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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Introducci&#243;n</span><p id="par0005" class="elsevierStylePara elsevierViewall">La emergencia de bacterias multirresistentes &#40;BMR&#41; es un fen&#243;meno biol&#243;gico natural y creciente a escala mundial&#44; amplificado por la utilizaci&#243;n amplia e inadecuada de antibi&#243;ticos<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">1</span></a>&#46; Incrementa los costes de la atenci&#243;n sanitaria&#44; los fracasos del tratamiento y la mortalidad&#44; tanto en hospitales como en la comunidad<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">2&#44;3</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Los pacientes ingresados en las unidades de cuidados intensivos &#40;UCI&#41; son especialmente susceptibles de adquirir BMR&#44; bien como colonizaci&#243;n o infecci&#243;n&#46; En el caso de las infecciones por BMR&#44; las opciones terap&#233;uticas son limitadas&#44; incrementando la probabilidad de un tratamiento emp&#237;rico inadecuado y el retraso de la terap&#233;utica apropiada&#44; agravando la enfermedad&#44; prolongando la estancia en la UCI&#44; as&#237; como los costes y la morbimortalidad<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">4&#44;5</span></a>&#46; La mortalidad de los pacientes con infecciones por BMR es superior a la producida por bacterias sensibles a los antibi&#243;ticos habitualmente empleados<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">4&#8211;6</span></a>&#46; Incluso en los casos de colonizaci&#243;n sin infecci&#243;n concomitante se ha demostrado un riesgo mayor de muerte y aumento en los tiempos de hospitalizaci&#243;n y costes<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">2&#44;7</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">En Espa&#241;a&#44; la Sociedad Espa&#241;ola de Medicina Intensiva&#44; Cr&#237;tica y Unidades Coronarias &#40;SEMICYUC&#41; ha liderado la implementaci&#243;n de los proyectos &#171;Tolerancia Zero&#187;&#44; patrocinados por el Ministerio de Sanidad&#44; con el objetivo de incrementar la seguridad de los pacientes cr&#237;ticos y disminuir las infecciones relacionadas a dispositivos<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">2</span></a>&#44; con resultados exitosos&#46; En el a&#241;o 2014 se inici&#243; el proyecto Resistencia Zero &#40;RZ&#41;&#44; con el objetivo de reducir la aparici&#243;n de BMR durante la estancia en la UCI<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">8</span></a>&#46; Entre las recomendaciones propuestas&#44; se contempla la identificaci&#243;n precoz de los portadores de BMR al ingreso en la UCI y la instauraci&#243;n de medidas de aislamiento preventivo en aquellos pacientes con factores de riesgo &#40;FR&#41; de ser portadores de BMR&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Los objetivos de este trabajo son conocer el rendimiento de los criterios de aislamiento preventivo propuestos por el proyecto RZ&#44; utilizados como FR para la condici&#243;n de portador de BMR de los pacientes cr&#237;ticos al ingreso en la UCI&#44; e identificar los factores que&#44; a&#241;adidos a dichos criterios&#44; pudieran mejorar su rendimiento&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Pacientes y m&#233;todos</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Dise&#241;o</span><p id="par0025" class="elsevierStylePara elsevierViewall">Estudio prospectivo&#44; observacional y multic&#233;ntrico&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">&#193;mbito</span><p id="par0030" class="elsevierStylePara elsevierViewall">El estudio se concibi&#243; dentro del Grupo de Trabajo de Infecciones y Sepsis &#40;GTEIS&#41; de la SEMICYUC&#46; Se envi&#243; una invitaci&#243;n a todas las unidades de cr&#237;ticos en Espa&#241;a a trav&#233;s de medios de difusi&#243;n de la misma sociedad&#46; Finalmente&#44; 9 UCI espa&#241;olas que participaron en el proyecto RZ de enero a diciembre de 2016 aceptaron la invitaci&#243;n de participar en el estudio&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Pacientes</span><p id="par0035" class="elsevierStylePara elsevierViewall">Se incluyeron los ingresados en la UCI a los que se les realizaron en las primeras 48<span class="elsevierStyleHsp" style=""></span>h cultivos de frotis de diferentes mucosas para la b&#250;squeda activa de BMR &#40;nasal&#44; far&#237;ngeo&#44; axilar&#44; rectal&#41; seg&#250;n recomendaciones del proyecto RZ y el protocolo de cada hospital&#44; adem&#225;s de cultivos diagn&#243;sticos de muestras cl&#237;nicas seg&#250;n criterio m&#233;dico&#46; Se excluyeron los pacientes menores de 15 a&#241;os y aquellos a los que no se realiz&#243; la toma de cultivos&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">M&#233;todo</span><p id="par0040" class="elsevierStylePara elsevierViewall">El cumplimiento del proyecto RZ incluye rellenar una lista de verificaci&#243;n en la que se recogen FR asociados a BMR&#58; ingreso hospitalario de m&#225;s de 5 d&#237;as en los 3 meses previos&#59; pacientes institucionalizados&#59; antecedente de portador de BMR&#59; antibioterapia durante m&#225;s de 7 d&#237;as en el mes previo al ingreso&#59; pacientes sometidos a hemodi&#225;lisis o di&#225;lisis peritoneal&#59; enfermedad cr&#243;nica con alta incidencia de colonizaci&#243;n&#47;infecci&#243;n por BMR &#40;fibrosis qu&#237;stica&#44; bronquiectasias&#44; &#250;lceras cr&#243;nicas&#44; etc&#46;&#41;&#46; A los pacientes que cumplen con alg&#250;n criterio se les aplican medidas de aislamiento preventivo de contacto&#44; que incluyen higiene de manos obligatoria seg&#250;n protocolo universal y uso de bata y guantes de un solo uso&#46; Seg&#250;n los resultados microbiol&#243;gicos&#44; se decide mantener o retirar dichas medidas&#46; Ninguna recogida de muestra adicional a las ya empleadas habitualmente en las UCI participantes fue necesaria para la realizaci&#243;n del estudio&#46; Se analizaron variables demogr&#225;ficas &#40;edad&#44; sexo&#44; <span class="elsevierStyleItalic">Acute Physiology And Chronic Health Evaluation</span> &#91;APACHE II&#93;&#44; como <span class="elsevierStyleItalic">score</span> de gravedad al ingreso en las UCI&#41;&#44; estancia y mortalidad&#44; y otras variables patol&#243;gicas y comorbilidades incluidas en el registro ENVIN-HELICS &#40;disponible en <a href="http://hws.vhebron.net/envin-helics/">http&#58;&#47;&#47;hws&#46;vhebron&#46;net&#47;envin-helics&#47;</a>&#41;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">9</span></a> &#40;diabetes mellitus &#91;DM&#93;&#44; insuficiencia renal aguda o cr&#243;nica &#91;IRAC&#93;&#44; inmunodepresi&#243;n&#44; neoplasia previa&#44; cirrosis hep&#225;tica&#44; enfermedad pulmonar obstructiva cr&#243;nica &#91;EPOC&#93;&#44; desnutrici&#243;n y trasplante de &#243;rgano s&#243;lido&#41;&#46; Se incluy&#243; la procedencia &#40;comunidad&#44; residencia u otra instituci&#243;n&#44; planta de hospitalizaci&#243;n u otra UCI&#41; y el motivo de ingreso &#40;paciente m&#233;dico&#44; quir&#250;rgico programado&#44; quir&#250;rgico urgente&#44; traumatol&#243;gico o coronario&#41;&#44; y si se indic&#243; tratamiento antibi&#243;tico &#40;ATB&#41; al ingreso en la UCI&#46; La informaci&#243;n se recogi&#243; inicialmente en un cuaderno de recogida de datos en formato papel&#44; que luego se transcribi&#243; a un cuaderno digital en formato Access&#174;&#46; Los pacientes y&#47;o familiares recibieron informaci&#243;n sobre los procedimientos microbiol&#243;gicos y sobre la pol&#237;tica de aislamiento preventivo&#46; Se obtuvo la aprobaci&#243;n por el comit&#233; de &#233;tica de Hospital del Mar&#44; Hospital 12 de Octubre y Burgos para el registro ENVIN&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Definiciones</span><p id="par0045" class="elsevierStylePara elsevierViewall">Se consider&#243; un paciente como portador de BMR al ingreso cuando uno de los cultivos de vigilancia y&#47;o las muestras cl&#237;nicas &#40;hemocultivos&#44; urinocultivo&#44; cultivos de esputo&#44; aspirado traqueal o broncoalveolar&#44; frotis de herida quir&#250;rgica u otro&#41;&#44; tomadas en las primeras 48<span class="elsevierStyleHsp" style=""></span>h de ingreso en la UCI resultaron positivos para una BMR&#46; Los BMR incluidas fueron&#58; <span class="elsevierStyleItalic">Staphylococcus aureus</span> resistente a metilicina &#40;SARM&#41;&#59; <span class="elsevierStyleItalic">Enterococcus</span> spp resistente a vancomicina &#40;ERV&#41;&#59; enterobacterias productoras de betalactamasa de espectro extendido &#40;BLEE&#41; y carbapenemasas&#59; <span class="elsevierStyleItalic">Pseudomonas aeruginosa</span> resistente a &#8805;<span class="elsevierStyleHsp" style=""></span>3 familias de antibi&#243;ticos habitualmente sensibles&#59; <span class="elsevierStyleItalic">Acinetobacter baumannii</span> resistente a carbapen&#233;micos&#46; Las BMR no incluidas en ese listado &#40;<span class="elsevierStyleItalic">Enterobacterlaes</span> gram-negativas resistentes a 3 o m&#225;s familias de antibi&#243;ticos o productoras de otros mecanismos de resistencia como las AmpC&#41; se clasificaron como &#171;otras&#187;&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">An&#225;lisis estad&#237;stico</span><p id="par0050" class="elsevierStylePara elsevierViewall">Las variables se describieron como mediana &#40;intervalo intercuartil&#41; o como porcentaje seg&#250;n tipo de variable&#46; La comparaci&#243;n entre grupos se realiz&#243; con los test de Mann-Whitney o Chi-cuadrado seg&#250;n el tipo de variable &#40;significaci&#243;n estad&#237;stica con p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41;&#46; El an&#225;lisis se realiza en 2 fases&#58; una primera que incluye a todos los hospitales con datos sobre criterios de aislamiento RZ&#44; y una segunda fase de estudio de factores de riesgo que excluye a 2 hospitales que no recogieron esos datos&#46; Se realizaron 2 modelos de regresi&#243;n log&#237;stica binaria multivariante con variable resultado la positividad de BMR&#46; En el primer modelo&#44; ajustado por edad y sexo&#44; se incluyeron los factores definidos por el programa RZ<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">10</span></a>&#46; En el segundo modelo se incluyeron las variables que alcanzaron significaci&#243;n en el an&#225;lisis bivariado a&#241;adidas a las de criterio de aislamiento RZ &#40;&#8805;<span class="elsevierStyleHsp" style=""></span>1 criterio&#41;&#44; con un sistema de selecci&#243;n de variables por pasos&#46; Se realiz&#243; an&#225;lisis de sensibilidad del segundo modelo obteniendo valores de sensibilidad&#44; especificidad&#44; valor predictivo positivo &#40;VPP&#41; y valor predictivo negativo &#40;VPN&#41; con intervalos de confianza del 95&#37; &#40;IC 95&#37;&#41;&#46; Los c&#225;lculos fueron realizados con el paquete estad&#237;stico SPSS&#174; &#40;v&#46;23&#41;&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Resultados</span><p id="par0055" class="elsevierStylePara elsevierViewall">En este estudio participaron 9 UCI espa&#241;olas de 6 comunidades auton&#243;micas&#58; Arag&#243;n&#44; Castilla y Le&#243;n&#44; Catalu&#241;a&#44; Galicia&#44; Madrid y Pa&#237;s Vasco&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Se incluyeron 2&#46;252 registros&#46; De las 9 UCI participantes&#44; solo en 7 de ellas se tomaron muestras de vigilancia de todos los pacientes a su ingreso en la UCI&#44; mientras que en las otras 2 se tomaron &#250;nicamente de los que ten&#237;an FR de ser portadores de BMR seg&#250;n la lista de verificaci&#243;n RZ&#46; Por ese motivo&#44; el estudio se dividi&#243; en 2 fases&#58; una primera que incluy&#243; a los 9 hospitales con datos de pacientes con criterios de aislamiento y las BMR encontradas&#44; y una segunda fase con datos de los 7 hospitales que recogieron tambi&#233;n los pacientes sin criterios de aislamiento RZ&#44; utilizados para realizar el estudio de factores de riesgo&#46;</p><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Fase 1&#46; Diferencias seg&#250;n hospitales y bacterias multirresistentes</span><p id="par0065" class="elsevierStylePara elsevierViewall">Un total de 2252 pacientes se incluyeron en esta fase&#46; En la <a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a> se analizan las caracter&#237;sticas demogr&#225;ficas de los pacientes&#44; nivel de gravedad&#44; muestras de vigilancia realizadas y BMR identificadas para cada una de las UCI participantes&#46; Se objetivan diferencias en el porcentaje de BMR &#40;con un rango del 3&#44;6 al 21&#44;8&#37;&#41;&#44; en la utilizaci&#243;n de cultivos de vigilancia &#40;muchos hospitales no realizan cultivo axilar y en uno de ellos solo cultivos rectales&#41; y en las BMR identificadas&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">Se identificaron una o m&#225;s BMR en 283 pacientes &#40;12&#44;6&#37; del total de ingresos&#41;&#44; de los cuales 193 &#40;68&#44;2&#37;&#41; presentaban uno o m&#225;s FR seg&#250;n la lista de verificaci&#243;n RZ&#46; En la <a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a> se incluyen las caracter&#237;sticas de esos pacientes con BMR diferenciadas seg&#250;n germen&#46; Se observan diferencias en la presencia de criterios de aislamiento RZ&#44; siendo <span class="elsevierStyleItalic">P&#46; aeruginosa</span> la BMR que presenta m&#225;s FR&#46; Se objetiva la variabilidad en la utilizaci&#243;n y en la rentabilidad de los cultivos en la detecci&#243;n de las distintas BMR&#44; predominando el cultivo nasal en SARM y el rectal en BLEEs y <span class="elsevierStyleItalic">Acinetobacter</span> spp&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Fase 2&#46; Estudio de factores de riesgo de portador de bacterias multirresistentes</span><p id="par0075" class="elsevierStylePara elsevierViewall">En esta fase se incluyeron 2&#46;175 pacientes de 7 hospitales con 264 aislamientos de BMR en los cultivos realizados&#46; En la <a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a> se muestran sus caracter&#237;sticas demogr&#225;ficas&#44; comorbilidades&#44; gravedad&#44; procedencia&#44; criterios de aislamiento y evoluci&#243;n del grupo total y diferenciando seg&#250;n la presencia de BMR&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">El porcentaje de BMR es del 6&#44;4&#37; en la poblaci&#243;n sin FR del proyecto RZ &#40;1&#46;438 pacientes&#41;&#44; elev&#225;ndose al 21&#44;6&#37; cuando s&#237; los presentan&#46; Setecientos treinta y siete pacientes presentaban FR del proyecto RZ &#40;33&#44;9&#37; del total de ingresos&#41;&#44; y de estos en 174 se aisl&#243; una BMR &#40;sensibilidad del 65&#44;9&#37; y especificidad del 79&#44;5&#37;&#41;&#46; Se objetiv&#243; que el aumento progresivo del n&#250;mero de criterios RZ se acompa&#241;a de un mayor porcentaje de detecci&#243;n de BMR&#58; 16&#37; en los que presentaban 1 FR &#40;407 pacientes&#41;&#59; 20&#37; con 2 FR &#40;240 pacientes&#41;&#59; 64&#37; con 3 FR &#40;75 pacientes&#41;&#59; 81&#44;8&#37; con 4 FR &#40;11 pacientes&#41; y el 100&#37; de pacientes con 5 FR &#40;4 pacientes&#41; seg&#250;n la lista de verificaci&#243;n RZ&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Al analizar los criterios de aislamiento RZ &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">tabla 4</a>&#41; se obtiene que el criterio de &#171;colonizaci&#243;n previa&#187; es el que alcanza mayor valor de <span class="elsevierStyleItalic">odds ratio</span> &#40;OR&#41;&#46; El criterio de &#171;insuficiencia renal&#187; es el &#250;nico que no alcanza significaci&#243;n estad&#237;stica en el an&#225;lisis multivariable&#44; pero s&#237; en el univariable&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">En el estudio para buscar nuevos FR &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">tabla 5</a>&#41;&#44; se observa que 3 factores alcanzan significaci&#243;n estad&#237;stica en el an&#225;lisis multivariable y se a&#241;aden al criterio de aislamiento RZ&#58; inmunodepresi&#243;n &#40;10&#44;1&#37;&#41;&#44; indicaci&#243;n de tratamiento antibi&#243;tico al ingreso en las UCI &#40;56&#44;0&#37;&#41; y sexo masculino &#40;63&#44;6&#37;&#41;&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">El an&#225;lisis de pacientes con indicaci&#243;n de tratamiento antibi&#243;tico al ingreso en las UCI mostr&#243; que eran diferentes en el diagn&#243;stico &#40;mayor presencia de problemas m&#233;dicos con 72&#44;5 vs&#46; 37&#44;2&#37; de quir&#250;rgicos&#44; coronarios o traum&#225;ticos&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; mayor presencia de criterios RZ &#40;40&#44;8 vs&#46; 25&#44;1&#37;&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; m&#225;s graves con puntuaci&#243;n de APACHE II &#40;19 &#91;13-25&#93; vs&#46; 11 &#91;6-17&#93;&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; y con mayor mortalidad hospitalaria &#40;17&#44;3 vs&#46; 6&#44;7&#37;&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Los pacientes varones presentaban m&#225;s antecedentes de EPOC &#40;19&#44;2 vs&#46; 8&#44;6&#37;&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; y de cirrosis &#40;5&#44;7 vs&#46; 3&#44;3&#37;&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;011&#41;&#44; y diferente diagn&#243;stico con menor porcentaje de ingresos programados &#40;17&#44;8 vs&#46; 23&#44;0&#37;&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; y m&#225;s traum&#225;ticos &#40;6&#44;9 vs&#46; 4&#44;9&#37;&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;04&#41;&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">En la <a class="elsevierStyleCrossRef" href="#fig0005">figura 1</a> se muestra que la inclusi&#243;n progresiva de los FR encontrados consigue aumentar la sensibilidad en la detecci&#243;n de BMR&#46; Analizando el rendimiento&#44; se observa que para este aumento de la sensibilidad se debe aumentar el porcentaje de aislamientos preventivos &#40;por ejemplo&#44; para conseguir una sensibilidad del 90&#37; debemos aislar al 68&#44;3&#37; de los pacientes al ingreso&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165">Discusi&#243;n</span><p id="par0110" class="elsevierStylePara elsevierViewall">Uno de los principales hallazgos de este trabajo es documentar que un 12&#37; de pacientes cr&#237;ticos son portadores de BMR al ingreso en las UCI&#44; similar al reportado en el informe anual del ECDC<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">3</span></a>&#46; Este porcentaje se eleva hasta el 21&#44;6&#37; cuando existe la presencia de uno de los factores de riesgo incluidos en proyecto RZ&#46; En Espa&#241;a&#44; Abella et al&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">10</span></a> observaron cifras similares de pacientes con criterios de aislamiento RZ &#40;en torno a un 30&#37;&#41; con la presencia de BMR alrededor del 14&#37; del total de pacientes ingresados en las UCI&#44; y un 7&#37; en los pacientes sin FR&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">En nuestra serie&#44; aunque la mortalidad es superior en el grupo con BMR&#44; un 16&#37; frente a un 12&#37;&#44; no alcanza significaci&#243;n estad&#237;stica&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">El <span class="elsevierStyleItalic">screening</span> de BMR al ingreso en las UCI es una de las recomendaciones del paquete de recomendaciones propuesto por el proyecto RZ&#46; El estudio deja en evidencia que no todas las UCI que participan en RZ realizan cultivos de vigilancia a todos los pacientes al ingreso&#44; algunas toman muestras de rutina solo a los que presentan los FR de la lista de verificaci&#243;n&#46; En la literatura<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">11</span></a> est&#225; descrito su escaso beneficio cuando la prevalencia de BMR es baja &#40;&#60;<span class="elsevierStyleHsp" style=""></span>5&#37;&#41;&#44; aunque s&#237; es &#250;til como herramienta de control de trasmisi&#243;n nosocomial cuando la prevalencia es m&#225;s alta&#46; Tambi&#233;n se observa variabilidad en los cultivos realizados en los distintos hospitales participantes&#46; Un estudio reciente<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">12</span></a> report&#243; que&#44; cuando hay una incidencia aproximada del 4&#44;5&#37;&#44; m&#225;s de un tercio de los casos de SAMR se identifica en muestras de cultivos distintos al frotis nasal&#44; mientras otros autores reportan que el frotis far&#237;ngeo aumenta la detecci&#243;n de BMR hasta en un 10&#37;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">13</span></a>&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">En nuestro estudio&#44; con una muestra de m&#225;s de 2&#46;000 pacientes&#44; los criterios cl&#237;nicos incluidos en la lista de verificaci&#243;n RZ como FR de ser portadores de BMR han demostrado ser &#250;tiles &#40;solo la insuficiencia renal no alcanz&#243; significaci&#243;n estad&#237;stica por el n&#250;mero reducido de pacientes&#41; identificando al 68&#37; de los pacientes con BMR&#46; El m&#225;s importante&#44; y coincidente con otras publicaciones&#44; es el antecedente de portador de BMR<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">10</span></a>&#46; La presencia simult&#225;nea de m&#225;s de un FR incrementa la probabilidad de presentar BMR<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">14</span></a>&#46; Men&#233;ndez et al&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">15</span></a> encontraron resultados similares estudiando FR de BMR en pacientes con bronquiectasias que necesitan ingreso hospitalario por exacerbaci&#243;n infecciosa&#44; considerando como FR independientes la hospitalizaci&#243;n el a&#241;o previo al ingreso&#44; la insuficiencia renal cr&#243;nica y el antecedente de portador BMR&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Sin embargo&#44; la estrategia seguida en el proyecto RZ tiene debilidades ya que las BMR aparecen en hasta el 31&#44;8&#37; de pacientes sin los FR incluidos en la lista de verificaci&#243;n y el 31&#44;5&#37; de los pacientes se a&#237;slan de manera innecesaria&#44; sin evidenciarse la presencia de BMR&#46; Los FR del proyecto RZ por s&#237; solos tienen una sensibilidad del 66&#37; y una especificidad cercana al 80&#37; que podr&#237;a ser mejorable&#46; Callejo-Torre et al&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">16</span></a> proponen la creaci&#243;n de una herramienta diagn&#243;stica que utilice de manera combinada los FR con test r&#225;pidos de laboratorio&#44; como la PCR en tiempo real&#44; que es relativamente f&#225;cil de utilizar y coste-efectiva&#46; Otros autores<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">17</span></a> desde hace a&#241;os abogan por el uso de algoritmos cl&#237;nicos&#44; que incluyen test diagn&#243;sticos r&#225;pidos y con elevado valor predictivo negativo&#44; aunque todav&#237;a hoy no se ha conseguido un modelo universal en cuanto a microorganismos y geograf&#237;a&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Como aportaci&#243;n a mejorar la predicci&#243;n de BMR en pacientes cr&#237;ticos&#44; en nuestro estudio se ha creado un modelo de riesgo para mejorar los criterios propuestos por el proyecto RZ a&#241;adiendo otras variables identificadas en el an&#225;lisis de regresi&#243;n log&#237;stica multivariante&#58; inmunodepresi&#243;n&#44; tratamiento antibi&#243;tico al ingreso en las UCI&#44; y sexo masculino&#46; El primer factor refuerza el concepto de paciente con enfermedad cr&#243;nica al incorporar a los pacientes inmunodeprimidos&#44; consiguiendo mejorar la sensibilidad en 5 puntos y debiendo aislar un 5&#37; m&#225;s del total de pacientes&#46; Para conseguir mejorar la sensibilidad hasta el 90&#37;&#44; el factor que encontramos es la indicaci&#243;n de tratamiento antibi&#243;tico al ingreso en las UCI&#46; Este factor puede explicarse por el hecho de que los pacientes que no reciben antibi&#243;tico est&#225;n ingresados por causa no infecciosa &#40;como enfermedad coronaria&#44; intervenciones programadas y trauma&#41;&#44; presentando menos FR y menor utilizaci&#243;n de pruebas microbiol&#243;gicas&#46; Los que s&#237; reciben antibi&#243;ticos se caracterizan por su diagn&#243;stico m&#233;dico&#44; ingreso urgente y mayor gravedad&#46; La adici&#243;n de este criterio exige el aislamiento&#44; de forma preventiva&#44; de dos tercios del total de ingresos&#46; El &#250;ltimo factor encontrado es el sexo masculino&#46; Eso se podr&#237;a explicar porque los varones tienen m&#225;s antecedentes de EPOC y menor porcentaje de ingresos programados&#46; A&#241;adiendo este factor al modelo&#44; se consigue una mejora en la sensibilidad hasta casi el 99&#37;&#44; pero con la exigencia de aislar casi al 90&#37; de los pacientes que ingresan en las UCI&#46; Otras publicaciones tambi&#233;n han observado el sexo masculino como FR<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">14</span></a>&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Se debe seguir trabajando en buscar modelos que consigan mejorar este rendimiento e incorporar t&#233;cnicas r&#225;pidas de identificaci&#243;n de BMR<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">16&#44;17</span></a>&#46; Buscar un equilibrio entre el n&#250;mero de aislamientos preventivos y el rendimiento de detecci&#243;n de BMR puede depender de la situaci&#243;n particular de cada UCI&#59; unidades con mayor problema de BMR podr&#237;an beneficiarse de un aumento del n&#250;mero de aislamientos preventivos&#46; Tambi&#233;n debemos se&#241;alar el problema que supone tener a un paciente aislado&#58; dificulta su manejo y aumenta la carga asistencial<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">18</span></a>&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Nuestro estudio tiene varias limitaciones&#46; Por una parte&#44; siempre es deseable una mayor muestra que incluyera m&#225;s aislamientos de BMR e hiciera posible un an&#225;lisis espec&#237;fico seg&#250;n cada microorganismo&#44; y queda pendiente la validaci&#243;n externa del modelo&#46; No se han detectado <span class="elsevierStyleItalic">Enterococcus</span> spp resistentes a vancomicina&#44; por lo que no se puede en este estudio validar los FR para ese germen&#46; Otra limitaci&#243;n ha sido la no estandarizaci&#243;n en la toma de muestras para cultivo de vigilancia&#59; algunos centros utilizan frotis nasal y rectal&#44; otros tambi&#233;n incluyen el axilar&#44; y eso depende&#44; a pesar de las recomendaciones del proyecto RZ&#44; de la pol&#237;tica de cada hospital&#44; as&#237; como de los recursos disponibles en sus laboratorios de microbiolog&#237;a&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Por otro lado&#44; el punto fuerte est&#225; en que apenas hay publicaciones de estudios multic&#233;ntricos que agrupen a todos los grupos de BMR en pacientes en las UCI&#44; siendo esta serie la m&#225;s larga encontrada hasta ahora&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">En resumen&#44; en este estudio se han descrito los FR independientes para ser portador de BMR al ingreso en las UCI&#44; corroborando parte de la lista de verificaci&#243;n del proyecto RZ e identificando otros potenciales&#46; Los criterios de aislamiento basados en el programa RZ obtienen un rendimiento aceptable&#44; pero no identifican a un tercio de las BMR&#46; El criterio m&#225;s importante es el antecedente de portador de BMR&#46; Parece indiscutible que la acumulaci&#243;n de FR implica una probabilidad elevada de predecir la presencia de una BMR&#46; Se podr&#237;a mejorar ese modelo a&#241;adiendo el criterio de inmunodepresi&#243;n&#46; Para conseguir una sensibilidad del 90&#37;&#44; debemos incluir en el modelo el grupo de pacientes que requieren de tratamiento antibi&#243;tico al ingreso en las UCI&#44; y eso lleva a aislar de forma preventiva a dos tercios de todos los pacientes que ingresan en las UCI&#46; Los hospitales participantes presentan diferencias geogr&#225;ficas y epidemiol&#243;gicas&#44; tanto en la incidencia como en el tipo de BMR&#44; pero tambi&#233;n en la utilizaci&#243;n de los medios diagn&#243;sticos&#46; Observamos en esta serie la escasa rentabilidad de los cultivos de frotis axilar&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Basados en la evidencia disponible hasta el momento&#44; cada UCI deber&#237;a crear sus propios protocolos de aislamiento de contacto seg&#250;n las variables cl&#237;nico-demogr&#225;ficas de sus pacientes al ingreso combinadas con la epidemiolog&#237;a local y potenciando la utilizaci&#243;n de pruebas microbiol&#243;gicas de manera eficiente y r&#225;pida&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0170">Financiaci&#243;n</span><p id="par0165" class="elsevierStylePara elsevierViewall">En la realizaci&#243;n de este trabajo no se ha contado con fondos p&#250;blicos ni privados&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0175">Autor&#237;as</span><p id="par0170" class="elsevierStylePara elsevierViewall">Concepto y dise&#241;o del estudio realizado por Sulamita Carvalho-Brugger y Mercedes Palomar&#46; Todos los autores han participado en la recogida de datos&#46; Sulamita Carvalho-Brugger y Javier Trujillano ha realizado el an&#225;lisis estad&#237;stico e interpretaci&#243;n de datos&#46; Sulamita Carvalho-Brugger&#44; Javier Trujillano&#44; Francisco &#193;lvarez Lerma y Mercedes Palomar han escrito el manuscrito&#46; Revisi&#243;n cr&#237;tica del manuscrito&#58; todos los autores han le&#237;do y revisado el manuscrito final&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0180">Conflicto de intereses</span><p id="par0175" class="elsevierStylePara elsevierViewall">Todos los autores declaran no tener conflictos de intereses potenciales relacionados a este estudio&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0185">Agradecimientos</span><p id="par0180" class="elsevierStylePara elsevierViewall">A Ana Ezpeleta&#44; Cristina Climent&#44; Manuel Solsona&#44; Mercedes Catal&#225;n&#44; Montserrat Ortiz&#44; Javier Blanco&#44; Francisco Javier Gonz&#225;lez de Molina&#44; Pedro Olaechea y Naia M&#225;s&#44; por su participaci&#243;n en la recogida de datos&#46;</p></span></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objetivo</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Conocer el rendimiento de los criterios de aislamiento preventivo del programa Resistencia Zero &#40;RZ&#41; e identificar los factores que pudieran mejorar su rendimiento&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Dise&#241;o</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Estudio de cohorte prospectivo y multic&#233;ntrico&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">&#193;mbito</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Unidades de cuidados cr&#237;ticos que aplicaban el protocolo RZ&#44; y que aceptaron la invitaci&#243;n al estudio&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Pacientes o participantes</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Pacientes a los que se les realizaron cultivos de vigilancia &#40;nasal&#44; far&#237;ngeo&#44; axilar y rectal&#41; y&#47;o diagn&#243;sticos al ingreso en la UCI&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Intervenciones</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">An&#225;lisis de los factores de riesgo &#40;FR&#41; RZ y otras variables del registro ENVIN&#46; Se realiz&#243; un estudio univariable y multivariable con metodolog&#237;a de regresi&#243;n log&#237;stica binaria &#40;significaci&#243;n con p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41;&#46; Se efectu&#243; an&#225;lisis de sensibilidad y especificidad para cada uno de los factores seleccionados&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Variables de inter&#233;s principales</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Portador de bacteria multirresistente &#40;BMR&#41; al ingreso en la UCI&#44; FR &#40;antecedente de colonizaci&#243;n&#47;infecci&#243;n por BMR&#44; ingreso hospitalario en los 3 meses previos&#44; uso de antibi&#243;tico el mes previo&#44; estar institucionalizado&#44; di&#225;lisis y otras condiciones cr&#243;nicas&#41; y comorbilidades&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Participaron 2&#46;252 pacientes de 9 UCI espa&#241;olas&#46; Fueron identificados BMR en 283 &#40;12&#44;6&#37;&#41;&#46; Ciento noventa y tres &#40;68&#44;2&#37;&#41; presentaban alg&#250;n FR &#40;OR&#58; 4&#44;6&#59; IC 95&#37;&#58; 3&#44;5-6&#44;0&#41;&#46; Todos los FR del programa RZ alcanzaron significaci&#243;n estad&#237;stica &#40;sensibilidad&#58; 66&#37;&#59; especificidad&#58; 79&#37;&#41;&#44; siendo el antecedente de BMR el factor con m&#225;s peso&#46; Inmunodepresi&#243;n&#44; tratamiento antibi&#243;tico al ingreso y sexo masculino son FR adicionales para BMR&#46; Se aislaron BMR en 87 &#40;31&#44;8&#37;&#41; sin FR&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">La presencia de al menos un FR aumenta el riesgo de ser portador de BMR&#44; siendo el m&#225;s importante el antecedente de colonizaci&#243;n&#47;infecci&#243;n por BMR&#46; Casi el 32&#37; de las BMR se encuentran en pacientes sin FR&#46; Inmunodepresi&#243;n&#44; tratamiento antibi&#243;tico al ingreso y sexo masculino podr&#237;an ser a&#241;adidos al algoritmo de FR para decidir el aislamiento preventivo&#46;</p></span>"
        "secciones" => array:8 [
          0 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Objetivo"
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          1 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Dise&#241;o"
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          2 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "&#193;mbito"
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          3 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Pacientes o participantes"
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          4 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "Intervenciones"
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          5 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Variables de inter&#233;s principales"
          ]
          6 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Resultados"
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          7 => array:2 [
            "identificador" => "abst0045"
            "titulo" => "Conclusiones"
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      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Objective</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">To verify the validity of a check list of risk factors &#40;RF&#41; proposed by the Spanish &#8220;Resistencia Zero&#8221; project &#40;RZ&#41; in the detection of multi-resistant bacteria &#40;MRB&#41;&#44; as well as to identify other possible RF for colonization and infection by MRB at intensive care &#40;ICU&#41; admission&#46;</p></span> <span id="abst0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Design</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">A prospective cohort study&#44; conducted in 2016&#46;</p></span> <span id="abst0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Setting</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Multicenter study&#44; patients who needed admission to adult critical care units that applied the RZ protocol and accepted the invitation for the study&#46;</p></span> <span id="abst0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Patients or participants</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Consecutive sample of patients admitted to ICU&#44; who underwent surveillance &#40;nasal&#44; pharyngeal&#44; axillary&#44; and rectal&#41; or clinical cultures&#46;</p></span> <span id="abst0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Interventions</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Analysis of the RF of RZ project&#44; in addition to other comorbidities&#44; included in the ENVIN registry&#46; A univariate and multivariate study was conducted&#44; with binary logistic regression methodology &#40;significance with <span class="elsevierStyleItalic">P</span>&#60;&#46;05&#41;&#46; Sensitivity and specificity analyses were performed for each of the selected factors&#46;</p></span> <span id="abst0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Main variables of interest</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Carrier of BMR at ICU admission&#44; RF &#40;previous MRB colonization&#47;infection&#44; hospital admission in the previous 3 months&#44; antibiotic use in the past month&#44; institutionalization&#44; dialysis&#44; and other chronic conditions&#41; and comorbidities&#46;</p></span> <span id="abst0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Results</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Two thousand two hundred and seventy patients were included from 9 Spanish ICUs&#46; We identified BMR in 288 &#40;12&#46;6&#37; of total patients admitted&#41;&#46; One hundred and ninety-three &#40;68&#46;2&#37;&#41; had some RF &#40;OD 4&#46;6 -95&#37; CI 3&#46;5-6&#46;0&#41;&#46; All 6 RF from check list achieved statistical significance in the univariate analysis &#40;sensitivity 66&#37;&#44; specificity 79&#37;&#41;&#46; Immunosuppression&#44; antibiotic use at ICU admission and male gender were additional RF for BMR&#46; BMR were isolated in 87 patients &#40;31&#46;8&#37;&#41; without RF&#46;</p></span> <span id="abst0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conclusions</span><p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Patients with at least one RF had an increased risk of being a carrier of BMR&#46; However&#44; almost 32&#37; of BMR were isolated in patients without RF&#46; Other comorbidities such as immunosuppression&#44; antibiotic use at ICU admission and male gender could be considered as additional RF&#46;</p></span>"
        "secciones" => array:8 [
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            "titulo" => "Objective"
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          1 => array:2 [
            "identificador" => "abst0055"
            "titulo" => "Design"
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          2 => array:2 [
            "identificador" => "abst0060"
            "titulo" => "Setting"
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          3 => array:2 [
            "identificador" => "abst0065"
            "titulo" => "Patients or participants"
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          4 => array:2 [
            "identificador" => "abst0070"
            "titulo" => "Interventions"
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          5 => array:2 [
            "identificador" => "abst0075"
            "titulo" => "Main variables of interest"
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          6 => array:2 [
            "identificador" => "abst0080"
            "titulo" => "Results"
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          7 => array:2 [
            "identificador" => "abst0085"
            "titulo" => "Conclusions"
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          "es" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Rendimiento del n&#250;mero de aislamientos preventivos seg&#250;n sensibilidad y especificidad&#46; ATB ingreso UCI&#58; tratamiento antibi&#243;tico al ingreso en la UCI&#59; BMR&#58; bacteria multirresistente&#59; RZ&#58; Resistencia Zero&#59; VPN&#58; valor predictivo negativo&#59; VPP&#58; valor predictivo positivo&#46;</p>"
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                  \t\t\t\t">66 &#40;56-75&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">169 &#40;8&#44;8&#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="center" valign="\n
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                  \t\t\t\t">51 &#40;19&#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="center" 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></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>Neoplasia&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="center" valign="\n
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                  \t\t\t\t">530 &#40;24&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">470 &#40;24&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">60 &#40;22&#44;7&#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="center" valign="\n
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                  \t\t\t\t">0&#44;508&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>Cirrosis&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t">105 &#40;4&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">86 &#40;4&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">19 &#40;7&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t">0&#44;055&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Trasplantado&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t">41 &#40;1&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t">25 &#40;1&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">16 &#40;6&#44;1&#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="center" 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></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="elsevierStyleItalic">Procedencia</span>&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\ttable-entry\n
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                  \t\t\t\t  " align="center" 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></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>Urgencias&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t">1&#46;553 &#40;71&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#46;420 &#40;74&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">133 &#40;50&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Residencia&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t">25 &#40;1&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">21 &#40;1&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">4 &#40;1&#44;5&#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"><span class="elsevierStyleHsp" style=""></span>Planta&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="center" valign="\n
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                  \t\t\t\t">569 &#40;26&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">446 &#40;23&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">123 &#40;46&#44;6&#41;&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
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Otra UCI&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="center" valign="\n
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                  \t\t\t\t">28 &#40;1&#44;3&#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">24 &#40;1&#44;3&#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="center" valign="\n
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                  \t\t\t\t">4 &#40;1&#44;5&#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">&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="elsevierStyleItalic">Diagn&#243;stico</span>&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="" 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\ttable-entry\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  " align="" valign="\n
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                  \t\t\t\t">&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="center" 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></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>M&#233;dico&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="center" valign="\n
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                  \t\t\t\t">1&#46;238 &#40;56&#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="center" valign="\n
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                  \t\t\t\t">1&#46;053 &#40;55&#44;1&#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="center" valign="\n
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                  \t\t\t\t">185 &#40;70&#44;1&#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">&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>Quir&#250;rgico programado&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="center" valign="\n
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                  \t\t\t\t">428 &#40;19&#44;7&#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="center" valign="\n
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                  \t\t\t\t">395 &#40;20&#44;7&#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="center" valign="\n
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                  \t\t\t\t">33 &#40;12&#44;5&#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">&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>Quir&#250;rgico urgente&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="center" valign="\n
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                  \t\t\t\t">205 &#40;9&#44;4&#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="center" valign="\n
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                  \t\t\t\t">179 &#40;9&#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="center" valign="\n
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                  \t\t\t\t">26 &#40;9&#44;8&#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">&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>Traum&#225;tico&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="center" valign="\n
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                  \t\t\t\t">169 &#40;7&#44;8&#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="center" valign="\n
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                  \t\t\t\t">161 &#40;8&#44;4&#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="center" valign="\n
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                  \t\t\t\t">8 &#40;3&#44;0&#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">&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>Coronario&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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">135 &#40;6&#44;2&#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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">OR &#40;IC 95&#37;&#41;&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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p-valor&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-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">Ingreso hospitalario previo &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>591&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#44;46 &#40;1&#44;10-2&#44;14&#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;043&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Institucionalizado &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>44&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;005&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t">23&#44;74 &#40;14&#44;80-38&#44;01&#41;&nbsp;\t\t\t\t\t\t\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
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">Antibioterapia previa &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>332&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t">1&#44;81 &#40;1&#44;18-2&#44;79&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t">0&#44;007&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">IRC en di&#225;lisis &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>30&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#44;59 &#40;0&#44;83-5&#44;01&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Paciente cr&#243;nico<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">a</span></a> &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>56&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#44;82 &#40;1&#44;35-2&#44;46&#41;&nbsp;\t\t\t\t\t\t\n
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                  "referenciaCompleta" => "O&#769;Nell J&#46; WHO&#46; The Review on Antimicrobial Resistance - Infection prevention&#44; control and surveillance&#58; Limiting the development and spread of drug-resistance&#46; Publicado en 2016 &#91;consultado 4 Mar 2021&#93; Disponible en&#58; <a target="_blank" href="https://amr-review.org/Publications.html">https&#58;&#47;&#47;amr-review&#46;org&#47;Publications&#46;html</a>"
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              "etiqueta" => "2"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Combatting resistance in intensive care&#58; The multimodal approach of the Spanish ICU &#171;Zero Resistance&#187; program"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "J&#46; Garnacho Montero"
                            1 => "F&#46;&#193;&#46; Lerma"
                            2 => "P&#46;R&#46; Galleymore"
                            3 => "M&#46;P&#46; Mart&#237;nez"
                            4 => "L&#46;&#193;&#46; Rocha"
                            5 => "F&#46;B&#46; Gaite"
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1186/s13054-015-0800-5"
                      "Revista" => array:6 [
                        "tituloSerie" => "Crit Care"
                        "fecha" => "2015"
                        "volumen" => "19"
                        "paginaInicial" => "114"
                        "paginaFinal" => "121"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25880421"
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              "identificador" => "bib0105"
              "etiqueta" => "3"
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                0 => array:1 [
                  "referenciaCompleta" => "The bacterial challenge - time to react&#46; ECDC&#44; 2009&#46; &#91;consultado 4 Mar 2021&#93; Disponible en <a target="_blank" href="https://www.ema.europa.eu/en/documents/press-release/bacterial-challenge-time-react-call-narrow-gap-between-multidrug-resistant-bacteria-eu-development_en.pdf">https&#58;&#47;&#47;www&#46;ema&#46;europa&#46;eu&#47;en&#47;documents&#47;press-release&#47;bacterial-challenge-time-react-call-narrow-gap-between-multidrug-resistant-bacteria-eu-development&#95;en&#46;pdf</a>"
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                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Attributable mortality of ICU-acquired bloodstream infections&#58; Impact of the source&#44; causative micro-organism&#44; resistance profile and antimicrobial therapy"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
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                            1 => "M&#46; Garrouste-Orgeas"
                            2 => "W&#46; Ibn Essaied"
                            3 => "C&#46; Schwebel"
                            4 => "M&#46; Darmon"
                            5 => "B&#46; Mourvillier"
                          ]
                        ]
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                    0 => array:2 [
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                      "Revista" => array:6 [
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                        "fecha" => "2016"
                        "volumen" => "74"
                        "paginaInicial" => "131"
                        "paginaFinal" => "141"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27838521"
                            "web" => "Medline"
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                0 => array:2 [
                  "contribucion" => array:1 [
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                      "titulo" => "Mortality in patients with multidrug-resistant <span class="elsevierStyleItalic">Pseudomonas aeruginosa</span> infections&#58; A meta-analysis"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "E&#46;C&#46;O&#46; de Matos"
                            1 => "R&#46;B&#46; Andriolo"
                            2 => "Y&#46;C&#46; Rodrigues"
                            3 => "P&#46;D&#46;L&#46; de Lima"
                            4 => "I&#46;C&#46; do R&#46;S&#46; Carneiro"
                            5 => "K&#46;V&#46;B&#46; Lima"
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                    0 => array:2 [
                      "doi" => "10.1590/0037-8682-0506-2017"
                      "Revista" => array:6 [
                        "tituloSerie" => "Rev Soc Bras Med Trop"
                        "fecha" => "2018"
                        "volumen" => "51"
                        "paginaInicial" => "415"
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                      "titulo" => "Comparing the outcomes of patients with carbapenemase-producing and non-carbapenemase-producin carbapenem-resistant <span class="elsevierStyleItalic">Enterobacteriaceae</span> bacteriemia"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "P&#46;D&#46; Tamma"
                            1 => "K&#46;E&#46; Goodman"
                            2 => "A&#46; Harris"
                            3 => "T&#46; Tekle"
                            4 => "A&#46; Roberts"
                            5 => "A&#46; Taiwo"
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1093/cid/ciw741"
                      "Revista" => array:6 [
                        "tituloSerie" => "Clin Infect Dis"
                        "fecha" => "2017"
                        "volumen" => "64"
                        "paginaInicial" => "257"
                        "paginaFinal" => "264"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28013264"
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