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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Within the range of different nosocomial infections&#44; nosocomial urinary tract infections represent an important hospital problem&#44; particularly in Pediatric Intensive Care Units &#40;PICUs&#41;&#44; causing increased morbidity and mortality&#44; a prolongation of stay&#44; and increased healthcare costs&#46; The epidemiological monitorization of such infections is essential in order to improve our knowledge and these processes and to establish adequate prevention and control programs&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Urinary tract infection is the leading nosocomial infection among hospitalized adults and in critical care&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> However&#44; in PICUs the epidemiology differs&#44; and urinary infectious processes represent the second or third most common type of nosocomial infection&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#8211;5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">These infections account for 5&#8211;15&#37; of all nosocomial infections&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Their appearance is directly related to a series of risk factors&#44; and the identification and evaluation of such factors can contribute to establish more effective control programs&#46; Among all the different risk factors studied&#44; bladder catheterization is the most important&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> It is estimated that 5&#8211;25&#37; of all patients requiring a bladder catheter during hospital admission develop nosocomial urinary tract infection &#40;nUTI&#41;&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Other risk factors in adults are the duration of catheterization&#44; the female gender&#44; inadequate care of the bladder catheter&#44; or a lack of antibiotic coverage&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Despite their importance&#44; there are few studies of nUTIs in the PICU&#44; and their epidemiology in this patient population has not been well established&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The primary objective of this observational study is to determine the incidence density of nosocomial urinary infections in a second-level PICU&#46; The secondary objectives are to define the etiology and risk factors&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Patients and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Population</span><p id="par0030" class="elsevierStylePara elsevierViewall">A prospective&#44; descriptive observational study was carried out in a provincial reference PICU with seven beds&#46; The Unit treats medical and surgical disorders&#44; with the exception of cardiovascular surgery&#46; We included all patients between 15 days and 14 years of age admitted for over 48<span class="elsevierStyleHsp" style=""></span>h in the period between 1 January and 31 December 2009&#46; The exclusion criteria were as follows&#58; age under 15 days or over 14 years&#44; the presence of urinary infection or pyelonephritis upon admission or in under 48<span class="elsevierStyleHsp" style=""></span>h after admission&#44; and patients remaining in the PICU for less than 48<span class="elsevierStyleHsp" style=""></span>h&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The following data were collected from all subjects&#58; age&#44; gender&#44; reason for admission&#44; medical or surgical disease&#44; severity in the first 24<span class="elsevierStyleHsp" style=""></span>h &#40;PRISM III and PIM II scores&#41;&#44; and personal history of relevance &#40;infant brain paralysis&#44; premature delivery&#44; spina bifida&#44; heart disease&#44; neuromuscular disease&#44; liver or kidney disease&#44; immunodeficiency or hematological disease&#41;&#46; We documented the possible factors related to nUTI&#58; bladder catheter&#44; previous hospital stay&#44; corticosteroid treatment&#44; immunosuppressors&#44; surgery in the 2 months prior to admission&#44; neutropenia&#44; and antibiotic treatment received&#46; Clinical information indicative of UTI was collected on a daily basis in all cases&#46; The patients with a bladder catheter were subjected to daily urine culture until discharge from the PICU or removal of the catheter&#46; In patients without bladder catheterization&#44; or after removal of the catheter&#44; urine cultures were obtained upon admission and every 48<span class="elsevierStyleHsp" style=""></span>h until discharge&#46; In addition&#44; a urine culture was obtained 48<span class="elsevierStyleHsp" style=""></span>h after transfer to the hospital ward&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Definition</span><p id="par0040" class="elsevierStylePara elsevierViewall">Nosocomial infections were defined as all infections not present at the time of admission but which appeared within 48<span class="elsevierStyleHsp" style=""></span>h after admission to the PICU&#46; The diagnosis was based on the criteria of the CDC&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;7</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Contamination was defined by urine cultures with low counts &#40;&#8804;10<span class="elsevierStyleSup">4</span><span class="elsevierStyleHsp" style=""></span>cfu&#47;ml&#41; of microorganisms normally present in the skin or external or internal genitalia&#46; Mixed growth cultures are usually indicative of fecal microbiota contamination&#44; though clinical evaluation is required in such cases&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Colonization in turn was defined as the presence of microorganisms in urine culture&#44; without clinical repercussions&#44; and which disappear after removal of the bladder catheter&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The severity of the disease upon admission was assessed using the PRISM III and PIM II scales&#44; both validated for pediatric patients&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Sample collection</span><p id="par0060" class="elsevierStylePara elsevierViewall">In catheterized children urine cultures and systematic urine tests were made on a daily basis&#46; In order to avoid false-positive readings due to colonization&#44; in those children with positive urine culture findings we replaced the bladder catheter and then repeated urine culture for confirmation purposes&#46; If bladder catheterization was discontinued during admission&#44; sample collection was carried out as in the group described below&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">In non-catheterized children with preserved sphincter control&#44; we collected the middle portion of spontaneous micturition &#40;preferably in the morning&#41;&#44; after washing the genitals with water and soap&#44; rinsing with sterile water and drying with sterile gauze&#46; In no case were antiseptics capable of falsifying bacterial growth employed&#46; In patients without sphincter control&#44; the sample was collected with a perineal adhesive bag after cleaning of the zone&#44; with replacement every 30<span class="elsevierStyleHsp" style=""></span>min&#46; In this latter case urine culture collection was systematically spaced to once every 48<span class="elsevierStyleHsp" style=""></span>h in order to avoid irritation caused by the adhesive bag in the perineal region&#46; If the urine sample proved doubtful or showed contamination&#44; point catheterization was carried out&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">The urine samples were collected under sterile conditions and transported to the laboratory in under 1<span class="elsevierStyleHsp" style=""></span>h&#46; A closed system with a 500-ml capacity was used to control hourly diuresis&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Statistical analysis</span><p id="par0075" class="elsevierStylePara elsevierViewall">New variables were calculated for data analysis&#44; based on differences in dates referred to patient age&#44; days of hospital admission&#44; and days of bladder catheterization&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The descriptive analysis was based on calculation of the mean&#44; median and standard deviation &#40;SD&#41; and interval for quantitative variables&#44; while qualitative variables were reported as frequencies and percentages&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">For each categorical variable of interest we explored associations with urinary infection based on the comparison of proportions with the Mantel&#8211;Haenszel chi-squared test or the Fisher test in the case of variables including less than five individuals&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">The Kolmogorov&#8211;Smirnov test was used to assess normal distribution of the study variables&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Comparisons between means of quantitative variables in the study of children with or without infection were based on the Student&#39;s <span class="elsevierStyleItalic">t</span>-test or the Mann&#8211;Whitney <span class="elsevierStyleItalic">U</span>-test in the case of variables with a non-normal distribution&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Nonparametric tests were used for the study of factors associated to bacterial or fungal nUTIs&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">The level of significance was established as 95&#37; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; The SPSS version 15&#46;0 statistical package was used throughout&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Results</span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">General data</span><p id="par0110" class="elsevierStylePara elsevierViewall">During the study period a total of 178 patients were admitted to the PICU&#44; with a mean stay of over 48<span class="elsevierStyleHsp" style=""></span>h&#46; Seventy-four patients were excluded from the study due to some of the following reasons&#58; age under 15 days &#40;17 patients&#41; or over 14 years &#40;24 patients&#41;&#44; presence of UTI upon admission &#40;patients 22&#41;&#44; or other reasons &#40;patients 11&#41;&#46; The final sample consisted of 104 patients&#46; The general data are reported in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; The children with nUTI were younger than the children without infection &#40;15&#46;8 vs 35&#46;9 months&#41;&#44; though the difference was not statistically significant&#46; El group of children with nUTI showed a significantly higher percentage of personal antecedents of relevance than the group without nUTI&#46; Upon admission&#44; the children with and without nUTI showed similar median scores on the PRISM III and PIM II severity scales &#40;3&#37; and 1&#46;4&#37;&#44; respectively&#41;&#44; though the interval &#40;range&#41; was markedly greater in the children without infection&#46; The children with nUTI presented significantly longer stays&#46; The mortality rate among the children with and without nUTI was 0&#37; and 8&#46;7&#37;&#44; respectively&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Factors related to nUTI</span><p id="par0115" class="elsevierStylePara elsevierViewall">A total of 68&#37; of the patients carried a bladder catheter&#44; with a mean of 7 days and a total duration of 492 days&#46; The bladder catheter utilization rate was 0&#46;41&#46; The mean time from admission to the appearance of nUTI was 3&#46;83 days&#46; The urine cultures showed negative conversion after 7 days on average&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">All the patients with nUTI had received a bladder catheter&#44; and the catheterization period was longer than in the children without infection&#44; though the difference was not statistically significant &#40;6&#46;5 vs 5 days&#41;&#46; Likewise&#44; the days of corticosteroid treatment and of previous hospital stay showed no significant differences&#46; These data&#44; compared with the patients without nUTI&#44; are shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46; Three of the six cases of nUTI &#40;50&#37; vs 88&#46;5&#37; of the patients without nUTI&#41; were receiving antibiotic treatment at the time of diagnosis&#44; though only in the two documented cases of fungal infection did the treatment have to be changed&#46; In turn&#44; 4&#46;9&#37; of the patients without nUTI had undergone surgery in the previous 60 days&#44; 1&#37; presented neutropenia&#44; and 1&#46;9&#37; suffered immune deficiency&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Positive urine cultures</span><p id="par0125" class="elsevierStylePara elsevierViewall">A total of 27 patients showed positive urine cultures &#40;26&#37;&#41;&#46; Two of these cases were classified as colonization &#40;1&#46;9&#37;&#41;&#44; 19 as contamination &#40;18&#46;3&#37;&#41;&#44; and six as nosocomial urinary tract infection &#40;5&#46;8&#37;&#41;&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">The six cases of nUTI presented fever&#44; with no identification of urinary symptoms &#40;urgency&#44; abdominal pain&#44; pollakiuria&#44; dysuria&#44; or others&#41;&#46; The colonized patients suffered no symptoms&#44; while one of the 19 cases of contamination coincided with a fever process that did not meet the CDC criteria of nUTI&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Nosocomial urinary tract infection</span><p id="par0135" class="elsevierStylePara elsevierViewall">We documented six cases of nUTI&#44; all in catheterized children&#8212;this representing 5&#46;8&#37; of all the admissions for over 48<span class="elsevierStyleHsp" style=""></span>h&#44; and 8&#46;6&#37; of all children with bladder catheters&#46; A total of 1188 days of hospital stay were registered &#40;5&#46;05&#47;1000 patients&#47;day&#41;&#44; together with 492 days of bladder catheterization &#40;incidence density 12&#46;19&#47;1000 days of catheterization&#41;&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Two of the urinary infections were recorded in one same girl with spina bifida&#44; admitted on two occasions for different reasons&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Regarding the etiology of nUTI&#44; we identified four cases attributable to <span class="elsevierStyleItalic">Escherichia coli</span> &#40;multiresistant &#40;BLEE&#41; in once case&#41; and two to <span class="elsevierStyleItalic">Candida albicans</span>&#46;</p></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0150" class="elsevierStylePara elsevierViewall">In contrast to the data published on adult patients&#44;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;9&#44;10</span></a> there are few literature references to nUTI in the critical pediatric population&#44; and the existing information refers mainly to third-level PICUs or multicenter registries comprising numerous Units&#44; without specifying their characteristics&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a> The diseases seen in a second-level PICU are different&#44; and it is therefore reasonable to assume that the incidence and epidemiology of the nosocomial infections are also different&#46; We have found no specific publications on nUTIs in second-level PICUs&#46; In addition&#44; the few pediatric studies identified contain practically no prospective studies with a duration of over 6 months&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Our incidence density of device-related UTIs &#40;12&#46;19&#47;1000 days of bladder catheter&#41; is greater than in other series&#46; The National Nosocomial Infections Surveillance &#40;NNIS&#41; System Report compiles information on 52 PICUs in the United States&#44; and publishes an average of four nUTIs&#47;1000 days of bladder catheter<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>&#8212;though no specification is provided of the characteristics of the participating Units &#40;medical&#44; surgical&#44; medical&#8211;surgical&#44; traumatologic&#44; burn units&#44; with cardiovascular surgery or with transplants&#41;&#46; The International Nosocomial Infection Control Consortium &#40;INICC&#41; in turn compiles data on 22 PICUs in Latin America&#44; Asia&#44; Africa&#44; and Europe&#44; with the publication of an average of 4&#46;4 infections&#47;1000 days of bladder catheter&#8212;and likewise no specification is provided of the characteristics of the participating PICUs&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> In contrast&#44; in adult ICUs&#44; a division is made according to the characteristics of each Unit&#44; with the recording of quite different incidence densities&#46; In the Spanish national setting&#44; we have a registry system &#40;VINCIP-SECIP&#41; with a rate of 8&#46;2 infections&#47;1000 days of bladder catheter&#44;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> though here again the types of Units are not specified&#46; Other authors such as Richards et al&#46;&#44; analyzed the epidemiology in 61 PICUs in the United States&#44; with an average of 5&#46;9 episodes&#47;1000 days of bladder catheterization&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> In turn&#44; Urrea et al&#46;&#44; in a study of a third-level PICU&#44; reported a rate of 10&#46;7 infections&#47;1000 days of catheterization&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> Among the few studies specific of nUTIs&#44; mention must be made of the work of Matlow et al&#46;&#8212;a retrospective 10-year study in a third-level PICU&#46; However&#44; since these authors reflect the incidence per percentage of admissions &#40;0&#46;95&#47;100 admissions&#41;&#44; not per days of catheterization&#44; comparisons are difficult to establish&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">We consider that the greater incidence density of nUTIs in our PICU may be due to a number of reasons&#58; &#40;a&#41; Our bladder catheter utilization rate is greater than in other studies&#58; 0&#46;41 versus 0&#46;3 in the NNIS&#44; 0&#46;17 in the INICC&#44; and 0&#46;32 in the article published by Richards et al&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> In this context&#44; protocols designed to lessen catheter use and its duration are the strategies with the greatest impact in terms of reducing the incidence of infections&#59; &#40;b&#41; In our PICU there is a greater percentage of children admitted with invasive devices and without antibiotic treatment than in other higher-level Units&#44; and these patients are more susceptible to nosocomial infection&#46; In fact&#44; none of the patients with UTIs of bacterial origin received antibiotics&#44; or alternatively such drugs had only been prescribed for under 24<span class="elsevierStyleHsp" style=""></span>h&#59; &#40;c&#41; The high volume of our collector systems makes it necessary to manipulate the latter for the measurement of hourly diuresis in small children&#8212;thereby increasing the risk of contamination&#59; &#40;d&#41; nUTIs associated to bladder catheter are rarely symptomatic&#44; especially in critical patients<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;15</span></a>&#59; such infections therefore may be underdiagnosed&#46; In contrast to other studies&#44; we applied an exhaustive protocol of daily culture collection&#44; independently of the patient clinical or laboratory test condition&#44; and this may have led us to diagnose infections which otherwise would have gone undetected or been treated on an empirical basis&#46; On the other hand&#44; some studies have reported an increase in the rate of nUTIs &#40;VINCIP-SECIP study in the year 2007&#58; 5&#46;5 infections&#47;1000 days of catheterization to 8&#46;2 infections&#47;1000 days in 2009&#41;&#59; &#40;e&#41; The risk implied by repeated manipulation of the system for obtaining urine cultures in catheterized patients cannot be discarded&#44; despite the adoption of maximum aseptic measures&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Our recorded distribution of etiological agents differs with respect to the data found in the literature&#44; though the limited sample size makes it necessary to view the data with caution&#46; In 66&#46;6&#37; of the cases the isolated organisms were gramnegative bacilli &#40;<span class="elsevierStyleItalic">E&#46; coli</span>&#41;&#44; though a high percentage of fungal agents was also recorded &#40;44&#46;4&#37;&#41;&#44; corresponding to <span class="elsevierStyleItalic">C&#46; albicans</span>&#46; In turn&#44; 16&#37; of the isolated germs were multiresistant &#40;BLEE&#41;&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Among the risk factors studied in our series&#44; and in addition to the presence of a bladder catheter&#44; mention must be made of the association of nUTI to the duration of stay in the PICU &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;013&#41; and the presence of patient antecedents of relevance &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;017&#41;&#46; A younger patient age&#44; the severity scores&#44; and the duration of bladder catheterization were not significantly correlated to infection&#46; In contrast to other authors&#44; we found no relationship between the severity scores and the risk of nosocomial infection&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;17</span></a> This could be explained by a greater percentage of patients in less serious condition admitted without antibiotic treatment despite the need for external devices&#46; This aspect has already been commented by Platt et al&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall">In conclusion&#44; our incidence density of device-related urinary infections is greater than in other studies published in the literature&#46; Among the risk factors studied&#44; and in addition to the need for a bladder catheter&#44; mention must be made of the presence of patient antecedents of relevance and a longer duration of stay in the PICU&#46; The days of bladder catheterization and a younger patient age failed to reach statistical significance&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">It would be necessary to establish multicenter registry systems referred to nosocomial infections in critical pediatric patients&#44; similar to those already found in adults&#44;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> in order to compare PICUs with different characteristics and&#47;or corresponding to different care levels&#46;</p></span></span>"
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            0 => "Resumen"
            1 => "Objetivos"
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          "titulo" => "Palabras clave"
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        4 => array:2 [
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          "titulo" => "Introduction"
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          "titulo" => "Patients and methods"
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              "identificador" => "sec0015"
              "titulo" => "Population"
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            1 => array:2 [
              "identificador" => "sec0020"
              "titulo" => "Definition"
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            2 => array:2 [
              "identificador" => "sec0025"
              "titulo" => "Sample collection"
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              "identificador" => "sec0030"
              "titulo" => "Statistical analysis"
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              "identificador" => "sec0045"
              "titulo" => "Factors related to nUTI"
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            2 => array:2 [
              "identificador" => "sec0050"
              "titulo" => "Positive urine cultures"
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            3 => array:2 [
              "identificador" => "sec0055"
              "titulo" => "Nosocomial urinary tract infection"
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          "titulo" => "Discussion"
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    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2010-12-23"
    "fechaAceptado" => "2011-02-01"
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec10594"
          "palabras" => array:8 [
            0 => "Nosocomial urinary tract infections"
            1 => "Urinary tract infection device associated"
            2 => "Nosocomial infection"
            3 => "Pediatric"
            4 => "Children"
            5 => "Urinary catheter"
            6 => "Urinary tract infection"
            7 => "Pediatric intensive care medicine"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec10595"
          "palabras" => array:8 [
            0 => "Infecci&#243;n de orina nosocomial"
            1 => "Infecci&#243;n de orina asociada a dispositivo"
            2 => "Infecci&#243;n nosocomial"
            3 => "Pediatr&#237;a"
            4 => "Ni&#241;os"
            5 => "Sonda vesical"
            6 => "Infecci&#243;n del tracto urinario"
            7 => "Cuidados intensivos pedi&#225;tricos"
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        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To determine the incidence&#44; etiology&#44; and risk factors of nosocomial urinary tract infections &#40;nUTIs&#41; in a second level Pediatric Intensive Care Unit &#40;PICU&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Patients and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A prospective study of 104 patients admitted to the PICU with a length of stay of more than 48<span class="elsevierStyleHsp" style=""></span>h was carried out over a 1 year period &#40;January to December 2009&#41; to study the incidence and risk factors of nUTI&#46; Urine samples were collected and cultured in all patients admitted for more than 48<span class="elsevierStyleHsp" style=""></span>h to our PICU&#46; Those needing indwelling urinary catheters had urine samples collected upon admission and every 24<span class="elsevierStyleHsp" style=""></span>h until catheter retrieval&#44; while those who did not need catheters had samples collected upon admission and every 48<span class="elsevierStyleHsp" style=""></span>h until discharge from the PICU&#46;</p> <span class="elsevierStyleSectionTitle">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Six patients &#40;5&#46;8&#37; of those admitted&#41; were diagnosed of nUTI&#44; with an incidence density of 5&#47;1000 patients&#47;day and 12&#46;2&#47;1000 catheterization days&#46; Four of these were caused by <span class="elsevierStyleItalic">Escherichia coli</span> &#40;including a multiresistant strain&#41;&#44; and two by <span class="elsevierStyleItalic">Candida albicans</span>&#46; Patients suffering nUTIs had significantly more relevant medical antecedents and a longer period of admittance than patients without nUTI&#46; A statistically nonsignificant tendency towards increased infection risk was also found in younger patients and in those who needed an indwelling catheter for longer periods&#46;</p> <span class="elsevierStyleSectionTitle">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">We found a higher incidence density of catheter associated nUTI than in other reports&#46; This at least partially could be due to the characteristics of our patients&#44; and to the exhaustive methodology used for detection&#46;</p>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span class="elsevierStyleSectionTitle">Objetivos</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Determinar la densidad de incidencia&#44; etiolog&#237;a y factores de riesgo de la infecci&#243;n de orina nosocomial &#40;ITUn&#41; en una UCIP de segundo nivel&#46;</p> <span class="elsevierStyleSectionTitle">Dise&#241;o</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio prospectivo descriptivo durante un periodo de 1 a&#241;o que incluy&#243; a 104 pacientes ingresados durante m&#225;s de 48<span class="elsevierStyleHsp" style=""></span>h en nuestra UCIP&#46; Se recogieron urocultivos diarios a los pacientes con sonda vesical hasta su retirada y cada 48<span class="elsevierStyleHsp" style=""></span>h a los no sondados hasta el alta&#46;</p> <span class="elsevierStyleSectionTitle">&#193;mbito</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Unidad de cuidados intensivos pedi&#225;tricos de segundo nivel&#46;</p> <span class="elsevierStyleSectionTitle">Pacientes</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Se incluy&#243; a todos los pacientes que ingresaron por m&#225;s de 48<span class="elsevierStyleHsp" style=""></span>h en el a&#241;o 2009&#46; Se excluy&#243; a los menores de 15 d&#237;as y a los que presentaban una infecci&#243;n de orina o pielonefritis al ingreso o antes de las 48<span class="elsevierStyleHsp" style=""></span>h tras su ingreso&#46;</p> <span class="elsevierStyleSectionTitle">Resultados</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Seis pacientes presentaron una ITUn &#40;el 5&#44;8&#37; de los ingresos&#41;&#44; con una densidad de incidencia de 5&#47;1&#46;000 pacientes&#47;d&#237;a y de 12&#44;19&#47;1&#46;000 d&#237;as de sonda&#46; Se identificaron 4 casos por <span class="elsevierStyleItalic">Escherichia coli</span> &#40;uno&#44; multirresistente&#41; y 2 por <span class="elsevierStyleItalic">Candida albicans</span>&#46; Los ni&#241;os con ITUn tuvieron significativamente m&#225;s antecedentes personales y mayor estancia que los ni&#241;os sin infecci&#243;n y&#44; aunque sin significaci&#243;n estad&#237;stica&#44; menor edad y mayor n&#250;mero de d&#237;as con sonda&#46;</p> <span class="elsevierStyleSectionTitle">Conclusiones</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Nuestra densidad de incidencia de infecci&#243;n de orina asociada a dispositivo es superior a la publicada&#59; esto puede deberse&#44; entre otras causas&#44; a las caracter&#237;sticas de los pacientes atendidos y al m&#233;todo exhaustivo empleado para su detecci&#243;n&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara">Please cite this article as&#58; Flores-Gonz&#225;lez JC&#44; et al&#46; Infecci&#243;n nosocomial del tracto urinario en ni&#241;os cr&#237;ticos&#46; Med Intensiva&#46; 2011&#59;35&#58;344&#8211;8&#46;</p>"
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          "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Data expressed as median &#91;interval&#93; or percentages&#46;</p>"
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                  \t\t\t\t\tvoid\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Variables&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">No nUTI &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>98&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">nUTI &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Gender&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">50&#58;50&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">50&#58;50&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
                  \t\t\t\t\ttop\n
                  \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" 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">Age &#40;months&#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">22 &#91;0&#8211;168&#93;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8 &#91;0&#8211;39&#93;&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="char" valign="\n
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                  \t\t\t\t">0&#46;298&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
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Surgical patients&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">16&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">16&#46;7&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
                  \t\t\t\t</td></tr><tr title="table-row"><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">Stay in PICU &#40;days&#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">6 &#91;2&#8211;145&#93;&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">14&#46;5 &#91;6&#8211;90&#93;&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;013&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
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Personal antecedents&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">26&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">66&#46;66&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="char" valign="\n
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                  \t\t\t\t">0&#46;017&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
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">PRISM III&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">3&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">3&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="char" valign="\n
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                  \t\t\t\t">0&#46;738&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
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">PIM 2&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">1&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;523&nbsp;\t\t\t\t\t\t\n
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                  """
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">No nUTI &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>98&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">nUTI &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Days of bladder catheterization&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">5 &#91;1&#8211;25&#93;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">6&#46;5 &#91;5&#8211;14&#93;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t</td></tr><tr title="table-row"><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  " align="char" valign="\n
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                  \t\t\t\t">0&#46;778&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Previous hospital stay &#40;days&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3 &#91;0&#8211;120&#93;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">6 &#91;1&#8211;54&#93;&nbsp;\t\t\t\t\t\t\n
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      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:19 [
            0 => array:3 [
              "identificador" => "bib0005"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The Nationwide Nosocomial Infection Rate&#58; a new need for vital statistics"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "R&#46;W&#46; Haley"
                            1 => "D&#46;H&#46; Culver"
                            2 => "J&#46;W&#46; White"
                            3 => "W&#46;M&#46; Morgan"
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                        ]
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                  ]
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                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Epidemiol"
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                        "link" => array:1 [
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                            "web" => "Medline"
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Incidence and risk factors for acquiring nosocomial urinary tract infection in the critically ill"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "K&#46;B&#46; Laupland"
                            1 => "D&#46;A&#46; Zygun"
                            2 => "H&#46;D&#46; Davies"
                            3 => "D&#46;L&#46; Church"
                            4 => "T&#46;J&#46; Louie"
                            5 => "C&#46;J&#46; Doig"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "J Crit Care"
                        "fecha" => "2002"
                        "volumen" => "17"
                        "paginaInicial" => "50"
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12040549"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0015"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "International Nosocomial Infection Control Consortium &#40;INICC&#41; report&#44; data summary for 2003&#8211;2008&#44; issued June 2009"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "V&#46;D&#46; Rosenthal"
                            1 => "D&#46;G&#46; Maki"
                            2 => "S&#46; Jamulitrat"
                            3 => "E&#46;A&#46; Medeiros"
                            4 => "T&#46;S&#46; Kumar"
                            5 => "D&#46; Yepes G&#243;mez"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.ajic.2009.12.004"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Infect Control"
                        "fecha" => "2010"
                        "volumen" => "38"
                        "paginaInicial" => "95"
                        "paginaFinal" => "106"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20176284"
                            "web" => "Medline"
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                        ]
                      ]
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                ]
              ]
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              "identificador" => "bib0020"
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                0 => array:1 [
                  "referenciaCompleta" => "National Nosocomial Infections Surveillance &#40;NNIS&#41; System Report&#58; data summary from January 1992 trough June 2004&#44; issued October 2004&#46; Am J infect Control&#46; 2004&#59;32&#58;470&#8211;85&#46;"
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              ]
            ]
            4 => array:3 [
              "identificador" => "bib0025"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Infecci&#243;n nosocomial"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "A&#46; Bustinza Arriort&#250;a"
                            1 => "M&#46;J&#46; Solana Garc&#237;a"
                            2 => "M&#46; Botr&#225;n Prieto"
                            3 => "B&#46; Padilla Ortega"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Libro" => array:5 [
                        "edicion" => "3<span class="elsevierStyleSup">a</span> ed&#46;"
                        "titulo" => "Manual de Cuidados Intensivos Pedi&#225;tricos"
                        "fecha" => "2009"
                        "editorial" => "Publimed"
                        "editorialLocalizacion" => "Madrid"
                      ]
                    ]
                  ]
                ]
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            5 => array:3 [
              "identificador" => "bib0030"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Defining urinary tract infection in the critically ill child"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "J&#46;M&#46; Langley"
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                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/PCC.0000000000001052"
                      "Revista" => array:6 [
                        "tituloSerie" => "Pediatr Crit Care Med"
                        "fecha" => "2005"
                        "volumen" => "6 Suppl&#46;"
                        "paginaInicial" => "S25"
                        "paginaFinal" => "S29"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28248832"
                            "web" => "Medline"
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            6 => array:3 [
              "identificador" => "bib0035"
              "etiqueta" => "7"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "CDC definitions for nosocomial infections"
                      "autores" => array:1 [
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Original
Nosocomial urinary tract infection in critical pediatric patients
Infección nosocomial del tracto urinario en niños críticos
J.C. Flores-Gonzáleza,
Corresponding author
carlosflogon@gmail.com

Corresponding author.
, A. Hernández-Gonzáleza, C. Rodríguez-Lópeza, V. Roldán-Canoa, F. Rubio-Quiñonesa, S. Quintero-Oteroa, M.V. García-Palaciosb, S. Pantoja-Rossoa
a Unidad de Cuidados Intensivos Pediátricos, Unidad de Gestión Clínica de Pediatría, Hospital Universitario Puerta del Mar, Cádiz, Spain
b Servicio de Medicina Preventiva, Hospital Universitario Puerta del Mar, Cádiz, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Within the range of different nosocomial infections&#44; nosocomial urinary tract infections represent an important hospital problem&#44; particularly in Pediatric Intensive Care Units &#40;PICUs&#41;&#44; causing increased morbidity and mortality&#44; a prolongation of stay&#44; and increased healthcare costs&#46; The epidemiological monitorization of such infections is essential in order to improve our knowledge and these processes and to establish adequate prevention and control programs&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Urinary tract infection is the leading nosocomial infection among hospitalized adults and in critical care&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> However&#44; in PICUs the epidemiology differs&#44; and urinary infectious processes represent the second or third most common type of nosocomial infection&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#8211;5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">These infections account for 5&#8211;15&#37; of all nosocomial infections&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Their appearance is directly related to a series of risk factors&#44; and the identification and evaluation of such factors can contribute to establish more effective control programs&#46; Among all the different risk factors studied&#44; bladder catheterization is the most important&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> It is estimated that 5&#8211;25&#37; of all patients requiring a bladder catheter during hospital admission develop nosocomial urinary tract infection &#40;nUTI&#41;&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Other risk factors in adults are the duration of catheterization&#44; the female gender&#44; inadequate care of the bladder catheter&#44; or a lack of antibiotic coverage&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Despite their importance&#44; there are few studies of nUTIs in the PICU&#44; and their epidemiology in this patient population has not been well established&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The primary objective of this observational study is to determine the incidence density of nosocomial urinary infections in a second-level PICU&#46; The secondary objectives are to define the etiology and risk factors&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Patients and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Population</span><p id="par0030" class="elsevierStylePara elsevierViewall">A prospective&#44; descriptive observational study was carried out in a provincial reference PICU with seven beds&#46; The Unit treats medical and surgical disorders&#44; with the exception of cardiovascular surgery&#46; We included all patients between 15 days and 14 years of age admitted for over 48<span class="elsevierStyleHsp" style=""></span>h in the period between 1 January and 31 December 2009&#46; The exclusion criteria were as follows&#58; age under 15 days or over 14 years&#44; the presence of urinary infection or pyelonephritis upon admission or in under 48<span class="elsevierStyleHsp" style=""></span>h after admission&#44; and patients remaining in the PICU for less than 48<span class="elsevierStyleHsp" style=""></span>h&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The following data were collected from all subjects&#58; age&#44; gender&#44; reason for admission&#44; medical or surgical disease&#44; severity in the first 24<span class="elsevierStyleHsp" style=""></span>h &#40;PRISM III and PIM II scores&#41;&#44; and personal history of relevance &#40;infant brain paralysis&#44; premature delivery&#44; spina bifida&#44; heart disease&#44; neuromuscular disease&#44; liver or kidney disease&#44; immunodeficiency or hematological disease&#41;&#46; We documented the possible factors related to nUTI&#58; bladder catheter&#44; previous hospital stay&#44; corticosteroid treatment&#44; immunosuppressors&#44; surgery in the 2 months prior to admission&#44; neutropenia&#44; and antibiotic treatment received&#46; Clinical information indicative of UTI was collected on a daily basis in all cases&#46; The patients with a bladder catheter were subjected to daily urine culture until discharge from the PICU or removal of the catheter&#46; In patients without bladder catheterization&#44; or after removal of the catheter&#44; urine cultures were obtained upon admission and every 48<span class="elsevierStyleHsp" style=""></span>h until discharge&#46; In addition&#44; a urine culture was obtained 48<span class="elsevierStyleHsp" style=""></span>h after transfer to the hospital ward&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Definition</span><p id="par0040" class="elsevierStylePara elsevierViewall">Nosocomial infections were defined as all infections not present at the time of admission but which appeared within 48<span class="elsevierStyleHsp" style=""></span>h after admission to the PICU&#46; The diagnosis was based on the criteria of the CDC&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;7</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Contamination was defined by urine cultures with low counts &#40;&#8804;10<span class="elsevierStyleSup">4</span><span class="elsevierStyleHsp" style=""></span>cfu&#47;ml&#41; of microorganisms normally present in the skin or external or internal genitalia&#46; Mixed growth cultures are usually indicative of fecal microbiota contamination&#44; though clinical evaluation is required in such cases&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Colonization in turn was defined as the presence of microorganisms in urine culture&#44; without clinical repercussions&#44; and which disappear after removal of the bladder catheter&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The severity of the disease upon admission was assessed using the PRISM III and PIM II scales&#44; both validated for pediatric patients&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Sample collection</span><p id="par0060" class="elsevierStylePara elsevierViewall">In catheterized children urine cultures and systematic urine tests were made on a daily basis&#46; In order to avoid false-positive readings due to colonization&#44; in those children with positive urine culture findings we replaced the bladder catheter and then repeated urine culture for confirmation purposes&#46; If bladder catheterization was discontinued during admission&#44; sample collection was carried out as in the group described below&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">In non-catheterized children with preserved sphincter control&#44; we collected the middle portion of spontaneous micturition &#40;preferably in the morning&#41;&#44; after washing the genitals with water and soap&#44; rinsing with sterile water and drying with sterile gauze&#46; In no case were antiseptics capable of falsifying bacterial growth employed&#46; In patients without sphincter control&#44; the sample was collected with a perineal adhesive bag after cleaning of the zone&#44; with replacement every 30<span class="elsevierStyleHsp" style=""></span>min&#46; In this latter case urine culture collection was systematically spaced to once every 48<span class="elsevierStyleHsp" style=""></span>h in order to avoid irritation caused by the adhesive bag in the perineal region&#46; If the urine sample proved doubtful or showed contamination&#44; point catheterization was carried out&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">The urine samples were collected under sterile conditions and transported to the laboratory in under 1<span class="elsevierStyleHsp" style=""></span>h&#46; A closed system with a 500-ml capacity was used to control hourly diuresis&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Statistical analysis</span><p id="par0075" class="elsevierStylePara elsevierViewall">New variables were calculated for data analysis&#44; based on differences in dates referred to patient age&#44; days of hospital admission&#44; and days of bladder catheterization&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The descriptive analysis was based on calculation of the mean&#44; median and standard deviation &#40;SD&#41; and interval for quantitative variables&#44; while qualitative variables were reported as frequencies and percentages&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">For each categorical variable of interest we explored associations with urinary infection based on the comparison of proportions with the Mantel&#8211;Haenszel chi-squared test or the Fisher test in the case of variables including less than five individuals&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">The Kolmogorov&#8211;Smirnov test was used to assess normal distribution of the study variables&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Comparisons between means of quantitative variables in the study of children with or without infection were based on the Student&#39;s <span class="elsevierStyleItalic">t</span>-test or the Mann&#8211;Whitney <span class="elsevierStyleItalic">U</span>-test in the case of variables with a non-normal distribution&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Nonparametric tests were used for the study of factors associated to bacterial or fungal nUTIs&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">The level of significance was established as 95&#37; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; The SPSS version 15&#46;0 statistical package was used throughout&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Results</span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">General data</span><p id="par0110" class="elsevierStylePara elsevierViewall">During the study period a total of 178 patients were admitted to the PICU&#44; with a mean stay of over 48<span class="elsevierStyleHsp" style=""></span>h&#46; Seventy-four patients were excluded from the study due to some of the following reasons&#58; age under 15 days &#40;17 patients&#41; or over 14 years &#40;24 patients&#41;&#44; presence of UTI upon admission &#40;patients 22&#41;&#44; or other reasons &#40;patients 11&#41;&#46; The final sample consisted of 104 patients&#46; The general data are reported in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; The children with nUTI were younger than the children without infection &#40;15&#46;8 vs 35&#46;9 months&#41;&#44; though the difference was not statistically significant&#46; El group of children with nUTI showed a significantly higher percentage of personal antecedents of relevance than the group without nUTI&#46; Upon admission&#44; the children with and without nUTI showed similar median scores on the PRISM III and PIM II severity scales &#40;3&#37; and 1&#46;4&#37;&#44; respectively&#41;&#44; though the interval &#40;range&#41; was markedly greater in the children without infection&#46; The children with nUTI presented significantly longer stays&#46; The mortality rate among the children with and without nUTI was 0&#37; and 8&#46;7&#37;&#44; respectively&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Factors related to nUTI</span><p id="par0115" class="elsevierStylePara elsevierViewall">A total of 68&#37; of the patients carried a bladder catheter&#44; with a mean of 7 days and a total duration of 492 days&#46; The bladder catheter utilization rate was 0&#46;41&#46; The mean time from admission to the appearance of nUTI was 3&#46;83 days&#46; The urine cultures showed negative conversion after 7 days on average&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">All the patients with nUTI had received a bladder catheter&#44; and the catheterization period was longer than in the children without infection&#44; though the difference was not statistically significant &#40;6&#46;5 vs 5 days&#41;&#46; Likewise&#44; the days of corticosteroid treatment and of previous hospital stay showed no significant differences&#46; These data&#44; compared with the patients without nUTI&#44; are shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46; Three of the six cases of nUTI &#40;50&#37; vs 88&#46;5&#37; of the patients without nUTI&#41; were receiving antibiotic treatment at the time of diagnosis&#44; though only in the two documented cases of fungal infection did the treatment have to be changed&#46; In turn&#44; 4&#46;9&#37; of the patients without nUTI had undergone surgery in the previous 60 days&#44; 1&#37; presented neutropenia&#44; and 1&#46;9&#37; suffered immune deficiency&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Positive urine cultures</span><p id="par0125" class="elsevierStylePara elsevierViewall">A total of 27 patients showed positive urine cultures &#40;26&#37;&#41;&#46; Two of these cases were classified as colonization &#40;1&#46;9&#37;&#41;&#44; 19 as contamination &#40;18&#46;3&#37;&#41;&#44; and six as nosocomial urinary tract infection &#40;5&#46;8&#37;&#41;&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">The six cases of nUTI presented fever&#44; with no identification of urinary symptoms &#40;urgency&#44; abdominal pain&#44; pollakiuria&#44; dysuria&#44; or others&#41;&#46; The colonized patients suffered no symptoms&#44; while one of the 19 cases of contamination coincided with a fever process that did not meet the CDC criteria of nUTI&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Nosocomial urinary tract infection</span><p id="par0135" class="elsevierStylePara elsevierViewall">We documented six cases of nUTI&#44; all in catheterized children&#8212;this representing 5&#46;8&#37; of all the admissions for over 48<span class="elsevierStyleHsp" style=""></span>h&#44; and 8&#46;6&#37; of all children with bladder catheters&#46; A total of 1188 days of hospital stay were registered &#40;5&#46;05&#47;1000 patients&#47;day&#41;&#44; together with 492 days of bladder catheterization &#40;incidence density 12&#46;19&#47;1000 days of catheterization&#41;&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Two of the urinary infections were recorded in one same girl with spina bifida&#44; admitted on two occasions for different reasons&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Regarding the etiology of nUTI&#44; we identified four cases attributable to <span class="elsevierStyleItalic">Escherichia coli</span> &#40;multiresistant &#40;BLEE&#41; in once case&#41; and two to <span class="elsevierStyleItalic">Candida albicans</span>&#46;</p></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0150" class="elsevierStylePara elsevierViewall">In contrast to the data published on adult patients&#44;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;9&#44;10</span></a> there are few literature references to nUTI in the critical pediatric population&#44; and the existing information refers mainly to third-level PICUs or multicenter registries comprising numerous Units&#44; without specifying their characteristics&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a> The diseases seen in a second-level PICU are different&#44; and it is therefore reasonable to assume that the incidence and epidemiology of the nosocomial infections are also different&#46; We have found no specific publications on nUTIs in second-level PICUs&#46; In addition&#44; the few pediatric studies identified contain practically no prospective studies with a duration of over 6 months&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Our incidence density of device-related UTIs &#40;12&#46;19&#47;1000 days of bladder catheter&#41; is greater than in other series&#46; The National Nosocomial Infections Surveillance &#40;NNIS&#41; System Report compiles information on 52 PICUs in the United States&#44; and publishes an average of four nUTIs&#47;1000 days of bladder catheter<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>&#8212;though no specification is provided of the characteristics of the participating Units &#40;medical&#44; surgical&#44; medical&#8211;surgical&#44; traumatologic&#44; burn units&#44; with cardiovascular surgery or with transplants&#41;&#46; The International Nosocomial Infection Control Consortium &#40;INICC&#41; in turn compiles data on 22 PICUs in Latin America&#44; Asia&#44; Africa&#44; and Europe&#44; with the publication of an average of 4&#46;4 infections&#47;1000 days of bladder catheter&#8212;and likewise no specification is provided of the characteristics of the participating PICUs&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> In contrast&#44; in adult ICUs&#44; a division is made according to the characteristics of each Unit&#44; with the recording of quite different incidence densities&#46; In the Spanish national setting&#44; we have a registry system &#40;VINCIP-SECIP&#41; with a rate of 8&#46;2 infections&#47;1000 days of bladder catheter&#44;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> though here again the types of Units are not specified&#46; Other authors such as Richards et al&#46;&#44; analyzed the epidemiology in 61 PICUs in the United States&#44; with an average of 5&#46;9 episodes&#47;1000 days of bladder catheterization&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> In turn&#44; Urrea et al&#46;&#44; in a study of a third-level PICU&#44; reported a rate of 10&#46;7 infections&#47;1000 days of catheterization&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> Among the few studies specific of nUTIs&#44; mention must be made of the work of Matlow et al&#46;&#8212;a retrospective 10-year study in a third-level PICU&#46; However&#44; since these authors reflect the incidence per percentage of admissions &#40;0&#46;95&#47;100 admissions&#41;&#44; not per days of catheterization&#44; comparisons are difficult to establish&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">We consider that the greater incidence density of nUTIs in our PICU may be due to a number of reasons&#58; &#40;a&#41; Our bladder catheter utilization rate is greater than in other studies&#58; 0&#46;41 versus 0&#46;3 in the NNIS&#44; 0&#46;17 in the INICC&#44; and 0&#46;32 in the article published by Richards et al&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> In this context&#44; protocols designed to lessen catheter use and its duration are the strategies with the greatest impact in terms of reducing the incidence of infections&#59; &#40;b&#41; In our PICU there is a greater percentage of children admitted with invasive devices and without antibiotic treatment than in other higher-level Units&#44; and these patients are more susceptible to nosocomial infection&#46; In fact&#44; none of the patients with UTIs of bacterial origin received antibiotics&#44; or alternatively such drugs had only been prescribed for under 24<span class="elsevierStyleHsp" style=""></span>h&#59; &#40;c&#41; The high volume of our collector systems makes it necessary to manipulate the latter for the measurement of hourly diuresis in small children&#8212;thereby increasing the risk of contamination&#59; &#40;d&#41; nUTIs associated to bladder catheter are rarely symptomatic&#44; especially in critical patients<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;15</span></a>&#59; such infections therefore may be underdiagnosed&#46; In contrast to other studies&#44; we applied an exhaustive protocol of daily culture collection&#44; independently of the patient clinical or laboratory test condition&#44; and this may have led us to diagnose infections which otherwise would have gone undetected or been treated on an empirical basis&#46; On the other hand&#44; some studies have reported an increase in the rate of nUTIs &#40;VINCIP-SECIP study in the year 2007&#58; 5&#46;5 infections&#47;1000 days of catheterization to 8&#46;2 infections&#47;1000 days in 2009&#41;&#59; &#40;e&#41; The risk implied by repeated manipulation of the system for obtaining urine cultures in catheterized patients cannot be discarded&#44; despite the adoption of maximum aseptic measures&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Our recorded distribution of etiological agents differs with respect to the data found in the literature&#44; though the limited sample size makes it necessary to view the data with caution&#46; In 66&#46;6&#37; of the cases the isolated organisms were gramnegative bacilli &#40;<span class="elsevierStyleItalic">E&#46; coli</span>&#41;&#44; though a high percentage of fungal agents was also recorded &#40;44&#46;4&#37;&#41;&#44; corresponding to <span class="elsevierStyleItalic">C&#46; albicans</span>&#46; In turn&#44; 16&#37; of the isolated germs were multiresistant &#40;BLEE&#41;&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Among the risk factors studied in our series&#44; and in addition to the presence of a bladder catheter&#44; mention must be made of the association of nUTI to the duration of stay in the PICU &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;013&#41; and the presence of patient antecedents of relevance &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;017&#41;&#46; A younger patient age&#44; the severity scores&#44; and the duration of bladder catheterization were not significantly correlated to infection&#46; In contrast to other authors&#44; we found no relationship between the severity scores and the risk of nosocomial infection&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;17</span></a> This could be explained by a greater percentage of patients in less serious condition admitted without antibiotic treatment despite the need for external devices&#46; This aspect has already been commented by Platt et al&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall">In conclusion&#44; our incidence density of device-related urinary infections is greater than in other studies published in the literature&#46; Among the risk factors studied&#44; and in addition to the need for a bladder catheter&#44; mention must be made of the presence of patient antecedents of relevance and a longer duration of stay in the PICU&#46; The days of bladder catheterization and a younger patient age failed to reach statistical significance&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">It would be necessary to establish multicenter registry systems referred to nosocomial infections in critical pediatric patients&#44; similar to those already found in adults&#44;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> in order to compare PICUs with different characteristics and&#47;or corresponding to different care levels&#46;</p></span></span>"
    "textoCompletoSecciones" => array:1 [
      "secciones" => array:10 [
        0 => array:2 [
          "identificador" => "xres9155"
          "titulo" => array:5 [
            0 => "Abstract"
            1 => "Objective"
            2 => "Patients and methods"
            3 => "Results"
            4 => "Conclusions"
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        ]
        1 => array:2 [
          "identificador" => "xpalclavsec10594"
          "titulo" => "Keywords"
        ]
        2 => array:2 [
          "identificador" => "xres9154"
          "titulo" => array:7 [
            0 => "Resumen"
            1 => "Objetivos"
            2 => "Dise&#241;o"
            3 => "&#193;mbito"
            4 => "Pacientes"
            5 => "Resultados"
            6 => "Conclusiones"
          ]
        ]
        3 => array:2 [
          "identificador" => "xpalclavsec10595"
          "titulo" => "Palabras clave"
        ]
        4 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Introduction"
        ]
        5 => array:3 [
          "identificador" => "sec0010"
          "titulo" => "Patients and methods"
          "secciones" => array:4 [
            0 => array:2 [
              "identificador" => "sec0015"
              "titulo" => "Population"
            ]
            1 => array:2 [
              "identificador" => "sec0020"
              "titulo" => "Definition"
            ]
            2 => array:2 [
              "identificador" => "sec0025"
              "titulo" => "Sample collection"
            ]
            3 => array:2 [
              "identificador" => "sec0030"
              "titulo" => "Statistical analysis"
            ]
          ]
        ]
        6 => array:3 [
          "identificador" => "sec0035"
          "titulo" => "Results"
          "secciones" => array:4 [
            0 => array:2 [
              "identificador" => "sec0040"
              "titulo" => "General data"
            ]
            1 => array:2 [
              "identificador" => "sec0045"
              "titulo" => "Factors related to nUTI"
            ]
            2 => array:2 [
              "identificador" => "sec0050"
              "titulo" => "Positive urine cultures"
            ]
            3 => array:2 [
              "identificador" => "sec0055"
              "titulo" => "Nosocomial urinary tract infection"
            ]
          ]
        ]
        7 => array:2 [
          "identificador" => "sec0060"
          "titulo" => "Discussion"
        ]
        8 => array:2 [
          "identificador" => "xack839"
          "titulo" => "Acknowledgements"
        ]
        9 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2010-12-23"
    "fechaAceptado" => "2011-02-01"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec10594"
          "palabras" => array:8 [
            0 => "Nosocomial urinary tract infections"
            1 => "Urinary tract infection device associated"
            2 => "Nosocomial infection"
            3 => "Pediatric"
            4 => "Children"
            5 => "Urinary catheter"
            6 => "Urinary tract infection"
            7 => "Pediatric intensive care medicine"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec10595"
          "palabras" => array:8 [
            0 => "Infecci&#243;n de orina nosocomial"
            1 => "Infecci&#243;n de orina asociada a dispositivo"
            2 => "Infecci&#243;n nosocomial"
            3 => "Pediatr&#237;a"
            4 => "Ni&#241;os"
            5 => "Sonda vesical"
            6 => "Infecci&#243;n del tracto urinario"
            7 => "Cuidados intensivos pedi&#225;tricos"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To determine the incidence&#44; etiology&#44; and risk factors of nosocomial urinary tract infections &#40;nUTIs&#41; in a second level Pediatric Intensive Care Unit &#40;PICU&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Patients and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A prospective study of 104 patients admitted to the PICU with a length of stay of more than 48<span class="elsevierStyleHsp" style=""></span>h was carried out over a 1 year period &#40;January to December 2009&#41; to study the incidence and risk factors of nUTI&#46; Urine samples were collected and cultured in all patients admitted for more than 48<span class="elsevierStyleHsp" style=""></span>h to our PICU&#46; Those needing indwelling urinary catheters had urine samples collected upon admission and every 24<span class="elsevierStyleHsp" style=""></span>h until catheter retrieval&#44; while those who did not need catheters had samples collected upon admission and every 48<span class="elsevierStyleHsp" style=""></span>h until discharge from the PICU&#46;</p> <span class="elsevierStyleSectionTitle">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Six patients &#40;5&#46;8&#37; of those admitted&#41; were diagnosed of nUTI&#44; with an incidence density of 5&#47;1000 patients&#47;day and 12&#46;2&#47;1000 catheterization days&#46; Four of these were caused by <span class="elsevierStyleItalic">Escherichia coli</span> &#40;including a multiresistant strain&#41;&#44; and two by <span class="elsevierStyleItalic">Candida albicans</span>&#46; Patients suffering nUTIs had significantly more relevant medical antecedents and a longer period of admittance than patients without nUTI&#46; A statistically nonsignificant tendency towards increased infection risk was also found in younger patients and in those who needed an indwelling catheter for longer periods&#46;</p> <span class="elsevierStyleSectionTitle">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">We found a higher incidence density of catheter associated nUTI than in other reports&#46; This at least partially could be due to the characteristics of our patients&#44; and to the exhaustive methodology used for detection&#46;</p>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span class="elsevierStyleSectionTitle">Objetivos</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Determinar la densidad de incidencia&#44; etiolog&#237;a y factores de riesgo de la infecci&#243;n de orina nosocomial &#40;ITUn&#41; en una UCIP de segundo nivel&#46;</p> <span class="elsevierStyleSectionTitle">Dise&#241;o</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio prospectivo descriptivo durante un periodo de 1 a&#241;o que incluy&#243; a 104 pacientes ingresados durante m&#225;s de 48<span class="elsevierStyleHsp" style=""></span>h en nuestra UCIP&#46; Se recogieron urocultivos diarios a los pacientes con sonda vesical hasta su retirada y cada 48<span class="elsevierStyleHsp" style=""></span>h a los no sondados hasta el alta&#46;</p> <span class="elsevierStyleSectionTitle">&#193;mbito</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Unidad de cuidados intensivos pedi&#225;tricos de segundo nivel&#46;</p> <span class="elsevierStyleSectionTitle">Pacientes</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Se incluy&#243; a todos los pacientes que ingresaron por m&#225;s de 48<span class="elsevierStyleHsp" style=""></span>h en el a&#241;o 2009&#46; Se excluy&#243; a los menores de 15 d&#237;as y a los que presentaban una infecci&#243;n de orina o pielonefritis al ingreso o antes de las 48<span class="elsevierStyleHsp" style=""></span>h tras su ingreso&#46;</p> <span class="elsevierStyleSectionTitle">Resultados</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Seis pacientes presentaron una ITUn &#40;el 5&#44;8&#37; de los ingresos&#41;&#44; con una densidad de incidencia de 5&#47;1&#46;000 pacientes&#47;d&#237;a y de 12&#44;19&#47;1&#46;000 d&#237;as de sonda&#46; Se identificaron 4 casos por <span class="elsevierStyleItalic">Escherichia coli</span> &#40;uno&#44; multirresistente&#41; y 2 por <span class="elsevierStyleItalic">Candida albicans</span>&#46; Los ni&#241;os con ITUn tuvieron significativamente m&#225;s antecedentes personales y mayor estancia que los ni&#241;os sin infecci&#243;n y&#44; aunque sin significaci&#243;n estad&#237;stica&#44; menor edad y mayor n&#250;mero de d&#237;as con sonda&#46;</p> <span class="elsevierStyleSectionTitle">Conclusiones</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Nuestra densidad de incidencia de infecci&#243;n de orina asociada a dispositivo es superior a la publicada&#59; esto puede deberse&#44; entre otras causas&#44; a las caracter&#237;sticas de los pacientes atendidos y al m&#233;todo exhaustivo empleado para su detecci&#243;n&#46;</p>"
      ]
    ]
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara">Please cite this article as&#58; Flores-Gonz&#225;lez JC&#44; et al&#46; Infecci&#243;n nosocomial del tracto urinario en ni&#241;os cr&#237;ticos&#46; Med Intensiva&#46; 2011&#59;35&#58;344&#8211;8&#46;</p>"
      ]
    ]
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        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Data expressed as median &#91;interval&#93; or percentages&#46;</p>"
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            0 => array:2 [
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
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                  \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" style="border-bottom: 2px solid black">Variables&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">No nUTI &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>98&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">nUTI &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><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">Gender&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">50&#58;50&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">50&#58;50&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
                  \t\t\t\t\ttop\n
                  \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" 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">Age &#40;months&#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">22 &#91;0&#8211;168&#93;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8 &#91;0&#8211;39&#93;&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;298&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
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Surgical patients&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">16&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16&#46;7&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
                  \t\t\t\t\ttop\n
                  \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" 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">Stay in PICU &#40;days&#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">6 &#91;2&#8211;145&#93;&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">14&#46;5 &#91;6&#8211;90&#93;&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;013&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
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Personal antecedents&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">26&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">66&#46;66&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;017&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
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">PRISM III&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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        "identificador" => "xack839"
        "titulo" => "Acknowledgements"
        "texto" => "<p id="par0185" class="elsevierStylePara elsevierViewall">The authors wish to thank the personnel of the Pediatric Intensive Care Unit of Puerta del Mar University Hospital &#40;C&#225;diz&#44; Spain&#41;&#44; and especially the auxiliary nursing staff&#44; for making this study possible&#46;</p>"
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ISSN: 21735727
Original language: English
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