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Factores de riesgo asociados a osteomielitis por Corynebacterium striatum en pacientes con pie diabético
Risk factors associated with osteomyelitis due to Corynebacterium striatum in patients with diabetic foot
María del Mar Bermejo Olanoa, Carolina Campelo Gutierrezb, Rafael Hervas Gómezc, Jesús Manuel Alfayate Garcíad, Juan Pedro Sánchez Ríosd, Leonor Moreno Núñezc,
Autor para correspondencia
lmorenon@salud.madrid.org

Autor para correspondencia.
a Servicio de Medicina Interna, Hospital Universitario Fundación Alcorcón, Madrid, España
b Servicio de Microbiología, Hospital Universitario Fundación Alcorcón, Madrid, España
c Unidad de Infecciosas, Hospital Universitario Fundación Alcorcón, Madrid, España
d Servicio de Cirugía Vascular, Hospital Universitario Fundación Alcorcónr, Madrid, España
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striatum</span>&#41; como una de las especies m&#225;s prevalentes<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3&#44;4</span></a>&#46; La inmunosupresi&#243;n&#44; la hospitalizaci&#243;n prolongada o la toma previa de antibi&#243;ticos se consideran factor de riesgo &#40;FR&#41; para esta infecci&#243;n<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a>&#46; La <span class="elsevierStyleItalic">C&#46; striatum</span> constituye un pat&#243;geno emergente en infecciones profundas de pie diab&#233;tico<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">5&#44;6</span></a> con una prevalencia de 4-10&#37;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a>&#46; El objetivo de este estudio es evaluar los FR relacionados con la osteomielitis por <span class="elsevierStyleItalic">C&#46; striatum</span> en el paciente con pie diab&#233;tico&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material y m&#233;todos</span><p id="par0010" class="elsevierStylePara elsevierViewall">Estudio observacional de casos y controles en la Unidad de Pie diab&#233;tico del Hospital Universitario Fundaci&#243;n Alcorc&#243;n&#44; hospital secundario de 400 camas&#46; La Unidad de Pie diab&#233;tico es multidisciplinar y atiende a unos 1&#46;000 pacientes al a&#241;o de forma ambulatoria&#44; 17&#44;5&#37; con infecci&#243;n&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Se incluyeron todos los pacientes atendidos entre enero de 2015 y marzo de 2021 diagnosticados de osteomielitis por <span class="elsevierStyleItalic">C&#46; striatum</span> confirmada mediante cultivo &#243;seo&#44; considerando la infecci&#243;n por como el episodio de referencia en la recogida de datos&#46; Para el grupo control&#44; se seleccion&#243; una muestra aleatoria del mismo tama&#241;o &#40;relaci&#243;n 1&#58;1&#41; de los atendidos en el mismo periodo de tiempo con osteomielitis para otro microorganismo diferente&#46; En aquellos que ten&#237;an m&#225;s de un cultivo &#243;seo positivo&#44; se aleatoriz&#243; cu&#225;l de ellos se tomar&#237;a como episodio de referencia en la recogida de datos&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Se recogieron variables demogr&#225;ficas&#44; comorbilidades y las relacionadas con la infecci&#243;n de pie diab&#233;tico&#46; Se registr&#243; el grado de infecci&#243;n seg&#250;n la clasificaci&#243;n de la <span class="elsevierStyleItalic">Infectious Diseases Society of America</span> &#40;IDSA&#41;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a>&#59; consider&#225;ndose infecci&#243;n leve cuando los signos de infecci&#243;n local &#40;calor&#44; eritema&#44; edema y dolor&#41; envuelven solo la piel y el tejido celular subcut&#225;neo&#44; sin signos sist&#233;micos de infecci&#243;n&#44; siendo el eritema menor de 2 cm de di&#225;metro&#59; infecci&#243;n moderada definida como infecci&#243;n local &#40;seg&#250;n lo descrito previamente&#41; con eritema mayor de 2 cm o que envuelve estructuras m&#225;s profundas del tejido celular subcut&#225;neo &#40;presencia de abscesos&#44; osteomielitis&#44; artritis s&#233;ptica o fascitis&#41; sin signos de respuesta inflamatoria sist&#233;mica&#59; e infecci&#243;n grave aquella definida como local moderada&#44; pero con presencia de signos de respuesta inflamatoria sist&#233;mica&#46; Se recogi&#243; la existencia o no de otros hallazgos sugestivos de osteomielitis &#40;<span class="elsevierStyleItalic">probe-to-bone test</span> positivo o radiograf&#237;a patol&#243;gica&#41;&#44; si hubo aislamientos concomitantes o no&#44; si la infecci&#243;n era aguda o cr&#243;nica &#40;definida como el diagn&#243;stico previo de osteomielitis en la misma localizaci&#243;n sin haberse alcanzado curaci&#243;n cl&#237;nica tras recibir un ciclo apropiado de antibi&#243;tico&#41; y la antibioterapia previa recibida en este &#250;ltimo caso&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">El estudio fue aprobado por el Comit&#233; &#201;tico de Investigaci&#243;n Cl&#237;nica del Hospital Universitario Fundaci&#243;n Alcorc&#243;n&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Se realiz&#243; un an&#225;lisis descriptivo de la muestra y posteriormente un an&#225;lisis univariante para evaluar los FR relacionados con la infecci&#243;n por <span class="elsevierStyleItalic">C&#46; striatum</span>&#46; Para las variables cualitativas se aplic&#243; la prueba de <span class="elsevierStyleItalic">X</span><span class="elsevierStyleSup"><span class="elsevierStyleItalic">2</span></span> o <span class="elsevierStyleItalic">f</span>&#160;de Fisher y para las variables cuantitativas el test <span class="elsevierStyleItalic">t</span> Student para dos muestras independientes o el no param&#233;trico U de Mann-Whitney&#46; Finalmente se realiz&#243; un an&#225;lisis de regresi&#243;n log&#237;stica simple y multivariante para estimar el efecto como <span class="elsevierStyleItalic">odds ratio</span> &#40;OR&#41; de las variables de inter&#233;s sin ajustar y ajustando por edad y sexo&#46; Todos los test se consideran bilaterales y como estad&#237;sticamente significativo un valor de p &#60; 0&#44;05&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Resultados</span><p id="par0035" class="elsevierStylePara elsevierViewall">Un total de 88 pacientes con osteomielitis fueron estudiados&#44; 44 con infecci&#243;n por <span class="elsevierStyleItalic">C&#46; striatum</span> y 44 por otros microorganismos&#46; De ellos&#44; 85&#37; fueron hombres con edad media de 69 a&#241;os &#40;&#177;13&#41;&#44; 18&#37; ten&#237;an fibrilaci&#243;n auricular &#40;27 grupo <span class="elsevierStyleItalic">C&#46; striatum</span> vs&#46; 9&#37; grupo control&#59; p &#61; 0&#44;027&#41; y 71&#37; arteriopat&#237;a perif&#233;rica&#44; siendo m&#225;s frecuente en los pacientes con osteomielitis por <span class="elsevierStyleItalic">C&#46; striatum</span> &#40;82 vs&#46; 61&#37;&#59; p &#61; 0&#44;033&#41;&#46; La mayor&#237;a ten&#237;an una infecci&#243;n moderada &#40;95&#44;5&#37;&#41; siendo polimicrobiana con mayor frecuencia en el grupo de osteomielitis por <span class="elsevierStyleItalic">C&#46; striatum</span> &#40;50 vs&#46; 27&#37;&#59; p &#61; 0&#44;029&#41;&#46; Los microorganismos m&#225;s frecuentemente aislados junto a <span class="elsevierStyleItalic">C&#46; striatum</span> fueron bacilos gramnegativos &#40;8&#47;22&#41;&#44; <span class="elsevierStyleItalic">Staphylococcus aureus</span> &#40;<span class="elsevierStyleItalic">S&#46; aureus</span>&#41; &#40;7&#47;22&#41; y otros cocos grampositivos &#40;7&#47;22&#41;&#46; De los pacientes con osteomielitis por <span class="elsevierStyleItalic">C&#46; striatum</span> 57&#37; ten&#237;an una infecci&#243;n cr&#243;nica vs&#46; 39&#37; en el grupo control&#44; por lo que 50&#37; hab&#237;an recibido &#62; 14 d&#237;as de antibioterapia vs&#46; a 23&#37; en el caso de osteomielitis por otros microorganismos &#40;p &#61; 0&#44;032&#41;&#44; siendo los antibi&#243;ticos recibidos similares en ambos grupos&#46; La osteomielitis por <span class="elsevierStyleItalic">C&#46; striatum</span> asent&#243; con mayor frecuencia sobre un pie isqu&#233;mico &#40;84 vs&#46; 61&#37; en el grupo control&#59; p &#61; 0&#44;017&#41;&#46; De los pacientes con osteomielitis por <span class="elsevierStyleItalic">C&#46; striatum</span>&#44; 57&#37; &#40;25&#47;44&#41; recibieron tratamiento antibi&#243;tico espec&#237;fico con vancomicina&#44; linezolid o dalbavancina&#44; 86&#37; &#40;38&#47;44&#41; fue intervenido quir&#250;rgicamente &#40;87&#37; amputaci&#243;n menor y 13&#37; desbridamiento&#41; y en 45&#37; se realiz&#243; revascularizaci&#243;n &#40;34&#37; endovascular&#44; 11&#37; <span class="elsevierStyleItalic">bypass</span>&#41;&#46; El resto de las caracter&#237;sticas cl&#237;nicas y anal&#237;ticas se detallan en la <a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">En el an&#225;lisis univariante&#44; la arteriopat&#237;a perif&#233;rica &#40;OR&#58; 2&#44;8&#44; p &#61; 0&#44;037&#41;&#44; la fibrilaci&#243;n auricular &#40;OR&#58; 3&#44;7&#44; p &#61; 0&#44;034&#41;&#44; la antibioterapia &#62;14 d&#237;as &#40;OR&#58; 3&#44;4&#44; p &#61; 0&#44;012&#41; y el pie isqu&#233;mico &#40;OR&#58; 3&#44;3&#44; p &#61; 0&#44;020&#41; fueron FR de infecci&#243;n por <span class="elsevierStyleItalic">C&#46; striatum</span> estad&#237;sticamente significativos&#46; Al realizar el an&#225;lisis multivariante&#44; incluyendo las variables previas junto con el sexo y la edad&#44; los efectos estimados son de la misma magnitud que en el an&#225;lisis univariante&#44; pero el &#250;nico FR independiente y estad&#237;sticamente significativo fue haber recibido antibioterapia &#62;14 d&#237;as &#40;OR&#58; 3&#44;4&#44; p &#61; 0&#44;017&#41;&#44; como se muestra en la <a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discusi&#243;n</span><p id="par0045" class="elsevierStylePara elsevierViewall">Este estudio es el primero en describir los FR asociados a la osteomielitis por <span class="elsevierStyleItalic">C&#46; striatum</span> en el pie diab&#233;tico&#46; De nuestro an&#225;lisis se concluye que la antibioterapia previa prolongada&#44; el pie diab&#233;tico isqu&#233;mico y la fibrilaci&#243;n auricular son FR para el desarrollo de este tipo de infecci&#243;n&#59; siendo la antibioterapia prolongada el &#250;nico FR independiente&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">La toma previa de antibi&#243;ticos es un FR cl&#225;sico en las infecciones por <span class="elsevierStyleItalic">C&#46; striatum</span><a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a>&#44; aunque el motivo por el que se produce esta selecci&#243;n de flora no es bien conocido&#46; La infecci&#243;n del pie diab&#233;tico es un ejemplo donde la antibioterapia prolongada es habitual dado que suele tratarse de aquellas que son cr&#243;nicas y de alta complejidad<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a>&#46; Con respecto a la isquemia&#44; las infecciones sobre pie diab&#233;tico isqu&#233;mico son de mayor complejidad y peor pron&#243;stico de curaci&#243;n que las que asientan sobre pie neurop&#225;tico<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a>&#44; con tasas de cronicidad elevadas y tiempos hasta la curaci&#243;n m&#225;s prolongados&#44; condicionando ciclos repetidos y prolongados de antibioterapia&#46; De este modo&#44; la isquemia y la antibioterapia prolongada est&#225;n &#237;ntimamente relacionadas&#46; En cuanto a la fibrilaci&#243;n auricular&#44; no existen datos en la literatura que la relacionen con esta infecci&#243;n y ser&#237;a necesario realizar m&#225;s estudios para esclarecer su papel&#46; Otros FR cl&#225;sicamente relacionados con las infecciones por <span class="elsevierStyleItalic">C&#46; striatum</span> son el traumatismo&#44; la hospitalizaci&#243;n y la inmunodepresi&#243;n<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a>&#46; Los microtraumatismos de repetici&#243;n constituyen la piedra angular en la fisiopatolog&#237;a de las &#250;lceras de pie diab&#233;tico<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a>&#46; Con respecto al ambiente hospitalario&#44; los pacientes de la consulta de pie diab&#233;tico acuden frecuentemente al hospital para la cura de las lesiones&#46; Sin embargo&#44; dado que ambos factores son compartidos por todos los pacientes&#44; no se han analizado como FR para la infecci&#243;n por <span class="elsevierStyleItalic">C&#46; striatum&#46;</span> Finalmente&#44; en relaci&#243;n con la inmunodepresi&#243;n&#44; en nuestro estudio no hemos encontrado diferencias significativas entre los grupos en la tasa de neoplasias o inmunosupresi&#243;n&#46; Estudios recientes<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2&#44;3</span></a> reportan tasas de infecci&#243;n osteoarticular en pacientes inmunocompetentes por <span class="elsevierStyleItalic">C&#46; striatum</span> y <span class="elsevierStyleItalic">Corynebacterium spp</span> de 55 y 86&#37; por lo que puede que la inmunodepresi&#243;n no tenga un papel decisivo en el desarrollo de esta infecci&#243;n&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Nuestro estudio presenta las limitaciones propias de un estudio retrospectivo y de tama&#241;o muestral peque&#241;o&#46; Sin embargo&#44; aporta conocimiento para un tipo de infecciones poco estudiadas&#44; teniendo en cuenta que <span class="elsevierStyleItalic">C&#46; striatum</span> constituye un microorganismo emergente en las infecciones de pie diab&#233;tico con alta tasa de resistencia a antibi&#243;ticos<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#44;4</span></a>&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Los autores consideramos que debemos tener en cuenta a <span class="elsevierStyleItalic">C&#46; striatum</span> como un posible pat&#243;geno en pacientes con pie diab&#233;tico isqu&#233;mico y osteomielitis que hayan recibido tratamiento antibi&#243;tico prolongado para as&#237; optimizar el tratamiento antibi&#243;tico emp&#237;rico&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Financiaci&#243;n</span><p id="par0065" class="elsevierStylePara elsevierViewall">Este trabajo no ha recibido ning&#250;n tipo de financiaci&#243;n&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflicto de intereses</span><p id="par0070" class="elsevierStylePara elsevierViewall">Los autores declaran no tener ning&#250;n conflicto de intereses&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">El estudio se realiz&#243; de acuerdo con el Reglamento &#40;UE&#41; 2016&#47;679 del Parlamento Europeo y del Consejo del 27 de abril de 2016 de Protecci&#243;n de Datos y las Buenas Pr&#225;cticas Cl&#237;nicas en Investigaci&#243;n&#44; y fue aprobado por el Comit&#233; &#201;tico de Investigaci&#243;n Cl&#237;nica del Hospital Universitario Fundaci&#243;n Alcorc&#243;n&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objetivo</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Corynebacterium striatum</span> &#40;<span class="elsevierStyleItalic">C&#46; striatum</span>&#41; es un microorganismo emergente en la infecci&#243;n de pie diab&#233;tico poco estudiado&#46; El objetivo es evaluar los factores de riesgo &#40;FR&#41; relacionados con osteomielitis por <span class="elsevierStyleItalic">C&#46; striatum</span> en paciente con pie diab&#233;tico&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">M&#233;todos</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Estudio casos-controles en la Unidad de Pie Diab&#233;tico entre 2015 y 2021&#46; Un n&#250;mero de 44 pacientes con osteomielitis por <span class="elsevierStyleItalic">C&#46; striatum</span> &#40;casos&#41; y 44 con osteomielitis por microorganismo distinto &#40;controles&#41; fueron incluidos&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Enfermedad arterial perif&#233;rica &#40;<span class="elsevierStyleItalic">odds ratio</span> &#91;OR&#93;&#58; 2&#44;8&#44; p &#61; 0&#44;037&#41;&#44; fibrilaci&#243;n auricular &#40;OR&#58; 3&#44;7&#44; p &#61; 0&#44;034&#41;&#44; pie diab&#233;tico isqu&#233;mico &#40;OR&#58; 3&#44;3&#44; p &#61; 0&#44;020&#41; y antibioterapia previa prolongada m&#225;s de 14 d&#237;as &#40;OR&#58; 3&#44;4&#44; p &#61; 0&#44;012&#41; fueron FR para la osteomielitis por <span class="elsevierStyleItalic">C&#46; striatum&#46;</span> En el an&#225;lisis multivariado la antibioterapia m&#225;s de 14 d&#237;as fue el &#250;nico FR independiente &#40;OR&#58; 3&#44;46&#59; p &#61; 0&#44;017&#41; para osteomielitis por <span class="elsevierStyleItalic">C&#46; striatum</span>&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusiones</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">La antibioterapia previa recibida durante m&#225;s de 14 d&#237;as es un FR independiente y estad&#237;sticamente significativo de osteomielitis por <span class="elsevierStyleItalic">C&#46; striatum</span> en pacientes con pie diab&#233;tico&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objective</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Corynebacterium striatum</span> &#40;CS&#41; is an emerging micro-organism in diabetic foot infection for which there are currently few studies&#46; The objective was to analyze the risk factors &#40;RF&#41; related to CS osteomyelitis in patients with diabetic foot&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Methods</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">A case&#8211;control study was conducted in the Diabetic Foot Unit between 2015 and 2021&#46; Forty-four patients with osteomyelitis due to CS &#40;cases&#41; and 44 patients with osteomyelitis due a different micro-organism &#40;controls&#41; were included&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Peripheral artery disease &#40;OR&#58; 2&#46;8&#44; <span class="elsevierStyleItalic">p</span> &#61; 0&#46;037&#41;&#44; atrial fibrillation &#40;OR&#58; 3&#46;7&#44; <span class="elsevierStyleItalic">p</span> &#61; 0&#46;034&#41;&#44; ischemic diabetic foot &#40;OR&#58; 3&#46;3&#44; <span class="elsevierStyleItalic">p</span> &#61; 0&#46;020&#41; and previous prolonged antibiotic therapy more than 14 days &#40;OR&#58; 3&#46;4&#44; <span class="elsevierStyleItalic">p</span> &#61; 0&#46;012&#41; were identified as RF for osteomyelitis due to CS&#46; When performing the multivariate analysis antibiotic therapy &#62;14 days was independent RF &#40;OR&#58; 3&#46;46&#59; <span class="elsevierStyleItalic">p</span> &#61; 0&#46;017&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusions</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Previous antibiotic therapy received more than 14 days is an independent and statistically significant RF for CS osteomyelitis in patients with diabetic foot&#46;</p></span>"
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Total n &#40;&#37;&#41;<a class="elsevierStyleCrossRef" href="#tblfn0010">&#42;</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Osteomielitis por <span class="elsevierStyleItalic">C&#46; striatum</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Osteomielitis grupo control&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Datos demogr&#225;ficos</span></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
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Edad &#40;media &#177; DE&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">69&#44;5 &#40;13&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">71&#44;3 &#40;13&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">67&#44;8 &#40;13&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;2&nbsp;\t\t\t\t\t\t\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"><span class="elsevierStyleHsp" style=""></span>G&#233;nero&#44; var&#243;n&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">75 &#40;85&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">38 &#40;86&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">37 &#40;84&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;764&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Comorbilidades</span></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"><span class="elsevierStyleHsp" style=""></span>HTA&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">70 &#40;79&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">37 &#40;89&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">33 &#40;75&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;290&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"><span class="elsevierStyleHsp" style=""></span>Dislipemia&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">53 &#40;60&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">30 &#40;68&#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
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">23 &#40;52&#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
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;127&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"><span class="elsevierStyleHsp" style=""></span>Fumador&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">43 &#40;49&#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
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                  \t\t\t\t">21 &#40;48&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">22 &#40;50&#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;831&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"><span class="elsevierStyleHsp" style=""></span>Cardiopat&#237;a isqu&#233;mica &#40;IAM&#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;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">14 &#40;32&#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">11 &#40;25&#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;478&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"><span class="elsevierStyleHsp" style=""></span>Enfermedad coronaria&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">30 &#40;34&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">18 &#40;41&#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">12 &#40;27&#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;177&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"><span class="elsevierStyleHsp" style=""></span>Ictus&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">14 &#40;16&#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">6 &#40;14&#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">8 &#40;18&#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;560&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"><span class="elsevierStyleHsp" style=""></span>Arteriopat&#237;a perif&#233;rica&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">63 &#40;71&#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">36 &#40;82&#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">27 &#40;61&#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;033&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"><span class="elsevierStyleHsp" style=""></span>Fibrilaci&#243;n auricular&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">16 &#40;18&#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;27&#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">4 &#40;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">0&#44;027&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"><span class="elsevierStyleHsp" style=""></span>Insuficiencia Cardiaca&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">15 &#40;17&#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">5 &#40;11&#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">10 &#40;23&#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;156&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"><span class="elsevierStyleHsp" style=""></span>ERC &#40;filtrado glomerular&#60; 60 mL&#47;min&#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">64 &#40;73&#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">29 &#40;66&#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">35 &#40;79&#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;151&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"><span class="elsevierStyleHsp" style=""></span>Hemodi&#225;lisis&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"><span class="elsevierStyleHsp" style=""></span>Neoplasia&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#205;ndice de Charlson&#44; mediana &#40;q1-q3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Hemoglobina glicosilada&#44; &#40;media &#177; DE&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Grado de infecci&#243;n &#40;IDSA&#41;</span><a class="elsevierStyleCrossRef" href="#tblfn0015">&#42;&#42;</a></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Grave&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Tipo de pie diab&#233;tico</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Neurop&#225;tico&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Hallazgos de osteomielitis</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Probe-to-bone positivo&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Radiograf&#237;a simple patol&#243;gica&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Infecci&#243;n polimicrobiana&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Infecci&#243;n cr&#243;nica&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;088&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">0&#44;37-3&#44;9&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;764&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;90&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;24-3&#44;37&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">0&#44;879&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
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                  \t\t\t\t">Fibrilaci&#243;n auricular&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3&#44;75&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#44;1-12&#44;74&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">0&#44;034&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">3&#44;15&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;77-12&#44;94&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;111&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
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                  \t\t\t\t">Arteriopat&#237;a perif&#233;rica&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2&#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">1-7&#44;5&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;037&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Pie isqu&#233;mico&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">1&#44;21-9&#44;14&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;91-10&#44;41&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;069&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#62;14 d&#237;as de antibi&#243;tico&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#44;29-8&#44;63&nbsp;\t\t\t\t\t\t\n
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          "es" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">An&#225;lisis univariante y multivariante</p>"
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                      "titulo" => "Monomicrobial bone and joint infection due to Corynebacterium striatum&#58; literature review and amoxicillin-rifampin combination as treatment perspective"
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                      "titulo" => "Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections&#58; 2014 Update by the Infectious Diseases Society of America"
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                          "etal" => true
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                      "titulo" => "Documento de consenso sobre el tratamiento de las infecciones en el pie del diab&#233;tico"
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                          "colaboracion" => "Representantes de la Asociaci&#243;n Espa&#241;ola de Cirujanos &#40;AEC&#41;&#44; Sociedad Espa&#241;ola de Angiolog&#237;a y Cirug&#237;a Vascular &#40;SEACV&#41;&#44; Sociedad Espa&#241;ola de Medicina de Urgencias y Emergencias &#40;SEMES&#41;&#44; Sociedad Espa&#241;ola de Medicina Interna &#40;SEMI&#41;&#44; Sociedad Espa&#241;ola de Medicina Intensiva&#44; Cr&#237;tica y Unidades Coronarias &#40;SEMICYUC&#41;"
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                            0 => "J&#46;I&#46; Blanes Mompo"
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                    0 => array:1 [
                      "Revista" => array:6 [
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Información del artículo
ISSN: 00257753
Idioma original: Español
DOI:10.1016/j.medcli.2023.09.015
Datos actualizados diariamente
año/Mes Html Pdf Total
2024 Febrero 3 0 3
2024 Enero 1 0 1

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