Epidemiological study of Clostridium difficile infection in critical patients admitted to the Intensive Care Unit

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Vera, M. Palomar, F. Álvarez-Lerma" "autores" => array:3 [ 0 => array:2 [ "nombre" => "P." "apellidos" => "Vera" ] 1 => array:2 [ "nombre" => "M." "apellidos" => "Palomar" ] 2 => array:2 [ "nombre" => "F." "apellidos" => "Álvarez-Lerma" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173572714000770?idApp=WMIE" "url" => "/21735727/0000003800000009/v1_201412070106/S2173572714000770/v1_201412070106/en/main.assets" ] "en" => array:22 [ "idiomaDefecto" => true "cabecera" => "Original" "titulo" => "Epidemiological study of Clostridium difficile infection in critical patients admitted to the Intensive Care Unit" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "558" "paginaFinal" => "566" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "F. Alvarez-Lerma, M. Palomar, A. Villasboa, J. Amador, J. Almirall, M.P. Posada, M. Catalan, C. Pascual" "autores" => array:9 [ 0 => array:4 [ "nombre" => "F." "apellidos" => "Alvarez-Lerma" "email" => array:1 [ 0 => "Falvarez@parcdesalutmar.ct" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "M." "apellidos" => "Palomar" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "A." "apellidos" => "Villasboa" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "J." "apellidos" => "Amador" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] 4 => array:3 [ "nombre" => "J." "apellidos" => "Almirall" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "d" "identificador" => "aff0020" ] ] ] 5 => array:3 [ "nombre" => "M.P." 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"apellidos" => "Pascual" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "g" "identificador" => "aff0035" ] ] ] 8 => array:2 [ "colaborador" => "ENVIN-UCI Study Group" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "◊" "identificador" => "fn1" ] ] ] ] "afiliaciones" => array:7 [ 0 => array:3 [ "entidad" => "Servicio de Medicina Intensiva, Hospital del Mar, Parc de Salut Mar, Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Medicina Intensiva, Hospital Arnau de Vilanova, Lleida, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Medicina Intensiva, Hospital de Terrassa, Terrassa, Barcelona, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Servicio de Medicina Intensiva, Hospital de Mataró, Consorci Sanitari del Maresme, Mataró, Barcelona, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Servicio de Medicina Intensiva, Hospital Xeral Cíes, Vigo, Pontevedra, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Servicio de Medicina Intensiva, Hospital 12 de Octubre, Madrid, Spain" "etiqueta" => "f" "identificador" => "aff0030" ] 6 => array:3 [ "entidad" => "Servicio de Medicina Intensiva, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain" "etiqueta" => "g" "identificador" => "aff0035" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Estudio epidemiológico de infección por Clostridium difficile en pacientes críticos ingresados en una Unidad de Cuidados Intensivos" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1074 "Ancho" => 1585 "Tamanyo" => 66009 ] ] "descripcion" => array:1 [ "en" => "Distribution of the cases of Clostridium difficile infection (CDI) detected in the Intensive Care Units in the course of the months of the year (31 patients in the national vigilance period)." ] ] ] "textoCompleto" => "IntroductionInfections caused by Clostridium difficile (C. difficile) (CDI) are generally diagnosed by the presence of persistent liquid diarrhea, with the identification of C. difficile in a stool sample using some of the different tests available. A diagnosis based on colonoscopic or histopathological findings evidencing the presence of pseudomembranous colitis is less common.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> The importance of such infections is reflected by the fact that C. difficile may be present in 20–30% of the cases of diarrhea associated to antimicrobial use.<a class="elsevierStyleCrossRef" href="#bib0010">2</a> Few epidemiological data are available on the prevalence of CDI in hospitalized patients, and there is even less information referred to critical patients admitted to Departments of Intensive Care Medicine or Intensive Care Units (ICUs). A study made between 1997 and 2005 in Canadian hospitals recorded an incidence of between 3.4 and 8.4 cases per 1000 admissions in acute care hospitals, and of 3.8–9.5 cases per 10,000 patients-day.<a class="elsevierStyleCrossRefs" href="#bib0015">3,4</a> The mortality rate attributed to CDI is low (less than 2%),<a class="elsevierStyleCrossRefs" href="#bib0020">4,5</a> though the associated excess costs in American hospitals during the period 2000–2002 was estimated to be 3200million USD/year.<a class="elsevierStyleCrossRef" href="#bib0030">6</a>The risk factors underlying CDI include old age (>64 years),<a class="elsevierStyleCrossRefs" href="#bib0035">7,8</a> the duration of hospital stay,<a class="elsevierStyleCrossRef" href="#bib0045">9</a> exposure to antimicrobial drugs,<a class="elsevierStyleCrossRef" href="#bib0050">10</a> cancer chemotherapy,<a class="elsevierStyleCrossRefs" href="#bib0055">11,12</a> immune depression related to HIV infection,<a class="elsevierStyleCrossRef" href="#bib0065">13</a> gastrointestinal surgery,<a class="elsevierStyleCrossRef" href="#bib0070">14</a> enteral diet administered through a nasogastric tube,<a class="elsevierStyleCrossRef" href="#bib0075">15</a> and the administration of acid-suppressing drugs (antihistamines and proton pump inhibitors).<a class="elsevierStyleCrossRef" href="#bib0080">16</a> Many of these factors are present in critical patients admitted to the ICU. However, infection registries in such Units tend to focus on infections related to the use of invasive devices<a class="elsevierStyleCrossRef" href="#bib0085">17</a>–the information on CDI being scarce and limited to the description of epidemic outbreaks and mortality or cost increment estimates.<a class="elsevierStyleCrossRefs" href="#bib0090">18–23</a> The objective of this study is to determine the characteristics of critical patients with CDI admitted to Spanish ICUs in the year 2012, independently of the origin of the infection, and to describe the factors related to the development of CDI and the treatment strategies employed.MethodologyDesignA retrospective, non-interventional, multicenter observational study was carried out with the voluntary participation of ICUs that routinely collaborate in the ENVIN-ICU registry. Since the year 1994, this registry monitors the evolution of infections related to invasive devices, their etiology, resistance markers, and the antimicrobials used in Spanish ICUs (accessible at: <a id="intr0010" class="elsevierStyleInterRef" href="http://hws.vhebron.net/envin-helics/">http://hws.vhebron.net/envin-helics/</a>).Case definitionA case is defined as any patient admitted to an ICU or critical care unit and in which the presence of C. difficile is identified.Study periodWe included all patients with positive C. difficile isolates admitted to the ICUs participating in the abovementioned registry in the year 2012. The patients were followed-up on throughout their stay in the ICU and during the 72h after discharge from the Unit.Clostridium difficile detection techniquesThe identification of C. difficile was based on the routine techniques used in the Microbiology laboratory of each of the participating hospitals, and which comprised one or more of the following: stool culture, determination of the enzyme glutamate dehydrogenase (GDH), enzymoimmunoassay for toxins A and B, studies of cell cytotoxins and toxigenic cultures, and polymerase chain reaction (PCR) techniques.Data collectionA case report form (CRF) was used to record demographic data, hospital and ICU admission and discharge dates, diagnosis upon admission, severity as assessed by the APACHE II scale,<a class="elsevierStyleCrossRef" href="#bib0120">24</a> and the need for emergency surgery during admission. The patients were classified according to the diagnosis upon admission as coronary, surgical, trauma or clinical cases.<a class="elsevierStyleCrossRef" href="#bib0085">17</a> Coronary patients were those admitted due to acute or chronic coronary syndrome with or without ST-segment elevation. Trauma patients in turn were those admitted due to acute injuries, while surgical patients were defined as individuals admitted for postoperative control of scheduled surgery. Lastly, clinical patients were those admitted due to reasons unrelated to the above, including individuals admitted after non-scheduled surgery.We likewise documented the comorbidities, invasive devices, techniques and treatments used on the day of the isolation of C. difficile, and the previously administered antibiotics and their duration. The comorbidities evaluated were immune depression, immune suppression, neutropenia and solid organ transplantation. Instrumentations and controlled techniques comprised mechanical ventilation, bladder catheterization, central venous catheter placement, extrarenal filtration techniques, ventricular shunt catheters, parenteral nutrition, enteral nutrition and previous surgery. The following definitions were used<a class="elsevierStyleCrossRef" href="#bib0085">17</a>: immune suppression when the patient received treatment lowering resistance to infection (chemotherapy, radiation, prolonged or high-dose corticosteroids) or suffered disease in a sufficiently advanced stage to suppress the host defenses against infection; neutropenia in the presence of a neutrophil count of <500cells/mm3; and immune depression when the patient had been diagnosed with HIV infection or some other congenital or acquired immune deficiency.In etiological terms, CDI was classified as community-acquired when the patient presented liquid diarrhea and positive identification of C. difficile at the time of admission or in the first 48h after admission to hospital; nosocomial out-ICU when the clinical manifestations and diagnosis were registered after the first 48h in hospital and in the first 48h of admission to the ICU; and nosocomial in-ICU when the diagnosis was established after the first 48h in the ICU or in the first 72h after discharge from the Unit.The specific risk factors for CDI considered in the study were: age>64 years, previous antimicrobial use for over 7 days, other hospital admissions in the previous three months, a history of HIV disease, gastroduodenal surgery, chemotherapy use in the previous three months, and the current use of enteral nutrition and/or H2 inhibitors.The systemic response to infection was recorded, defined as the presence of sepsis, severe sepsis or septic shock not attributable to other infectious causes. The specific treatment administered for CDI was classified as monotherapy when the patient received a single antibiotic for the infection (independently of whether other antibiotics were also used to treat other infections), and dual therapy when two antibiotics were administered simultaneously. The clinical response in turn was classified as cure, improvement, without changes, and death related to the infection, while microbiological response was classified as the negative conversion of cultures, persistence, appearance of another microorganism in stools, and no follow-up. The patients were followed-up until discharge from hospital in order to identify possible reinfections. The classification of reinfection required cure or improvement of a previous episode and/or a negative stool test. Lastly, overall mortality was defined as death occurring during admission to the ICU or in the hospital, due to any cause.Calculation of ratesThe frequency of CDI was defined by the number of episodes recorded in patients admitted to the ICU (regardless of the origin of the infection) per 1000 patients admitted to the ICU and per 10,000 days of stay in the ICU. In calculating the rates we considered only those patients included in the ENVIN-ICU registry during the national vigilance period (April–June), since the data referred to the number of patients and days of stay in the ICU at Spanish national level are available for these months (19,521 patients and 150,832 days of stay in the ICU).Statistical analysisThe qualitative variables are described with the percentage distribution of each of the categories, while the quantitative variables are described using the mean and standard deviation in the case of a normal distribution, and the median and range in the case of a non-normal distribution.ResultsThe study included 68 patients with CDI in 33 (19.1%) ICUs of the 173 Units were participating in the ENVIN-ICU registry (2.1 patients per ICU with CDI; range 1–6). The distribution of cases over the months is shown in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>. The CDI episode rates referred to the national participation period in the registry (April–June) were 1.59 per 1000 patients admitted to the ICU, and 2.06 episodes per 10,000 days of stay in the ICU (patients-day). Forty-five patients were males (66.2%), with a mean age of 63.4 (16.4) years, an APACHE II score upon admission of 19.9 (7.4), and a predominantly clinical background disease condition in 44 cases (64.7%) (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia>In 62 cases (91.2%), CDI was associated to clinical manifestations in the form of liquid depositions, and in 40 cases (58.8%) a systemic inflammatory response was present in the form of severe sepsis or septic shock. In one case CDI evolved toward toxic megacolon requiring emergency surgery for control and treatment. In 13 cases (19.1%), CDI was classified as being community acquired, while another 13 (19.1%) were of nosocomial out-ICU origin, and 42 (61.8%) were nosocomial in-ICU infections (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).<elsevierMultimedia ident="tbl0010"></elsevierMultimedia><a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> shows the comorbidities and invasive devices in the patients with CDI. Of note is the great need for monitoring techniques (<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>). The specific factors related to CDI were a patient age of >64 years in 39 subjects (57.4%), admission to hospital in the preceding three months in 31 (45.6%), the use of antimicrobials in the 7 days before the diagnosis of CDI in 57 (83.8%), the use of enteral nutrition in 23 (33.8%), and the prescription of H2 inhibitors in 39 patients (57.4%). In contrast, chemotherapy (7 patients, 10.3%) and gastroduodenal surgery (5 patients, 7.4%) were much less frequent. Forty-four patients with CDI (64.8%) presented three or more specific risk factors for this infection. Among the groups of antimicrobials used before the diagnosis of CDI, mention must be made of betalactams associated to betalactamase inhibitors (36.8%), carbapenems (33.8%) and cephalosporin (23.5%).<elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0020"></elsevierMultimedia>Specific treatment for CDI was indicated in 66 patients (97.1%) (<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>) in the form of a single antibiotic in 42 cases (61.8%) and two or more in 24 (35.3%)–though in only 18 cases were both drugs administered simultaneously. Metronidazole predominated, with 60 (88.2%) cases, followed by vancomycin in 31 (45.6%). The use of these antibiotics, specifically prescribed for the treatment of CDI, was accompanied by the use of other antimicrobials for the treatment of other infections in 24 cases (35.3%). Seven patients (10.3%) presented adverse effects probably or possibly related to the administration of antimicrobials specific for CDI, including hematological disorders (2 cases) and water–electrolyte alterations (2 cases) in relation to the administration of metronidazole, and a case of severely altered liver function associated to the simultaneous use of metronidazole and vancomycin. In one case the initial treatment was changed because of the adverse effects.<elsevierMultimedia ident="tbl0025"></elsevierMultimedia>The clinical response was considered satisfactory (cure and/or improvement) in 51 cases (75.0%), while no changes or failures were recorded in 10 (14.7%). The response was not evaluable in another four cases (5.9%). Negative microbiological conversion was achieved in 37 cases (61.7%), follow-up was not conducted in 20 (29.4%), and persistence was detected in two subjects (2.9%). In the patients treated with metronidazole in monotherapy (n=36), the satisfactory response rate was 77.8%, versus 100% with vancomycin (n=7), and 61.1% with both antibiotics (n=18). Only two cases of reinfection were recorded. The overall in-ICU mortality rate was 25.0% (n=17), while another two patients died in hospital after discharge from the ICU (overall in-hospital mortality rate 27.9%; n=19). In no case could mortality be related to CDI (<a class="elsevierStyleCrossRefs" href="#tbl0025">Tables 5 and 6</a>).<elsevierMultimedia ident="tbl0030"></elsevierMultimedia>DiscussionThe main contribution of this study has been the description of the critical patients admitted to Spanish ICUs with Clostridium difficile infection (CDI). These patients are generally elderly, with background clinical disease and multiple comorbidities, a high degree of severity upon admission to the ICU, the need for broad-spectrum antibiotic treatment, and with abundant liquid depositions in the first week of stay in the ICU. In 62% of the cases the ICU was found to be the origin of CDI.The estimated CDI rates in the months of April to June were 1.6 cases per 1000 patients admitted to the ICU and 2.1 episodes per 10,000 stays in ICU (patients-day). Most studies in patients admitted to the ICU refer to epidemic outbreaks or endemic situations in one or more centers, or conduct an analysis of the impact of CDI upon stay, costs and mortality in an ICU characterized by a high proportion of patients with this infection. Recently, Bouza et al.,<a class="elsevierStyleCrossRef" href="#bib0090">18</a> on occasion of the European Congress of Clinical Microbiology and Infectious Diseases of the European Society of Clinical Microbiology and Infectious Diseases (April 2013, Berlin, Germany), reported the CDI rate corresponding to the last 10 years in the four ICUs of a general hospital. The global incidence of CDI was 13.2 cases per 10,000 days of stay in the ICU, and the figure showed a clear tendency to decrease in recent years (from 15.9 in 2003 to 8.8 in 2012). Likewise, the authors demonstrated the existence of important differences in rates depending on the characteristics of the ICU–the highest rates being found in clinical ICUs attending patients following heart surgery. Zahar et al.<a class="elsevierStyleCrossRef" href="#bib0095">19</a> in turn published a retrospective study on the clinical impact of CDI in patients admitted to three ICUs. The rates recorded in their study were 13.1 cases per 1000 patients (calculated figure) and 3.6 cases of CDI acquired in the ICU per 1000 patients-day. Lawrence et al.<a class="elsevierStyleCrossRef" href="#bib0110">22</a> conducted a retrospective analysis of the impact of C. difficile colonization as a risk factor for the development of CDI. They documented a rate of 35.3 new cases per 1000 patients admitted for over 24h to the ICU (calculated figure). In both of the aforementioned studies the rates were higher than those recorded in our registry. This may be because we included ICUs with very distinct characteristics and risks, and without endemic conditions for this particular pathogen. In fact, only one out of every 5 ICUs (19%) that contributed data to the registry identified cases of CDI.A possible reason for the reduced diagnosis of CDI in our setting may be the lack of a pre-established study method. A study conducted in a Spanish hospital has demonstrated that the application of a control and vigilance program doubles the recorded CDI rate.<a class="elsevierStyleCrossRef" href="#bib0125">25</a> In this sense, homogenization of the study methodology in cases of suspected CDI has been advocated at European and American level, proposing a search for the infection in all patients admitted to the ICU with liquid diarrhea, defined as three of more liquid depositions in the course of 24 consecutive hours (or less).<a class="elsevierStyleCrossRefs" href="#bib0130">26,27</a> The watery, liquid or unformed stool samples should be quickly sent to the Microbiology laboratory for routine study, including the investigation of C. difficile.In our study, the tests used for the diagnosis of CDI have been those routinely employed in each Microbiology laboratory, with a predominance of stool cultures, the determination glutamate dehydrogenase, enzymoimmunoassay for toxins A and B, and, in fewer cases, polymerase chain reaction (PCR). In order to homogenize the identification of CDI, a diagnostic protocol (2-step algorithm) has been proposed, with due adaptation to the possibilities of each individual laboratory.<a class="elsevierStyleCrossRefs" href="#bib0130">26,27</a> A first determination is made of glutamate dehydrogenase, followed in positive cases by enzymoimmunoassay for toxins A and B. Only when these two techniques prove negative is a more specific third technique suggested (PCR or toxigenic cultures). As a less expensive alternative, this step can be replaced by stool culture, followed in positive cases by direct toxin determination in the isolates.The treatment used mainly consisted of monotherapy with metronidazole and, in fewer cases, with vancomycin. The preferential choice of metronidazole evidences that the form of presentation of CDI is regarded by the clinicians as mild or moderate, since in the more severe or complicated presentations oral (or rectal, in the case of paralytic ileus) vancomycin is recommended, with or without metronidazole simultaneously.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> A recent review<a class="elsevierStyleCrossRef" href="#bib0140">28</a> has analyzed the studies that established comparative assessments of the efficacy of the different antimicrobials used to treat CDI. All of them were of low to moderate statistical power, and no differences were observed among the treatments. It should be mentioned that up to one-quarter of all the therapies used in our series were administered as the combination of both antibiotics, despite a lack of evidence warranting their effectiveness. In 7 of the cases (10%), adverse reactions attributed to the antibiotics used to treat CDI were recorded.The clinical response to the treatment provided was rated as satisfactory (cure or improvement) in 75% of the cases. In the rest of the cases evaluation was not possible or no changes were observed in patients who died as a result of progression of their background disease condition. The overall in-ICU mortality rate was 25%, and in no cases could death be related to CDI. Different studies have examined the impact of the presence of CDI upon mortality among critical patients. Most of them show the presence of CDI to be associated to high overall in-ICU and in-hospital mortality<a class="elsevierStyleCrossRefs" href="#bib0095">19–22,29</a>; however, on conducting comparative analyses (involving patients with diarrhea without CDI or case-controls), no relationship was observed between the presence of CDI and patient mortality.<a class="elsevierStyleCrossRefs" href="#bib0095">19,29</a>The reported frequency of CDI recurrence is between 6 and 25%.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> The recurrence rate in our study was low. This may be because a quarter of the patients have died, and follow-up was only made until discharge from hospital.This study has important limitations, such as its retrospective nature based on the analysis of reported cases in the context of a voluntary national registry. The registry of CDI was first included in the year 2012, and this may have caused omissions in recording the infection. On the other hand, no common protocol was used to request microbiological studies in patients at risk, and the tests applied to the stool samples varied from one hospital to another. Likewise, we have not been able to establish a relationship between the presence of CDI and outcome.In sum, the present study contributes information on the characteristics of the patients with CDI admitted to Spanish ICUs, and on the treatments provided. Of note in this respect is the fact that two antibiotics were administered simultaneously in one-quarter of the cases. The calculated infection rates were lower than those published by other authors and fell short of the rates expected from the CDI-specific risk factors present in these patients–thus evidencing that C. difficile infection is underdiagnosed in critically ill patients admitted to the ICU. A consensus-based study methodology is needed (collection and submission of samples and specific tests in the Microbiology laboratories) in reference to patients with liquid depositions in our setting.Financial supportM. Palomar has received an international grant from Pfizer for maintenance of the ENVIN-ICU registry. F. Alvarez-Lerma has received a grant from Astella-Farma for the collection and analysis of the data referred to Clostridium difficile infection.Conflicts of interestThe authors declare that they have no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:2 [ "identificador" => "xres388228" "titulo" => array:5 [ 0 => "Abstract" 1 => "Objective" 2 => "Materials and methods" 3 => "Results" 4 => "Conclusions" ] ] 1 => array:2 [ "identificador" => "xpalclavsec366924" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres388229" "titulo" => array:5 [ 0 => "Resumen" 1 => "Objetivo" 2 => "Material y método" 3 => "Resultados" 4 => "Conclusiones" ] ] 3 => array:2 [ "identificador" => "xpalclavsec366925" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0080" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0085" "titulo" => "Methodology" "secciones" => array:7 [ 0 => array:2 [ "identificador" => "sec0090" "titulo" => "Design" ] 1 => array:2 [ "identificador" => "sec0095" "titulo" => "Case definition" ] 2 => array:2 [ "identificador" => "sec0100" "titulo" => "Study period" ] 3 => array:2 [ "identificador" => "sec0105" "titulo" => "Clostridium difficile detection techniques" ] 4 => array:2 [ "identificador" => "sec0110" "titulo" => "Data collection" ] 5 => array:2 [ "identificador" => "sec0115" "titulo" => "Calculation of rates" ] 6 => array:2 [ "identificador" => "sec0120" "titulo" => "Statistical analysis" ] ] ] 6 => array:2 [ "identificador" => "sec0125" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0130" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0135" "titulo" => "Financial support" ] 9 => array:2 [ "identificador" => "sec0140" "titulo" => "Conflicts of interest" ] 10 => array:2 [ "identificador" => "xack106486" "titulo" => "Acknowledgements" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2013-06-14" "fechaAceptado" => "2013-11-04" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec366924" "palabras" => array:4 [ 0 => "Clostridium difficile" 1 => "Intensive Care Unit" 2 => "Critically ill patients" 3 => "ENVIN-UCI" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec366925" "palabras" => array:4 [ 0 => "Clostridium difficile" 1 => "Unidad de Cuidados Intensivos" 2 => "Paciente crítico" 3 => "ENVIN-UCI" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Data on the epidemiology of infections caused by Clostridium difficile (CDI) in critically ill patients are scarce and center on studies with a limited time framework and/or epidemic outbreaks. ObjectiveTo describe the characteristics and risk factors of critically ill patients admitted to the ICU with CDI, as well as the treatments used for the control of such infections. Materials and methodsA retrospective study was made of patients included in the ENVIN-ICU registry with CDI in 2012. Patients were followed up to 72h after discharge from the ICU. A case report form was used to record the following data: demographic variables, risk factors related to CDI, treatment and outcome. Infections were classified as community-acquired, nosocomial out-ICU and nosocomial in-ICU, according to the day on which Clostridium difficile isolates were obtained. Infection rates as episodes per 10,000 days of ICU stay are presented. The global in-ICU and hospital mortality rates were calculated. ResultsSixty-eight episodes of CDI in 33 out of a total of 173 ICUs participating in the registry were recorded (19.1%) (2.1 episodes per 10,000 days of ICU stay). Forty-five patients were men (66.2%), with a mean (SD) age of 63.4 (16.4) years, a mean APACHE II score on ICU admission of 19.9 (7.4), and an underlying medical condition in 44 (64.7%). Sixty-two patients (91.2%) presented more than 3 liquid depositions/day, 40 (58.8%) in association with severe sepsis or septic shock. Community-acquired infection occurred in 13 patients (19.1%), nosocomial out-ICU infection in 13 (19.1%), and in-ICU infection in 42 (61.8%). Risk factors included age>64 years in 39 cases (57.4%), previous hospital admission (3 months) in 32 (45.6%), use of antimicrobials (previous 7 days) in 57 (83.8%), enteral nutrition in 23 (33.8%), and the use of H2 inhibitors in 39 (57.4%). Initial combined treatment was administered to 18 patients (26.5%). Metronidazole was used in 60 (88.2%) and vancomycin in 31 (45.6%). The in-ICU mortality rate was 25.0% (n=17), with a hospital mortality 27.9% (n=19). ConclusionsThe rate of ICD in ICU patients is low, the infection affects severely ill patients, and is associated with high mortality. The presence of CDI is a marker of poor prognosis." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "La epidemiología de las infecciones por Clostridium difficile (ICD) en pacientes críticos es escasa y centrada en estudios limitados en tiempo y/o en brotes epidémicos. ObjetivoDescribir las características y los factores de riesgo de pacientes críticos ingresados en UCI con ICD, así como los tratamientos utilizados para su control. Material y métodoAnálisis retrospectivo de pacientes incluidos en el registro ENVIN-UCI con ICD en el año 2012. Los pacientes se han seguido hasta 72h después de su alta de UCI. Se ha cumplimentado un cuaderno de recogida de datos, en el que se incluyen variables demográficas, factores de riesgo relacionados con Clostridium difficile, tratamiento y evolución. Los aislamientos se han clasificado por su origen en comunitarios, nosocomiales extra-UCI y nosocomiales intra-UCI en función del día de aislamiento. Se presentan las tasas por episodios por 10.000 días de estancia en UCI. Se describe la mortalidad global intra-UCI y hospitalaria. ResultadosSe han detectado 68 episodios de ICD en 33 (19,1%) UCI de las 173 participantes en el registro (2,1 episodios por 10.000 días de estancia-UCI). En 45 (66,2%) casos eran hombres, con edad media de 63,4 (16,4) años, APACHE II al ingreso de 19,9 (7,4) y enfermedad de base médica 44 (64,7%). En 62 (91,2%) ocasiones presentaron más de 3 deposiciones líquidas/día y en 40 (58,8%) se asoció con sepsis severa o shock séptico. En 13 (19,1%) ocasiones fue de origen comunitario, en 13 (19,1%) de origen nosocomial extra-UCI y en 42 (61,8%) de origen intra-UCI. Factores de riesgo: edad>64 años 39 (57,4%), ingreso previo hospital (3 meses) 32 (45,6%), antimicrobianos (7 días previos) 57 (83,8%), nutrición enteral 23 (33,8%) e inhibidores H2 39 (57,4%). Siguieron tratamiento inicial combinado 18 (26,5%) casos y se ha utilizado metronidazol en 60 (88,2%) y vancomicina en 31 (45,6%) casos. Hubo mortalidad global intra-UCI en 17 (25,0%) casos y hospitalaria de 19 (27,9%). ConclusionesLa tasa de ICD en pacientes ingresados en UCI es baja y afecta a pacientes con elevada gravedad y mortalidad. La presencia de ICD es un marcador de mal pronóstico." ] ] "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "◊" "nota" => "The investigators that have contributed cases to this study are cited in <a class="elsevierStyleCrossRef" href="#sec0075">Annex</a>." ] 1 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Alvarez-Lerma F, Palomar M, Villasboa A, Amador J, Almirall J, Posada MP, et al. Estudio epidemiológico de infección por Clostridium difficile en pacientes críticos ingresados en una Unidad de Cuidados Intensivos. Med Intensiva. 2014;38:558–566." ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "List of supervising physicians in the ICUs who have completed the case report forms of patients with CDI: A. Bonet, L. Saló (Clínica Girona); G. Aguilar, C. García Márquez (Hospital Clínico Universitario de Valencia); M.L. Mora, M. Lequona (Complejo Hospitalario Universitario de Canarias); A. Díaz, L. Pita, R. Arrojo (Complexo Hospitalario Universitario A Coruña); J.C. Montejo, M. Catalán (Hospital 12 de Octubre, Madrid); M.J. Castro, F.J. Rodríguez (Hospital Arquitecto Marcide, Ferrol, A Coruña); F. Esteve (Hospital de Bellvitge, Hospitalet de Llobregat, Barcelona); D. Fontaneda Lopez, S. Gutierrez (Hospital de León); E. Antón (Hospital de Manacor); I. Catalán (Hospital de Manresa Altaya, Barcelona); J. Almirall, M. de la Torre (Hospital de Mataró, Barcelona); J.L. Antón, C. Dolera (Hospital de Sant Joan, Alacant); M.B. López, M.B. Estévanez (Hospital del Tajo, Aranjuez, Madrid); J. Amador, M.T. Jurado (Hospital de Terrassa, Barcelona); A. Villasboas, A. Rey (Hospital del Mar, Barcelona); R. Reig (Hospital General de Castellón); A.M. Rodríguez, M. Sánchez Palacios (Hospital Insular de las Palmas, Canarias); B. Gil, N. Llamas (Hospital Morales Massaguer, Murcia); J.A. Cambronero, M. Daguerre (Hospital Príncipe de Asturias, Alcalá de Henares, Madrid); A. Blanco (Hospital Universitario Central de Asturias, Oviedo); J.R. Iruretagoyena, M. Domezaín (Hospital Universitario de Cruces, Vizcaya); A. Abella, F. Gordo (Hospital Universitario de Henares, Madrid); P. Albert de la Cruz, E. García (Hospital Universitario del Sureste, Arganda del Rey, Madrid); S. Alcántara, I. Fernández Simón (Hospital Universitario Puerta de Hierro, Majadahonda, Madrid); A.J. Pontes, J.C. Pozo (Hospital Universitario Reina Sofía, Córdoba); Á. López, C. Susarte (Hospital Universitario Reina Sofía, Murcia); M. Palomar, C. Laborda (Hospital Vall d’Hebron, Barcelona); A. Martinez Pellús, E. Andreu (Hospital Virgen de la Arrixaca, Murcia); M.P. Posada (Hospital Xeral de Vigo); R. Ferrer (Mútua de Terrassa, Barcelona); J.M. Quiroga, M. Sadaba (Hospital de Cabueñes, Gijón); A.M. Mendía Gorostidi (Hospital de Donostia Ntra. Sra. de Aranzazu, San Sebastián); A. Rovira (Hospital General de Hospitalet, Barcelona); H. Abdel-Hadi (Hospital General, Ciudad Real)." "etiqueta" => "Annex" "titulo" => "The ENVIN-UCI Study Group" "identificador" => "sec0075" ] ] ] ] "multimedia" => array:7 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1074 "Ancho" => 1585 "Tamanyo" => 66009 ] ] "descripcion" => array:1 [ "en" => "Distribution of the cases of Clostridium difficile infection (CDI) detected in the Intensive Care Units in the course of the months of the year (31 patients in the national vigilance period)." ] ] 1 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "CD, Clostridium difficile; SD, standard deviation." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><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">Characteristics of the patients \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">n=68 \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">Age in years, mean (SD) (range) \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">63.4 (16.4) (24–87) \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">Sex, male, n (%) \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">45 (66.2) \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">APACHE II score, mean (SD) (range) \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">19.9 (7.4) (2–36) \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 " colspan="2" align="left" valign="\n \t\t\t\t\ttop\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 " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Type of patient, n (%)</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">Clinical \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">44 (64.7) \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 \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">22 (32.4) \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">Trauma \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">2 (2.9) \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 " colspan="2" align="left" valign="\n \t\t\t\t\ttop\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">Emergency surgery, n (%) \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">20 (29.4) \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 " colspan="2" align="left" valign="\n \t\t\t\t\ttop\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 " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Patient origin, n (%)</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">Home \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">30 (44.1) \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">Hospitalization unit \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">34 (50.0) \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">Other healthcare center \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">4 (5.9) \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 " colspan="2" align="left" valign="\n \t\t\t\t\ttop\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">Days of stay in hospital, mean (SD) (range) \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">40.2 (38.0) (3–179) \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">Days of stay in ICU, mean (SD) (range) \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">17.4 (19.9) (1–73) \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">Days of stay in hospital-isolation CD, mean (range) \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">14.1 (19.9) (0–77) \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">Days of stay in ICU-isolation CD, mean (range) \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">6.5 (13.3) (0–52) \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">Overall in-ICU mortality, n (%) \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">17 (25.0) \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">Overall hospital mortality, n (%) \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">19 (27.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab597165.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Characteristics of patients with Clostridium difficile infection (CDI) admitted to the Intensive Care Units." ] ] 2 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "EIA, enzymoimmunoassay; CDI, Clostridium difficile infection; GDH, glutamate dehydrogenase; PCR, polymerase chain reaction; ICU, Intensive Care Unit." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><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">Characteristics of CDI \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">n=68 \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 " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Form of presentation, n (%)</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">Liquid depositions \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">62 (91.1) \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">Three or more depositions/day \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">53 (77.9) \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 " colspan="2" align="left" valign="\n \t\t\t\t\ttop\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 " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Systemic inflammatory response, n (%)</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">Severe sepsis or septic shock \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">40 (58.8) \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 " colspan="2" align="left" valign="\n \t\t\t\t\ttop\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 " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Origin of CDI, n (%)</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">Community-acquired \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">13 (19.1) \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">Nosocomial in-hospital (out-ICU) \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">13 (19.1) \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">Nosocomial in-ICU \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">42 (61.8) \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 " colspan="2" align="left" valign="\n \t\t\t\t\ttop\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 " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Study method, n (%)</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">Stool culture \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">25 (36.8) \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">Enzyme studies (GDH) \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">36 (52.9) \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">Toxin detection tests (EIA) \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">17 (25.0) \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">PCR \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">6 (8.8) \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 " colspan="2" align="left" valign="\n \t\t\t\t\ttop\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 " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Number of tests per sample, n (%)</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">1 \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">50 (73.5) \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">2 \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">10 (14.7) \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">3 \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">4 (5.9) \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">Not known \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">4 (5.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab597167.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Characteristics of Clostridium difficile infection (CDI) and diagnostic methods." ] ] 3 => array:7 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "COPD, chronic obstructive pulmonary disease." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \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">n=68 \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 " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Disease antecedents, n (%)</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">Diabetes mellitus \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">17 (25.0) \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">COPD \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">12 (17.6) \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">Solid organ neoplasm \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">8 (11.8) \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">Hematological malignancy \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">8 (11.8) \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">Liver cirrhosis \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">5 (7.4) \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">Chronic renal failure \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">13 (19.1) \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">Solid organ transplant \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">4 (5.9) \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">Bone marrow transplant \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">1 (1.5) \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">Radiotherapy \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">2 (3.0) \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">Chemotherapy \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">9 (13.2) \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">Neutropenia \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">4 (5.9) \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">Immune depression \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">12 (17.6) \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 " colspan="2" align="left" valign="\n \t\t\t\t\ttop\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 " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Invasive devices, n (%)</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">Central venous catheter \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">54 (79.4) \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">Arterial catheter \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">34 (50.0) \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">Mechanical ventilation \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">29 (42.6) \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">Bladder catheter \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">56 (82.4) \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">Parenteral nutrition \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">23 (33.8) \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">Extrarenal filtration \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">7 (10.3) \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">Antimicrobial use>7 days \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">46 (67.6) \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">Corticosteroids, n (%) \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">22 (32.4) \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">Surgery during admission, n (%) \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">17 (25.0) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab597164.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Disease antecedents, invasive devices and complementary treatments of patients with Clostridium difficile infection (CDI) admitted to the Intensive Care Units." ] ] 4 => array:7 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "ATB, antibiotics; CDI, Clostridium difficile infection; HIV, human immunodeficiency virus." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><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">Specific risk factors for CDI, n (%) \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">n=68 \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">Age>64 years \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">39 (57.4) \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">Hospital admission in the previous 3 months \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">31 (45.6) \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">Use of ATB in the previous 7 days \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">57 (83.8) \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">Chemotherapy \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">7 (10.3) \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">HIV infection \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">1 (1.5) \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">Gastroduodenal surgery, n (%) \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">5 (7.4) \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">Enteral nutrition, n (%) \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">23 (33.8) \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">Use of H2inhibitors \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">39 (57.4) \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 " colspan="2" align="left" valign="\n \t\t\t\t\ttop\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 " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Number of specific factors per CDI patient</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">0 \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">3 (4.4) \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">1–2 \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">21 (30.9) \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">3–4 \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">39 (57.4) \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">>4 \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">5 (7.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab597166.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Risk factors related to Clostridium difficile infection (CDI) in patients admitted to the Intensive Care Units." ] ] 5 => array:7 [ "identificador" => "tbl0025" "etiqueta" => "Table 5" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "ATB, antibiotics; CDI, Clostridium difficile infection." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><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">Specific treatment for CDI \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">n=68 \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">Patients with previous ATP, n (%) \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">57 (83.8) \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 " colspan="2" align="left" valign="\n \t\t\t\t\ttop\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 " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Patients with ATB, according to administered number, n (%)</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">None/not specified \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">8 (11.8) \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">1 \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">17 (25.0) \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">2 \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">16 (23.5) \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">3 or more \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">27 (39.7) \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 " colspan="2" align="left" valign="\n \t\t\t\t\ttop\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">Previously administered ATB, n \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">130 \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">Semisynthetic penicillins, n (%) \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">7 (10.3) \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">Betalactams plus betalactamase inhibitors, n (%) \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">25 (36.8) \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 " colspan="2" align="left" valign="\n \t\t\t\t\ttop\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">Cephalosporins, n (%) \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">16 (23.5) \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">First generation \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">2 (2.9) \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">Second generation \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">2 (2.9) \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">Third generation \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">9 (13.2) \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">Fourth generation \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">3 (4.4) \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 " colspan="2" align="left" valign="\n \t\t\t\t\ttop\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">Carbapenems, n (%) \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">23 (33.8) \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">Aminoglycosides, n (%) \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">6 (8.8) \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">Quinolones, n (%) \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">10 (14.7) \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">Clindamycin, n (%) \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">1 (1.5) \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">Glycopeptides, n (%) \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">6 (8.8) \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">Cotrimoxazole, n (%) \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">1 (1.5) \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">Linezolid, n (%) \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">11 (16.2) \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 " colspan="2" align="left" valign="\n \t\t\t\t\ttop\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 " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Antimicrobials specific for CDI, n (%)</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">Metronidazole \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">60 (88.2) \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">Vancomycin \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">31 (45.6) \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">Vancomycin and metronidazole \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">18 (26.5) \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 " colspan="2" align="left" valign="\n \t\t\t\t\ttop\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">Antimicrobials simultaneous to those administered for CDI, n (%) \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">24 (35.3) \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 " colspan="2" align="left" valign="\n \t\t\t\t\ttop\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">Patients with adverse effects related to specific ATB, n (%) \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">7 (10.3) \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">Water-electrolyte alterations (hypopotassemia, hypomagnesemia) \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">2 \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">Hematological alterations \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">2 \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">Liver function alterations \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">1 \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">Others \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">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab597168.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Specific treatment for Clostridium difficile infection (CDI) in patients admitted to the Intensive Care Units." ] ] 6 => array:7 [ "identificador" => "tbl0030" "etiqueta" => "Table 6" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \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">n=68 \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 " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Clinical response, n (%)</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">Cure \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">44 (64.7) \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">Improvement \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">7 (10.3) \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">Without changes (failure) \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">10 (14.7) \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">Not evaluable \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">4 (5.9) \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 " colspan="2" align="left" valign="\n \t\t\t\t\ttop\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 " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Microbiological response, n (%)</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">Negative conversion \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">37 (61.7) \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">Persistence \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">2 (2.9) \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">Appearance of other microorganisms \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">1 (1.5) \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">No follow-up \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">20 (29.4) \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">Reinfection \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">2 (2.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab597169.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Clinical and microbiological response to specific treatment for Clostridium difficile infection (CDI) in patients admitted to the Intensive Care Units." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:29 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => 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Currie" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jcrc.2009.04.002" "Revista" => array:6 [ "tituloSerie" => "J Crit Care" "fecha" => "2010" "volumen" => "25" "paginaInicial" => "282" "paginaFinal" => "286" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19592210" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack106486" "titulo" => "Acknowledgements" "texto" => "The ENVIN-ICU registry is promoted by the Infectious diseases Work Group of the Spanish Society of Intensive Care and Coronary Units (GTEI-SEMICYUC), and has been maintained in the year 2012 thanks to an international grant from Pfizer S.A. The list of participating centers and the collaborators in the registry are contained in the report corresponding to the year 2012, which can be freely accessed at: <a class="elsevierStyleInterRef" id="intr0015" href="http://hws.vhebron.net/envin-helics/">http://hws.vhebron.net/envin-helics/</a>. The analysis of the cases of C. difficile has been carried out in part with the support of Astella-Farma. The authors thank Sergio Mojal, of the Instituto Municipal de Investigación of Hospital del Mar, for methodological counseling and statistical analysis." "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/21735727/0000003800000009/v1_201412070106/S2173572714000721/v1_201412070106/en/main.assets" "Apartado" => null "PDF" => "https://static.elsevier.es/multimedia/21735727/0000003800000009/v1_201412070106/S2173572714000721/v1_201412070106/en/main.pdf?idApp=WMIE&text.app=https://medintensiva.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173572714000721?idApp=WMIE"]

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Epidemiological study of Clostridium difficile infection in critical patients admitted to the Intensive Care Unit

Estudio epidemiológico de infección por Clostridium difficile en pacientes críticos ingresados en una Unidad de Cuidados Intensivos

F. Alvarez-Lermaa,

Corresponding author

Falvarez@parcdesalutmar.ct

Corresponding author.

, M. Palomarb, A. Villasboaa, J. Amadorc, J. Almiralld, M.P. Posadae, M. Catalanf, C. Pascualg, ENVIN-UCI Study Group ◊

a Servicio de Medicina Intensiva, Hospital del Mar, Parc de Salut Mar, Barcelona, Spain

b Servicio de Medicina Intensiva, Hospital Arnau de Vilanova, Lleida, Spain

c Servicio de Medicina Intensiva, Hospital de Terrassa, Terrassa, Barcelona, Spain

d Servicio de Medicina Intensiva, Hospital de Mataró, Consorci Sanitari del Maresme, Mataró, Barcelona, Spain

e Servicio de Medicina Intensiva, Hospital Xeral Cíes, Vigo, Pontevedra, Spain

f Servicio de Medicina Intensiva, Hospital 12 de Octubre, Madrid, Spain

g Servicio de Medicina Intensiva, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain

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        "titulo" => "Estudio epidemiol&#243;gico de infecci&#243;n por <span class="elsevierStyleItalic">Clostridium difficile</span> en pacientes cr&#237;ticos ingresados en una Unidad de Cuidados Intensivos"
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Distribution of the cases of <span class="elsevierStyleItalic">Clostridium difficile</span> infection &#40;CDI&#41; detected in the Intensive Care Units in the course of the months of the year &#40;31 patients in the national vigilance period&#41;&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Infections caused by <span class="elsevierStyleItalic">Clostridium difficile</span> &#40;<span class="elsevierStyleItalic">C&#46; difficile</span>&#41; &#40;CDI&#41; are generally diagnosed by the presence of persistent liquid diarrhea&#44; with the identification of <span class="elsevierStyleItalic">C&#46; difficile</span> in a stool sample using some of the different tests available&#46; A diagnosis based on colonoscopic or histopathological findings evidencing the presence of pseudomembranous colitis is less common&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The importance of such infections is reflected by the fact that <span class="elsevierStyleItalic">C&#46; difficile</span> may be present in 20&#8211;30&#37; of the cases of diarrhea associated to antimicrobial use&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Few epidemiological data are available on the prevalence of CDI in hospitalized patients&#44; and there is even less information referred to critical patients admitted to Departments of Intensive Care Medicine or Intensive Care Units &#40;ICUs&#41;&#46; A study made between 1997 and 2005 in Canadian hospitals recorded an incidence of between 3&#46;4 and 8&#46;4 cases per 1000 admissions in acute care hospitals&#44; and of 3&#46;8&#8211;9&#46;5 cases per 10&#44;000 patients-day&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a> The mortality rate attributed to CDI is low &#40;less than 2&#37;&#41;&#44;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a> though the associated excess costs in American hospitals during the period 2000&#8211;2002 was estimated to be 3200<span class="elsevierStyleHsp" style=""></span>million USD&#47;year&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The risk factors underlying CDI include old age &#40;&#62;64 years&#41;&#44;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;8</span></a> the duration of hospital stay&#44;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> exposure to antimicrobial drugs&#44;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> cancer chemotherapy&#44;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;12</span></a> immune depression related to HIV infection&#44;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> gastrointestinal surgery&#44;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> enteral diet administered through a nasogastric tube&#44;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> and the administration of acid-suppressing drugs &#40;antihistamines and proton pump inhibitors&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> Many of these factors are present in critical patients admitted to the ICU&#46; However&#44; infection registries in such Units tend to focus on infections related to the use of invasive devices<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a>&#8211;the information on CDI being scarce and limited to the description of epidemic outbreaks and mortality or cost increment estimates&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#8211;23</span></a> The objective of this study is to determine the characteristics of critical patients with CDI admitted to Spanish ICUs in the year 2012&#44; independently of the origin of the infection&#44; and to describe the factors related to the development of CDI and the treatment strategies employed&#46;</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methodology</span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Design</span><p id="par0015" class="elsevierStylePara elsevierViewall">A retrospective&#44; non-interventional&#44; multicenter observational study was carried out with the voluntary participation of ICUs that routinely collaborate in the ENVIN-ICU registry&#46; Since the year 1994&#44; this registry monitors the evolution of infections related to invasive devices&#44; their etiology&#44; resistance markers&#44; and the antimicrobials used in Spanish ICUs &#40;accessible at&#58; <a id="intr0010" class="elsevierStyleInterRef" href="http://hws.vhebron.net/envin-helics/">http&#58;&#47;&#47;hws&#46;vhebron&#46;net&#47;envin-helics&#47;</a>&#41;&#46;</p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Case definition</span><p id="par0020" class="elsevierStylePara elsevierViewall">A case is defined as any patient admitted to an ICU or critical care unit and in which the presence of <span class="elsevierStyleItalic">C&#46; difficile</span> is identified&#46;</p></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Study period</span><p id="par0025" class="elsevierStylePara elsevierViewall">We included all patients with positive <span class="elsevierStyleItalic">C&#46; difficile</span> isolates admitted to the ICUs participating in the abovementioned registry in the year 2012&#46; The patients were followed-up on throughout their stay in the ICU and during the 72<span class="elsevierStyleHsp" style=""></span>h after discharge from the Unit&#46;</p></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090"><span class="elsevierStyleItalic">Clostridium difficile</span> detection techniques</span><p id="par0030" class="elsevierStylePara elsevierViewall">The identification of <span class="elsevierStyleItalic">C&#46; difficile</span> was based on the routine techniques used in the Microbiology laboratory of each of the participating hospitals&#44; and which comprised one or more of the following&#58; stool culture&#44; determination of the enzyme glutamate dehydrogenase &#40;GDH&#41;&#44; enzymoimmunoassay for toxins A and B&#44; studies of cell cytotoxins and toxigenic cultures&#44; and polymerase chain reaction &#40;PCR&#41; techniques&#46;</p></span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Data collection</span><p id="par0035" class="elsevierStylePara elsevierViewall">A case report form &#40;CRF&#41; was used to record demographic data&#44; hospital and ICU admission and discharge dates&#44; diagnosis upon admission&#44; severity as assessed by the APACHE II scale&#44;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> and the need for emergency surgery during admission&#46; The patients were classified according to the diagnosis upon admission as coronary&#44; surgical&#44; trauma or clinical cases&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> Coronary patients were those admitted due to acute or chronic coronary syndrome with or without ST-segment elevation&#46; Trauma patients in turn were those admitted due to acute injuries&#44; while surgical patients were defined as individuals admitted for postoperative control of scheduled surgery&#46; Lastly&#44; clinical patients were those admitted due to reasons unrelated to the above&#44; including individuals admitted after non-scheduled surgery&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">We likewise documented the comorbidities&#44; invasive devices&#44; techniques and treatments used on the day of the isolation of <span class="elsevierStyleItalic">C&#46; difficile</span>&#44; and the previously administered antibiotics and their duration&#46; The comorbidities evaluated were immune depression&#44; immune suppression&#44; neutropenia and solid organ transplantation&#46; Instrumentations and controlled techniques comprised mechanical ventilation&#44; bladder catheterization&#44; central venous catheter placement&#44; extrarenal filtration techniques&#44; ventricular shunt catheters&#44; parenteral nutrition&#44; enteral nutrition and previous surgery&#46; The following definitions were used<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a>&#58; immune suppression when the patient received treatment lowering resistance to infection &#40;chemotherapy&#44; radiation&#44; prolonged or high-dose corticosteroids&#41; or suffered disease in a sufficiently advanced stage to suppress the host defenses against infection&#59; neutropenia in the presence of a neutrophil count of &#60;500<span class="elsevierStyleHsp" style=""></span>cells&#47;mm<span class="elsevierStyleSup">3</span>&#59; and immune depression when the patient had been diagnosed with HIV infection or some other congenital or acquired immune deficiency&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">In etiological terms&#44; CDI was classified as <span class="elsevierStyleItalic">community-acquired</span> when the patient presented liquid diarrhea and positive identification of <span class="elsevierStyleItalic">C&#46; difficile</span> at the time of admission or in the first 48<span class="elsevierStyleHsp" style=""></span>h after admission to hospital&#59; <span class="elsevierStyleItalic">nosocomial out-ICU</span> when the clinical manifestations and diagnosis were registered after the first 48<span class="elsevierStyleHsp" style=""></span>h in hospital and in the first 48<span class="elsevierStyleHsp" style=""></span>h of admission to the ICU&#59; and <span class="elsevierStyleItalic">nosocomial in-ICU</span> when the diagnosis was established after the first 48<span class="elsevierStyleHsp" style=""></span>h in the ICU or in the first 72<span class="elsevierStyleHsp" style=""></span>h after discharge from the Unit&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The specific risk factors for CDI considered in the study were&#58; age<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>64 years&#44; previous antimicrobial use for over 7 days&#44; other hospital admissions in the previous three months&#44; a history of HIV disease&#44; gastroduodenal surgery&#44; chemotherapy use in the previous three months&#44; and the current use of enteral nutrition and&#47;or H<span class="elsevierStyleInf">2</span> inhibitors&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The systemic response to infection was recorded&#44; defined as the presence of sepsis&#44; severe sepsis or septic shock not attributable to other infectious causes&#46; The specific treatment administered for CDI was classified as monotherapy when the patient received a single antibiotic for the infection &#40;independently of whether other antibiotics were also used to treat other infections&#41;&#44; and dual therapy when two antibiotics were administered simultaneously&#46; The clinical response in turn was classified as cure&#44; improvement&#44; without changes&#44; and death related to the infection&#44; while microbiological response was classified as the negative conversion of cultures&#44; persistence&#44; appearance of another microorganism in stools&#44; and no follow-up&#46; The patients were followed-up until discharge from hospital in order to identify possible reinfections&#46; The classification of reinfection required cure or improvement of a previous episode and&#47;or a negative stool test&#46; Lastly&#44; overall mortality was defined as death occurring during admission to the ICU or in the hospital&#44; due to any cause&#46;</p></span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Calculation of rates</span><p id="par0060" class="elsevierStylePara elsevierViewall">The frequency of CDI was defined by the number of episodes recorded in patients admitted to the ICU &#40;regardless of the origin of the infection&#41; per 1000 patients admitted to the ICU and per 10&#44;000 days of stay in the ICU&#46; In calculating the rates we considered only those patients included in the ENVIN-ICU registry during the national vigilance period &#40;April&#8211;June&#41;&#44; since the data referred to the number of patients and days of stay in the ICU at Spanish national level are available for these months &#40;19&#44;521 patients and 150&#44;832 days of stay in the ICU&#41;&#46;</p></span><span id="sec0120" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Statistical analysis</span><p id="par0065" class="elsevierStylePara elsevierViewall">The qualitative variables are described with the percentage distribution of each of the categories&#44; while the quantitative variables are described using the mean and standard deviation in the case of a normal distribution&#44; and the median and range in the case of a non-normal distribution&#46;</p></span></span><span id="sec0125" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Results</span><p id="par0070" class="elsevierStylePara elsevierViewall">The study included 68 patients with CDI in 33 &#40;19&#46;1&#37;&#41; ICUs of the 173 Units were participating in the ENVIN-ICU registry &#40;2&#46;1 patients per ICU with CDI&#59; range 1&#8211;6&#41;&#46; The distribution of cases over the months is shown in <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#46; The CDI episode rates referred to the national participation period in the registry &#40;April&#8211;June&#41; were 1&#46;59 per 1000 patients admitted to the ICU&#44; and 2&#46;06 episodes per 10&#44;000 days of stay in the ICU &#40;patients-day&#41;&#46; Forty-five patients were males &#40;66&#46;2&#37;&#41;&#44; with a mean age of 63&#46;4 &#40;16&#46;4&#41; years&#44; an APACHE II score upon admission of 19&#46;9 &#40;7&#46;4&#41;&#44; and a predominantly clinical background disease condition in 44 cases &#40;64&#46;7&#37;&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">In 62 cases &#40;91&#46;2&#37;&#41;&#44; CDI was associated to clinical manifestations in the form of liquid depositions&#44; and in 40 cases &#40;58&#46;8&#37;&#41; a systemic inflammatory response was present in the form of severe sepsis or septic shock&#46; In one case CDI evolved toward toxic megacolon requiring emergency surgery for control and treatment&#46; In 13 cases &#40;19&#46;1&#37;&#41;&#44; CDI was classified as being community acquired&#44; while another 13 &#40;19&#46;1&#37;&#41; were of nosocomial out-ICU origin&#44; and 42 &#40;61&#46;8&#37;&#41; were nosocomial in-ICU infections &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> shows the comorbidities and invasive devices in the patients with CDI&#46; Of note is the great need for monitoring techniques &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46; The specific factors related to CDI were a patient age of &#62;64 years in 39 subjects &#40;57&#46;4&#37;&#41;&#44; admission to hospital in the preceding three months in 31 &#40;45&#46;6&#37;&#41;&#44; the use of antimicrobials in the 7 days before the diagnosis of CDI in 57 &#40;83&#46;8&#37;&#41;&#44; the use of enteral nutrition in 23 &#40;33&#46;8&#37;&#41;&#44; and the prescription of H<span class="elsevierStyleInf">2</span> inhibitors in 39 patients &#40;57&#46;4&#37;&#41;&#46; In contrast&#44; chemotherapy &#40;7 patients&#44; 10&#46;3&#37;&#41; and gastroduodenal surgery &#40;5 patients&#44; 7&#46;4&#37;&#41; were much less frequent&#46; Forty-four patients with CDI &#40;64&#46;8&#37;&#41; presented three or more specific risk factors for this infection&#46; Among the groups of antimicrobials used before the diagnosis of CDI&#44; mention must be made of betalactams associated to betalactamase inhibitors &#40;36&#46;8&#37;&#41;&#44; carbapenems &#40;33&#46;8&#37;&#41; and cephalosporin &#40;23&#46;5&#37;&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">Specific treatment for CDI was indicated in 66 patients &#40;97&#46;1&#37;&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>&#41; in the form of a single antibiotic in 42 cases &#40;61&#46;8&#37;&#41; and two or more in 24 &#40;35&#46;3&#37;&#41;&#8211;though in only 18 cases were both drugs administered simultaneously&#46; Metronidazole predominated&#44; with 60 &#40;88&#46;2&#37;&#41; cases&#44; followed by vancomycin in 31 &#40;45&#46;6&#37;&#41;&#46; The use of these antibiotics&#44; specifically prescribed for the treatment of CDI&#44; was accompanied by the use of other antimicrobials for the treatment of other infections in 24 cases &#40;35&#46;3&#37;&#41;&#46; Seven patients &#40;10&#46;3&#37;&#41; presented adverse effects probably or possibly related to the administration of antimicrobials specific for CDI&#44; including hematological disorders &#40;2 cases&#41; and water&#8211;electrolyte alterations &#40;2 cases&#41; in relation to the administration of metronidazole&#44; and a case of severely altered liver function associated to the simultaneous use of metronidazole and vancomycin&#46; In one case the initial treatment was changed because of the adverse effects&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">The clinical response was considered satisfactory &#40;cure and&#47;or improvement&#41; in 51 cases &#40;75&#46;0&#37;&#41;&#44; while no changes or failures were recorded in 10 &#40;14&#46;7&#37;&#41;&#46; The response was not evaluable in another four cases &#40;5&#46;9&#37;&#41;&#46; Negative microbiological conversion was achieved in 37 cases &#40;61&#46;7&#37;&#41;&#44; follow-up was not conducted in 20 &#40;29&#46;4&#37;&#41;&#44; and persistence was detected in two subjects &#40;2&#46;9&#37;&#41;&#46; In the patients treated with metronidazole in monotherapy &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>36&#41;&#44; the satisfactory response rate was 77&#46;8&#37;&#44; versus 100&#37; with vancomycin &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>7&#41;&#44; and 61&#46;1&#37; with both antibiotics &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>18&#41;&#46; Only two cases of reinfection were recorded&#46; The overall in-ICU mortality rate was 25&#46;0&#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>17&#41;&#44; while another two patients died in hospital after discharge from the ICU &#40;overall in-hospital mortality rate 27&#46;9&#37;&#59; n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>19&#41;&#46; In no case could mortality be related to CDI &#40;<a class="elsevierStyleCrossRefs" href="#tbl0025">Tables 5 and 6</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0030"></elsevierMultimedia></span><span id="sec0130" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Discussion</span><p id="par0100" class="elsevierStylePara elsevierViewall">The main contribution of this study has been the description of the critical patients admitted to Spanish ICUs with <span class="elsevierStyleItalic">Clostridium difficile</span> infection &#40;CDI&#41;&#46; These patients are generally elderly&#44; with background clinical disease and multiple comorbidities&#44; a high degree of severity upon admission to the ICU&#44; the need for broad-spectrum antibiotic treatment&#44; and with abundant liquid depositions in the first week of stay in the ICU&#46; In 62&#37; of the cases the ICU was found to be the origin of CDI&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">The estimated CDI rates in the months of April to June were 1&#46;6 cases per 1000 patients admitted to the ICU and 2&#46;1 episodes per 10&#44;000 stays in ICU &#40;patients-day&#41;&#46; Most studies in patients admitted to the ICU refer to epidemic outbreaks or endemic situations in one or more centers&#44; or conduct an analysis of the impact of CDI upon stay&#44; costs and mortality in an ICU characterized by a high proportion of patients with this infection&#46; Recently&#44; Bouza et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> on occasion of the European Congress of Clinical Microbiology and Infectious Diseases of the European Society of Clinical Microbiology and Infectious Diseases &#40;April 2013&#44; Berlin&#44; Germany&#41;&#44; reported the CDI rate corresponding to the last 10 years in the four ICUs of a general hospital&#46; The global incidence of CDI was 13&#46;2 cases per 10&#44;000 days of stay in the ICU&#44; and the figure showed a clear tendency to decrease in recent years &#40;from 15&#46;9 in 2003 to 8&#46;8 in 2012&#41;&#46; Likewise&#44; the authors demonstrated the existence of important differences in rates depending on the characteristics of the ICU&#8211;the highest rates being found in clinical ICUs attending patients following heart surgery&#46; Zahar et al&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> in turn published a retrospective study on the clinical impact of CDI in patients admitted to three ICUs&#46; The rates recorded in their study were 13&#46;1 cases per 1000 patients &#40;calculated figure&#41; and 3&#46;6 cases of CDI acquired in the ICU per 1000 patients-day&#46; Lawrence et al&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> conducted a retrospective analysis of the impact of <span class="elsevierStyleItalic">C&#46; difficile</span> colonization as a risk factor for the development of CDI&#46; They documented a rate of 35&#46;3 new cases per 1000 patients admitted for over 24<span class="elsevierStyleHsp" style=""></span>h to the ICU &#40;calculated figure&#41;&#46; In both of the aforementioned studies the rates were higher than those recorded in our registry&#46; This may be because we included ICUs with very distinct characteristics and risks&#44; and without endemic conditions for this particular pathogen&#46; In fact&#44; only one out of every 5 ICUs &#40;19&#37;&#41; that contributed data to the registry identified cases of CDI&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">A possible reason for the reduced diagnosis of CDI in our setting may be the lack of a pre-established study method&#46; A study conducted in a Spanish hospital has demonstrated that the application of a control and vigilance program doubles the recorded CDI rate&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> In this sense&#44; homogenization of the study methodology in cases of suspected CDI has been advocated at European and American level&#44; proposing a search for the infection in all patients admitted to the ICU with liquid diarrhea&#44; defined as three of more liquid depositions in the course of 24 consecutive hours &#40;or less&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">26&#44;27</span></a> The watery&#44; liquid or unformed stool samples should be quickly sent to the Microbiology laboratory for routine study&#44; including the investigation of <span class="elsevierStyleItalic">C&#46; difficile</span>&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">In our study&#44; the tests used for the diagnosis of CDI have been those routinely employed in each Microbiology laboratory&#44; with a predominance of stool cultures&#44; the determination glutamate dehydrogenase&#44; enzymoimmunoassay for toxins A and B&#44; and&#44; in fewer cases&#44; polymerase chain reaction &#40;PCR&#41;&#46; In order to homogenize the identification of CDI&#44; a diagnostic protocol &#40;2-step algorithm&#41; has been proposed&#44; with due adaptation to the possibilities of each individual laboratory&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">26&#44;27</span></a> A first determination is made of glutamate dehydrogenase&#44; followed in positive cases by enzymoimmunoassay for toxins A and B&#46; Only when these two techniques prove negative is a more specific third technique suggested &#40;PCR or toxigenic cultures&#41;&#46; As a less expensive alternative&#44; this step can be replaced by stool culture&#44; followed in positive cases by direct toxin determination in the isolates&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">The treatment used mainly consisted of monotherapy with metronidazole and&#44; in fewer cases&#44; with vancomycin&#46; The preferential choice of metronidazole evidences that the form of presentation of CDI is regarded by the clinicians as mild or moderate&#44; since in the more severe or complicated presentations oral &#40;or rectal&#44; in the case of paralytic ileus&#41; vancomycin is recommended&#44; with or without metronidazole simultaneously&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> A recent review<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> has analyzed the studies that established comparative assessments of the efficacy of the different antimicrobials used to treat CDI&#46; All of them were of low to moderate statistical power&#44; and no differences were observed among the treatments&#46; It should be mentioned that up to one-quarter of all the therapies used in our series were administered as the combination of both antibiotics&#44; despite a lack of evidence warranting their effectiveness&#46; In 7 of the cases &#40;10&#37;&#41;&#44; adverse reactions attributed to the antibiotics used to treat CDI were recorded&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">The clinical response to the treatment provided was rated as satisfactory &#40;cure or improvement&#41; in 75&#37; of the cases&#46; In the rest of the cases evaluation was not possible or no changes were observed in patients who died as a result of progression of their background disease condition&#46; The overall in-ICU mortality rate was 25&#37;&#44; and in no cases could death be related to CDI&#46; Different studies have examined the impact of the presence of CDI upon mortality among critical patients&#46; Most of them show the presence of CDI to be associated to high overall in-ICU and in-hospital mortality<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19&#8211;22&#44;29</span></a>&#59; however&#44; on conducting comparative analyses &#40;involving patients with diarrhea without CDI or case-controls&#41;&#44; no relationship was observed between the presence of CDI and patient mortality&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19&#44;29</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">The reported frequency of CDI recurrence is between 6 and 25&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The recurrence rate in our study was low&#46; This may be because a quarter of the patients have died&#44; and follow-up was only made until discharge from hospital&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">This study has important limitations&#44; such as its retrospective nature based on the analysis of reported cases in the context of a voluntary national registry&#46; The registry of CDI was first included in the year 2012&#44; and this may have caused omissions in recording the infection&#46; On the other hand&#44; no common protocol was used to request microbiological studies in patients at risk&#44; and the tests applied to the stool samples varied from one hospital to another&#46; Likewise&#44; we have not been able to establish a relationship between the presence of CDI and outcome&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">In sum&#44; the present study contributes information on the characteristics of the patients with CDI admitted to Spanish ICUs&#44; and on the treatments provided&#46; Of note in this respect is the fact that two antibiotics were administered simultaneously in one-quarter of the cases&#46; The calculated infection rates were lower than those published by other authors and fell short of the rates expected from the CDI-specific risk factors present in these patients&#8211;thus evidencing that <span class="elsevierStyleItalic">C&#46; difficile</span> infection is underdiagnosed in critically ill patients admitted to the ICU&#46; A consensus-based study methodology is needed &#40;collection and submission of samples and specific tests in the Microbiology laboratories&#41; in reference to patients with liquid depositions in our setting&#46;</p></span><span id="sec0135" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Financial support</span><p id="par0145" class="elsevierStylePara elsevierViewall">M&#46; Palomar has received an international grant from <span class="elsevierStyleGrantSponsor" id="gs1">Pfizer</span> for maintenance of the ENVIN-ICU registry&#46; F&#46; Alvarez-Lerma has received a grant from <span class="elsevierStyleGrantSponsor" id="gs2">Astella-Farma</span> for the collection and analysis of the data referred to <span class="elsevierStyleItalic">Clostridium difficile</span> infection&#46;</p></span><span id="sec0140" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Conflicts of interest</span><p id="par0150" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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        "titulo" => "Abstract"
        "resumen" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Data on the epidemiology of infections caused by <span class="elsevierStyleItalic">Clostridium difficile</span> &#40;CDI&#41; in critically ill patients are scarce and center on studies with a limited time framework and&#47;or epidemic outbreaks&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">To describe the characteristics and risk factors of critically ill patients admitted to the ICU with CDI&#44; as well as the treatments used for the control of such infections&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0015">Materials and methods</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">A retrospective study was made of patients included in the ENVIN-ICU registry with CDI in 2012&#46; Patients were followed up to 72<span class="elsevierStyleHsp" style=""></span>h after discharge from the ICU&#46; A case report form was used to record the following data&#58; demographic variables&#44; risk factors related to CDI&#44; treatment and outcome&#46; Infections were classified as community-acquired&#44; nosocomial out-ICU and nosocomial in-ICU&#44; according to the day on which <span class="elsevierStyleItalic">Clostridium difficile</span> isolates were obtained&#46; Infection rates as episodes per 10&#44;000 days of ICU stay are presented&#46; The global in-ICU and hospital mortality rates were calculated&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Sixty-eight episodes of CDI in 33 out of a total of 173 ICUs participating in the registry were recorded &#40;19&#46;1&#37;&#41; &#40;2&#46;1 episodes per 10&#44;000 days of ICU stay&#41;&#46; Forty-five patients were men &#40;66&#46;2&#37;&#41;&#44; with a mean &#40;SD&#41; age of 63&#46;4 &#40;16&#46;4&#41; years&#44; a mean APACHE II score on ICU admission of 19&#46;9 &#40;7&#46;4&#41;&#44; and an underlying medical condition in 44 &#40;64&#46;7&#37;&#41;&#46; Sixty-two patients &#40;91&#46;2&#37;&#41; presented more than 3 liquid depositions&#47;day&#44; 40 &#40;58&#46;8&#37;&#41; in association with severe sepsis or septic shock&#46; Community-acquired infection occurred in 13 patients &#40;19&#46;1&#37;&#41;&#44; nosocomial out-ICU infection in 13 &#40;19&#46;1&#37;&#41;&#44; and in-ICU infection in 42 &#40;61&#46;8&#37;&#41;&#46; Risk factors included age<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>64 years in 39 cases &#40;57&#46;4&#37;&#41;&#44; previous hospital admission &#40;3 months&#41; in 32 &#40;45&#46;6&#37;&#41;&#44; use of antimicrobials &#40;previous 7 days&#41; in 57 &#40;83&#46;8&#37;&#41;&#44; enteral nutrition in 23 &#40;33&#46;8&#37;&#41;&#44; and the use of H<span class="elsevierStyleInf">2</span> inhibitors in 39 &#40;57&#46;4&#37;&#41;&#46; Initial combined treatment was administered to 18 patients &#40;26&#46;5&#37;&#41;&#46; Metronidazole was used in 60 &#40;88&#46;2&#37;&#41; and vancomycin in 31 &#40;45&#46;6&#37;&#41;&#46; The in-ICU mortality rate was 25&#46;0&#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>17&#41;&#44; with a hospital mortality 27&#46;9&#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>19&#41;&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">The rate of ICD in ICU patients is low&#44; the infection affects severely ill patients&#44; and is associated with high mortality&#46; The presence of CDI is a marker of poor prognosis&#46;</p>"
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        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">La epidemiolog&#237;a de las infecciones por <span class="elsevierStyleItalic">Clostridium difficile</span> &#40;ICD&#41; en pacientes cr&#237;ticos es escasa y centrada en estudios limitados en tiempo y&#47;o en brotes epid&#233;micos&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Describir las caracter&#237;sticas y los factores de riesgo de pacientes cr&#237;ticos ingresados en UCI con ICD&#44; as&#237; como los tratamientos utilizados para su control&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todo</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">An&#225;lisis retrospectivo de pacientes incluidos en el registro ENVIN-UCI con ICD en el a&#241;o 2012&#46; Los pacientes se han seguido hasta 72<span class="elsevierStyleHsp" style=""></span>h despu&#233;s de su alta de UCI&#46; Se ha cumplimentado un cuaderno de recogida de datos&#44; en el que se incluyen variables demogr&#225;ficas&#44; factores de riesgo relacionados con <span class="elsevierStyleItalic">Clostridium difficile</span>&#44; tratamiento y evoluci&#243;n&#46; Los aislamientos se han clasificado por su origen en comunitarios&#44; nosocomiales extra-UCI y nosocomiales intra-UCI en funci&#243;n del d&#237;a de aislamiento&#46; Se presentan las tasas por episodios por 10&#46;000 d&#237;as de estancia en UCI&#46; Se describe la mortalidad global intra-UCI y hospitalaria&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Se han detectado 68 episodios de ICD en 33 &#40;19&#44;1&#37;&#41; UCI de las 173 participantes en el registro &#40;2&#44;1 episodios por 10&#46;000 d&#237;as de estancia-UCI&#41;&#46; En 45 &#40;66&#44;2&#37;&#41; casos eran hombres&#44; con edad media de 63&#44;4 &#40;16&#44;4&#41; a&#241;os&#44; APACHE II al ingreso de 19&#44;9 &#40;7&#44;4&#41; y enfermedad de base m&#233;dica 44 &#40;64&#44;7&#37;&#41;&#46; En 62 &#40;91&#44;2&#37;&#41; ocasiones presentaron m&#225;s de 3 deposiciones l&#237;quidas&#47;d&#237;a y en 40 &#40;58&#44;8&#37;&#41; se asoci&#243; con sepsis severa o shock s&#233;ptico&#46; En 13 &#40;19&#44;1&#37;&#41; ocasiones fue de origen comunitario&#44; en 13 &#40;19&#44;1&#37;&#41; de origen nosocomial extra-UCI y en 42 &#40;61&#44;8&#37;&#41; de origen intra-UCI&#46; Factores de riesgo&#58; edad<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>64 a&#241;os 39 &#40;57&#44;4&#37;&#41;&#44; ingreso previo hospital &#40;3 meses&#41; 32 &#40;45&#44;6&#37;&#41;&#44; antimicrobianos &#40;7 d&#237;as previos&#41; 57 &#40;83&#44;8&#37;&#41;&#44; nutrici&#243;n enteral 23 &#40;33&#44;8&#37;&#41; e inhibidores H<span class="elsevierStyleInf">2</span> 39 &#40;57&#44;4&#37;&#41;&#46; Siguieron tratamiento inicial combinado 18 &#40;26&#44;5&#37;&#41; casos y se ha utilizado metronidazol en 60 &#40;88&#44;2&#37;&#41; y vancomicina en 31 &#40;45&#44;6&#37;&#41; casos&#46; Hubo mortalidad global intra-UCI en 17 &#40;25&#44;0&#37;&#41; casos y hospitalaria de 19 &#40;27&#44;9&#37;&#41;&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La tasa de ICD en pacientes ingresados en UCI es baja y afecta a pacientes con elevada gravedad y mortalidad&#46; La presencia de ICD es un marcador de mal pron&#243;stico&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0010">The investigators that have contributed cases to this study are cited in <a class="elsevierStyleCrossRef" href="#sec0075">Annex</a>&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Alvarez-Lerma F&#44; Palomar M&#44; Villasboa A&#44; Amador J&#44; Almirall J&#44; Posada MP&#44; et al&#46; Estudio epidemiol&#243;gico de infecci&#243;n por <span class="elsevierStyleItalic">Clostridium difficile</span> en pacientes cr&#237;ticos ingresados en una Unidad de Cuidados Intensivos&#46; Med Intensiva&#46; 2014&#59;38&#58;558&#8211;566&#46;</p>"
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            "apendice" => "<p id="par0160" class="elsevierStylePara elsevierViewall">List of supervising physicians in the ICUs who have completed the case report forms of patients with CDI&#58; A&#46; Bonet&#44; L&#46; Sal&#243; &#40;Cl&#237;nica Girona&#41;&#59; G&#46; Aguilar&#44; C&#46; Garc&#237;a M&#225;rquez &#40;Hospital Cl&#237;nico Universitario de Valencia&#41;&#59; M&#46;L&#46; Mora&#44; M&#46; Lequona &#40;Complejo Hospitalario Universitario de Canarias&#41;&#59; A&#46; D&#237;az&#44; L&#46; Pita&#44; R&#46; Arrojo &#40;Complexo Hospitalario Universitario A Coru&#241;a&#41;&#59; J&#46;C&#46; Montejo&#44; M&#46; Catal&#225;n &#40;Hospital 12 de Octubre&#44; Madrid&#41;&#59; M&#46;J&#46; Castro&#44; F&#46;J&#46; Rodr&#237;guez &#40;Hospital Arquitecto Marcide&#44; Ferrol&#44; A Coru&#241;a&#41;&#59; F&#46; Esteve &#40;Hospital de Bellvitge&#44; Hospitalet de Llobregat&#44; Barcelona&#41;&#59; D&#46; Fontaneda Lopez&#44; S&#46; Gutierrez &#40;Hospital de Le&#243;n&#41;&#59; E&#46; Ant&#243;n &#40;Hospital de Manacor&#41;&#59; I&#46; Catal&#225;n &#40;Hospital de Manresa Altaya&#44; Barcelona&#41;&#59; J&#46; Almirall&#44; M&#46; de la Torre &#40;Hospital de Matar&#243;&#44; Barcelona&#41;&#59; J&#46;L&#46; Ant&#243;n&#44; C&#46; Dolera &#40;Hospital de Sant Joan&#44; Alacant&#41;&#59; M&#46;B&#46; L&#243;pez&#44; M&#46;B&#46; Est&#233;vanez &#40;Hospital del Tajo&#44; Aranjuez&#44; Madrid&#41;&#59; J&#46; Amador&#44; M&#46;T&#46; Jurado &#40;Hospital de Terrassa&#44; Barcelona&#41;&#59; A&#46; Villasboas&#44; A&#46; Rey &#40;Hospital del Mar&#44; Barcelona&#41;&#59; R&#46; Reig &#40;Hospital General de Castell&#243;n&#41;&#59; A&#46;M&#46; Rodr&#237;guez&#44; M&#46; S&#225;nchez Palacios &#40;Hospital Insular de las Palmas&#44; Canarias&#41;&#59; B&#46; Gil&#44; N&#46; Llamas &#40;Hospital Morales Massaguer&#44; Murcia&#41;&#59; J&#46;A&#46; Cambronero&#44; M&#46; Daguerre &#40;Hospital Pr&#237;ncipe de Asturias&#44; Alcal&#225; de Henares&#44; Madrid&#41;&#59; A&#46; Blanco &#40;Hospital Universitario Central de Asturias&#44; Oviedo&#41;&#59; J&#46;R&#46; Iruretagoyena&#44; M&#46; Domeza&#237;n &#40;Hospital Universitario de Cruces&#44; Vizcaya&#41;&#59; A&#46; Abella&#44; F&#46; Gordo &#40;Hospital Universitario de Henares&#44; Madrid&#41;&#59; P&#46; Albert de la Cruz&#44; E&#46; Garc&#237;a &#40;Hospital Universitario del Sureste&#44; Arganda del Rey&#44; Madrid&#41;&#59; S&#46; Alc&#225;ntara&#44; I&#46; Fern&#225;ndez Sim&#243;n &#40;Hospital Universitario Puerta de Hierro&#44; Majadahonda&#44; Madrid&#41;&#59; A&#46;J&#46; Pontes&#44; J&#46;C&#46; Pozo &#40;Hospital Universitario Reina Sof&#237;a&#44; C&#243;rdoba&#41;&#59; &#193;&#46; L&#243;pez&#44; C&#46; Susarte &#40;Hospital Universitario Reina Sof&#237;a&#44; Murcia&#41;&#59; M&#46; Palomar&#44; C&#46; Laborda &#40;Hospital Vall d&#8217;Hebron&#44; Barcelona&#41;&#59; A&#46; Martinez Pell&#250;s&#44; E&#46; Andreu &#40;Hospital Virgen de la Arrixaca&#44; Murcia&#41;&#59; M&#46;P&#46; Posada &#40;Hospital Xeral de Vigo&#41;&#59; R&#46; Ferrer &#40;M&#250;tua de Terrassa&#44; Barcelona&#41;&#59; J&#46;M&#46; Quiroga&#44; M&#46; Sadaba &#40;Hospital de Cabue&#241;es&#44; Gij&#243;n&#41;&#59; A&#46;M&#46; Mend&#237;a Gorostidi &#40;Hospital de Donostia Ntra&#46; Sra&#46; de Aranzazu&#44; San Sebasti&#225;n&#41;&#59; A&#46; Rovira &#40;Hospital General de Hospitalet&#44; Barcelona&#41;&#59; H&#46; Abdel-Hadi &#40;Hospital General&#44; Ciudad Real&#41;&#46;</p>"
            "etiqueta" => "Annex"
            "titulo" => "The ENVIN-UCI Study Group"
            "identificador" => "sec0075"
          ]
        ]
      ]
    ]
    "multimedia" => array:7 [
      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
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        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Distribution of the cases of <span class="elsevierStyleItalic">Clostridium difficile</span> infection &#40;CDI&#41; detected in the Intensive Care Units in the course of the months of the year &#40;31 patients in the national vigilance period&#41;&#46;</p>"
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      1 => array:7 [
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">CD&#44; <span class="elsevierStyleItalic">Clostridium difficile</span>&#59; SD&#44; standard deviation&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Characteristics of the patients&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
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                  \t\t\t\t" style="border-bottom: 2px solid black">n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>68&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Age in years&#44; mean &#40;SD&#41; &#40;range&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">63&#46;4 &#40;16&#46;4&#41; &#40;24&#8211;87&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Sex&#44; male&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">45 &#40;66&#46;2&#41;&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"><span class="elsevierStyleItalic">APACHE II score&#44; mean &#40;SD&#41; &#40;range&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">19&#46;9 &#40;7&#46;4&#41; &#40;2&#8211;36&#41;&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  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Type of patient&#44; n &#40;&#37;&#41;</span></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"><span class="elsevierStyleHsp" style=""></span>Clinical&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">44 &#40;64&#46;7&#41;&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"><span class="elsevierStyleHsp" style=""></span>Surgical&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">22 &#40;32&#46;4&#41;&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"><span class="elsevierStyleHsp" style=""></span>Trauma&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">2 &#40;2&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Emergency surgery&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">20 &#40;29&#46;4&#41;&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  " colspan="2" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Home&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">30 &#40;44&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Hospitalization unit&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">34 &#40;50&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Other healthcare center&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">4 &#40;5&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Days of stay in hospital&#44; mean &#40;SD&#41; &#40;range&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">40&#46;2 &#40;38&#46;0&#41; &#40;3&#8211;179&#41;&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"><span class="elsevierStyleItalic">Days of stay in ICU&#44; mean &#40;SD&#41; &#40;range&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">17&#46;4 &#40;19&#46;9&#41; &#40;1&#8211;73&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Days of stay in hospital-isolation CD&#44; mean &#40;range&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14&#46;1 &#40;19&#46;9&#41; &#40;0&#8211;77&#41;&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"><span class="elsevierStyleItalic">Days of stay in ICU-isolation CD&#44; mean &#40;range&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#46;5 &#40;13&#46;3&#41; &#40;0&#8211;52&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Overall in-ICU mortality&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">17 &#40;25&#46;0&#41;&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"><span class="elsevierStyleItalic">Overall hospital mortality&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">19 &#40;27&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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        "descripcion" => array:1 [
          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Characteristics of patients with <span class="elsevierStyleItalic">Clostridium difficile</span> infection &#40;CDI&#41; admitted to the Intensive Care Units&#46;</p>"
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          "leyenda" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">EIA&#44; enzymoimmunoassay&#59; CDI&#44; <span class="elsevierStyleItalic">Clostridium difficile</span> infection&#59; GDH&#44; glutamate dehydrogenase&#59; PCR&#44; polymerase chain reaction&#59; ICU&#44; Intensive Care Unit&#46;</p>"
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Characteristics of CDI&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
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                  \t\t\t\t" style="border-bottom: 2px solid black">n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>68&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Liquid depositions&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">62 &#40;91&#46;1&#41;&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
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                  \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">53 &#40;77&#46;9&#41;&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  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\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"><span class="elsevierStyleHsp" style=""></span>Severe sepsis or septic shock&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">40 &#40;58&#46;8&#41;&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  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Origin of CDI&#44; n &#40;&#37;&#41;</span></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
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                  \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">13 &#40;19&#46;1&#41;&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"><span class="elsevierStyleHsp" style=""></span>Nosocomial in-hospital &#40;out-ICU&#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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13 &#40;19&#46;1&#41;&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"><span class="elsevierStyleHsp" style=""></span>Nosocomial in-ICU&nbsp;\t\t\t\t\t\t\n
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                  \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">42 &#40;61&#46;8&#41;&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  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Study method&#44; n &#40;&#37;&#41;</span></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"><span class="elsevierStyleHsp" style=""></span>Stool culture&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">25 &#40;36&#46;8&#41;&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"><span class="elsevierStyleHsp" style=""></span>Enzyme studies &#40;GDH&#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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">36 &#40;52&#46;9&#41;&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"><span class="elsevierStyleHsp" style=""></span>Toxin detection tests &#40;EIA&#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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">17 &#40;25&#46;0&#41;&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"><span class="elsevierStyleHsp" style=""></span>PCR&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">6 &#40;8&#46;8&#41;&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  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Number of tests per sample&#44; n &#40;&#37;&#41;</span></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"><span class="elsevierStyleHsp" style=""></span>1&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">50 &#40;73&#46;5&#41;&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"><span class="elsevierStyleHsp" style=""></span>2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10 &#40;14&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4 &#40;5&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Not known&nbsp;\t\t\t\t\t\t\n
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                  \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">4 &#40;5&#46;9&#41;&nbsp;\t\t\t\t\t\t\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">n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>68&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Diabetes mellitus&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">17 &#40;25&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>COPD&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">12 &#40;17&#46;6&#41;&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"><span class="elsevierStyleHsp" style=""></span>Solid organ neoplasm&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">8 &#40;11&#46;8&#41;&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"><span class="elsevierStyleHsp" style=""></span>Hematological malignancy&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">8 &#40;11&#46;8&#41;&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"><span class="elsevierStyleHsp" style=""></span>Liver cirrhosis&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">5 &#40;7&#46;4&#41;&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"><span class="elsevierStyleHsp" style=""></span>Chronic renal failure&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">13 &#40;19&#46;1&#41;&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"><span class="elsevierStyleHsp" style=""></span>Solid organ transplant&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">4 &#40;5&#46;9&#41;&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"><span class="elsevierStyleHsp" style=""></span>Bone marrow transplant&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">1 &#40;1&#46;5&#41;&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"><span class="elsevierStyleHsp" style=""></span>Radiotherapy&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">2 &#40;3&#46;0&#41;&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"><span class="elsevierStyleHsp" style=""></span>Chemotherapy&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">9 &#40;13&#46;2&#41;&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"><span class="elsevierStyleHsp" style=""></span>Neutropenia&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">4 &#40;5&#46;9&#41;&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"><span class="elsevierStyleHsp" style=""></span>Immune depression&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">12 &#40;17&#46;6&#41;&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  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Invasive devices&#44; n &#40;&#37;&#41;</span></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"><span class="elsevierStyleHsp" style=""></span>Central venous catheter&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">54 &#40;79&#46;4&#41;&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"><span class="elsevierStyleHsp" style=""></span>Arterial catheter&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">34 &#40;50&#46;0&#41;&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"><span class="elsevierStyleHsp" style=""></span>Mechanical ventilation&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">29 &#40;42&#46;6&#41;&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"><span class="elsevierStyleHsp" style=""></span>Bladder catheter&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">56 &#40;82&#46;4&#41;&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"><span class="elsevierStyleHsp" style=""></span>Parenteral nutrition&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">23 &#40;33&#46;8&#41;&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"><span class="elsevierStyleHsp" style=""></span>Extrarenal filtration&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">7 &#40;10&#46;3&#41;&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"><span class="elsevierStyleHsp" style=""></span>Antimicrobial use<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>7 days&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">46 &#40;67&#46;6&#41;&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"><span class="elsevierStyleHsp" style=""></span>Corticosteroids&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">22 &#40;32&#46;4&#41;&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"><span class="elsevierStyleHsp" style=""></span>Surgery during admission&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">17 &#40;25&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab597164.png"
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Disease antecedents&#44; invasive devices and complementary treatments of patients with <span class="elsevierStyleItalic">Clostridium difficile</span> infection &#40;CDI&#41; admitted to the Intensive Care Units&#46;</p>"
        ]
      ]
      4 => array:7 [
        "identificador" => "tbl0020"
        "etiqueta" => "Table 4"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">ATB&#44; antibiotics&#59; CDI&#44; <span class="elsevierStyleItalic">Clostridium difficile</span> infection&#59; HIV&#44; human immunodeficiency virus&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><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">Specific risk factors for CDI&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-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">n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>68&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"><span class="elsevierStyleItalic">Age</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#62;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">64 years</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">39 &#40;57&#46;4&#41;&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"><span class="elsevierStyleItalic">Hospital admission in the previous 3 months</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">31 &#40;45&#46;6&#41;&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"><span class="elsevierStyleItalic">Use of ATB in the previous 7 days</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">57 &#40;83&#46;8&#41;&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"><span class="elsevierStyleItalic">Chemotherapy</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7 &#40;10&#46;3&#41;&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"><span class="elsevierStyleItalic">HIV infection</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;1&#46;5&#41;&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"><span class="elsevierStyleItalic">Gastroduodenal surgery&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;7&#46;4&#41;&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"><span class="elsevierStyleItalic">Enteral nutrition&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">23 &#40;33&#46;8&#41;&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"><span class="elsevierStyleItalic">Use of H</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">2</span></span><span class="elsevierStyleItalic">inhibitors</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">39 &#40;57&#46;4&#41;&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  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Number of specific factors per CDI patient</span></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"><span class="elsevierStyleHsp" style=""></span>0&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">3 &#40;4&#46;4&#41;&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"><span class="elsevierStyleHsp" style=""></span>1&#8211;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">21 &#40;30&#46;9&#41;&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"><span class="elsevierStyleHsp" style=""></span>3&#8211;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">39 &#40;57&#46;4&#41;&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"><span class="elsevierStyleHsp" style=""></span>&#62;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">5 &#40;7&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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          "en" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Risk factors related to <span class="elsevierStyleItalic">Clostridium difficile</span> infection &#40;CDI&#41; in patients admitted to the Intensive Care Units&#46;</p>"
        ]
      ]
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        "identificador" => "tbl0025"
        "etiqueta" => "Table 5"
        "tipo" => "MULTIMEDIATABLA"
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        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0105" class="elsevierStyleSimplePara elsevierViewall">ATB&#44; antibiotics&#59; CDI&#44; <span class="elsevierStyleItalic">Clostridium difficile</span> infection&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><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">Specific treatment for CDI&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">n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>68&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"><span class="elsevierStyleItalic">Patients with previous ATP&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">57 &#40;83&#46;8&#41;&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  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Patients with ATB&#44; according to administered number&#44; n &#40;&#37;&#41;</span></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"><span class="elsevierStyleHsp" style=""></span>None&#47;not specified&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">8 &#40;11&#46;8&#41;&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"><span class="elsevierStyleHsp" style=""></span>1&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">17 &#40;25&#46;0&#41;&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"><span class="elsevierStyleHsp" style=""></span>2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16 &#40;23&#46;5&#41;&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"><span class="elsevierStyleHsp" style=""></span>3 or more&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">27 &#40;39&#46;7&#41;&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  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Previously administered ATB&#44; n</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">130&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"><span class="elsevierStyleItalic">Semisynthetic penicillins&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7 &#40;10&#46;3&#41;&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"><span class="elsevierStyleItalic">Betalactams plus betalactamase inhibitors&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">25 &#40;36&#46;8&#41;&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  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Cephalosporins&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16 &#40;23&#46;5&#41;&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"><span class="elsevierStyleHsp" style=""></span>First generation&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">2 &#40;2&#46;9&#41;&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"><span class="elsevierStyleHsp" style=""></span>Second generation&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">2 &#40;2&#46;9&#41;&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"><span class="elsevierStyleHsp" style=""></span>Third generation&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">9 &#40;13&#46;2&#41;&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"><span class="elsevierStyleHsp" style=""></span>Fourth generation&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">3 &#40;4&#46;4&#41;&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  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Carbapenems&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">23 &#40;33&#46;8&#41;&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"><span class="elsevierStyleItalic">Aminoglycosides&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6 &#40;8&#46;8&#41;&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"><span class="elsevierStyleItalic">Quinolones&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10 &#40;14&#46;7&#41;&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"><span class="elsevierStyleItalic">Clindamycin&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;1&#46;5&#41;&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"><span class="elsevierStyleItalic">Glycopeptides&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6 &#40;8&#46;8&#41;&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"><span class="elsevierStyleItalic">Cotrimoxazole&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;1&#46;5&#41;&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"><span class="elsevierStyleItalic">Linezolid&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11 &#40;16&#46;2&#41;&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  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Antimicrobials specific for CDI&#44; n &#40;&#37;&#41;</span></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"><span class="elsevierStyleHsp" style=""></span>Metronidazole&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">60 &#40;88&#46;2&#41;&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"><span class="elsevierStyleHsp" style=""></span>Vancomycin&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">31 &#40;45&#46;6&#41;&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"><span class="elsevierStyleHsp" style=""></span>Vancomycin and metronidazole&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">18 &#40;26&#46;5&#41;&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  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Antimicrobials simultaneous to those administered for CDI&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">24 &#40;35&#46;3&#41;&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  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Patients with adverse effects related to specific ATB&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7 &#40;10&#46;3&#41;&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"><span class="elsevierStyleHsp" style=""></span>Water-electrolyte alterations &#40;hypopotassemia&#44; hypomagnesemia&#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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></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"><span class="elsevierStyleHsp" style=""></span>Hematological alterations&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">2&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"><span class="elsevierStyleHsp" style=""></span>Liver function alterations&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">1&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"><span class="elsevierStyleHsp" style=""></span>Others&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">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                  \t\t\t\t\tvoid\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">n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>68&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " colspan="2" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cure&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">44 &#40;64&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Improvement&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">7 &#40;10&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Without changes &#40;failure&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">4 &#40;5&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">2 &#40;2&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">1 &#40;1&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">20 &#40;29&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">2 &#40;2&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
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                      "titulo" => "Clinical practice guidelines for <span class="elsevierStyleItalic">Clostridium difficile</span> infection in adults&#58; 2010 update by the society for Healthcare epidemiology of America &#40;SHEA&#41; and the Infectious Diseases Society of America &#40;IDSA&#41;"
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                            4 => "V&#46;G&#46; Loo"
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                          "colaboracion" => "Canadian Hospital Epidemiology Committee&#46; Canadian Nosocomial Infection Surveillance Program"
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        "identificador" => "xack106486"
        "titulo" => "Acknowledgements"
        "texto" => "<p id="par0155" class="elsevierStylePara elsevierViewall">The ENVIN-ICU registry is promoted by the Infectious diseases Work Group of the Spanish Society of Intensive Care and Coronary Units &#40;GTEI-SEMICYUC&#41;&#44; and has been maintained in the year 2012 thanks to an international grant from Pfizer S&#46;A&#46; The list of participating centers and the collaborators in the registry are contained in the report corresponding to the year 2012&#44; which can be freely accessed at&#58; <a class="elsevierStyleInterRef" id="intr0015" href="http://hws.vhebron.net/envin-helics/">http&#58;&#47;&#47;hws&#46;vhebron&#46;net&#47;envin-helics&#47;</a>&#46; The analysis of the cases of <span class="elsevierStyleItalic">C&#46; difficile</span> has been carried out in part with the support of Astella-Farma&#46; The authors thank Sergio Mojal&#44; of the <span class="elsevierStyleItalic">Instituto Municipal de Investigaci&#243;n</span> of <span class="elsevierStyleItalic">Hospital del Mar</span>&#44; for methodological counseling and statistical analysis&#46;</p>"
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Article information

ISSN: 21735727
Original language: English

DOI:10.1016/j.medine.2013.11.003

The statistics are updated each day

Year/Month	Html	Pdf	Total

2024 November	10	12	22
2024 October	66	44	110
2024 September	57	25	82
2024 August	55	44	99
2024 July	53	26	79
2024 June	47	46	93
2024 May	55	59	114
2024 April	74	26	100
2024 March	41	23	64
2024 February	34	39	73
2024 January	54	32	86
2023 December	41	43	84
2023 November	54	30	84
2023 October	49	34	83
2023 September	35	40	75
2023 August	33	17	50
2023 July	32	26	58
2023 June	31	20	51
2023 May	50	37	87
2023 April	33	14	47
2023 March	47	32	79
2023 February	52	30	82
2023 January	28	23	51
2022 December	43	30	73
2022 November	62	35	97
2022 October	40	53	93
2022 September	54	30	84
2022 August	33	32	65
2022 July	33	36	69
2022 June	33	22	55
2022 May	55	43	98
2022 April	36	39	75
2022 March	62	57	119
2022 February	35	37	72
2022 January	36	29	65
2021 December	45	43	88
2021 November	36	39	75
2021 October	49	75	124
2021 September	39	44	83
2021 August	22	39	61
2021 July	31	29	60
2021 June	32	34	66
2021 May	51	50	101
2021 April	122	63	185
2021 March	67	32	99
2021 February	53	28	81
2021 January	51	33	84
2020 December	37	26	63
2020 November	36	14	50
2020 October	39	27	66
2020 September	71	32	103
2020 August	29	17	46
2020 July	53	14	67
2020 June	45	23	68
2020 May	29	11	40
2020 April	42	20	62
2020 March	25	14	39
2020 February	119	57	176
2020 January	39	28	67
2019 December	34	19	53
2019 November	50	37	87
2019 October	63	26	89
2019 September	49	26	75
2019 August	57	21	78
2019 July	41	28	69
2019 June	46	32	78
2019 May	67	38	105
2019 April	54	16	70
2019 March	57	25	82
2019 February	59	38	97
2019 January	55	38	93
2018 December	49	46	95
2018 November	162	38	200
2018 October	308	25	333
2018 September	72	9	81
2018 August	32	1	33
2018 July	43	9	52
2018 June	28	7	35
2018 May	25	4	29
2018 April	24	4	28
2018 March	22	8	30
2018 February	28	5	33
2018 January	43	12	55
2017 December	33	6	39
2017 November	37	15	52
2017 October	29	3	32
2017 September	36	7	43
2017 August	23	7	30
2017 July	24	5	29
2017 June	26	9	35
2017 May	26	11	37
2017 April	26	11	37
2017 March	9	5	14
2017 February	16	6	22
2017 January	13	8	21
2016 December	39	10	49
2016 November	44	9	53
2016 October	47	19	66
2016 September	34	12	46
2016 August	33	6	39
2016 July	27	7	34

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