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"cita" => "Enferm Infecc Microbiol Clin. 2018;36:633-9" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 788 "formatos" => array:3 [ "EPUB" => 2 "HTML" => 420 "PDF" => 366 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original article</span>" "titulo" => "Dermatological manifestations in onchocerciasis: A retrospective study of 400 imported cases" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "633" "paginaFinal" => "639" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Manifestaciones dermatológicas en oncocercosis: estudio retrospectivo de 400 casos importados" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" 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"apellidos" => "Falcó Ferrer" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0213005X17303270?idApp=UINPBA00004N" "url" => "/0213005X/0000003600000010/v2_201812190632/S0213005X17303270/v2_201812190632/en/main.assets" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original article</span>" "titulo" => "In vitro assessment of the anti-biofilm activity of ethanol alone and in combination with enoxaparin 60<span class="elsevierStyleHsp" style=""></span>IU" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "627" "paginaFinal" => "632" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "María Jesús Pérez-Granda, Beatriz Alonso, Ana Rodríguez-Huerta, Carmen Rodríguez, María Guembe" "autores" => array:5 [ 0 => array:3 [ "nombre" => "María Jesús" "apellidos" => "Pérez-Granda" "referencia" => array:4 [ 0 => array:2 [ "etiqueta" => "<span 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"entidad" => "CIBER Enfermedades Respiratorias-CIBERES, Madrid, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Department of Nursing, Faculty of Nursing, Physiotherapy and Pediatry, Universidad Complutense de Madrid, Madrid, Spain" "etiqueta" => "d" "identificador" => "aff0035" ] 4 => array:3 [ "entidad" => "Servicio de Microbiología Clínica y Enfermedades Infecciosas, Hospital General Universitario Gregorio Marañón, Madrid, Spain" "etiqueta" => "e" "identificador" => "aff0020" ] 5 => array:3 [ "entidad" => "Servicio de Hematología, Hospital General Universitario Gregorio Marañón, Madrid, Spain" "etiqueta" => "f" "identificador" => "aff0025" ] 6 => array:3 [ "entidad" => "Servicio de Farmacia, Hospital General Universitario Gregorio Marañón, Madrid, Spain" "etiqueta" => "g" "identificador" => "aff0030" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Determinación in vitro de la actividad anti-biopelícula del etanol solo y en combinación con enoxaparina 60<span class="elsevierStyleHsp" style=""></span>UI" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 3704 "Ancho" => 3156 "Tamanyo" => 399579 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Median reduction in metabolic activity of the various biofilm-forming strains after treatment with an ethanol-based lock solution. (A) <span class="elsevierStyleItalic">Staphylococcus aureus</span> ATCC25923. (B) <span class="elsevierStyleItalic">Staphylococcus epidermidis</span> (clinical strain). (C) <span class="elsevierStyleItalic">Enterococcus faecalis</span> ATCC33186. (D) <span class="elsevierStyleItalic">Escherichia coli</span> ATCC25922. (E) <span class="elsevierStyleItalic">Candida albicans</span> ATCC14058. Asterics correspond to extreme outliers.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Catheter-related bloodstream infection (C-RBSI) is one of the most common nosocomial infections. Approximately 1–2 episodes per 1,000 catheter days have been recorded in intensive care units (ICU), and the mortality rate has been reported to rise to 25%.<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">1–3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The distribution of causative microorganisms is as follows: Gram-positive cocci, 70% (coagulase-negative staphylococci, <span class="elsevierStyleItalic">Staphylococcus aureus</span>, enterococci); Gram-negative bacilli, 20% (<span class="elsevierStyleItalic">Escherichia coli</span>, <span class="elsevierStyleItalic">Klebsiella pneumoniae</span>); and yeasts, 10% (<span class="elsevierStyleItalic">Candida</span> spp.).<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">2,4,5</span></a> The ability of bacteria and yeasts to cause C-RBSI depends on their capacity to form biofilms on the catheter surface, and their adherence to medical devices promotes persistent infection and treatment failure.<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">6,7</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Guidelines recommend removing the catheter when C-RBSI is suspected. However, when the infection has to be managed with the catheter in place, combining systemic antimicrobial treatment with antibiotic lock therapy (ALT) is also recommended.<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">4,8–12</span></a> ALT is based on the instillation of approximately 2<span class="elsevierStyleHsp" style=""></span>ml of a high concentration of antimicrobials (MIC ×100–×1,000) for 2–24<span class="elsevierStyleHsp" style=""></span>h.<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">10</span></a> However, the properties of biofilm and the increasing frequency of multidrug-resistant strains are leading ALTs to fail.<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">13</span></a> Alternatively, antiseptic lock solutions have been proposed as a novel alternative to ALTs, as no resistance to antiseptic has been reported.<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">14,15</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Ethanol is one of the most commonly used antiseptics in the clinical setting. It is administered in combination with an anticoagulant to prevent catheter occlusion and cracking after more than 2<span class="elsevierStyleHsp" style=""></span>h of antiseptic lock therapy.<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">16</span></a> In a recent in vitro study, ethanol was shown not to affect the activity of enoxaparin.<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">17</span></a> However, to the best of our knowledge, the efficacy of combining ethanol with enoxaparin as a catheter lock solution has not been assessed against microbial biofilms in a 96-well microplate.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Our objective was to test the efficacy of ethanol at 30%, 35%, and 40% alone and in combination with enoxaparin 60<span class="elsevierStyleHsp" style=""></span>IU as a lock solution for eradication of pre-formed biofilms of various microorganisms.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Materials and methods</span><p id="par0030" class="elsevierStylePara elsevierViewall">We ran a static in vitro model in a 96-well polystyrene plate in which ethanol-based lock solutions were tested against 24-h-old biofilms of the following strains: <span class="elsevierStyleItalic">S. aureus</span> ATCC25923, <span class="elsevierStyleItalic">Staphylococcus epidermidis</span> (clinical strain), <span class="elsevierStyleItalic">Enterococcus faecalis</span> ATCC33186, <span class="elsevierStyleItalic">E. coli</span> ATCC25922, and <span class="elsevierStyleItalic">Candida albicans</span> ATCC14058.</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Laboratory procedure</span><p id="par0035" class="elsevierStylePara elsevierViewall">A loopful of 24-h-old culture of the following strains was inoculated into 20<span class="elsevierStyleHsp" style=""></span>ml of their corresponding liquid media: staphylococci in Tryptic Soy Broth (TSB), <span class="elsevierStyleItalic">E. faecalis</span> in TSB enriched with 1% glucose, <span class="elsevierStyleItalic">C. albicans</span> in Roswell Park Memorial Institute (RPMI), and <span class="elsevierStyleItalic">E. coli</span> in Luria-Bertani Broth (LB).<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">18–20</span></a> Microbial suspensions were cultured overnight at 30<span class="elsevierStyleHsp" style=""></span>°C under orbital shaking. Biofilms were formed as described elsewhere.<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">21</span></a> Briefly, inoculums were washed 3 times with phosphate buffered saline (PBS) and adjusted to an optical density of 0.5<span class="elsevierStyleHsp" style=""></span>McFarland, or 0.35<span class="elsevierStyleHsp" style=""></span>McFarland in the case of <span class="elsevierStyleItalic">C. albicans</span>. From this suspension, 100<span class="elsevierStyleHsp" style=""></span>μl was added to each well, and plates were cultured at 37<span class="elsevierStyleHsp" style=""></span>°C for 24<span class="elsevierStyleHsp" style=""></span>h. Each strain was tested 12 times using a positive control treated with medium and a negative control treated without microorganisms. After incubation, plates were washed 3 times with PBS and 120-μl ethanol-based solutions mixed with 120<span class="elsevierStyleHsp" style=""></span>μl of medium were added to each well except in positive control wells, where only 120<span class="elsevierStyleHsp" style=""></span>μl of medium was added. Plates were incubated again for 2 and 24<span class="elsevierStyleHsp" style=""></span>h at 37<span class="elsevierStyleHsp" style=""></span>°C, before being washed 3 times with PBS and dried completely. Then, 100<span class="elsevierStyleHsp" style=""></span>μl of XTT-menadione (10<span class="elsevierStyleHsp" style=""></span>ml 1<span class="elsevierStyleHsp" style=""></span>mg/ml–40<span class="elsevierStyleHsp" style=""></span>μl 1.72<span class="elsevierStyleHsp" style=""></span>mg/ml), which was prepared immediately before the experiment, was added to each well, and the plates were incubated in darkness at 37<span class="elsevierStyleHsp" style=""></span>°C for 2<span class="elsevierStyleHsp" style=""></span>h. Absorbance was measured at 492<span class="elsevierStyleHsp" style=""></span>nm in a spectrophotometer (Biochrom EZ Read 400).</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Preparation of ethanol-based solutions</span><p id="par0040" class="elsevierStylePara elsevierViewall">Solutions were prepared immediately before each experiment as follows: 30%, 35%, and 40% ethanol alone and with 60<span class="elsevierStyleHsp" style=""></span>IU of enoxaparin (Clexane<span class="elsevierStyleSup">®</span> 40<span class="elsevierStyleHsp" style=""></span>mg, 4000<span class="elsevierStyleHsp" style=""></span>IU, enoxaparina sódica, Sanofi-Aventis, SA.A, Barcelona, Spain) (as is the standard used in our institution for catheter lock). All ethanol concentrations are expressed as % (v/v) in distilled water.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Data analysis</span><p id="par0045" class="elsevierStylePara elsevierViewall">We assessed the percentage reduction in metabolic activity by comparing absorbance at 490<span class="elsevierStyleHsp" style=""></span>nm in the positive control wells and in the treated wells. We considered therapy to be successful when metabolic activity was reduced by >90%.</p><p id="par0050" class="elsevierStylePara elsevierViewall">The qualitative variables appear with their frequency distribution. The quantitative variables are summarized as the median (IQR). Continuous variables were compared using the <span class="elsevierStyleItalic">t</span> test; non-normally distributed variables were compared using the Kruskal–Wallis test. The differences between groups were compared using the Mann–Whitney test with a Bonferroni correction. All statistical tests were 2-tailed. Statistical significance was set at <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.05 for all the tests. Statistical analysis was performed using IBM SPSS Statistics for Windows, Version 21.0 (IBM Corp., Armonk, NY, USA).</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Results</span><p id="par0055" class="elsevierStylePara elsevierViewall">The overall median reduction in metabolic activity is shown in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>. The median reduction obtained for each strain tested with all the solutions at different times of exposure is shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Two-hour regimen</span><p id="par0060" class="elsevierStylePara elsevierViewall">In the 2-h regimen, therapy was successful in all the microorganisms tested when the solution of ≥35% ethanol alone was used. For 30% ethanol, this reduction was only achieved for <span class="elsevierStyleItalic">S. epidermidis</span> and <span class="elsevierStyleItalic">E. coli</span> (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>B and D). No significant differences in reduction were found between ethanol 35% and 40% (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>0.05).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">Concentrations of 30% ethanol–enoxaparin reduced the overall median metabolic activity by up to 36%. At 35% ethanol–enoxaparin, the median reduction in metabolic activity ranged from 49% to 89.2%. The same range was observed when 40% ethanol–enoxaparin solutions were used (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). However, no reduction was found for <span class="elsevierStyleItalic">C. albicans</span> with any of the 3 concentrations of ethanol–enoxaparin tested (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>E).</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Twenty-four-hour regimen</span><p id="par0070" class="elsevierStylePara elsevierViewall">In the 24-h regimen, therapy was successful in all the microorganisms tested at all the ethanol concentrations (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). However, when ethanol was combined with enoxaparin, a significant reduction in metabolic activity was observed only for <span class="elsevierStyleItalic">S. epidermidis</span>, <span class="elsevierStyleItalic">E. coli</span>, and <span class="elsevierStyleItalic">C. albicans</span> at all the ethanol concentrations (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001) (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>B, D, and E). In contrast, with <span class="elsevierStyleItalic">S. aureus</span> and <span class="elsevierStyleItalic">E. faecalis</span>, the median reduction in metabolic activity did not reach 90% when they were treated with solutions of ethanol at any concentration combined with enoxaparin (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>A and C).</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Discussion</span><p id="par0075" class="elsevierStylePara elsevierViewall">Our data showed that enoxaparin used as an adjuvant anticoagulant in ethanol-based lock solutions negatively affects the anti-biofilm activity of ethanol. Higher concentrations of ethanol were required to obtain better percentage reductions in metabolic activity after combination with enoxaparin.</p><p id="par0080" class="elsevierStylePara elsevierViewall">The consequences of C-RBSI after insertion of a central venous catheter (CVC) in ICU patients can be fatal.<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">22</span></a> Guidelines recommend removing the catheter when there is suspicion of C-RBSI. However, in situations where catheter withdrawal is not possible, the combination of systemic therapy and ALT can be useful.<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">8,10,23</span></a> Several studies have shown antiseptic lock solutions such as ethanol to be a sufficiently efficacious alternative to ALTs.<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">9,11,16</span></a> However, the heterogeneity of the study designs prevents consensus on the appropriate concentration and regimen to be used.<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">24</span></a> Most studies showed the best activity with 70% ethanol. However, it has also been demonstrated that 70% ethanol was not only unsafe for patients, but also disrupted the catheter surface.<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">25,26</span></a> In our study, we showed that 35% or 40% ethanol alone was sufficiently high for a >90% reduction in the metabolic activity of the biofilm of all the tested microorganisms in a 2-h lock solution regimen (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001).</p><p id="par0085" class="elsevierStylePara elsevierViewall">When ALT is administered for >2<span class="elsevierStyleHsp" style=""></span>h, the solution must contain anticoagulants in order to prevent catheter occlusion. The most popular anticoagulant in lock solutions is heparin, both in its unfractionated form (UFH) and low-molecular-weight form (LMWH).<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">27</span></a> Enoxaparin is the most representative LMWH and is replacing UFH owing to its more predictable pharmacokinetic profile and ease of use, although data on its effect and stability in ethanol lock solutions are scarce.<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">28</span></a> Calvet et al. demonstrated that enoxaparin was stable in 40% ethanol and that it had only a marginal impact on the catheter surface. Moreover, in a study by Balestrino et al., the efficacy of enoxaparin 400<span class="elsevierStyleHsp" style=""></span>IU/ml and 40% ethanol made it possible to eradicate the biofilm of <span class="elsevierStyleItalic">S. aureus</span> and <span class="elsevierStyleItalic">C. albicans</span>. In addition, the authors confirmed that the integrity of the catheter was not affected.<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">16,17</span></a> Biofilms were formed and treated in microfermentors containing segments of silicon catheters, and a significant reduction in the viability of cells (in colony-forming units) was achieved for all their strains when a 24-h regimen was followed, even in <span class="elsevierStyleItalic">S. aureus</span>. In contrast to these results, we found that 60<span class="elsevierStyleHsp" style=""></span>IU of enoxaparin altered the anti-biofilm activity of ethanol in <span class="elsevierStyleItalic">S. aureus</span> and <span class="elsevierStyleItalic">E. faecalis</span> for the 24-h therapy. However, the combination worked properly with <span class="elsevierStyleItalic">S. epidermidis</span>, <span class="elsevierStyleItalic">C. albicans</span>, and <span class="elsevierStyleItalic">E. coli</span> biofilms. Moreover, the shortest regimen used by Balestrino et al. was 4<span class="elsevierStyleHsp" style=""></span>h, compared with 2<span class="elsevierStyleHsp" style=""></span>h in our study, thus showing that the effect of ethanol–enoxaparin solutions was not only ethanol concentration–dependent but also time-dependent. However, although the methodology used was different, both XTT and colony-forming unit counts could help to assess the in vitro anti-biofilm activity of ethanol.</p><p id="par0090" class="elsevierStylePara elsevierViewall">Based on our data, we consider that a 2-h regimen of either 35% or 40% ethanol alone could be used until the microorganism has been identified. However, if a 24-h regimen of ethanol is used, anticoagulants other than enoxaparin should be administered, at least in the case of <span class="elsevierStyleItalic">S. aureus</span> and <span class="elsevierStyleItalic">E. faecalis</span> infections.</p><p id="par0095" class="elsevierStylePara elsevierViewall">Although ours is one of the first studies to assess the anti-biofilm activity of ethanol combined with enoxaparin as a lock solution, it has some limitations. First, our methodology using a static in vitro model was only based on calculating the percentage reduction in metabolic activity as an indirect measure for biofilm reduction. Besides, we also used a clinical strain of <span class="elsevierStyleItalic">S. epidermidis</span> instead of an ATCC which could have different behaviour. Therefore, future studies including more clinical strains must be performed to assess the correlation between metabolic activity and cell viability or re-growth assays.</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conclusion</span><p id="par0100" class="elsevierStylePara elsevierViewall">Based on our in vitro results, enoxaparin could negatively affect the anti-biofilm properties of ethanol. We consider that a 35% ethanol-based lock solution is appropriate to be used as a lock therapy. For therapies of >2<span class="elsevierStyleHsp" style=""></span>h, anticoagulants other than enoxaparin may be used at least in the case of <span class="elsevierStyleItalic">S. aureus</span> and <span class="elsevierStyleItalic">E. faecalis</span> infections.</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Financial support</span><p id="par0105" class="elsevierStylePara elsevierViewall">M. Guembe is supported by the Miguel Servet Program (ISCIIIMICINN, CP13/00268) from the <span class="elsevierStyleGrantSponsor" id="gs1">Health Research Fund (FIS) of the Carlos III Health Institute (ISCIII), Madrid, Spain</span>. Beatriz Alonso is supported by the <span class="elsevierStyleGrantSponsor" id="gs2">Consejería de Educación, Juventud y Deporte de la Comunidad de Madrid</span> and <span class="elsevierStyleGrantSponsor" id="gs3">Fondo Social Europeo</span> (<span class="elsevierStyleGrantNumber" refid="gs3">PEJ15/BIO/AI-0406</span>). The study was partially funded by the <span class="elsevierStyleGrantSponsor" id="gs4">European Regional Development Fund (FEDER)</span> “A way of making Europe”.</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Conflicts of interest</span><p id="par0110" class="elsevierStylePara elsevierViewall">The authors declare no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:13 [ 0 => array:3 [ "identificador" => "xres1128791" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1062189" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1128792" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1062190" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Materials and methods" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Laboratory procedure" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Preparation of ethanol-based solutions" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Data analysis" ] ] ] 6 => array:3 [ "identificador" => "sec0030" "titulo" => "Results" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0035" "titulo" => "Two-hour regimen" ] 1 => array:2 [ "identificador" => "sec0040" "titulo" => "Twenty-four-hour regimen" ] ] ] 7 => array:2 [ "identificador" => "sec0045" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0050" "titulo" => "Conclusion" ] 9 => array:2 [ "identificador" => "sec0055" "titulo" => "Financial support" ] 10 => array:2 [ "identificador" => "sec0060" "titulo" => "Conflicts of interest" ] 11 => array:2 [ "identificador" => "xack384254" "titulo" => "Acknowledgements" ] 12 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-09-12" "fechaAceptado" => "2017-11-05" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1062189" "palabras" => array:4 [ 0 => "Ethanol" 1 => "Lock therapy" 2 => "Anti-biofilm activity" 3 => "Enoxaparin" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1062190" "palabras" => array:4 [ 0 => "Etanol" 1 => "Terapia de sellado" 2 => "Actividad anti-biopelícula" 3 => "Enoxaparina" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Catheter-related bloodstream infection (C-RBSI) can sometimes be managed without catheter removal by combining systemic therapy with catheter lock therapy. Most antiseptic lock solutions are made up of ethanol combined with an anticoagulant. However, data regarding the anti-biofilm activity of ethanol combined with enoxaparin are scarce. We aimed to assess the efficacy of ethanol at different concentrations combined with enoxaparin 60<span class="elsevierStyleHsp" style=""></span>IU as a lock solution for eradication of the biofilm of different microorganisms.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Using a static 96-well plate in vitro model, we tested 30%, 35%, and 40% ethanol alone and combined with 60<span class="elsevierStyleHsp" style=""></span>IU of enoxaparin against 24-h-old biofilm from the following microorganisms: <span class="elsevierStyleItalic">Staphylococcus aureus</span>, <span class="elsevierStyleItalic">Staphylococcus epidermidis</span>, <span class="elsevierStyleItalic">Enterococcus faecalis</span>, <span class="elsevierStyleItalic">Escherichia coli</span>, and <span class="elsevierStyleItalic">Candida albicans</span>. Time of exposure was assessed during a 2-h and 24-h regimen. We analysed the percentage reduction in metabolic activity using the XTT assay. We considered therapy to be successful when metabolic activity was reduced by >90%.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">In the 2-h regimen, the therapy was successful against all microorganisms at 35% and 40% ethanol without enoxaparin (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001). In the 24-h regimen, the therapy was successful against all microorganisms at all ethanol solutions without enoxaparin (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001). When ethanol was combined with enoxaparin, the therapy was only successful in the 24-h regimen in biofilms of <span class="elsevierStyleItalic">S. epidermidis</span>, <span class="elsevierStyleItalic">C. albicans</span> and <span class="elsevierStyleItalic">E. coli</span> at all concentrations of ethanol assessed.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Our in vitro model demonstrated that when ethanol is combined with enoxaparin in a lock solution, it negatively affects ethanol anti-biofilm activity after both short and long exposures.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducción</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La bacteriemia relacionada con el catéter (BRC) puede ser manejada sin la retirada del catéter mediante la combinación de terapia sistémica y terapia de sellado de catéter. Las soluciones de sellado con antisépticos más utilizadas están compuestas de etanol combinado con anticoagulante. Sin embargo, los datos sobre la actividad anti-biopelícula del etanol combinado con enoxaparina son escasos. Nuestro objetivo fue evaluar la eficacia del etanol a diferentes concentraciones combinado con enoxaparina 60<span class="elsevierStyleHsp" style=""></span>UI como solución de sellado para la erradicación de la biopelícula de diferentes microorganismos.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Mediante un modelo in vitro estático en placa de 96 pocillos, testamos etanol al 30, 35 y 40% solo y combinado con 60<span class="elsevierStyleHsp" style=""></span>UI de enoxaparina frente a una biopelícula de 24<span class="elsevierStyleHsp" style=""></span>h de los siguientes microorganismos: <span class="elsevierStyleItalic">Staphylococcus aureus</span>, <span class="elsevierStyleItalic">Staphylococcus epidermidis</span>, <span class="elsevierStyleItalic">Enterococcus faecalis</span>, <span class="elsevierStyleItalic">Escherichia coli</span> y <span class="elsevierStyleItalic">Candida albicans</span>. El tiempo de exposición se evaluó durante un régimen de 2 y 24<span class="elsevierStyleHsp" style=""></span>h. Se analizó el porcentaje de reducción de la actividad metabólica mediante el ensayo XTT. Consideramos éxito de la terapia cuando la actividad metabólica se redujo >90%.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">En el régimen de 2<span class="elsevierStyleHsp" style=""></span>h, la terapia fue exitosa contra todos los microorganismos a concentraciones de etanol del 35 y 40% sin enoxaparina (p<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0,001). En el régimen de 24<span class="elsevierStyleHsp" style=""></span>h, la terapia fue exitosa contra todos los microorganismos en todas las soluciones de etanol sin enoxaparina (p<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0,001). Cuando se combinó etanol con enoxaparina, la terapia solo tuvo éxito en el régimen de 24<span class="elsevierStyleHsp" style=""></span>h en todas las concentraciones de etanol evaluadas frente a biopelículas de <span class="elsevierStyleItalic">S. epidermidis</span>, <span class="elsevierStyleItalic">C. albicans</span> y <span class="elsevierStyleItalic">E. coli</span>.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Nuestro modelo in vitro demostró que la adición de enoxaparina a etanol en solución de sellado afecta negativamente a la actividad anti-biopelícula del etanol tanto tras exposiciones cortas como largas.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "multimedia" => array: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" => 1740 "Ancho" => 2286 "Tamanyo" => 132430 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Overall median reduction in metabolic activity after treatment with an ethanol-based lock solution. Asterics correspond to extreme outliers.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 3704 "Ancho" => 3156 "Tamanyo" => 399579 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Median reduction in metabolic activity of the various biofilm-forming strains after treatment with an ethanol-based lock solution. (A) <span class="elsevierStyleItalic">Staphylococcus aureus</span> ATCC25923. (B) <span class="elsevierStyleItalic">Staphylococcus epidermidis</span> (clinical strain). (C) <span class="elsevierStyleItalic">Enterococcus faecalis</span> ATCC33186. (D) <span class="elsevierStyleItalic">Escherichia coli</span> ATCC25922. (E) <span class="elsevierStyleItalic">Candida albicans</span> ATCC14058. Asterics correspond to extreme outliers.</p>" ] ] 2 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">ET, ethanol; ENOX, enoxaparin; IQR, interquartile range.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="table-head ; entry_with_role_rowhead " align="left" valign="top" scope="col">Lock solution composition \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">Duration of exposure \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="5" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Median (IQR) percentage reduction in metabolic activity</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="" 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">S. aureus</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"><span class="elsevierStyleItalic">S. epidermidis</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"><span class="elsevierStyleItalic">E. faecalis</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"><span class="elsevierStyleItalic">E. coli</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"><span class="elsevierStyleItalic">C. albicans</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" title="table-entry " rowspan="2" align="left" valign="middle">30% ET</td><td class="td" title="table-entry " align="char" valign="top">2<span class="elsevierStyleHsp" style=""></span>h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">34.1 (0–43.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">93.7 (90.7–96.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">92.1 (82.9–94.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">98.9 (98.6–99.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">79.8 (75.2–86.1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">24<span class="elsevierStyleHsp" style=""></span>h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">95.5 (94.4–96.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">100 (99.5–100) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">97.9 (95.6–98.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">100 (99.6–100) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">99.8 (99.6–99.7) \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 " rowspan="2" align="left" valign="middle">30%ET-ENOX</td><td class="td" title="table-entry " align="char" valign="top">2<span class="elsevierStyleHsp" style=""></span>h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.9 (0–26.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">33.2 (27.8–47.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">69.8 (14.4–83.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">21.8 (13.1–40.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9.4 (7.6–11.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">24<span class="elsevierStyleHsp" style=""></span>h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">99.6 (99.4–99.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">96.6 (94.4–99.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">62.6 (53.8–77.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">99.7 (95.8–99.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">99.3 (98.3–99.6) \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 " rowspan="2" align="left" valign="middle">35%ET</td><td class="td" title="table-entry " align="char" valign="top">2<span class="elsevierStyleHsp" style=""></span>h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">98.9 (95.1–99.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">98.1 (96.6–100) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">99.8 (99.3–100) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">98.8 (98.7–99.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">99.4 (99.3–99.5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">24<span class="elsevierStyleHsp" style=""></span>h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">99.6 (99.4–99.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">100 (100–100) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">99.5 (99.1–100) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">100 (100–100) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">99.7 (99.6–99.8) \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 " rowspan="2" align="left" valign="middle">35%ET-ENOX</td><td class="td" title="table-entry " align="char" valign="top">2<span class="elsevierStyleHsp" style=""></span>h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">89.6 (87.7–93.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">60.5 (40.2–70.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">66.8 (52.1–71.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">98.5 (83.2–99.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">18.3 (0–31.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">24<span class="elsevierStyleHsp" style=""></span>h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">87.8 (78.7–91.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">92.2 (87.9–97.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">75.3 (73.0–87.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">100 (99.4–100) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">94.0 (90.0–97.5) \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 " rowspan="2" align="left" valign="middle">40%ET</td><td class="td" title="table-entry " align="char" valign="top">2<span class="elsevierStyleHsp" style=""></span>h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">99.0 (97.5–99.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">100 (98.1–100) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">99.6 (99.1–100) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">98.8 (97.3–99.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">99.5 (99.3–99.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">24<span class="elsevierStyleHsp" style=""></span>h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">99.2 (98.5–99.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">100 (99.6–100) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">98.4 (97.8–99.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">100 (99.8–100) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">99.6 (99.4–99.7) \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 " rowspan="2" align="left" valign="middle">40%ET-ENOX</td><td class="td" title="table-entry " align="char" valign="top">2<span class="elsevierStyleHsp" style=""></span>h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">90.2 (84.1–93.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">44.7 (28.7–61.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">30.2 (24.7–70.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">89.6 (62.9–95.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0.0–0.0) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">24<span class="elsevierStyleHsp" style=""></span>h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">83.6 (80.6–93.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">96.4 (92.6–96.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">62.1 (43.6–86.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">100 (98.4–100) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">98.1 (96.9–98.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1924377.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Reduction in metabolic activity of the biofilm-forming strains after treatment with an ethanol-based lock solution.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:28 [ 0 => array:3 [ "identificador" => "bib0145" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prevention of vascular catheter-related bloodstream infections" "autores" => array:1 [ 0 => array:2 [ "etal" => 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año/Mes | Html | Total | |
---|---|---|---|
2024 Octubre | 6 | 4 | 10 |
2024 Septiembre | 40 | 24 | 64 |
2024 Agosto | 23 | 21 | 44 |
2024 Julio | 17 | 7 | 24 |
2024 Junio | 21 | 7 | 28 |
2024 Mayo | 16 | 11 | 27 |
2024 Abril | 27 | 31 | 58 |
2024 Marzo | 37 | 21 | 58 |
2024 Febrero | 29 | 24 | 53 |
2024 Enero | 21 | 7 | 28 |
2023 Diciembre | 22 | 29 | 51 |
2023 Noviembre | 27 | 14 | 41 |
2023 Octubre | 44 | 18 | 62 |
2023 Septiembre | 26 | 10 | 36 |
2023 Agosto | 20 | 6 | 26 |
2023 Julio | 26 | 61 | 87 |
2023 Junio | 40 | 25 | 65 |
2023 Mayo | 65 | 25 | 90 |
2023 Abril | 30 | 8 | 38 |
2023 Marzo | 26 | 12 | 38 |
2023 Febrero | 24 | 9 | 33 |
2023 Enero | 16 | 13 | 29 |
2022 Diciembre | 29 | 15 | 44 |
2022 Noviembre | 52 | 29 | 81 |
2022 Octubre | 36 | 24 | 60 |
2022 Septiembre | 37 | 21 | 58 |
2022 Agosto | 36 | 18 | 54 |
2022 Julio | 22 | 28 | 50 |
2022 Junio | 24 | 20 | 44 |
2022 Mayo | 26 | 19 | 45 |
2022 Abril | 39 | 19 | 58 |
2022 Marzo | 41 | 15 | 56 |
2022 Febrero | 27 | 7 | 34 |
2022 Enero | 46 | 22 | 68 |
2021 Diciembre | 34 | 31 | 65 |
2021 Noviembre | 18 | 25 | 43 |
2021 Octubre | 21 | 21 | 42 |
2021 Septiembre | 28 | 14 | 42 |
2021 Agosto | 22 | 9 | 31 |
2021 Julio | 38 | 12 | 50 |
2021 Junio | 25 | 19 | 44 |
2021 Mayo | 19 | 17 | 36 |
2021 Abril | 34 | 23 | 57 |
2021 Marzo | 20 | 22 | 42 |
2021 Febrero | 31 | 16 | 47 |
2021 Enero | 27 | 23 | 50 |
2020 Diciembre | 17 | 18 | 35 |
2020 Noviembre | 25 | 17 | 42 |
2020 Octubre | 20 | 4 | 24 |
2020 Septiembre | 32 | 21 | 53 |
2020 Agosto | 25 | 13 | 38 |
2020 Julio | 36 | 18 | 54 |
2020 Junio | 29 | 20 | 49 |
2020 Mayo | 20 | 22 | 42 |
2020 Abril | 19 | 11 | 30 |
2020 Marzo | 33 | 24 | 57 |
2020 Febrero | 23 | 20 | 43 |
2020 Enero | 30 | 25 | 55 |
2019 Diciembre | 35 | 67 | 102 |
2019 Noviembre | 15 | 13 | 28 |
2019 Octubre | 24 | 13 | 37 |
2019 Septiembre | 18 | 13 | 31 |
2019 Agosto | 24 | 16 | 40 |
2019 Julio | 31 | 17 | 48 |
2019 Junio | 35 | 19 | 54 |
2019 Mayo | 0 | 54 | 54 |
2019 Abril | 2 | 26 | 28 |
2019 Marzo | 3 | 3 | 6 |
2019 Febrero | 0 | 4 | 4 |
2019 Enero | 4 | 8 | 12 |
2018 Diciembre | 15 | 8 | 23 |
2018 Noviembre | 36 | 22 | 58 |
2018 Enero | 1 | 1 | 2 |
2017 Diciembre | 3 | 5 | 8 |