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Relevancia clínica de la codetección viral en lactantes con bronquiolitis por virus respiratorio sincitial
Clinical relevance of viral codetection in infants with respiratory syncytial virus bronchiolitis
Albert Bernet Sáncheza,b,
Autor para correspondencia
abernet.lleida.ics@gencat.cat

Autor para correspondencia.
, Alba Bellés Bellésa,b, Mercè García Gonzáleza,b, Laura Minguell Domingoc, Eduard Solé Mirb,c
a Sección de Microbiología, Hospital Universitari Arnau de Vilanova, Lleida, España
b Institut de Recerca Biomèdica de Lleida (IRBLleida), Lleida, España
c Servicio de Pediatría, Hospital Universitari Arnau de Vilanova, Lleida, España
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sobre todo a causa de la obstrucci&#243;n de la v&#237;a a&#233;rea y del distr&#233;s respiratorio<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">4</span></a>&#44; produci&#233;ndose unos 7&#46;000-14&#46;000 ingresos hospitalarios-a&#241;o en Espa&#241;a<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">5</span></a>&#46; El principal virus implicado es el virus respiratorio sincitial &#40;VRS&#41;&#44; aunque otros virus respiratorios tambi&#233;n pueden producir este cuadro<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">2&#44;4&#44;6</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Las codetecciones virales en este tipo de infecciones son frecuentes&#44; y su implicaci&#243;n en la gravedad del cuadro cl&#237;nico es un hecho poco estudiado&#44; m&#225;s a&#250;n en las bronquiolitis por VRS&#46; Se han propuesto varias hip&#243;tesis para explicar la asociaci&#243;n entre m&#250;ltiples virus respiratorios y la gravedad de las infecciones respiratorias agudas&#44; como la modificaci&#243;n de las respuestas inmunitarias despu&#233;s de la infecci&#243;n inicial&#44; la susceptibilidad del hu&#233;sped a m&#250;ltiples agentes virales y las asociaciones de virus respiratorios espec&#237;ficos con bacterias colonizadoras del tracto respiratorio<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">7</span></a>&#46; Adem&#225;s&#44; cabe destacar que detectar un agente viral no implica necesariamente la participaci&#243;n en el proceso infeccioso actual<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">8</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">El objetivo del presente trabajo es evaluar si los casos con codetecci&#243;n viral en las bronquiolitis por VRS que acuden al servicio de urgencias presentan un mejor o peor pron&#243;stico cl&#237;nico que aquellos con detecci&#243;n exclusiva de VRS&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">M&#233;todos</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Pacientes incluidos en el estudio</span><p id="par0020" class="elsevierStylePara elsevierViewall">Estudio prospectivo en el que se incluyeron todos los lactantes menores de 2 a&#241;os que acudieron al servicio de urgencias del Hospital Universitario Arnau de Vilanova de Lleida con diagn&#243;stico de bronquiolitis desde el 1 de noviembre de 2016 al 30 de abril de 2019&#44; y con detecci&#243;n de VRS positiva en muestra nasofar&#237;ngea&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Se consider&#243; como bronquiolitis aguda el primer episodio de dificultad respiratoria en un ni&#241;o de menos de 24 meses de edad con sibilancias y&#47;o crepitantes asociado con s&#237;ntomas del tracto respiratorio superior durante el per&#237;odo epid&#233;mico<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">9</span></a>&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Detecci&#243;n de los virus respiratorios</span><p id="par0030" class="elsevierStylePara elsevierViewall">Se tom&#243; una muestra nasofar&#237;ngea a cada paciente con un escobill&#243;n en un medio est&#225;ndar de transporte de virus &#40;Universal Virus Transport&#174;&#44; Becton Dickinson&#44; Franklin Lakes&#44; EE&#46; UU&#46;&#41; de 1 o 3<span class="elsevierStyleHsp" style=""></span>ml&#46; Las muestras fueron remitidas al Laboratorio de Microbiolog&#237;a para la realizaci&#243;n de t&#233;cnicas moleculares&#46; La detecci&#243;n de virus de influenza A &#40;Flu A&#41;&#44; influenza B &#40;Flu B&#41; y VRS se realiz&#243; de forma urgente con una PCR m&#250;ltiple en tiempo real &#40;GeneXpert&#174;&#44; Xpert&#174;Flu&#47;RSV X<span class="elsevierStyleSmallCaps">C</span>&#44; Cepheid Inc&#46;&#44; Sunnyvale&#44; EE&#46; UU&#46;&#41;&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">En todos los pacientes en los que se detect&#243; VRS se ampli&#243; el estudio molecular de virus respiratorios&#46; Para ello&#44; se realiz&#243; una extracci&#243;n con una eluci&#243;n de 60<span class="elsevierStyleHsp" style=""></span>&#956;L partiendo de 200<span class="elsevierStyleHsp" style=""></span>&#956;L de muestra &#40;Virus Mini Kit v2&#46;0&#44; equipo EZ1&#174; &#91;Qiagen GmbH&#44; Alemania&#93; o DSP Virus&#47;Pathogen Minikit&#44; sistema QIAsymphony&#174; &#91;Qiagen GmbH&#44; Alemania&#93;&#44; seg&#250;n instrucciones del fabricante&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Desde 2016 hasta el primer semestre de 2018 la detecci&#243;n del resto de los virus respiratorios se realiz&#243; con Allplex&#174; Respiratory Panel &#40;Seegene&#44; Se&#250;l&#44; Corea del Sur&#41; en el termociclador CFX96&#174; &#40;Bio-Rad Laboratories&#44; Hercules&#44; EE&#46; UU&#46;&#41;&#46; Esta t&#233;cnica detecta adenovirus &#40;Adv&#41;&#44; enterovirus &#40;EV&#41;&#44; virus parainfluenza &#40;PiV&#41; 1&#44; 2&#44; 3 y 4&#44; metaneumovirus &#40;MPV&#41;&#44; bocavirus &#40;BoV&#41;&#44; rhinovirus &#40;HRV&#41; y coronavirus &#40;CoV&#41; NL63&#44; 229E y OC43&#46; A partir del segundo semestre de 2018 y durante 2019 se realiz&#243; con el kit Light Mix&#174; &#40;TIB Molbiol&#44; Berl&#237;n&#44; Alemania&#41; en el termociclador LightCycler&#174; 480 II &#40;Roche Diagnostics&#44; Penzberg&#44; Alemania&#41;&#44; que incluye&#44; adem&#225;s de los previamente citados&#44; parechovirus &#40;PeV&#41; y CoV de forma gen&#233;rica&#44; diferenciando los subtipos HKU1 y MERS&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Recogida de datos</span><p id="par0045" class="elsevierStylePara elsevierViewall">Se revisaron las historias cl&#237;nicas de los pacientes diagnosticados de bronquiolitis aguda por VRS y se recogieron los siguientes datos cl&#237;nicos y microbiol&#243;gicos&#58; resultados de la detecci&#243;n del resto de los virus respiratorios&#44; edad&#44; &#237;ndice Bronchiolitis Score of Sant Joan de D&#233;u &#40;BROSJOD&#41;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">10</span></a>&#44; duraci&#243;n de la hospitalizaci&#243;n &#40;tiempo de estancia del paciente en el centro hospitalario&#44; incluyendo la sala de urgencias&#44; observaci&#243;n y planta&#41;&#44; necesidad de oxigenoterapia&#44; d&#237;as de tratamiento con ox&#237;geno&#44; m&#225;xima concentraci&#243;n de fracci&#243;n inspiratoria de ox&#237;geno &#40;FiO<span class="elsevierStyleInf">2</span>&#41; requerida&#44; necesidad de soporte respiratorio o ventilaci&#243;n mec&#225;nica&#44; admisi&#243;n a unidad de cuidados intensivos &#40;UCI&#41; pedi&#225;tricos&#44; necesidad de alimentaci&#243;n por sonda nasog&#225;strica &#40;SNG&#41;&#44; necesidad de traslado a un centro de tercer nivel y administraci&#243;n de palivizumab previa al ingreso&#46; Este estudio fue aprobado por el comit&#233; &#233;tico del Hospital Universitari Arnau de Vilanova&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">An&#225;lisis estad&#237;stico</span><p id="par0050" class="elsevierStylePara elsevierViewall">El an&#225;lisis descriptivo incluy&#243; la mediana y el intervalo intercuart&#237;lico para las variables cuantitativas&#44; y las frecuencias absolutas y relativas para las cualitativas&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Se realizaron an&#225;lisis bivariantes para comparar los 2 grupos de pacientes en funci&#243;n de la detecci&#243;n viral en las muestras nasofar&#237;ngeas &#40;VRS &#250;nicamente o codetecci&#243;n viral&#41; y 2 grupos de edad de los lactantes &#40;menores y mayores de 3 meses&#41;&#46; Para ello se utiliz&#243; la prueba de chi-cuadrado para variables categ&#243;ricas y la U de Mann-Whitney para variables cuantitativas&#46; Se estim&#243; un modelo de regresi&#243;n log&#237;stica para estimar la asociaci&#243;n de la presencia de infecciones mixtas en relaci&#243;n con la edad&#44; permitiendo relaciones no lineales&#46; Para el an&#225;lisis estad&#237;stico se utiliz&#243; el software R214&#44; aplicando un nivel de significaci&#243;n de 0&#44;05&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Resultados</span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Detecci&#243;n de virus respiratorios en lactantes con bronquiolitis por VRS</span><p id="par0060" class="elsevierStylePara elsevierViewall">Durante el per&#237;odo de estudio se diagnosticaron 437 episodios de bronquiolitis por VRS en 435 lactantes&#46; En 199 de las 437 muestras &#40;45&#44;5&#37;&#41; se detect&#243; otro agente viral adem&#225;s del VRS&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Los principales virus codetectados fueron HRV &#40;83&#47;199&#59; 19&#37;&#41;&#44; BoV &#40;75&#47;199&#59; 17&#44;2&#37;&#41;&#44; Adv &#40;41&#47;199&#59; 38&#37;&#41;&#44; CoV &#40;23&#47;199&#59; 5&#44;26&#37;&#41;&#44; PiV &#40;10&#47;199&#59; 2&#44;29&#37;&#41;&#44; EV &#40;6&#47;199&#59; 1&#44;37&#37;&#41;&#44; Flu A &#40;5&#47;199&#59; 1&#44;14&#37;&#41; &#40;4 del subtipo H3 y uno del subtipo H1&#41;&#44; Flu B &#40;3&#47;199&#59; 0&#44;69&#37;&#41; y MPV &#40;4&#47;199&#59; 0&#44;92&#37;&#41;&#46; La detecci&#243;n de PeV se realiz&#243; &#250;nicamente en el &#250;ltimo a&#241;o y se detect&#243; en un solo episodio &#40;1&#47;199&#59; 0&#44;23&#37;&#41;&#46; Se detectaron 2 virus aparte del VRS en 47 episodios &#40;10&#44;75&#37;&#41; y 3 virus en 5 episodios &#40;1&#44;14&#37;&#41;&#46; El virus m&#225;s frecuentemente detectado en estas detecciones m&#250;ltiples fue el Adv &#40;20&#47;41&#41;&#44; seguido del CoV &#40;11&#47;23&#41; y del BoV &#40;35&#47;75&#41;&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Datos cl&#237;nicos y epidemiol&#243;gicos</span><p id="par0070" class="elsevierStylePara elsevierViewall">El 52&#44;9&#37; de las bronquiolitis por VRS &#40;231&#47;437&#41; se dieron en pacientes menores de 3 meses de edad&#46; La duraci&#243;n media de la estancia en el hospital &#40;tanto en la sala de urgencias como observaci&#243;n o planta&#41; fue de 5 d&#237;as y requirieron suplementaci&#243;n con ox&#237;geno el 62&#44;9&#37; &#40;275&#47;437&#41;&#44; con una duraci&#243;n media del aporte de un d&#237;a&#46; La FiO<span class="elsevierStyleInf">2</span> m&#225;xima requerida fue de 27&#37; de media&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Requirieron SNG el 20&#44;9&#37; de los episodios &#40;91&#47;437&#41;&#44; soporte respiratorio el 21&#44;6&#37; &#40;94&#47;437&#41;&#44; ingreso en UCI neonatal el 29&#44;5&#37; &#40;129&#47;437&#41; y traslado a un centro de tercer nivel el 5&#37; &#40;22&#47;437&#41;&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">En cuanto a la gravedad de las bronquiolitis&#44; 72 episodios &#40;16&#44;5&#37;&#41; presentaron un BROSJOD leve&#44; 320 &#40;73&#44;2&#37;&#41; moderado y 45 &#40;10&#44;3&#37;&#41; grave&#46; No hubo ning&#250;n caso de exitus ni historial de haber recibido profilaxis con palivizumab&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">La <a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a> muestra las caracter&#237;sticas de los episodios de bronquiolitis con detecci&#243;n &#250;nica de VRS y de los de codetecci&#243;n con otros virus respiratorios&#46; No se encontraron diferencias estad&#237;sticamente significativas en ninguna de las variables estudiadas entre estos 2 grupos &#40;p<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">Al comparar las caracter&#237;sticas de los lactantes menores y mayores de 3 meses&#44; se encontraron diferencias estad&#237;sticamente significativas &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41;&#46; Los lactantes con edad inferior a 3 meses tuvieron una estancia m&#225;s prolongada en el hospital &#40;6 vs&#46; 4 d&#237;as&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; m&#225;s duraci&#243;n en la administraci&#243;n de ox&#237;geno &#40;2 vs&#46; un d&#237;a&#44; p<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#61;</span><span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; un mayor requerimiento de FiO<span class="elsevierStyleInf">2</span> m&#225;xima &#40;35 vs&#46; 30&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; mayor necesidad de SNG &#40;33&#44;0 vs&#46; 7&#44;3&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; mayor necesidad de soporte respiratorio &#40;35&#44;9 vs&#46; 5&#44;4&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; y mayor ingreso en UCI pedi&#225;trica &#40;49&#44;8 vs&#46; 6&#44;8&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">En cuanto a la detecci&#243;n de otros virus&#44; los lactantes menores de 3 meses globalmente presentaron menos codetecciones &#40;39&#44;4 vs&#46; 52&#44;4&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;008&#41;&#46; En funci&#243;n del agente viral&#44; presentaron menos codetecciones por Adv &#40;5&#44;19 vs&#46; 14&#44;1&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;003&#41; y por BoV &#40;11&#44;3 vs&#46; 23&#44;8&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; que el grupo de lactantes mayores&#46; En este grupo se detect&#243; la presencia de m&#225;s de 2 virus en el 18&#44;68&#37; de los episodios &#40;17&#47;91&#41; en comparaci&#243;n con el grupo de mayores de 3 meses&#44; donde fue del 27&#44;78&#37; &#40;30&#47;108&#41;&#46;</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Discusi&#243;n</span><p id="par0100" class="elsevierStylePara elsevierViewall">La prevalencia de codetecci&#243;n viral en lactantes con bronquiolitis por VRS en este trabajo ha sido cercana al 50&#37;&#46; Este dato es mucho mayor que los descritos en otros estudios similares&#44; que reportan valores entre el 11&#44;33 y el 24&#44;4&#37;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">11&#8211;14</span></a>&#44; llegando hasta el 29&#44;8&#37; en bronquiolitis graves por VRS<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">15</span></a>&#46; Un estudio realizado en nuestro pa&#237;s detect&#243; un 35&#44;8&#37; de codetecci&#243;n viral en lactantes menores de 18 meses con bronquiolitis por VRS<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">16</span></a>&#44; valor m&#225;s cercano&#44; aunque menor&#44; al detectado en nuestro trabajo&#46; Las grandes diferencias entre los resultados de estos trabajos podr&#237;an explicarse por la utilizaci&#243;n de diferentes t&#233;cnicas de PCR&#44; diferentes poblaciones estudiadas y distintas zonas geogr&#225;ficas&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Los resultados obtenidos en nuestro estudio no muestran diferencias significativas entre el grupo de pacientes con bronquiolitis con monodetecci&#243;n de VRS y los pacientes con codetecci&#243;n de VRS y otro virus respiratorio en cuanto a los factores de gravedad evaluados<span class="elsevierStyleBold">&#44;</span> en concordancia con los obtenidos en trabajos similares<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">11&#44;17&#8211;19</span></a>&#46; Un estudio realizado por Nascimiento et al&#46; en lactantes menores de 2 a&#241;os que acudieron a urgencias con bronquiolitis concluy&#243; que la presencia &#250;nica de VRS se asociaba con un mayor riesgo de ingreso hospitalario&#44; pero las codetecciones no se asociaban con una mayor gravedad cl&#237;nica o ingreso en UCI<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">20</span></a>&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">En esta l&#237;nea&#44; una revisi&#243;n sistem&#225;tica y metaan&#225;lisis realizada en 2016 sobre codetecciones virales en ni&#241;os menores de 5 a&#241;os hospitalizados con infecci&#243;n v&#237;rica respiratoria<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">21</span></a> no mostr&#243; diferencias en la admisi&#243;n en UCI&#44; el uso de ox&#237;geno&#44; la ventilaci&#243;n mec&#225;nica ni las anormalidades radiol&#243;gicas entre el grupo de ni&#241;os con monodetecci&#243;n y el de codetecci&#243;n&#46; En ese mismo a&#241;o&#44; otro metaan&#225;lisis concluy&#243; que la coinfecci&#243;n viral no aumentaba el riesgo de ninguno de los factores evaluados en pacientes menores de 18 a&#241;os con infecci&#243;n respiratoria aguda<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">22</span></a>&#46; Una revisi&#243;n sistem&#225;tica publicada en 2013 tampoco relacion&#243; un aumento de la gravedad en los casos de codetecci&#243;n viral en ni&#241;os menores de 6 a&#241;os<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">23</span></a>&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">No obstante&#44; Midulla et al&#46; reportaron que los lactantes con codetecci&#243;n VRS y BoV ten&#237;an mayor gravedad y m&#225;s d&#237;as de estancia hospitalaria que los que presentaban monodetecci&#243;n por VRS&#44; HRV o BoV<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">24</span></a>&#46; Resch et al&#46; analizaron 745 infecciones graves por VRS &#40;bronquiolitis en el 70&#37;&#41; sobre una poblaci&#243;n mayoritaria de lactantes&#44; concluyendo que los pacientes con codetecci&#243;n viral hab&#237;an necesitado tasas m&#225;s elevadas de ox&#237;geno suplementario y soporte respiratorio<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">25</span></a>&#46; Otros autores analizan bronquiolitis por cualquier agente viral&#44; concluyendo que los pacientes con codetecci&#243;n viral presentaban 2&#44;7 veces m&#225;s riesgo de ingreso en UCI que aquellos con detecci&#243;n exclusiva de un &#250;nico agente viral<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">13</span></a>&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Por otro lado&#44; hay estudios que relacionan una mayor gravedad en las bronquiolitis por VRS exclusivamente comparadas con las bronquiolitis en las que adem&#225;s se detectan otros virus respiratorios&#46; Marguet et al&#46; observaron una mayor duraci&#243;n de la estancia hospitalaria en aquellos con monodetecci&#243;n de VRS frente a los que presentaban codetecci&#243;n VRS&#47;HRV<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">12</span></a>&#46; Otro trabajo&#44; realizado en Italia&#44; concluy&#243; que la monodetecci&#243;n de VRS comportaba m&#225;s tiempo de hospitalizaci&#243;n y m&#225;s hipoxia que la codetecci&#243;n MPV&#47;VRS en lactantes hospitalizados por enfermedad respiratoria aguda<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">26</span></a>&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">En cuanto al tiempo medio de hospitalizaci&#243;n&#44; no se encontraron diferencias estad&#237;sticamente significativas entre los lactantes en los que se detect&#243; &#250;nicamente VRS y los que presentaron codetecci&#243;n viral en nuestro estudio&#46; En cambio&#44; se observa una menor duraci&#243;n de la estancia hospitalaria de los lactantes ingresados por bronquiolitis por VRS que en otros estudios publicados en Espa&#241;a &#40;5 vs&#46; 5&#44;9 d&#237;as&#41;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">27</span></a>&#44; y muy por debajo de otro estudio realizado en Austria en infecciones graves por VRS &#40;6&#44;7 d&#237;as de media&#41;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">25</span></a>&#46; Sin embargo&#44; otros trabajos reflejan tiempos medios de hospitalizaci&#243;n mucho menores &#40;2-3 d&#237;as en un estudio multic&#233;ntrico realizado en EE&#46; UU&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">15</span></a>&#41;&#46; El tiempo medio de hospitalizaci&#243;n es un par&#225;metro subjetivo que depende del facultativo y el servicio en el que est&#233; ingresado el paciente&#44; as&#237; como del centro hospitalario y del criterio para considerar a un paciente como hospitalizado&#46; En nuestro trabajo se ha considerado como estancia hospitalaria todo el tiempo que el paciente ha permanecido en el centro hospitalario&#44; independientemente de si ha permanecido en urgencias&#44; observaci&#243;n o planta&#46; Por tanto&#44; no es un par&#225;metro consistente para comparar nuestros datos con otros centros o estudios realizados&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Entre las fortalezas de nuestro trabajo se&#241;alamos el dise&#241;o prospectivo&#44; la duraci&#243;n del mismo y la considerable cantidad de pacientes incluidos&#44; todos ellos lactantes con bronquiolitis por VRS&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Las principales limitaciones derivan de las propias t&#233;cnicas de detecci&#243;n de virus respiratorios &#40;PCR en tiempo real&#41;&#46; El hecho de detectar m&#225;s de un agente viral no implica necesariamente la participaci&#243;n de los pat&#243;genos en el proceso infeccioso&#44; ya que la presencia de material gen&#233;tico puede detectarse hasta 5 o 6 semanas despu&#233;s en algunos casos<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">8</span></a>&#46; Por otro lado&#44; puede haber una baja recuperaci&#243;n de agentes virales y subestimar las muestras positivas por factores como la toma de muestra retardada&#44; ya que la carga viral disminuye con el tiempo<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">28&#44;29</span></a>&#46; Cabe resaltar que existe una gran variabilidad metodol&#243;gica &#40;distintos grupos de edad&#44; diferente localizaci&#243;n geogr&#225;fica&#44; diferentes t&#233;cnicas de PCR utilizadas&#44; etc&#46;&#41; en los estudios publicados sobre la relevancia cl&#237;nica de la codetecci&#243;n viral en pacientes con infecci&#243;n respiratoria&#44; lo que dificulta la comparaci&#243;n de los resultados obtenidos&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Como conclusi&#243;n&#44; no parece haber mayor gravedad entre aquellos lactantes con bronquiolitis por VRS y aquellos con VRS m&#225;s otro agente viral&#46; No obstante&#44; consideramos necesario realizar m&#225;s estudios multic&#233;ntricos prospectivos con una metodolog&#237;a com&#250;n para poder definir mejor la relevancia cl&#237;nica de la codetecci&#243;n viral en este tipo de pacientes&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Conflicto de intereses</span><p id="par0145" class="elsevierStylePara elsevierViewall">Los autores declaran que no tienen conflicto de intereses&#46;</p></span></span>"
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              "titulo" => "Detecci&#243;n de virus respiratorios en lactantes con bronquiolitis por VRS"
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              "titulo" => "Datos cl&#237;nicos y epidemiol&#243;gicos"
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    "fechaRecibido" => "2023-03-15"
    "fechaAceptado" => "2023-04-24"
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            0 => "Respiratory syncytial virus"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introducci&#243;n</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">La bronquiolitis es una infecci&#243;n respiratoria grave en lactantes causada principalmente por el virus respiratorio sincitial &#40;VRS&#41;&#46; El objetivo de este estudio es evaluar si la codetecci&#243;n de VRS y otros virus respiratorios puede desencadenar un cuadro de mayor o menor gravedad que la presencia de VRS exclusivamente&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">M&#233;todos</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Se realiz&#243; un estudio prospectivo en menores de 2 a&#241;os que acudieron a urgencias del Hospital Universitario Arnau de Vilanova de Lleida con diagn&#243;stico de bronquiolitis aguda desde 2016 a 2019&#46; A todos ellos se les realiz&#243; PCR de VRS y gripe en muestra nasofar&#237;ngea &#40;GeneXpert&#174;&#41; y a los pacientes con detecci&#243;n de VRS se les realiz&#243; PCR m&#250;ltiple de virus respiratorios&#46; Se recogieron datos cl&#237;nicos de los pacientes &#40;tiempo de hospitalizaci&#243;n&#44; &#237;ndice de BROSJOD&#44; ingreso en UCI&#44; necesidad de soporte respiratorio&#44; traslado a un centro de tercer nivel&#41; y se realizaron an&#225;lisis bivariantes para comparar el grupo de bronquiolitis con detecci&#243;n exclusiva de VRS con el de codetecci&#243;n con otros virus respiratorios&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Durante el per&#237;odo de estudio se diagnosticaron 437 bronquiolitis por VRS&#46; En 199 de ellas &#40;199&#47;437&#59; 45&#44;5&#37;&#41; se detect&#243; concomitantemente otro virus respiratorio&#46; El an&#225;lisis bivariante de los datos no mostr&#243; diferencias estad&#237;sticamente significativas en ninguna de las variables estudiadas&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusiones</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">La codetecci&#243;n viral en lactantes con bronquiolitis por VRS se da con elevada frecuencia&#44; aunque no parece afectar a la gravedad del cuadro cl&#237;nico&#46;</p></span>"
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            "identificador" => "abst0010"
            "titulo" => "M&#233;todos"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introduction</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Respiratory syncytial virus &#40;RSV&#41; is the main cause of severe bronchiolitis&#44; especially in infants&#46; The aim of this study is to assess whether codetection of RSV and other respiratory viruses could affect the severity of this infection comparing with unique RSV detection&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Methods</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">A prospective study from 2016 to 2019 including children under 2 years who were admitted in the Emergency Service of the Hospital Universitari Arnau de Vilanova de Lleida &#40;Spain&#41; was performed&#46; Nasopharyngeal samples from all patients were sent to the laboratory for RSV real-time PCR detection &#40;GeneXpert&#174;&#41;&#46; A multiplex PCR that detects other respiratory viruses was done in all RSV-positive samples&#46; Patients&#8217; medical records were checked to collect clinical data &#40;hospital length of stay&#44; BROSJOD score&#44; ICU admission&#44; need for ventilatory support or transfer to a reference hospital&#41;&#46; Patients were divided in 2 groups&#58; infants with unique RSV detection and infants with viral codetection&#46; Bivariant analyses were performed to analyze the data obtained&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">During the period of study 437 RSV bronchiolitis were diagnosed&#46; In 199 of them &#40;177&#47;437&#59; 45&#46;5&#37;&#41; another respiratory virus was detected concomitantly&#46; Bivariant analyses do not show statistically significant differences between both groups&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusions</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Viral codetection in infants with RSV bronchiolitis is frequent&#46; However&#44; it does not seems to affect the severity of this infection&#46;</p></span>"
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          "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">FiO<span class="elsevierStyleInf">2</span>&#58; fracci&#243;n inspiratoria de ox&#237;geno&#59; SNG&#58; sonda nasog&#225;strica&#59; UCIP&#58; unidad de cuidados intensivos pedi&#225;tricos&#59; VRS&#58; virus respiratorio sincitial&#46;</p>"
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">N&#250;mero de episodios &#40;&#37;&#41; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>437&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">N&#250;mero de episodios con VRS &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">N&#250;mero de episodios con codetecci&#243;n &#40;VRS<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>otros&#41; &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Duraci&#243;n de la hospitalizaci&#243;n &#40;d&#237;as&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">5&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">5&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">5&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;525&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">Necesidad de ox&#237;geno&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">275 &#40;62&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">142 &#40;59&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">133 &#40;66&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Duraci&#243;n ox&#237;geno &#40;d&#237;as&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;449&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">FiO<span class="elsevierStyleInf">2</span> m&#225;xima suministrada &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">32&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">32&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">34&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;562&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">Pacientes con necesidad de SNG&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">91 &#40;20&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">36 &#40;18&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Traslados a hospital tercer nivel&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">36 &#40;15&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">36 &#40;18&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;679&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">&#205;ndice de BROSJOD&#58; moderado &#40;6-10&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">320 &#40;73&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">178 &#40;74&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;679&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#205;ndice de BROSJOD&#58; grave &#40;11-16&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">45 &#40;10&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">24 &#40;10&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">21 &#40;10&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;679&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Pacientes con soporte respiratorio&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">94 &#40;21&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">56 &#40;23&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ingreso en UCIP&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">80 &#40;33&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">49 &#40;24&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;052&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">N&#250;mero de pacientes &#40;&#37;&#41; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>437&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Duraci&#243;n de la hospitalizaci&#243;n &#40;d&#237;as&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">436&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Necesidad de ox&#237;geno&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">151 &#40;65&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Duraci&#243;n ox&#237;geno &#40;d&#237;as&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">FiO<span class="elsevierStyleInf">2</span> m&#225;xima suministrada &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">436&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Pacientes con necesidad de SNG&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">91 &#40;20&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15 &#40;7&#44;28&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">76 &#40;33&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">436&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Traslados a hospital tercer nivel&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">22 &#40;5&#44;03&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">12 &#40;5&#44;83&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">10 &#40;4&#44;33&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;621&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">437&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#205;ndice de BROSJOD&#58; leve &#40;1-5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">72 &#40;16&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">35 &#40;17&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">37 &#40;16&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;908&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">437&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#205;ndice de BROSJOD&#58; moderado &#40;6-10&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">320 &#40;73&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">151 &#40;73&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">169 &#40;73&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;908&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">437&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#205;ndice de BROSJOD&#58; grave &#40;11-16&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">45 &#40;10&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">20 &#40;9&#44;71&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">25 &#40;10&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;908&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">437&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Duraci&#243;n de la hospitalizaci&#243;n en los pacientes que requirieron ox&#237;geno &#40;d&#237;as&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">270&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">FiO<span class="elsevierStyleInf">2</span> m&#225;xima suministrada en los pacientes que requirieron ox&#237;geno &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">35&#44;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">34&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">37&#44;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">274&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Necesidad de soporte respiratorio&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">94 &#40;21&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">11 &#40;5&#44;37&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">83 &#40;35&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">436&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ingreso en UCIP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">129 &#40;29&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">14 &#40;6&#44;80&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">115 &#40;49&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">437&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Monodetecci&#243;n VRS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">238 &#40;54&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">98 &#40;47&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">140 &#40;60&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;008&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">437&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Codetecci&#243;n viral&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">199 &#40;45&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">108 &#40;52&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">91 &#40;39&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;008&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">437&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Codetecci&#243;n con Flu&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8 &#40;1&#44;83&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t">Codetecci&#243;n con Adv&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Codetecci&#243;n con EV&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Codetecci&#243;n con PiV&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Codetecci&#243;n con MPV&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Codetecci&#243;n con BoV&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Codetecci&#243;n con HRV&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Codetecci&#243;n con CoV&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">Codetecci&#243;n con PeV&nbsp;\t\t\t\t\t\t\n
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                  """
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        "descripcion" => array:1 [
          "es" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Caracter&#237;sticas de los pacientes con bronquiolitis por VRS menores de 3 meses comparados con los pacientes con 3 o m&#225;s meses de edad</p>"
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                    0 => array:2 [
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                      "titulo" => "Clinical Practice Guideline&#58; The diagnosis&#44; management&#44; and prevention of bronchiolitis"
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                          "etal" => true
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                            3 => "B&#46;K&#46; Alverson"
                            4 => "J&#46;E&#46; Baley"
                            5 => "A&#46;M&#46; Gadomski"
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                    0 => array:2 [
                      "doi" => "10.1542/peds.2014-2742"
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                        "tituloSerie" => "Pediatrics&#46;"
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                        "volumen" => "134"
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                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25349312"
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                      "titulo" => "Association between multiple respiratory viral infections and pediatric intensive care unit admission among infants with bronchiolitis"
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                            2 => "M&#46; Kovvuri"
                            3 => "N&#46; Garg"
                            4 => "M&#46; Thangavelu"
                            5 => "Y&#46; Wang"
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                        ]
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                    0 => array:2 [
                      "doi" => "10.1016/j.arcped.2019.11.006"
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                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/31780096"
                            "web" => "Medline"
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                0 => array:2 [
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                      "titulo" => "Dual infection of infants by human metapneumovirus and human respiratory syncytial virus is strongly associated with severe bronchiolitis"
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                        0 => array:2 [
                          "etal" => true
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                            4 => "P&#46;S&#46; McNamara"
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                    0 => array:2 [
                      "titulo" => "Recomendaciones para la prevenci&#243;n de la infecci&#243;n por virus respiratorio sincitial"
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Información del artículo
ISSN: 0213005X
Idioma original: Español
DOI:10.1016/j.eimc.2023.04.009
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