Brief report
Staphylococcus aureus colonization in an institutionalized elderly population in the Bay of Cadiz area, Spain: Prevalence and associated risk factors
Colonización por Staphylococcus aureus en población anciana institucionalizada en el área de la Bahía de Cádiz: prevalencia y factores de riesgo asociados
María Pérez-Eslavaa,
, Nuria López-Ruízb, Elvira María Flores-Cebadaa, Manuel Rodríguez-Iglesiasc,d, Fátima Galán-Sánchezc,d
Corresponding author
a Centro de Salud Barrio Bajo, Arcos de la Frontera, Arcos de la Frontera, Cádiz, Spain
b Servicio de Medicina Preventiva y Salud Pública, Hospital Universitario Puerta del Mar, Cádiz, Spain
c Servicio de Microbiología, Hospital Universitario Puerta del Mar, Cádiz, Spain
d Departamento de Biomedicina, Biotecnología y Salud Pública, Facultad de Medicina, Universidad de Cádiz, Cádiz, Spain
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array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Centro de Salud Barrio Bajo, Arcos de la Frontera, Arcos de la Frontera, Cádiz, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Medicina Preventiva y Salud Pública, Hospital Universitario Puerta del Mar, Cádiz, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Microbiología, Hospital Universitario Puerta del Mar, Cádiz, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Departamento de Biomedicina, Biotecnología y Salud Pública, Facultad de Medicina, Universidad de Cádiz, Cádiz, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Colonización por <span class="elsevierStyleItalic">Staphylococcus aureus</span> en población anciana institucionalizada en el área de la Bahía de Cádiz: prevalencia y factores de riesgo asociados" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2228 "Ancho" => 2917 "Tamanyo" => 237038 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">ROC curves, logistic regression model for <span class="elsevierStyleItalic">S. aureus</span>, MSSA and MRSA.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Most (90%) of the antimicrobial prescriptions are made in Primary Care, and it is estimated that more than 30% are unnecessary.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> As a consequence, strains resistant to antibiotics appear, diminishing their efficacy.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Staphylococcus aureus</span> causes a wide variety of infections, some fatal – methicillin-sensitive <span class="elsevierStyleItalic">S. aureus</span> (MSSA) can cause serious infections in the community.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> In addition, methicillin-resistant <span class="elsevierStyleItalic">S. aureus</span> (MRSA) is a problem for public health due to its antimicrobial resistance and its pandemic nature.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4,5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Given the heterogeneity of sociosanitary centres, the limited implementation of prevention and control programmes, and the tendency to perform empirical antibiotherapy, the clinical and microbiological epidemiology of <span class="elsevierStyleItalic">S. aureus</span> strains in this setting is not completely understood.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4,6</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Studies published in socio-sanitary centres, suggest that possible factors for colonisation include, age, taking antibiotics, recent hospital admission and high comorbidity.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4,7,8</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The objective of the study was to explore the prevalence and associated factors that carriers of MSSA and MRSA present, from a sample of institutionalised persons in three socio-health centres in the Bahía Cádiz-La Janda health area.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Patients and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Design and study population</span><p id="par0030" class="elsevierStylePara elsevierViewall">Cross-sectional study carried out between September 2016 and May 2017. All the institutionalised residents (<span class="elsevierStyleItalic">N</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>359) from the three largest socio-sanitary centres in Cádiz and San Fernando were included, whose reference hospital was the University of Puerta del Mar. 66 residents did not participate in the study: 20 chose not to, 39 were excluded because they were not cognitively able to give consent and we were unable to contact their legal guardians, and seven were not in the centre at the time of the sample collection. Hand hygiene protocols of each residence were complied with. The clinical and epidemiological data were collected through the Historia Única de Salud Digital [Digital Health Unique History].</p><p id="par0035" class="elsevierStylePara elsevierViewall">The study response variable was to be a carrier of sensitive and resistant to methicillin <span class="elsevierStyleItalic">S. aureus</span>. Independent variables were: age, sex, comorbidity (Charlson index, a score of ≥3 was categorised as high comorbidity and low <3), functional status (Barthel scale, categorised as dependent or non-dependent, with a cut-off point of ≤40), antibiotherapy and hospital admission in the last three months.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Collection and processing of samples</span><p id="par0040" class="elsevierStylePara elsevierViewall">Samples were taken from each resident's nostrils and armpits using cotton swabs and Amies-Stuart transport medium.</p><p id="par0045" class="elsevierStylePara elsevierViewall">All colonies with morphotypes compatible with <span class="elsevierStyleItalic">S. aureus</span> were identified by mass spectrometry. Those identified as <span class="elsevierStyleItalic">S. aureus</span> were confirmed, and their sensitivity was studied according to the EUCAST criteria.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Statistical analysis</span><p id="par0050" class="elsevierStylePara elsevierViewall">Descriptive analysis of collected variables. The association between being a carrier of <span class="elsevierStyleItalic">S. aureus</span>, MSSA and MRSA was studied (response variables, categorical) and possible risk factors (explanatory, categorical variables) was analysed using the Chi-square test (<span class="elsevierStyleItalic">χ</span><span class="elsevierStyleSup">2</span>) or Fisher's test as appropriate. Three logistic regression models were constructed: the response variable was being an <span class="elsevierStyleItalic">S. aureus</span>, MSSA and MRSA carrier and the explanatory variables were those that in the bivariate would have obtained a <span class="elsevierStyleItalic">p</span>-value of <0.2. We used the <span class="elsevierStyleItalic">forward stepwise</span> methodology, forcing age and sex. Colinearity tests were performed before including variables in the model. Finally, the area under the ROC curve was studied for the three models.</p><p id="par0055" class="elsevierStylePara elsevierViewall">The statistical analysis was performed using the statistical package STATA 14, considering values to be statistically significant if <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>≤<span class="elsevierStyleHsp" style=""></span>0.05.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Ethical aspects</span><p id="par0060" class="elsevierStylePara elsevierViewall">The study complied with the provisions of the Declaration of Helsinki and was approved by the University Hospital Puerta del Mar Ethics Committee. All the participants, or their legal representatives, were given the study's informed consent to sign.</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Results</span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">293 subjects were included in the study</span><p id="par0065" class="elsevierStylePara elsevierViewall">The median age was 83.9 (50.7–99.6). 37.5% of the sample obtained a Charlson score of ≥3 and 46.1% obtained <40 on the Barthel scale. In the three months prior to the sample collection, 19.1% of the subjects received beta-lactams and 16% quinolones. Of the total sample, 37.5% received an antibiotic.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Fifty-one patients in the studied sample (17.4%) were colonised by MSSA and 11 (3.8%) were by MRSA.</p><p id="par0075" class="elsevierStylePara elsevierViewall">The factors with a statistically significant association to colonisation by <span class="elsevierStyleItalic">S. aureus</span>, in the bivariate study, were: having a Charlson index score of ≥3 (OR<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>1.92 95% CI 1.1–3.4), recent hospital admission (OR<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>3.1, 95% CI 1.3–7.6) and having taken quinolones and beta-lactams in the previous three months (OR<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>2.2, CI 95% 1.1–4.4) (OR<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>3, 9 95% CI 2.1–7.4).</p><p id="par0080" class="elsevierStylePara elsevierViewall">The factors associated with colonisation by MSSA and MRSA, in the bivariate study, are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. The intake of beta-lactams in the three months prior to the sample collection was statistically significant with being colonised with MSSA and MRSA. There was also a significant relationship with taking quinolones in the previous three months and colonisation by MSSA.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">The final logistic regression model to study the association between being an <span class="elsevierStyleItalic">S. aureus</span>, MSSA and MRSA carrier and variables that are related to them, in the bivariate analysis, are shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>. In the first model, for <span class="elsevierStyleItalic">S. aureus</span>, we maintained the significant association between being colonised and having a Charlson index score of ≥3 and receiving beta-lactams in the previous months. In the other two models, receiving beta-lactams as antibiotic therapy in the last three months was significantly related. All models were controlled by age and sex.</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">The quality of the prediction of the three logistic regression models was acceptable since the ROC curves were 0.71, 0.61 and 0.78 for <span class="elsevierStyleItalic">S. aureus</span>, MSSA and MRSA, respectively (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Discussion</span><p id="par0095" class="elsevierStylePara elsevierViewall">The prevalence of MRSA (3.8%) was low, especially given that previous studies into the prevalence of institutionalised MRSA colonisation varied between 7 and 30%.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> The risk of transmission decreases with correct compliance. One possible explanation of the higher prevalence rates may lie in whether these centres performed standard precautions, such as hand hygiene, correctly, as they are the most effective measures to reduce the risk of transmission.<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">9,10</span></a> Although there are different national working groups for the prevention of the transmission of multiresistant microorganisms in institutionalised patients, there is still no clear criteria on whether it is pertinent to perform routine surveillance of the <span class="elsevierStyleItalic">S. aureus</span> carrier/coloniser's status. In addition, there are no universal guidelines on the relevance of decolonising treatments. The literature concurs with the importance of combining measures to prevent and control the transmission of infections: reinforce standard precautions (hand hygiene), increase knowledge about local clinical and molecular epidemiology, and educating health personnel.<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">9,10</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">A high percentage (37.5%) had taken at least one antibiotic in the three months prior to the sample collection, with betalactams and quinolones being the most prescribed. Antibiotics are the most commonly used drugs in social health centres (up to 50% of institutionalised elderly use them).<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> Having taken beta-lactams in the three months prior was significantly related to being colonised by MSSA and MRSA. These results concur with the literature, which relates antibiotherapy as a risk factor of being a carrier of <span class="elsevierStyleItalic">S. aureus</span>.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">7,8</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">There were limitations to the study: the 18.33% non-participation rate and the fact that participation was voluntary. Because of this and the sample characteristics, it may not be possible to extrapolate results to another type of population. In addition, variables such as time spent in the residence were not collected.</p><p id="par0110" class="elsevierStylePara elsevierViewall">In conclusion, reflecting on the inadequate use of antibiotic treatment in Primary Care would be of interest, specifically in the institutionalised longevity population, whose consequences are, among others, the appearance of potentially pathogenic multiresistant strains.</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Conflict of interest</span><p id="par0115" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres1148385" "titulo" => "Abstract" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background and objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Patients and method" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Population" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Results" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1077688" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1148384" "titulo" => "Resumen" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0030" "titulo" => "Antecedentes y objetivo" ] 1 => array:2 [ "identificador" => "abst0035" "titulo" => "Pacientes y método" ] 2 => array:2 [ "identificador" => "abst0040" "titulo" => "Población" ] 3 => array:2 [ "identificador" => "abst0045" "titulo" => "Resultados" ] 4 => array:2 [ "identificador" => "abst0050" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1077689" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Patients and methods" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Design and study population" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Collection and processing of samples" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Statistical analysis" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Ethical aspects" ] ] ] 6 => array:3 [ "identificador" => "sec0035" "titulo" => "Results" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0040" "titulo" => "293 subjects were included in the study" ] ] ] 7 => array:2 [ "identificador" => "sec0045" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0050" "titulo" => "Conflict of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-09-19" "fechaAceptado" => "2018-03-08" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1077688" "palabras" => array:3 [ 0 => "<span class="elsevierStyleItalic">Staphylococcus aureus</span>" 1 => "Elderly patient" 2 => "Risk factors" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1077689" "palabras" => array:3 [ 0 => "<span class="elsevierStyleItalic">Staphylococcus aureus</span>" 1 => "Paciente anciano" 2 => "Factores de riesgo" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background and objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Staphylococcus aureus</span> is a health problem behind a great variety of infections. The objective of the study was to establish the prevalence and risk factors of <span class="elsevierStyleItalic">S. aureus</span> carriers in community nursing homes in Cadiz.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Patients and method</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A cross study from September 2016 to May 2017.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Population</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">All residents institutionalized in the largest long-term care facilities centres in Cadiz. The main variable was being a <span class="elsevierStyleItalic">S. aureus</span> carrier (sensitive and resistant to methicillin, MSSA and MRSA). The independent variables were age, sex, comorbidity, functional status, antibiotic therapy and hospitalisation in the last three months. Bivariate analysis with logistic regression was conducted.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Prevalence of colonization: MSSA 17,4% and MRSA 3.8%. Use of beta-lactams was significantly related to a MSSA and MRSA carrier status using multivariate logistic regression OR<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>3.3 and OR<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>3.8.</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">There is a low prevalence of <span class="elsevierStyleItalic">S. aureus</span> carriers in the study population. Use of beta-lactams before the study was significantly associated with being a carrier colonised by MSSA and MRSA. Primary care prescriptions are a key in controlling pathogenic multiresistant strains.</p></span>" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background and objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Patients and method" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Population" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Results" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Antecedentes y objetivo</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Staphylococcus aureus</span> es un problema para la salud causante de gran variedad de infecciones. El objetivo del estudio fue conocer la prevalencia y factores asociados a personas portadoras de <span class="elsevierStyleItalic">S. aureus</span> institucionalizadas en Cádiz.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Pacientes y método</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Estudio transversal entre septiembre de 2016 y mayo de 2017.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Población</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Residentes institucionalizados en los centros sociosanitarios con mayor número de plazas de Cádiz (N=359). La variable respuesta fue ser portador de <span class="elsevierStyleItalic">S. aureus</span> (sensible y resistente a meticilina, SASM y SARM respectivamente). Las variables independientes fueron: edad, sexo, comorbilidad, estado funcional, antibioterapia e ingreso hospitalario en los últimos tres meses. Se realizó análisis bivariado y con regresión logística.</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Resultados</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Prevalencia de colonización: SASM 17,4% y SARM 3,8%. Haber recibido betalactámicos se relacionó significativamente con ser portador de SASM y SARM mediante regresión logística multivariante con una OR=3,3 y OR=3,8 respectivamente.</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conclusiones</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Existe baja prevalencia de portadores de <span class="elsevierStyleItalic">S. aureus</span> en la población estudiada. Recibir previamente betalactámicos se asoció significativamente con estar colonizado por SASM y SARM. Las prescripciones desde atención primaria son esenciales para el control de cepas patógenas multirresistentes.</p></span>" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0030" "titulo" => "Antecedentes y objetivo" ] 1 => array:2 [ "identificador" => "abst0035" "titulo" => "Pacientes y método" ] 2 => array:2 [ "identificador" => "abst0040" "titulo" => "Población" ] 3 => array:2 [ "identificador" => "abst0045" "titulo" => "Resultados" ] 4 => array:2 [ "identificador" => "abst0050" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Please cite this article as: Pérez-Eslava M, López-Ruíz N, Flores-Cebada EM, Rodríguez-Iglesias M, Galán-Sánchez F. Colonización por <span class="elsevierStyleItalic">Staphylococcus aureus</span> en población anciana institucionalizada en el área de la Bahía de Cádiz: prevalencia y factores de riesgo asociados. Med Clin (Barc). 2019;152:141–144.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2228 "Ancho" => 2917 "Tamanyo" => 237038 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">ROC curves, logistic regression model for <span class="elsevierStyleItalic">S. aureus</span>, MSSA and MRSA.</p>" ] ] 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: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">Variables \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="4" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">MSSA (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>51)</th><th class="td" title="table-head " colspan="4" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">MRSA (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>11)</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"><span class="elsevierStyleItalic">n</span> (%) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">OR \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">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"><span class="elsevierStyleItalic">p</span>-Value \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">n</span> (%) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">OR \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">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"><span class="elsevierStyleItalic">p</span>-Value \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>75 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">42 (82.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.5–2.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.672 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 (81.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.3–0.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.000 \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">Sex (female) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">33 (64.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.6–2.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.560 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 (72.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.5–6.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.538 \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">Barthel ≤40 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">28 (54.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.8–2.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.164 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (36.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.2–2.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.510 \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">Charlson score ≥3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">25 (49) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.97–3.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.063 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (54.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.6–6.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.341 \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 admission last three months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 (13.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1–6.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.067 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (18.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0–13.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.182 \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">Beta-lactams last three months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">19 (37.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.7–6.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.001<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">*</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (45.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.2–12.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.039<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">*</span></a> \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">Quinolones last three months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14 (27.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.2–4.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.015<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">*</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (18.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0–5.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.691 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1959481.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "*" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Statistically significant.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Bivariate analysis of being a carrier of methicillin sensitive and resistant <span class="elsevierStyleItalic">Staphylococcus aureus</span>.</p>" ] ] 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: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">Variables \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"><span class="elsevierStyleItalic">S. aureus</span> (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>62)</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">MSSA (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>51)</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">MRSA (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>11)</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">OR (CI 95%) \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> \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 (CI 95%) \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> \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 (CI 95%) \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> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (0.9–1.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.361 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.9 (0.9–1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.963 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.9 (0.9–1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.112 \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">Sex (female) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.5 (0.7–2.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.257 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.2 (0.6–2.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.642 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.4 (0.6–10.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.233 \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">Beta-lactams last three months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.9 (2–7.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.001<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">*</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.3 (1.7–6.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.001<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">*</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.9 (1.1–13.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.032 \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">Charlson score ≥3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.9 (1.1–3.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.027<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">*</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1959480.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "*" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Statistically significant.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Multivariate analysis of being an <span class="elsevierStyleItalic">S. aureus</span>, MSSA and MRSA carrier.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Guía de terapéutica antimicrobiana del área Aljarafe. 3.ª ed. 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