&#39;s recommendations&#41;&#46; The solution was left to act during 3<span class="elsevierStyleHsp" style=""></span>min&#46;&#44; after which the skin was rinsed using water before being dried with clean towels&#46; The hair was washed every 3 days&#46; This period lasted for 11 months&#46;</p></li></ul></p><p id="par0095" class="elsevierStylePara elsevierViewall">Prior to commencing periods 1 and 3 patient bathing technique was protocolised with the nursing and auxiliary staff&#46; This technique emphasised sequential washing from clean zones to dirty ones&#46; The stools of incontinent patients were washed off using soap and water or chlorhexidine&#44; depending on the study group&#46; The skin was hydrated using solutions that do not give rise to interference with the bactericide activity of chlorhexidine&#46; Strict compliance with the hand hygiene protocol was recommended before and after contract with patients&#46; Likewise&#44; before periods 1 and 3 we implemented continuous training programs&#44; emphasising the blood culture extraction and processing protocol &#40;<a class="elsevierStyleCrossRef" href="#sec0095">Appendix A</a>&#58; blood culture extraction and processing technique&#41;&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Data gathering</span><p id="par0100" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#40;a&#41;</span><p id="par0105" class="elsevierStylePara elsevierViewall">Basic level&#46; On the admission to the ICU of each patient we recorded their age&#44; sex&#44; height&#44; weight&#44; disease type &#40;medical&#44; surgical or cardiological&#41;&#44; degree of severity &#40;APACHE II&#44; SAPS II&#41;&#46; All non-cardiological patients whose disease did not require surgery were considered to be medical&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#40;b&#41;</span><p id="par0110" class="elsevierStylePara elsevierViewall">Follow-up&#46; We recorded the date and time of each blood culture&#44; the data and time of body washing&#44; the location of blood culture extraction&#44; days of admission in the ICU and hospital mortality&#46; We also recorded the presence of central venous catheter&#44; a bladder catheter&#44; the need for mechanical ventilation&#44; renal replacement therapy&#44; antibiotic therapy and the presence of multiresistant germs &#40;colonisation or infection&#41;&#46;</p></li></ul></p><p id="par0115" class="elsevierStylePara elsevierViewall">Every day the nursing staff evaluated patient skin integrity using a SCORAD<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">13</span></a> grading scale&#44; a clinical tool used to evaluate the extension and severity of eczema in atypical dermatitis&#46; If skin alterations were detected as a side effect of the chlorhexidine the patient&#39;s doctor or Dermatology Department proposed a therapeutic intervention&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Blood cultures were requested under medical criterion when there was a suspicion of infection and body temperature above 38<span class="elsevierStyleHsp" style=""></span>&#176;C&#46; Blood cultures were always requested in sets of 2&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">It is difficult to distinguish between contaminated blood cultures and a true infection without a &#8220;gold standard&#8221;&#46; The initial independent evaluation was undertaken by the doctors in charge of the patient blood cultures had been extracted from&#46; They were subsequently reviewed by 2 doctors involved in the study&#44; based on the type of germ isolated&#44; the number of jars with growth&#44; the use of empirical antibodies following the extraction of blood cultures and the clinical evolution of the patient&#46; All blood cultures were defined as cases of contamination when&#44; after being extracted in the ICU on the order of a doctor due to the suspicion of infection&#44; the Microbiology Laboratory reported the growth of germs in at least two blood cultures and these were interpreted by 2 doctors to be a caused by a germ with a low probability of being the cause of the suspected infection&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">The study was simple blind&#58; the patients did not know which study group they belonged to&#46; The medical staff was aware of the product used in the daily hygiene of each patient taking part in the study&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Data analysis</span><p id="par0135" class="elsevierStylePara elsevierViewall">The normal distribution of the groups was checked using the Shapiro&#8211;Wilk test&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">The comparison between groups of continuous variables was undertaken using the Student <span class="elsevierStyleItalic">t</span>-test or the non-parametric Mann&#8211;Whitney test according to correspondence and the categorical variables test using <span class="elsevierStyleItalic">&#967;</span><span class="elsevierStyleSup">2</span>&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">To graphically compare the time to appearance of blood culture contaminations following the daily bodily washing between group we made Kaplan&#8211;Meier curves and calculated the log-rank for each one&#46; In survival analysis each contaminated blood culture was considered to be an event&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">The difference between blood culture contamination incidence density rates between groups was determined using Cox regression controlled for confusion variables&#46; We considered previous antibiotic treatment and the presence of multiresistant germs to be confusion variables&#46; We also controlled regression according to level of severity and days of admission in the ICU&#44; assuming that more severe patients and those with prolonged admission are at greater risk of colonisation&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">We used the IBM SPSS 20 &#40;Chicago&#44; USA&#41; statistics program for statistical analysis&#46; Differences with a value of <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;05 were considered to be statistically significant&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Ethical aspects</span><p id="par0160" class="elsevierStylePara elsevierViewall">This study was carried out according to the ethical principles of the Helsinki Declaration and it was approved by the Hospital Ethics Committee&#44; which considered that it was necessary to obtain informed consent&#46; The patients or their legal representatives were asked to give their informed consent after the purpose and nature of the study had been explained&#46; Checks were made to ensure that the patient or their family members had understood the risks and benefits of taking part&#46; A simple answer was given to all of the questions that arose&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">To ensure the confidentiality of the data of each individual&#44; as a guarantee of the protection of personal information and to prevent divulgation of the same without their consent&#44; alphanumerical identification codes were used to identify them computerised analysis&#46; Access to these codes was restricted to the authors&#44; and printed records were kept in a locked and protected place&#46;</p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Results</span><p id="par0170" class="elsevierStylePara elsevierViewall">1061 patients were admitted during the period from April 2013 to March 2015&#59; of these&#44; 237 patients fulfilled the inclusion criteria and agreed to take part in the study&#46; They were then distributed as follows&#58; 118 in the control group and 119 in the intervention group&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Patient characteristics were similar in both groups in terms of age&#44; sex&#44; degree of severity in the first 24<span class="elsevierStyleHsp" style=""></span>h &#40;APACHE II&#44; SAPS II&#41;&#44; BMI&#44; central venous catheter&#44; bladder catheter&#44; the need for assisted respiration or renal replacement therapy&#44; the presence of multiresistant germs &#40;colonisation or infection&#41; and antibiotic treatment&#44; days of admission in the ICU and hospitalisation &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#44; as well as intra-ICU and hospital mortality &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; Respecting the type of disease a higher proportion of medical patients were included in the control group&#44; and there were more surgical patients in the intervention group&#46; Nevertheless&#44; the differences were not statistically significant &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46; No skin alterations were detected that were considered to be side effects of the chlorhexidine&#46; We found no differences in the SCORAD score between the two groups studied&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0180" class="elsevierStylePara elsevierViewall">259 blood cultures were extracted&#44; 148 in the control group and 111 in the intervention group&#44; of which 30 were considered to be contaminated &#40;23 and 7&#44; respectively&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46; This showed that there was a higher proportion of contaminated blood cultures during the control group period than was the case during the intervention group period &#40;15&#46;5&#37; and 6&#46;3&#37;&#44; respectively&#41;&#46; The difference between these proportions amounted to 9&#46;23&#37; &#40;95&#37; CI&#58; 1&#46;34&#8211;16&#46;7&#37;&#41;&#46; This is a statistically significant difference&#44; with an odds ratio of 2&#46;73 &#40;95&#37; CI&#58; 1&#46;13&#8211;6&#46;63&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><p id="par0185" class="elsevierStylePara elsevierViewall">Survival analysis considered blood culture contamination to be an event and showed a statistically significant difference in favour of the intervention group&#46; We found the probability of blood culture contamination was lower up to 18<span class="elsevierStyleHsp" style=""></span>h after bathing in the group bathed using chlorhexidine&#44; after which both curves become closer &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0190" class="elsevierStylePara elsevierViewall">Cox regression study&#44; taking the presence of multiresistant germs&#44; previous antibiotic treatment&#44; degree of severity and days of admission in the ICU to be confusion variables&#44; showed that bathing without chlorhexidine increased the risk of blood culture contamination&#58; HR 3&#46;05 &#40;95&#37; CI&#58; 1&#46;14&#8211;8&#46;12&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;05&#41;&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Discussion</span><p id="par0195" class="elsevierStylePara elsevierViewall">There is now increasing interest in improving the quality of healthcare while also restricting the cost of the same&#46; In the context of patients admitted to critical care units&#44; actions such as daily bathing with chlorhexidine has the aim of improving both aspects&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">Some studies show that daily hygiene using chlorhexidine in ICU patients gives rise to a decontamination effect that prevents infections from developing<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">14&#8211;18</span></a> and reduces the possibility of crossed transmission&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">19</span></a></p><p id="par0205" class="elsevierStylePara elsevierViewall">Bleasdale et al&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">12</span></a> show a significant reduction in cases of bacteraemia as well as a tendency to reduce the incidence of contaminated blood cultures&#46; Popovich et al&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">18</span></a> found that as well as reducing catheter bacteraemia&#44; bathing with chlorhexidine also reduced the possibility of blood culture contamination in critical medical patients&#46; Nevertheless&#44; in a subsequent publication<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">20</span></a> these authors once again show a significant reduction in the incidence of contaminated blood cultures in surgical patients admitted to the UCI who were bathed daily using chlorhexidine&#44; although they did not find a fall in catheter bacteraemia&#46; A recent study by Noto et al&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">21</span></a> does not show a reduction in the incidence of infections associated with healthcare procedures or a fall in contaminated blood cultures in patients bathed every day with chlorhexidine&#46; Among other weak points this work did not monitor adherence to protocols and provides weak evidence of the effect of chlorhexidine on the incidence of nosocomial infections&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">Septimus et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">22</span></a> in another recent study that includes a large sample of patients admitted to an ICU&#44; but without ensuring that a skin disinfection protocol was followed or that a uniform blood sample extraction technique was used&#44; conclude that daily bathing using chlorhexidine and the use of nasal mupirocin is effective in reducing bacteraemia and blood culture contamination&#46; This work does not discriminate the individual benefits of mupirocin and chlorhexidine&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">The published studies which show that daily washing with chlorhexidine leads to a reduction in blood culture contamination use wipes with 2&#37; chlorhexidine&#46; In our work we used sponges with 4&#37; chlorhexidine digluconate&#44; leading to a drastic reduction in the contamination rate&#44; the effect of which persisted for up to 18<span class="elsevierStyleHsp" style=""></span>h after washing&#46; Although our study did not aim to compare the different commercial preparations of chlorhexidine at different concentrations&#44; it may be thought that higher concentrations may have a greater protective effect against blood culture contamination&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">The study by Popovich et al&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">23</span></a> showed the importance of chlorhexidine concentration&#46; This study used colorimetric techniques to analyse the concentration of the said antiseptic on specific zones of the skin of patients in a medical ICU and made quantitative microbiological cultures of germs from the same zones of the skin&#46; They thereby established that an inverse relationship exists between microbial density and chlorhexidine concentration&#44; the activity of which persists for up to 24<span class="elsevierStyleHsp" style=""></span>h after it is applied&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">The results of our study show a high incidence of blood culture contamination in our ICU in spite of the revision and diffusion of the blood culture extraction protocols&#46; The use of daily washing with chlorhexidine has a good cost-efficacy ratio&#44; given the reduction in costs arising due to blood culture contamination&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">Nevertheless&#44; our study has methodological limitations&#46; One of these is the fact that it took place in a single hospital with a small sample and a before and after design which may inappropriately attribute the effect studied to the intervention&#46; We also started with an unacceptably high blood culture contamination rate&#44; even though the extraction protocols had been revised and training programs had been implemented&#46; Although these factors may weaken the results by introducing distortions&#44; we believe that this is the most practical type of study&#46;</p><p id="par0235" class="elsevierStylePara elsevierViewall">No development of resistant microorganisms or allergic reactions to the use of chlorhexidine were detected&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">19</span></a> In our case&#44; nor were any cutaneous reactions observed due to the use of this antiseptic&#46;</p><p id="par0240" class="elsevierStylePara elsevierViewall">There is ongoing debate about the efficacy of different antiseptics in preventing the contamination of blood cultures&#46; Alcohol solutions are more effective decontaminants than water-based ones&#46;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">24&#44;25</span></a> Although alcohol-free 2&#37; chlorhexidine antiseptic solution was used to decontaminate the skin in our blood culture extraction protocol&#44; we believe that the results are due to the use of chlorhexidine soap in daily washing&#44; which reduced blood culture contamination&#46; Studies in the future will be needed to evaluate the effect of alcohol-based antiseptic as skin decontaminants in patients washed every day with chlorhexidine&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Conclusions</span><p id="par0245" class="elsevierStylePara elsevierViewall">The use of 4&#37; chlorhexidine soap in the daily washing of critical patients reduces the incidence of blood culture contamination&#44; and its effect lasts over time&#46; A low rate of blood culture contamination is a quality of care marker&#46; It gives rise to cost savings due to the use of diagnostic tests and unnecessary treatments&#44; as well as aiding the clinical management of patients&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Ethical disclosures</span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Protection of human and animal subjects</span><p id="par0250" class="elsevierStylePara elsevierViewall">The authors declare that the procedures followed are in accordance with the ethical norms of the responsible human experimentation ethical committee&#44; the World Medical Association and the Helsinki Declaration&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Confidentiality of data</span><p id="par0255" class="elsevierStylePara elsevierViewall">The authors declare that they followed the protocols of their centre of work regarding the publication of patient data&#46;</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Right to privacy and informed consent</span><p id="par0260" class="elsevierStylePara elsevierViewall">The authors declare that they obtained the informed consent of the patients or subjects included in the paper&#46; This document is held by the corresponding author&#46;</p></span></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Conflict of interests</span><p id="par0265" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare&#46;</p></span></span>"
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    "fechaRecibido" => "2016-04-06"
    "fechaAceptado" => "2016-10-19"
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            0 => "Chlorhexidine bathing"
            1 => "Contaminated blood cultures"
            2 => "Critically-ill patient"
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            0 => "Ba&#241;o con clorhexidina"
            1 => "Hemocultivos contaminados"
            2 => "Paciente cr&#237;tico"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To evaluate the efficacy of daily cleaning with 4&#37; chlorhexidine-impregnated sponges in decreasing contamination of blood cultures in critically-ill patients&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Prospective&#44; quasi-experimental&#44; longitudinal&#44; single-centre trial&#46; During 24 months &#40;April 2013 to March 2015&#41;&#44; we analysed 237 patients who fulfilled the inclusion criteria&#44; divided into 2 groups&#58; one underwent daily cleaning with common soap &#40;control group&#44; n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>108&#41;&#44; and the other with chlorhexidine &#40;intervention group&#44; n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>109&#41;&#46; Demographic variables&#44; pathology group&#44; severity scores&#44; ICU and hospital length of stay and mortality&#44; and time passed since cleaning to blood culture extraction were included&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Statistical analysis showed a higher proportion of contaminated blood cultures during the control group period in contrast with the intervention group period &#40;15 vs&#46; 6&#46;3&#37;&#41;&#44; with a significant difference&#58; 9&#46;23&#37; &#40;CI 95&#37;&#58; 1&#46;34&#8211;16&#46;7&#37;&#41;&#44; with an odds ratio of 2&#46;73 &#40;CI 95&#37;&#58; 1&#46;13&#8211;6&#46;63&#41;&#46; Surveillance analysis showed lower probability of blood culture contamination within the 18<span class="elsevierStyleHsp" style=""></span>h following daily cleaning&#46; Cleaning without chlorhexidine increased contamination of blood cultures &#40;HR&#58; 3&#46;05&#59; CI 95&#37;&#58; 1&#46;14&#8211;8&#46;12&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The use of 4&#37; chlorhexidine-impregnated sponges for daily cleaning of critically-ill patients decreases blood culture contamination incidence and its protection lasts for almost 18<span class="elsevierStyleHsp" style=""></span>h&#46;</p></span>"
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            "titulo" => "Objective"
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          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Material and methods"
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          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Evaluar la eficacia de la higiene diaria con esponjas impregnadas con clorhexidina al 4&#37; para disminuir la contaminaci&#243;n de hemocultivos en pacientes ingresados en UCI&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todo</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio prospectivo&#44; cuasi experimental&#44; longitudinal&#44; unic&#233;ntrico&#46; Durante 24 meses &#40;de abril de 2013 a marzo de 2015&#41; fueron analizados 237 pacientes que cumplieron los criterios de inclusi&#243;n&#44; y fueron divididos en 2<span class="elsevierStyleHsp" style=""></span>grupos&#58; uno recibi&#243; higiene corporal diaria con jab&#243;n com&#250;n &#40;grupo control&#44; n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>118&#41; y el otro con clorhexidina &#40;grupo intervenci&#243;n&#44; n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>119&#41;&#46; Fueron incluidas variables demogr&#225;ficas&#44; tipo de enfermedad&#44; nivel de gravedad&#44; estancia y mortalidad en UCI y hospitalaria&#44; y tiempo trascurrido &#40;minutos&#41; desde el ba&#241;o hasta la extracci&#243;n de los hemocultivos&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">El an&#225;lisis estad&#237;stico mostr&#243; una mayor proporci&#243;n de contaminaci&#243;n de los hemocultivos durante el per&#237;odo control con respecto al de intervenci&#243;n &#40;15&#44;5 vs&#46; 6&#44;3&#37;&#41;&#59; con una diferencia significativa&#58; 9&#44;23&#37; &#40;IC 95&#37;&#58; 1&#44;34-16&#44;7&#37;&#41;&#44; <span class="elsevierStyleItalic">odds ratio</span> de 2&#44;73 &#40;IC 95&#37;&#58; 1&#44;13-6&#44;63&#41;&#46; El an&#225;lisis de supervivencia mostr&#243; una menor probabilidad de contaminaci&#243;n de los hemocultivos hasta las 18 h desde el ba&#241;o&#46; El ba&#241;o sin clorhexidina aument&#243; el riesgo de contaminaci&#243;n de los hemocultivos &#40;HR&#58; 3&#44;05&#59; IC 95&#37;&#58; 1&#44;14-8&#44;12&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">El empleo de jab&#243;n con clorhexidina al 4&#37; en la higiene diaria de los pacientes cr&#237;ticos disminuy&#243; la incidencia de contaminaciones de hemocultivos y su efecto perdur&#243; al menos 18 h&#46;</p></span>"
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0035">Please cite this article as&#58; Garrido-Benedicto P&#44; Cueto-Quintana P&#44; Farr&#233;-Termens E&#44; Marin&#233;-Cabr&#233; M&#44; Riba-Reig J&#44; Molina-Chueca R&#46; Efecto de la higiene diaria con clorhexidina sobre la incidencia de contaminaciones de hemocultivos en el paciente cr&#237;tico&#46; Enferm Intensiva&#46; 2017&#59;28&#58;97&#8211;104&#46;</p>"
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          0 => array:4 [
            "etiqueta" => "Appendix A"
            "titulo" => "Blood culture extraction and processing technique"
            "identificador" => "sec0095"
            "apendiceSeccion" => array:2 [
              0 => array:4 [
                "apendice" => "<p id="par0275" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0030"><p id="par0280" class="elsevierStylePara elsevierViewall">2&#37; water-based chlorhexidine</p></li><li class="elsevierStyleListItem" id="lsti0035"><p id="par0285" class="elsevierStylePara elsevierViewall">Vein compressor</p></li><li class="elsevierStyleListItem" id="lsti0040"><p id="par0290" class="elsevierStylePara elsevierViewall">Gauze</p></li><li class="elsevierStyleListItem" id="lsti0045"><p id="par0295" class="elsevierStylePara elsevierViewall">Sterile wipe</p></li><li class="elsevierStyleListItem" id="lsti0050"><p id="par0300" class="elsevierStylePara elsevierViewall">70&#176; alcohol</p></li><li class="elsevierStyleListItem" id="lsti0055"><p id="par0305" class="elsevierStylePara elsevierViewall">Sterile latex gloves</p></li><li class="elsevierStyleListItem" id="lsti0060"><p id="par0310" class="elsevierStylePara elsevierViewall">Surgical mask</p></li><li class="elsevierStyleListItem" id="lsti0065"><p id="par0315" class="elsevierStylePara elsevierViewall">IV needle</p></li><li class="elsevierStyleListItem" id="lsti0070"><p id="par0320" class="elsevierStylePara elsevierViewall">20<span class="elsevierStyleHsp" style=""></span>ml syringe or needle<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>holder</p></li><li class="elsevierStyleListItem" id="lsti0075"><p id="par0325" class="elsevierStylePara elsevierViewall">Blood culture flasks &#40;anaerobic&#47;aerobic&#41;</p></li></ul></p>"
                "etiqueta" => "A&#46;1"
                "titulo" => "Material"
                "identificador" => "sec0100"
              ]
              1 => array:4 [
                "etiqueta" => "A&#46;2"
                "titulo" => "Procedure"
                "identificador" => "sec0105"
                "apendiceSeccion" => array:3 [
                  0 => array:4 [
                    "apendice" => "<p id="par0330" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0080"><p id="par0335" class="elsevierStylePara elsevierViewall">Hygienic hand washing&#46; Putting on a surgical mask&#46;</p></li><li class="elsevierStyleListItem" id="lsti0085"><p id="par0340" class="elsevierStylePara elsevierViewall">Select extraction site&#46;</p></li><li class="elsevierStyleListItem" id="lsti0090"><p id="par0345" class="elsevierStylePara elsevierViewall">Disinfect the selected extraction zone with 2&#37; water-based chlorhexidine and let it dry&#46; Once disinfected the puncture point must not be touched&#44; unless this is done in a sterile way&#46; Put the sterile cover into place and put on sterile gloves&#46;</p></li></ul></p>"
                    "etiqueta" => "A&#46;2&#46;1"
                    "titulo" => "Skin preparation"
                    "identificador" => "sec0110"
                  ]
                  1 => array:4 [
                    "apendice" => "<p id="par0350" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0095"><p id="par0355" class="elsevierStylePara elsevierViewall">Remove the plastic caps from the flasks&#46;</p></li><li class="elsevierStyleListItem" id="lsti0100"><p id="par0360" class="elsevierStylePara elsevierViewall">The rubber cap is not sterile and must be disinfected&#46;</p></li><li class="elsevierStyleListItem" id="lsti0105"><p id="par0365" class="elsevierStylePara elsevierViewall">Disinfect the rubber cap using 70&#176; alcohol&#46;</p></li><li class="elsevierStyleListItem" id="lsti0110"><p id="par0370" class="elsevierStylePara elsevierViewall">Let it dry&#46;</p></li></ul></p>"
                    "etiqueta" => "A&#46;2&#46;2"
                    "titulo" => "Preparation of blood culture flasks"
                    "identificador" => "sec0115"
                  ]
                  2 => array:4 [
                    "apendice" => "<p id="par0375" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0115"><p id="par0380" class="elsevierStylePara elsevierViewall">Extract 20<span class="elsevierStyleHsp" style=""></span>ml blood and inoculate 10<span class="elsevierStyleHsp" style=""></span>ml in the anaerobic flask and 10<span class="elsevierStyleHsp" style=""></span>ml in the aerobic flask&#46;</p></li><li class="elsevierStyleListItem" id="lsti0120"><p id="par0385" class="elsevierStylePara elsevierViewall">Blood is extracted by direct puncture of a vein or artery&#46;</p></li><li class="elsevierStyleListItem" id="lsti0125"><p id="par0390" class="elsevierStylePara elsevierViewall">The gauze must not touch the needle when it is withdrawn&#46;</p></li><li class="elsevierStyleListItem" id="lsti0130"><p id="par0395" class="elsevierStylePara elsevierViewall">The needle of the syringe does not have to be changed to inoculate the flasks&#46;</p></li><li class="elsevierStyleListItem" id="lsti0135"><p id="par0400" class="elsevierStylePara elsevierViewall">Do not touch the flask cap membrane after it has been disinfected with 70&#176; alcohol&#46;</p></li><li class="elsevierStyleListItem" id="lsti0140"><p id="par0405" class="elsevierStylePara elsevierViewall">Record patient data on the flasks &#40;request label&#41; without covering the barcode or batch number&#46;</p></li></ul></p> <p id="par0410" class="elsevierStylePara elsevierViewall">Send the flasks to the laboratory as soon as possible&#44; where they will be incubated in a stove within a blood culture processing automatic system &#40;BacT&#47;ALERT&#41;&#46;</p>"
                    "etiqueta" => "A&#46;2&#46;3"
                    "titulo" => "Blood extraction and flask inoculation"
                    "identificador" => "sec0120"
                  ]
                ]
              ]
            ]
          ]
        ]
      ]
    ]
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        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
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        "figura" => array:1 [
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            "Alto" => 1911
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        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">The probability of blood culture non-contamination&#46;</p>"
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      1 => array:8 [
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        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
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          "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">APACHE II&#58; Acute Physiology And Chronic Health Evaluation II&#59; C&#58; control&#59; Hosp days&#58; days of admission to hospital&#59; ICU days&#58; days of admission in the intensive care unit&#59; MRG&#58; multiresistant germs&#59; I&#58; intervention&#59; BMI&#58; body mass index&#59; SAPS II&#58; Simplified Acute Physiology Score II&#59; BC&#58; bladder catheter&#59; CRRT&#58; continuous renal replacement therapy&#59; CVC&#58; central venous catheter&#59; MV&#58; mechanical ventilation&#46;</p>"
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                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="table-head ; entry_with_role_rowhead " align="left" valign="top" scope="col">Characteristics&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Study period</th><th class="td" title="table-head  " colspan="4" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Statistical tests</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Control group&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Intervention group&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Shapiro&#8211;Wilk<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> &#40;C&#47;I&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">t</span>-Test<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mann&#8211;Whitney<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">&#967;</span><span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span><a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="7" align="left" valign="top"><span class="elsevierStyleItalic">Categorical variable</span>&#44; <span class="elsevierStyleItalic">percentage</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Sex M&#47;F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">56&#46;8&#47;43&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">60&#46;5&#47;39&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#62;0&#46;05&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>MV yes&#47;no&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">56&#46;8&#47;43&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">66&#46;4&#47;33&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#62;0&#46;05&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>BC yes&#47;no&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">90&#46;7&#47;9&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">90&#46;8&#47;9&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#62;0&#46;05&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>CVC yes&#47;no&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">78&#46;8&#47;21&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">79&#46;8&#47;20&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#62;0&#46;05&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>CRRT yes&#47;no&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12&#46;7&#47;87&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12&#46;6&#47;87&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#62;0&#46;05&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>MRG yes&#47;no&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">18&#46;6&#47;81&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">15&#46;1&#47;84&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#62;0&#46;05&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>ATB yes&#47;no&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">93&#46;4&#47;6&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">91&#46;1&#47;8&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#62;0&#46;05&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="7" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="7" align="left" valign="top"><span class="elsevierStyleItalic">Continuous variables&#44; median &#40;RIC</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">25&#8211;75</span></span><span class="elsevierStyleItalic">&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Age&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">65&#46;6 &#40;53&#46;9&#8211;75&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">63&#46;9 &#40;51&#46;6&#8211;73&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;0&#46;05&#47;&#60;0&#46;05&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#62;0&#46;05&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>APACHE II&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">16 &#40;11&#8211;21&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">16 &#40;11&#46;5&#8211;21&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;4&#47;0&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#62;0&#46;05&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>SASP II&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">36 &#40;28&#8211;47&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">34 &#40;27&#8211;45&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;86&#47;0&#46;31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#62;0&#46;05&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>ICU days&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8 &#40;5&#8211;15&#46;25&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8 &#40;4&#8211;16&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;0&#46;05&#47;&#60;0&#46;05&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#62;0&#46;05&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Hosp days&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">20 &#40;12&#8211;36&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">24 &#40;14&#8211;41&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;0&#46;05&#47;&#60;0&#46;05&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#62;0&#46;05&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>BMI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">26&#46;4 &#40;23&#46;3&#8211;31&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">26&#46;6 &#40;23&#46;1&#8211;31&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;2&#47;&#60;0&#46;05&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#62;0&#46;05&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab1487672.png"
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          "notaPie" => array:1 [
            0 => array:3 [
              "identificador" => "tblfn0005"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Differences where <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;05 are considered significant&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Comparison of patient characteristics in the study groups&#46;</p>"
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        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at2"
            "detalle" => "Table "
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          "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">ICU&#58; intensive care unit&#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-with-role" title="table-head ; entry_with_role_rowhead " align="left" valign="top" scope="col">Characteristics&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Study period</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Statistical tests</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Control group&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Intervention group&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">OR &#40;95&#37; CI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P</span><a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">Categorical variable&#58; percentage</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>ICU mortality&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">16&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;75 &#40;0&#46;36&#8211;1&#46;56&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#62;0&#46;05&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Hospital mortality&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">25&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">16&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;59 &#40;0&#46;31&#8211;1&#46;12&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#62;0&#46;05&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab1487673.png"
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          ]
          "notaPie" => array:1 [
            0 => array:3 [
              "identificador" => "tblfn0010"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0010">The <span class="elsevierStyleItalic">&#967;</span><span class="elsevierStyleSup">2</span> test was used for the calculation&#44; and differences where <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;05 were considered to be significant&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Comparison between the mortality of patients in both study groups&#46;</p>"
        ]
      ]
      3 => array:8 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at3"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "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="table-head ; entry_with_role_rowhead " align="left" valign="top" scope="col">Characteristics&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Study period</th><th class="td" title="table-head  " align="left" valign="top" scope="col">Statistical tests&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Control group&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Intervention group&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P</span><a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Categorical variable&#58; percentage</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Medical&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">77&#46;1<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">65&#46;5<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#62;0&#46;05&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Cardiological&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Surgical&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">18&#46;6<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">29&#46;4<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab1487670.png"
              ]
            ]
          ]
          "notaPie" => array:2 [
            0 => array:3 [
              "identificador" => "tblfn0015"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0015">The <span class="elsevierStyleItalic">&#967;</span><span class="elsevierStyleSup">2</span> test &#40;3<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>2 table&#41; was used for the calculation&#44; and differences where <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;05 were considered to be significant&#46;</p>"
            ]
            1 => array:3 [
              "identificador" => "tblfn0020"
              "etiqueta" => "b"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0020">In the comparison between &#8216;Medical&#8217; and &#8216;Non-medical&#8217; &#40;Cardiological<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>Surgical&#41; a significant difference was detected between the distribution within the groups&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Comparison between the study groups respecting pathologies on admission&#46;</p>"
        ]
      ]
      4 => array:8 [
        "identificador" => "tbl0020"
        "etiqueta" => "Table 4"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at4"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:1 [
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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="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Study period</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Control group&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Intervention group&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleItalic">Isolated germs&#59; number &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Staphylococcus</span> coag&#46; neg&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20 &#40;76&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7 &#40;100&#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="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Staphylococcus epidermidis</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;15&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Corynebacterium</span> sp&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;7&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab1487671.png"
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          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Comparison of contaminant pathogens between the study groups&#46;</p>"
        ]
      ]
      5 => array:8 [
        "identificador" => "tbl0025"
        "etiqueta" => "Table 5"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at5"
            "detalle" => "Table "
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        "tabla" => array:2 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Study period</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Statistical tests</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Control group&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Intervention group&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P</span><a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">OR &#40;95&#37; CI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">Contaminated blood cultures&#59; number &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Contaminated&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">23 &#40;15&#46;5&#41;<a class="elsevierStyleCrossRef" href="#tblfn0030"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7 &#40;6&#46;3&#41;<a class="elsevierStyleCrossRef" href="#tblfn0030"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;0&#46;05&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#46;73 &#40;1&#46;13&#8211;6&#46;63&#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="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Not contaminated&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">125 &#40;84&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">104 &#40;93&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab1487669.png"
              ]
            ]
          ]
          "notaPie" => array:2 [
            0 => array:3 [
              "identificador" => "tblfn0025"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0025">The <span class="elsevierStyleItalic">&#967;</span><span class="elsevierStyleSup">2</span> test &#40;2<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>2 table&#41; was used for the calculation&#44; and differences where <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;05 were considered to be significant&#46;</p>"
            ]
            1 => array:3 [
              "identificador" => "tblfn0030"
              "etiqueta" => "b"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0030">The difference between the proportions of contaminated blood cultures is 9&#46;23&#37;&#44; with a 95&#37; CI&#58; 1&#46;34&#8211;16&#46;7&#37; &#40;Newcombe method&#41;&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Comparison of blood culture contamination between the study groups&#46;</p>"
        ]
      ]
      6 => array:5 [
        "identificador" => "tb0005"
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          "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">What is known&#47;what is the contribution of this&#63;</span><p id="par0010" class="elsevierStylePara elsevierViewall">A high rate of false positives in critically-ill patient blood cultures leads to increased healthcare costs&#46; The use of aseptic techniques to extract blood cultures gives rise to a reduction in the number of contaminations&#44; which are often due to germs that colonise the skin&#46; Nevertheless&#44; it may sometimes be necessary to adopt additional measures if&#44; in spite of compliance with blood culture extraction protocols the aim of maintaining a less than 3&#37; level of contamination is unmet&#46; Daily chlorhexidine bathing of patients in the ICU may reduce the possibility of blood culture contamination&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">This study demonstrates the efficacy of daily chlorhexidine bathing in reducing the incidence of blood culture contamination in critically ill patients&#44; and it may be especially useful in units with a high contamination rate&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Implications of the study</span><p id="par0020" class="elsevierStylePara elsevierViewall">The use of sponges with 4&#37; chlorhexidine digluconate in the daily hygiene of critically ill patients helps to maintain a low rate of blood culture contamination&#46; It is also a care quality indicator and leads to a reduction in healthcare costs due to diagnostic tests and unnecessary treatments&#46;</p></span></span>"
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              "identificador" => "bib0130"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Peripheral blood culture contamination in adults and venepuncture technique&#58; prospective cohort study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "A&#46; Qamruddin"
                            1 => "N&#46; Khanna"
                            2 => "D&#46; Orr"
                          ]
                        ]
                      ]
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1136/jcp.2007.047647"
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                        "tituloSerie" => "J Clin Pathol"
                        "fecha" => "2007"
                        "volumen" => "61"
                        "paginaInicial" => "509"
                        "paginaFinal" => "513"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17761739"
                            "web" => "Medline"
                          ]
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            1 => array:3 [
              "identificador" => "bib0135"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Contaminant blood cultures and resource utilization&#46; The true consequences of false-positive results"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "D&#46;W&#46; Bates"
                            1 => "L&#46; Goldman"
                            2 => "T&#46;H&#46; Lee"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "JAMA"
                        "fecha" => "2005"
                        "volumen" => "265"
                        "paginaInicial" => "365"
                        "paginaFinal" => "369"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/1984535"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "identificador" => "bib0140"
              "etiqueta" => "3"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Clinical impact of blood cultures contaminated with coagulase-negative staphylococci at an academic medical center"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "Y&#46;F&#46; Van der Heijden"
                            1 => "G&#46; Miller"
                            2 => "P&#46;W&#46; Wright"
                            3 => "B&#46;E&#46; Shepherd"
                            4 => "T&#46;L&#46; Daniels"
                            5 => "T&#46;R&#46; Talbot"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1086/660096"
                      "Revista" => array:7 [
                        "tituloSerie" => "Infect Control Hosp Epidemiol"
                        "fecha" => "2011"
                        "volumen" => "32"
                        "paginaInicial" => "623"
                        "paginaFinal" => "625"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21558778"
                            "web" => "Medline"
                          ]
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                          "pii" => "S1078143914002920"
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                          "issn" => "10781439"
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              ]
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              "identificador" => "bib0145"
              "etiqueta" => "4"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Comparative of a new and innovative 2&#37; chlorhexidine gluconate-impregnated cloth with 4 antiseptic for preparation of the skin prior to surgery"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "C&#46;E&#46; Edmiston Jr&#46;"
                            1 => "G&#46;R&#46; Seabrook"
                            2 => "C&#46;P&#46; Johnson"
                            3 => "D&#46;S&#46; Paulson"
                            4 => "C&#46;M&#46; Beausoleil"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.ajic.2006.06.012"
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                        "tituloSerie" => "Am J Infect Control"
                        "fecha" => "2007"
                        "volumen" => "35"
                        "paginaInicial" => "89"
                        "paginaFinal" => "96"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17327187"
                            "web" => "Medline"
                          ]
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                      ]
                    ]
                  ]
                ]
              ]
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              "identificador" => "bib0150"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Presurgical skin preparation with a novel 2&#37; chlorhexidine gluconate cloth reduces rates of surgical site infection in orthopaedic surgical patients"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "D&#46; Eiselt"
                          ]
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                      ]
                    ]
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                    0 => array:2 [
                      "doi" => "10.1097/NOR.0b013e3181a469db"
                      "Revista" => array:7 [
                        "tituloSerie" => "Orthop Nurs"
                        "fecha" => "2009"
                        "volumen" => "28"
                        "paginaInicial" => "141"
                        "paginaFinal" => "145"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19494763"
                            "web" => "Medline"
                          ]
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                          "pii" => "S0302283813002583"
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              "identificador" => "bib0155"
              "etiqueta" => "6"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Advance pre-operative chlorhexidine reduces the incidence of surgical site infections in knee arthroplasty"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "M&#46;G&#46; Zywiel"
                            1 => "J&#46;A&#46; Daley"
                            2 => "R&#46;E&#46; Delanois"
                            3 => "Q&#46; Naziri"
                            4 => "A&#46;J&#46; Johnson"
                            5 => "M&#46;A&#46; Mont"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s00264-010-1078-5"
                      "Revista" => array:6 [
                        "tituloSerie" => "Int Orthop"
                        "fecha" => "2011"
                        "volumen" => "35"
                        "paginaInicial" => "1001"
                        "paginaFinal" => "1006"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20563806"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "identificador" => "bib0160"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Preoperative chlorhexidine preparation and the incidence of surgical site infections after hip arthroplasty"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "A&#46;J&#46; Johnson"
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                            2 => "M&#46;G&#46; Zywiel"
                            3 => "R&#46;E&#46; Delanois"
                            4 => "M&#46;A&#46; Mont"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.arth.2010.04.012"
                      "Revista" => array:7 [
                        "tituloSerie" => "J Arthroplasty"
                        "fecha" => "2012"
                        "volumen" => "25"
                        "numero" => "Suppl&#46;"
                        "paginaInicial" => "98"
                        "paginaFinal" => "102"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20570089"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            7 => array:3 [
              "identificador" => "bib0165"
              "etiqueta" => "8"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Use of 4 per cent chlorhexidine detergent solution &#40;hibiscrub&#41; and other methods of skin disinfection"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "E&#46;J&#46; Lowbury"
                            1 => "H&#46;A&#46; Lilly"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:7 [
                        "tituloSerie" => "Br Med J"
                        "fecha" => "1973"
                        "volumen" => "1"
                        "paginaInicial" => "510"
                        "paginaFinal" => "515"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/626868"
                            "web" => "Medline"
                          ]
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                          "pii" => "S0302283815006077"
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              "identificador" => "bib0170"
              "etiqueta" => "9"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Agents and techniques for disinfection of the skin"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "A&#46;F&#46; Kaul"
                            1 => "J&#46;F&#46; Jewett"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:7 [
                        "tituloSerie" => "Surg Gynecol Obstet"
                        "fecha" => "1981"
                        "volumen" => "152"
                        "paginaInicial" => "677"
                        "paginaFinal" => "685"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7013126"
                            "web" => "Medline"
                          ]
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            9 => array:3 [
              "identificador" => "bib0175"
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                0 => array:3 [
                  "comentario" => "M47-A&#44;27&#40;17&#41;&#46; Available from&#58; <span class="elsevierStyleInterRef" id="intr0010" href="http://shop.clsi.org/site/Sample_pdf/M47A_sample.pdf">http&#58;&#47;&#47;shop&#46;clsi&#46;org&#47;site&#47;Sample&#95;pdf&#47;M47A&#95;sample&#46;pdf</span>"
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Principles and procedures for blood cultures&#59; approved guideline&#46; Clinical and Laboratory Standards Institute Document"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "M&#46;L&#46; Wilson"
                            1 => "M&#46; Mitchell"
                            2 => "A&#46;J&#46; Morris"
                            3 => "P&#46;R&#46; Murray"
                            4 => "L&#46;G&#46; Reimer"
                            5 => "L&#46;B&#46; Reller"
                          ]
                        ]
                      ]
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                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Libro" => array:1 [
                        "fecha" => "2007"
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            10 => array:3 [
              "identificador" => "bib0180"
              "etiqueta" => "11"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Reducing blood culture contamination in community hospital emergency departments&#58; a multicenter evaluation of a quality improvement intervention"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "W&#46;H&#46; Self"
                            1 => "J&#46; Mickanin"
                            2 => "C&#46;G&#46; Grijalva"
                            3 => "F&#46;H&#46; Grant"
                            4 => "M&#46;C&#46; Henderson"
                            5 => "G&#46; Corley"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/acem.12337"
                      "Revista" => array:7 [
                        "tituloSerie" => "Acad Emerg Med"
                        "fecha" => "2014"
                        "volumen" => "21"
                        "paginaInicial" => "274"
                        "paginaFinal" => "282"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24628752"
                            "web" => "Medline"
                          ]
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                          "pii" => "S0090429515011887"
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                          "issn" => "00904295"
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                  ]
                ]
              ]
            ]
            11 => array:3 [
              "identificador" => "bib0185"
              "etiqueta" => "12"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Effectiveness of chlorhexidine bathing to reduce catheter-associated bloodstream infections in medical intensive care unit patients"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "S&#46;C&#46; Bleasdale"
                            1 => "W&#46;E&#46; Trick"
                            2 => "I&#46;M&#46; Gonzalez"
                            3 => "R&#46;D&#46; Lyles"
                            4 => "M&#46;K&#46; Hayden"
                            5 => "R&#46;A&#46; Weinstein"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1001/archinte.167.19.2073"
                      "Revista" => array:6 [
                        "tituloSerie" => "Arch Intern Med"
                        "fecha" => "2007"
                        "volumen" => "167"
                        "paginaInicial" => "2073"
                        "paginaFinal" => "2079"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17954801"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "identificador" => "bib0190"
              "etiqueta" => "13"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:1 [
                      "titulo" => "Severity scoring of atopic dermatitis&#58; the Scorad index&#46; Consensus report of the European task force on atopic dermatitis"
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Dermatology"
                        "fecha" => "1993"
                        "volumen" => "186"
                        "paginaInicial" => "23"
                        "paginaFinal" => "31"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8435513"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "identificador" => "bib0195"
              "etiqueta" => "14"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Effect of daily chlorhexidine bathing on hospital-acquired infection"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "M&#46;W&#46; Climo"
                            1 => "D&#46;S&#46; Yokoe"
                            2 => "D&#46;K&#46; Warren"
                            3 => "T&#46;M&#46; Perl"
                            4 => "M&#46; Bolon"
                            5 => "L&#46;A&#46; Herwaldt"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1056/NEJMoa1113849"
                      "Revista" => array:6 [
                        "tituloSerie" => "N Engl J Med"
                        "fecha" => "2013"
                        "volumen" => "368"
                        "paginaInicial" => "533"
                        "paginaFinal" => "542"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23388005"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            14 => array:3 [
              "identificador" => "bib0200"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The effect of daily bathing with chlorhexidine on the acquisition of methicillin-resistant <span class="elsevierStyleItalic">Staphylococcus aureus</span>&#44; vancomycin-resistant enterococcus&#44; and healthcare-associated bloodstream infections&#58; results of a quasi-experimental multicenter trial"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "M&#46;W&#46; Climo"
                            1 => "K&#46;A&#46; Sepkowitz"
                            2 => "G&#46; Zuccotti"
                            3 => "V&#46;J&#46; Fraser"
                            4 => "D&#46;K&#46; Warren"
                            5 => "T&#46;M&#46; Perl"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/CCM.0b013e31819ffe6d"
                      "Revista" => array:7 [
                        "tituloSerie" => "Crit Care Med"
                        "fecha" => "2009"
                        "volumen" => "37"
                        "paginaInicial" => "1858"
                        "paginaFinal" => "1865"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19384220"
                            "web" => "Medline"
                          ]
                        ]
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                          "pii" => "S0302283815002468"
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                          "issn" => "03022838"
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                  ]
                ]
              ]
            ]
            15 => array:3 [
              "identificador" => "bib0205"
              "etiqueta" => "16"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Effect of chlorhexidine whole-body bathing on hospital-acquired infections among trauma patients"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "H&#46;L&#46; Evans"
                            1 => "T&#46;H&#46; Dellit"
                            2 => "J&#46; Chan"
                            3 => "A&#46;B&#46; Nathens"
                            4 => "R&#46;V&#46; Maier"
                            5 => "J&#46; Cuschieri"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1001/archsurg.2010.5"
                      "Revista" => array:6 [
                        "tituloSerie" => "Arch Surg"
                        "fecha" => "2010"
                        "volumen" => "145"
                        "paginaInicial" => "240"
                        "paginaFinal" => "246"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20231624"
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                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Impact of chlorhexidine bathing on hospital-acquired infections among general medical patients"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "S&#46;Z&#46; Kassakian"
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                            3 => "S&#46;L&#46; Parenteau"
                            4 => "J&#46;T&#46; Machan"
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                      ]
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                    0 => array:2 [
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                        "paginaInicial" => "238"
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                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21460508"
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                    0 => array:2 [
                      "titulo" => "Effectiveness of routine patient cleansing with chlorhexidine gluconate for infection prevention in the medical intensive care unit"
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                          "etal" => false
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                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1086/605925"
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                        "tituloSerie" => "Infect Control Hosp Epidemiol"
                        "fecha" => "2009"
                        "volumen" => "30"
                        "paginaInicial" => "959"
                        "paginaFinal" => "963"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19712033"
                            "web" => "Medline"
                          ]
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                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "identificador" => "bib0220"
              "etiqueta" => "19"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Chlorhexidine gluconate to cleanse patients in a medical intensive care unit&#58; the effectiveness of source control to reduce the bioburden of vancomycin-resistant enterococci"
                      "autores" => array:1 [
                        0 => array:3 [
                          "colaboracion" => "Project Chicago Antimicrobial Resistance"
                          "etal" => false
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                            2 => "W&#46;E&#46; Trick"
                            3 => "R&#46;A&#46; Hayes"
                            4 => "D&#46;W&#46; Blom"
                            5 => "R&#46;A&#46; Weinstein"
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                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1001/archinte.166.3.306"
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                        "tituloSerie" => "Arch Intern Med"
                        "fecha" => "2006"
                        "volumen" => "166"
                        "paginaInicial" => "306"
                        "paginaFinal" => "312"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16476870"
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                ]
              ]
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Daily skin cleansing with chlorhexidine did not reduce the rate of central-line associated bloodstream infection in a surgical intensive care unit"
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                          "etal" => false
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                        "paginaFinal" => "858"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20213074"
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                      "titulo" => "Chlorhexidine bathing and health care-associated infections&#58; a randomized clinical trial"
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                          "etal" => true
                          "autores" => array:6 [
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                            3 => "T&#46; Talbot"
                            4 => "T&#46;W&#46; Rice"
                            5 => "G&#46;R&#46; Bernard"
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                        "paginaInicial" => "369"
                        "paginaFinal" => "378"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25602496"
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                  ]
                ]
              ]
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                    0 => array:2 [
                      "titulo" => "Does chlorhexidine bathing in adult intensive care units reduce blood culture contamination&#63; A pragmatic cluster-randomized trial"
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                          "etal" => true
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                            2 => "K&#46; Kleinman"
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                            4 => "J&#46; Moody"
                            5 => "R&#46;A&#46; Weinstein"
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                      "doi" => "10.1086/677822"
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                        "numero" => "Suppl&#46; 3"
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                0 => array:2 [
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                    0 => array:2 [
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                        "paginaInicial" => "889"
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22869262"
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                      "titulo" => "Skin antiseptics in venous puncture-site disinfection for prevention of blood culture contamination&#58; systematic review with meta-analysis"
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Article information

ISSN: 25299840
Original language: English

DOI:10.1016/j.enfie.2017.03.001

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Year/Month	Html	Pdf	Total

2024 October	18	11	29
2024 September	38	14	52
2024 August	41	11	52
2024 July	44	6	50
2024 June	56	10	66
2024 May	44	5	49
2024 April	56	8	64
2024 March	40	11	51
2024 February	62	8	70
2024 January	44	13	57
2023 December	46	13	59
2023 November	69	7	76
2023 October	68	8	76
2023 September	53	11	64
2023 August	43	3	46
2023 July	55	6	61
2023 June	50	4	54
2023 May	81	3	84
2023 April	81	3	84
2023 March	92	2	94
2023 February	73	9	82
2023 January	55	19	74
2022 December	49	12	61
2022 November	49	13	62
2022 October	30	7	37
2022 September	44	28	72
2022 August	48	11	59
2022 July	26	8	34
2022 June	43	10	53
2022 May	26	12	38
2022 April	56	13	69
2022 March	51	14	65
2022 February	70	6	76
2022 January	71	11	82
2021 December	43	17	60
2021 November	45	14	59
2021 October	48	12	60
2021 September	60	31	91
2021 August	56	9	65
2021 July	45	12	57
2021 June	19	11	30
2021 May	35	11	46
2021 April	83	29	112
2021 March	77	16	93
2021 February	48	10	58
2021 January	70	8	78
2020 December	64	13	77
2020 November	39	13	52
2020 October	35	8	43
2020 September	28	13	41
2020 August	26	11	37
2020 July	28	6	34
2020 June	35	13	48
2020 May	33	12	45
2020 April	27	9	36
2020 March	38	9	47
2020 February	37	15	52
2020 January	30	16	46
2019 December	27	14	41
2019 November	19	4	23
2019 October	14	6	20
2019 September	11	11	22
2019 August	14	3	17
2019 July	18	19	37

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