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Correlación y pronóstico en pacientes con sepsis respiratoria" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0030" "etiqueta" => "Figure 6" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr6.jpeg" "Alto" => 1230 "Ancho" => 2204 "Tamanyo" => 206221 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0110" class="elsevierStyleSimplePara elsevierViewall">Area Under Receiver Operating Characteristic (AUROC) curves for skeletal muscle rSO<span class="elsevierStyleInf">2</span> in brachioradialis and deltoid muscle at ICU admission (baseline) and at 24<span class="elsevierStyleHsp" style=""></span>h for mortality.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "A. Rodríguez, L. Claverias, J. Marín, M. Magret, S. Rosich, M. Bodí, S. Trefler, S. Pascual, J. Gea" "autores" => array:9 [ 0 => array:2 [ "nombre" => "A." "apellidos" => "Rodríguez" ] 1 => array:2 [ "nombre" => "L." "apellidos" => "Claverias" ] 2 => array:2 [ "nombre" => "J." "apellidos" => "Marín" ] 3 => array:2 [ "nombre" => "M." "apellidos" => "Magret" ] 4 => array:2 [ "nombre" => "S." "apellidos" => "Rosich" ] 5 => array:2 [ "nombre" => "M." "apellidos" => "Bodí" ] 6 => array:2 [ "nombre" => "S." "apellidos" => "Trefler" ] 7 => array:2 [ "nombre" => "S." "apellidos" => "Pascual" ] 8 => array:2 [ "nombre" => "J." "apellidos" => "Gea" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173572715000107?idApp=WMIE" "url" => "/21735727/0000003900000002/v2_201503111049/S2173572715000107/v2_201503111049/en/main.assets" ] "en" => array:14 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Point of view</span>" "titulo" => "Nebulized antibiotics. An adequate option for treating ventilator-associated respiratory infection?" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "97" "paginaFinal" => "100" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "A. Rodríguez, F. Barcenilla" "autores" => array:2 [ 0 => array:4 [ "nombre" => "A." "apellidos" => "Rodríguez" "email" => array:1 [ 0 => "ahr1161@yahoo.es" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "F." "apellidos" => "Barcenilla" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Medicina Intensiva, Hospital Universitario de Tarragona Joan XXIII, Institut d’Investigació Sanitària Pere Virgili, Universitat Rovira i Virgili, Tarragona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Unidad Funcional de Infección Nosocomial, Hospital Universitario Arnau de Vilanova, Lleida, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Antibióticos nebulizados. ¿Una opción adecuada para el tratamiento de la infección respiratoria relacionada con la ventilación mecánica?" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Ventilator-associated pneumonia (VAP) is a frequent cause of morbidity–mortality in critical patients, and is responsible for over 50% of the antibiotics (ATBs) used in the Intensive Care Unit (ICU).<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">1–3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">According to the Spanish National Surveillance Study on Nosocomial Infections in the ICU, associated to the European project Hospitals in Europe Link for Infection Control through Surveillance (ENVIN/HELICS) of 2013,<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">4</span></a> the number of patients who have suffered some infection in the ICU has gradually decreased over the years from 15.5% in 2009 to 10.6% in 2013. The report underscores the notorious drop in VAP rate, from 11.4 episodes per 1000 days on mechanical ventilation (MV) in 2009 to 6.87 episodes per 1000 days on MV in 2013. On analyzing the successive ENVIN/HELICS reports, we observe a decrease in the number of patients treated with ATBs for infections acquired in the ICU, from 25.78% in 2009 to 20.88% in 2013. However, the total number of patients receiving ATBs remained stable during these years, with rates of between 60% (2010) and 63% (2013). This situation does not seem to correspond to a purely local phenomenon. Recently, Wunderink<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">5</span></a> pointed out that the apparent decrease in the incidence of VAP is not correlated to the corresponding decrease in ATB use or mortality in the United States. The explanation for this discrepancy could be the use of ATBs for the management of scantly defined disease conditions different from VAP. In this context, and considering the new surveillance classification proposed by the United States Centers for Disease Control and Prevention referred to events associated to MV,<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">6</span></a> the frequency of use of ATBs in the ICU could in fact be higher. Ventilator-associated tracheobronchitis (VAT) is considered to be common in ventilated patients, as evidenced by a recent international survey.<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">7</span></a> An interesting finding of this survey is that carbapenems were the most frequent initial empirical treatment in such patients. These results are reinforced by the findings of the ENVIN/HELICS program. According to data from 2013, a total of 1275 antibiotic treatments were administered to treat VAT, with a mean duration of 7.77 days, and a total of 9912 days of ATBs. These figures are similar to those published for VAP, with the administration of 1118 antimicrobial treatments, with a mean duration of 9.11 days, and a total of 10,188 days of ATBs.<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Taking into account the fact that microbial resistance levels are directly related to the amount of ATBs used,<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">8,9</span></a> together with the almost certain existence of an overdiagnosis of ventilator-associated infections, including VAP,<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">10</span></a> adequate antimicrobial use is a fundamental objective in order to define strategies for avoiding the development of resistances.</p><p id="par0020" class="elsevierStylePara elsevierViewall">In this context, nebulized ATBs could be a valid option for the treatment of infectious complications associated to MV, such as VAT or even VAP.<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">6</span></a> The possible use of this type of ATB treatment is based on the idea that an adequate nebulization technique is able to directly release the ATB at the site of infection and reach very high concentrations, with minimum systemic toxicity and effects upon the intestinal flora, and can contribute to reduce the appearance of resistances.<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">11–13</span></a> To date, the international guides<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">1</span></a> only mention the use of nebulized aminoglycosides or polymyxin as coadjuvant therapy in pneumonia caused by multiresistant gramnegative bacilli that fails to respond adequately to systemic therapy. In this context we should ask ourselves whether this is the only possible scenario for the use of nebulized ATB, or whether there are also other clinical situations in which the use of these formulations may be justified, despite the lack of solid supporting scientific evidence.</p><p id="par0025" class="elsevierStylePara elsevierViewall">In patients suffering from cystic fibrosis, with chronic airway infection/colonization, the use of nebulized ATBs has been associated to a decrease in the number of hospital admissions due to exacerbations, and to improved lung function.<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">14–17</span></a> Based on these observations, the ATBs used in nebulized formulations (tobramycin, colistin and aztreonam) have been approved by the different health authorities only for use in this special group of patients. However, the characteristics of the airway in ventilated patients who develop tracheobronchial infection/colonization (as for example in VAT) are similar to those of patients with cystic fibrosis. Both groups of patients have an altered and inflamed respiratory epithelium, with different degrees of infection/colonization. Furthermore, it is now recognized that biofilm development in the endotracheal tube may be similar to that seen in the airway of patients with cystic fibrosis.<a class="elsevierStyleCrossRefs" href="#bib0295"><span class="elsevierStyleSup">18,19</span></a> This situation favors resistance to ATB treatment on the part of certain microorganisms such as <span class="elsevierStyleItalic">Pseudomonas aeruginosa</span> or <span class="elsevierStyleItalic">Staphylococcus aureus</span> – the main causes of respiratory infections in both groups of patients.<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">11,20–22</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">However, nebulized ATBs for the treatment of infectious complications related to MV continue to be prescribed on a “compassionate use” basis. The first studies carried out in the 1970s<a class="elsevierStyleCrossRefs" href="#bib0320"><span class="elsevierStyleSup">23,24</span></a> with polymyxin B through instillation and an atomizer observed an increase in VAP attributable to microorganisms resistant to polymyxin. Although these same investigators demonstrated that this complication could have been due to the prolonged use of polymyxin B, the findings generated great uncertainty among clinicians, and no further studies were made over the next 30 years. Although the instillation of ATBs results in a high drug concentration in tracheal secretions,<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">25</span></a> the distribution of the antibiotic is not homogeneous, and the amount distributed within the alveoli is not known.<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">26</span></a> In contrast, nebulization generates particles of smaller size and thus offers the theoretical advantage of producing a more homogeneous distribution of the drug throughout the lower airway. The findings of studies in animals<a class="elsevierStyleCrossRefs" href="#bib0340"><span class="elsevierStyleSup">27,28</span></a> reveal high ATB concentrations in lung tissue, in the distal airway, and in the alveoli. A recent study<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">29</span></a> involving 69 ventilated patients with VAP produced by gramnegative bacilli found nebulized amikacin to be adequately distributed within the lung tissues–with high tracheal concentrations reaching 16.2<span class="elsevierStyleHsp" style=""></span>mg/ml upon administering 400<span class="elsevierStyleHsp" style=""></span>mg every 12<span class="elsevierStyleHsp" style=""></span>h.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Despite these results, the main concern of intensivists in using nebulized ATBs refers to the capacity of the drug to penetrate the lung tissues. Although tissue penetration is good in healthy volunteers,<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">30</span></a> it is less certain in patients with lung tissue consolidation. Animal models<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">23</span></a> evidence good nebulized amikacin concentrations even in poorly ventilated areas. Luyt et al.<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">31</span></a> recorded a high concentration of amikacin in lung consolidation zones among patients with VAP due to gramnegative bacilli. Although in most cases the concentrations obtained in alveolar fluid are far above the minimum inhibitory concentration of the main pathogens responsible for VAP, such concentrations appear to be closely related to the quality of nebulization and the type of nebulizer used.<a class="elsevierStyleCrossRefs" href="#bib0365"><span class="elsevierStyleSup">32,33</span></a> The “ideal” and “safe” conditions described in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> appear to be easy to reach with modern nebulizers–particularly the vibration (ultrasound) devices.<a class="elsevierStyleCrossRefs" href="#bib0365"><span class="elsevierStyleSup">32,33</span></a> Compliance with these conditions is essential if we wish not only to reach the treatment objectives but also to avoid serious complications such as severe bronchospasm produced by the nebulization of substances not suited to this administration route. On the other hand, Lu et al.,<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">34</span></a> in a phase II trial, found that amikacin and ceftazidime treatment administered via the intravenous route or in nebulized formulation exhibits similar efficacy in patients with VAP due to sensitive <span class="elsevierStyleItalic">Pseudomonas aeruginosa</span> strains. Notoriously, and although the clinical failure rate was similar in both groups, the persistence of colonization or recurrence due to resistant microorganisms was only observed in the intravenous treatment group.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">Different studies in critical patients<a class="elsevierStyleCrossRefs" href="#bib0380"><span class="elsevierStyleSup">35–38</span></a> have shown that nebulized ATBs may be an adequate option as coadjuvant treatment for VAP produced by multiresistant bacilli. A particularly interesting study is that published by Kwa et al.,<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">38</span></a> who recorded a favorable clinical response in 85.7% of the patients with VAP due to multiresistant bacilli administered nebulized colistin as sole ATB treatment.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Although the evidence on VAP management with nebulized ATBs is admittedly scarce in reference to the adequacy or inadequacy of nebulized drug penetration capacity in consolidated lung tissues, another frequent complication of MV, specifically VAT (an infection limited to the airway), could also be a clear target for treatment with nebulized ATBs, affording good clinical resolution.<a class="elsevierStyleCrossRefs" href="#bib0400"><span class="elsevierStyleSup">39–41</span></a> This type of treatment strategy could significantly lessen the use of broad spectrum ATBs via the systemic route in patients with this disorder (over 9900 days of ATB treatment according to data from the ENVIN-HELICS). Furthermore, we must remember that systemic ATBs are associated to low drug levels in alveolar fluid, as well as to strong pressure upon the local flora and the appearance of multiresistance phenomena.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Lastly, there is no doubt that well designed studies are needed to confirm the above considerations. Our opinion is that on the basis of the existing evidence, the treatment of VAT with nebulized ATBs could reduce the development of VAP and the need for systemic antibiotics. However, the impact of this strategy in terms of a decrease in multiresistance phenomena remains to be evaluated in the context of future studies.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0055" class="elsevierStylePara elsevierViewall">This study has been financed in part by grants <span class="elsevierStyleGrantSponsor" id="gs1">FIS PI13/02011</span> and <span class="elsevierStyleGrantSponsor" id="gs2">AGAUR 2014/SGR926</span>.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflicts of interest</span><p id="par0060" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest in relation to this study.</p><p id="par0065" class="elsevierStylePara elsevierViewall">AR has received compensation for conferences on behalf of Pfizer, Gilead, Astellas, Novartis, Thermo-Fisher Roche and MSD.</p><p id="par0070" class="elsevierStylePara elsevierViewall">FB has received compensation for conferences on behalf of Pfizer, Astellas, Novartis and MSD.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Funding" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Conflicts of interest" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Rodríguez A, Barcenilla F. Antibióticos nebulizados. ¿Una opción adecuada para el tratamiento de la infección respiratoria relacionada con la ventilación mecánica? Med Intensiva. 2015;39:97–100.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">ATB: antibiotic; MMAD: mean mass aerodynamic diameter (mean diameter of the particles generated by the nebulizer device).</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Source: Boe et al.<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">32</span></a> and Le et al.<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">33</span></a></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"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Physical properties of the nebulized ATB \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Particle characteristics \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Aerosol release method \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Solutions instead of suspensions \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">MMAD 1.0–5.0<span class="elsevierStyleHsp" style=""></span>μm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Ultrasound better than jet nebulizer \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Osmolarity 150–1200<span class="elsevierStyleHsp" style=""></span>mOsm/kg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Particle diameter 1–5<span class="elsevierStyleHsp" style=""></span>μm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Ensure minimum residual volume \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Sodium content 77–154<span class="elsevierStyleHsp" style=""></span>mEq/l \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Little change in release with flow \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">pH 2.6–10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Use of flow above 6<span class="elsevierStyleHsp" style=""></span>l/min \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Use of a volume similar to the total capacity of the nebulizer \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Release only during inspiration phase \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No warming the nebulized solution \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Nebulizer in the inspiratory branch 30–45<span class="elsevierStyleHsp" style=""></span>cm from connection to the tube \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Remove filter or moisture exchanger \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Minimize system humidification \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab700675.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">“Ideal” characteristics in order to adequately administer nebulized antibiotics and avoid complications.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:41 [ 0 => array:3 [ "identificador" => "bib0210" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Guidelines for the management of adults with hospital-acquired, ventilator-associated and health care-associated pneumonia" "autores" => array:1 [ 0 => array:2 [ "colaboracion" => "American Thoracic Society, Infectious Disease Society of America" "etal" => false ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Am J Respir Crit Care Med" "fecha" => "2005" "volumen" => "17" "paginaInicial" => "388" 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Year/Month | Html | Total | |
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2024 November | 14 | 13 | 27 |
2024 October | 53 | 50 | 103 |
2024 September | 66 | 63 | 129 |
2024 August | 64 | 58 | 122 |
2024 July | 60 | 35 | 95 |
2024 June | 75 | 48 | 123 |
2024 May | 59 | 39 | 98 |
2024 April | 71 | 47 | 118 |
2024 March | 84 | 40 | 124 |
2024 February | 49 | 63 | 112 |
2024 January | 49 | 33 | 82 |
2023 December | 41 | 41 | 82 |
2023 November | 44 | 44 | 88 |
2023 October | 60 | 39 | 99 |
2023 September | 56 | 44 | 100 |
2023 August | 44 | 15 | 59 |
2023 July | 33 | 31 | 64 |
2023 June | 37 | 33 | 70 |
2023 May | 55 | 43 | 98 |
2023 April | 52 | 22 | 74 |
2023 March | 110 | 30 | 140 |
2023 February | 91 | 20 | 111 |
2023 January | 60 | 19 | 79 |
2022 December | 72 | 34 | 106 |
2022 November | 68 | 38 | 106 |
2022 October | 75 | 32 | 107 |
2022 September | 56 | 29 | 85 |
2022 August | 52 | 30 | 82 |
2022 July | 40 | 32 | 72 |
2022 June | 66 | 48 | 114 |
2022 May | 74 | 32 | 106 |
2022 April | 127 | 49 | 176 |
2022 March | 74 | 54 | 128 |
2022 February | 88 | 34 | 122 |
2022 January | 88 | 37 | 125 |
2021 December | 78 | 48 | 126 |
2021 November | 89 | 39 | 128 |
2021 October | 94 | 74 | 168 |
2021 September | 42 | 35 | 77 |
2021 August | 67 | 35 | 102 |
2021 July | 50 | 47 | 97 |
2021 June | 45 | 37 | 82 |
2021 May | 61 | 45 | 106 |
2021 April | 167 | 62 | 229 |
2021 March | 128 | 48 | 176 |
2021 February | 113 | 32 | 145 |
2021 January | 103 | 27 | 130 |
2020 December | 81 | 25 | 106 |
2020 November | 66 | 23 | 89 |
2020 October | 71 | 34 | 105 |
2020 September | 70 | 21 | 91 |
2020 August | 64 | 12 | 76 |
2020 July | 56 | 23 | 79 |
2020 June | 78 | 16 | 94 |
2020 May | 83 | 22 | 105 |
2020 April | 54 | 13 | 67 |
2020 March | 67 | 17 | 84 |
2020 February | 135 | 35 | 170 |
2020 January | 65 | 25 | 90 |
2019 December | 96 | 18 | 114 |
2019 November | 107 | 30 | 137 |
2019 October | 121 | 26 | 147 |
2019 September | 100 | 34 | 134 |
2019 August | 63 | 31 | 94 |
2019 July | 64 | 33 | 97 |
2019 June | 46 | 21 | 67 |
2019 May | 79 | 35 | 114 |
2019 April | 73 | 33 | 106 |
2019 March | 61 | 30 | 91 |
2019 February | 62 | 41 | 103 |
2019 January | 54 | 35 | 89 |
2018 December | 63 | 30 | 93 |
2018 November | 176 | 82 | 258 |
2018 October | 149 | 30 | 179 |
2018 September | 25 | 9 | 34 |
2018 August | 17 | 7 | 24 |
2018 July | 31 | 9 | 40 |
2018 June | 26 | 10 | 36 |
2018 May | 15 | 7 | 22 |
2018 April | 35 | 8 | 43 |
2018 March | 26 | 4 | 30 |
2018 February | 25 | 8 | 33 |
2018 January | 29 | 7 | 36 |
2017 December | 37 | 6 | 43 |
2017 November | 31 | 12 | 43 |
2017 October | 33 | 7 | 40 |
2017 September | 33 | 9 | 42 |
2017 August | 34 | 8 | 42 |
2017 July | 40 | 22 | 62 |
2017 June | 40 | 18 | 58 |
2017 May | 37 | 14 | 51 |
2017 April | 42 | 17 | 59 |
2017 March | 29 | 27 | 56 |
2017 February | 19 | 18 | 37 |
2017 January | 34 | 8 | 42 |
2016 December | 44 | 13 | 57 |
2016 November | 63 | 22 | 85 |
2016 October | 56 | 20 | 76 |
2016 September | 69 | 10 | 79 |
2016 August | 54 | 13 | 67 |
2016 July | 26 | 11 | 37 |