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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The World Health Organization &#40;WHO&#41; defines that patients receive appropriate medications to their clinical needs if they are prescribed in doses that meet their own individual requirements&#44; for an adequate period of time&#44; and at the lowest cost to them and their community&#46; These general principles are obviously applicable to antimicrobial use in general and to the administration of antimicrobials in the critical care setting&#46; Many parameters of importance for optimal quality of antimicrobial therapy have already been defined&#46; Maximal efficacy of the treatment should be combined with minimal toxicity at the lowest cost&#46; Quality of antimicrobial drug use is dependent on knowledge of many aspects of infectious diseases and patient characteristics&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Inappropriate use of antimicrobial drugs is the major determinant of antimicrobial resistance development increasing the costs of care&#44; morbidity and mortality&#46; Critically ill patients are especially complex suffering profound pathophysiological changes that can affect PK&#47;PD properties of antibiotics&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Institutional programs aiming at reducing the inappropriate use of antibiotics have been launched worldwide&#46; These activities require accurate comparators of antibiotic consumption to benchmark antimicrobial drug use&#46; The three more common metrics for measuring aggregate antimicrobial use are the defined daily dose &#40;DDD&#41;&#44; the prescribed daily doses &#40;PDD&#41;&#44; and the days of therapy &#40;DOT&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The DDD is the measure endorsed by the WHO&#44; and nowadays&#44; the metric most widely used for comparisons of antibiotic use in primary care and in hospitals&#46; The consensus document of the Spanish programs for optimizing the use of antibiotics &#40;PROA&#41; in hospitals recommends DDD as the basic meter for monitoring antibiotic consumption considering DOT and DDP as metrics of excellence&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">4</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">However&#44; many studies have documented that DDD does not accurately reflect the antibiotic consumption and the quality of antibiotic prescription&#46; One of the major drawbacks of DDD measurement is that it underestimates antibiotic consumption when the WHO-consigned DDD is greater than the administered dose as occurs in patients with renal insufficiency or in pediatric populations&#46; Conversely&#44; DDD overestimates antibiotic consumption when reference DDD is lower than the administered dose as occurs very frequently in the critical care setting&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">In this issue&#44; the study by Vall&#232;s et al&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">5</span></a> has documented that DDD misjudges antibiotic use in adult critically ill patients overestimating the utilization of the majority of antibacterial and antifungal drugs&#46; Previous studies have shown discordant measurements between DDD and DOT&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">6&#8211;8</span></a> The measurement of DOT favors those situations where broad spectrum monotherapy is used&#44; independently of the dosages administered&#46; DOT punishes the use of combination therapy including those with narrow spectrum antimicrobials&#46; DOT is more difficult to measure requiring patient-level antibiotic use data&#44; but it has been demonstrated to be a superior measurement methodology than DDD&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">9</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">These differences may be even greater in burns or neurocritical care units&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">7</span></a> Severe burn injury results in a complex physiological derangement that significantly alters drug PK&#47;PD&#46; Burns patients require higher and more frequent dosing to reach and maintain therapeutic levels&#46; Similarly&#44; antibiotic doses are higher for central nervous system &#40;CNS&#41; infections than for other infections in order to achieve therapeutic levels in the CNS&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Nowadays&#44; high doses of antimicrobials are used appropriately in the ICUs&#46; The advent of therapeutic drug monitoring has revealed that up to 50&#37; of critically ill patients have suboptimal antibiotic plasma concentrations &#40;beta lactam&#44; aminoglycosides&#44; etc&#46;&#41;&#44; especially those with augmented renal clearance or high volume of distribution&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">10</span></a> The dramatic increase in bacterial resistance is the other factor that forces clinicians to increase antibiotic dosing to prevent therapeutic failure and death&#46; Therefore&#44; in this scenario&#44; DDD will not accurately reflect the quality of antibiotic prescription punishing hospital with routine use of TDM or those with outbreaks or endemics of multi-drug resistant bacteria&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">In the study by Vall&#232;s and colleagues&#44;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">5</span></a> discrepancies between DDDs and DOTs were major &#40;&#62;25&#37;&#41; in nine antibiotics and in three antifungals&#46; It is true that in 2019&#44; WHO has modified the DDD of several critical antibiotics to bring DDD closer to the usual dose of antibiotics&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">11</span></a> This modification affects only to four of the antimicrobials including in the list of &#8220;major differences&#8221; &#40;amoxicillin&#8211;clavulanic&#44; cefepime&#44; ciprofloxacin&#44; and meropenem&#41; and none of the antifungals&#46; Moreover&#44; these updated DDD are still lower than the doses used in many critically ill patients&#46; As examples&#44; 3<span class="elsevierStyleHsp" style=""></span>g a day of meropenem may be clearly insufficient in hyperdynamic critically ill patients as occurs with de new DDD of ampicillin &#40;6<span class="elsevierStyleHsp" style=""></span>g a day&#41; for the treatment of a bacteremia caused by <span class="elsevierStyleItalic">Enterococcus faecalis</span>&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The study by Vall&#232;s et al&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">5</span></a> is not absent of some limitations&#46; It is a single center study so their findings cannot be extrapolated to other Units with different levels of complexity&#46; However&#44; its compelling data should be taken into account to consider DOT as the standard measurement to monitor antibiotic use in the critical care setting&#46; In fact&#44; the new Infectious Diseases Society of America &#40;IDSA&#41; antibiotic stewardship guidelines suggests the use of DOT over the DDD for antibiotic consumption monitoring&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">12</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">There is room for improvement in antibiotic prescriptions in all hospitals and obviously in the ICUs&#46; However&#44; validated antibiotic use data are needed to provide correct feedback to clinicians&#46; The DOT method should be also used to carry out national and international comparisons among different Units&#46; In critical care units&#44; DOT&#44; undoubtfully with its limitations&#44; reflects more appropriately the quality of antibiotic prescription and ecological antibiotic pressure&#46;</p></span>"
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            0 => array:3 [
              "identificador" => "bib0065"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "WHO &#124; Rational use of medicines&#58; activities&#46; WHO&#46; s&#46; f&#46;"
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            1 => array:3 [
              "identificador" => "bib0070"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Antibiotic dose optimization in critically ill patients"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "M&#46;O&#46; Cotta"
                            1 => "J&#46;A&#46; Roberts"
                            2 => "J&#46; Lipman"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.medin.2015.07.009"
                      "Revista" => array:6 [
                        "tituloSerie" => "Med Intensiva"
                        "fecha" => "2015"
                        "volumen" => "39"
                        "paginaInicial" => "563"
                        "paginaFinal" => "572"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26415688"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "identificador" => "bib0075"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Antimicrobial use metrics and benchmarking to improve stewardship outcomes&#58; methodology&#44; opportunities&#44; and challenges"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "O&#46;M&#46; Ibrahim"
                            1 => "R&#46;E&#46; Polk"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.idc.2014.01.006"
                      "Revista" => array:6 [
                        "tituloSerie" => "Infect Dis Clin North Am"
                        "fecha" => "2014"
                        "volumen" => "28"
                        "paginaInicial" => "195"
                        "paginaFinal" => "214"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24857388"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "&#91;Programs for optimizing the use of antibiotics &#40;PROA&#41; in Spanish hospitals&#58; GEIH-SEIMC&#44; SEFH and SEMPSPH consensus document&#93;"
                      "autores" => array:1 [
                        0 => array:2 [
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                          "autores" => array:6 [
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                            1 => "J&#46;R&#46; Pa&#241;o-Pardo"
                            2 => "L&#46; Alvarez-Rocha"
                            3 => "A&#46; Asensio"
                            4 => "E&#46; Calbo"
                            5 => "E&#46; Cercenado"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:3 [
                        "tituloSerie" => "Enferm Infecc Microbiol Clin"
                        "fecha" => "2012"
                        "volumen" => "30"
                      ]
                    ]
                  ]
                ]
              ]
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Comparison of the defined daily dose and days of treatment methods for evaluating the consumption of antibiotics and antifungals in the intensive care unit"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
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                            1 => "S&#46; Fern&#225;ndez"
                            2 => "E&#46; Cort&#233;s"
                            3 => "A&#46; Mor&#243;n"
                            4 => "E&#46; Fondevilla"
                            5 => "J&#46;C&#46; Oliva"
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                        ]
                      ]
                    ]
                  ]
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                      "Revista" => array:2 [
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              ]
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              "identificador" => "bib0090"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Discrepancies between prescribed daily doses and WHO defined daily doses of antibacterials at a university hospital"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
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                            2 => "D&#46; Talon"
                            3 => "T&#46; H&#233;non"
                            4 => "X&#46; Bertrand"
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                        ]
                      ]
                    ]
                  ]
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                    0 => array:2 [
                      "doi" => "10.1111/j.1365-2125.2006.02605.x"
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                        "tituloSerie" => "Br J Clin Pharmacol"
                        "fecha" => "2006"
                        "volumen" => "61"
                        "paginaInicial" => "585"
                        "paginaFinal" => "591"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16669851"
                            "web" => "Medline"
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                      ]
                    ]
                  ]
                ]
              ]
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                            1 => "A&#46; El-Saed"
                            2 => "A&#46; El-Metwally"
                            3 => "Y&#46;M&#46; Arabi"
                            4 => "S&#46;M&#46; Aljohany"
                            5 => "M&#46; Al Zaibag"
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                        ]
                      ]
                    ]
                  ]
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                    0 => array:2 [
                      "doi" => "10.1186/s13756-018-0451-9"
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                        "tituloSerie" => "Antimicrob Resist Infect Control"
                        "fecha" => "2018"
                        "volumen" => "7"
                        "paginaInicial" => "156"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/30598819"
                            "web" => "Medline"
                          ]
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                      ]
                    ]
                  ]
                ]
              ]
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "How to measure quantitative antibiotic use in order to support antimicrobial stewardship in acute care hospitals&#58; a retrospective observational study"
                      "autores" => array:1 [
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                          "autores" => array:6 [
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                            1 => "S&#46; Natsch"
                            2 => "B&#46;C&#46; Opmeer"
                            3 => "M&#46;E&#46;J&#46;L&#46; Hulscher"
                            4 => "J&#46;A&#46; Schouten"
                            5 => "J&#46;M&#46; Prins"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s10096-018-3434-0"
                      "Revista" => array:6 [
                        "tituloSerie" => "Eur J Clin Microbiol Infect Dis"
                        "fecha" => "2019"
                        "volumen" => "38"
                        "paginaInicial" => "347"
                        "paginaFinal" => "355"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/30478815"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Measurement of adult antibacterial drug use in 130 US hospitals&#58; comparison of defined daily dose and days of therapy"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "R&#46;E&#46; Polk"
                            1 => "C&#46; Fox"
                            2 => "A&#46; Mahoney"
                            3 => "J&#46; Letcavage"
                            4 => "C&#46; MacDougall"
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                        ]
                      ]
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1086/511640"
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                        "tituloSerie" => "Clin Infect Dis"
                        "fecha" => "2007"
                        "volumen" => "44"
                        "paginaInicial" => "664"
                        "paginaFinal" => "670"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17278056"
                            "web" => "Medline"
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                      ]
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                  ]
                ]
              ]
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Subtherapeutic initial &#946;-lactam concentrations in select critically ill patients&#58; association between augmented renal clearance and low trough drug concentrations"
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                          "autores" => array:6 [
                            0 => "A&#46;A&#46; Udy"
                            1 => "J&#46;M&#46; Varghese"
                            2 => "M&#46; Altukroni"
                            3 => "S&#46; Briscoe"
                            4 => "B&#46;C&#46; McWhinney"
                            5 => "J&#46;P&#46; Ungerer"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1378/chest.11-1671"
                      "Revista" => array:6 [
                        "tituloSerie" => "Chest"
                        "fecha" => "2012"
                        "volumen" => "142"
                        "paginaInicial" => "30"
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Editorial
Adequate antibiotic monitoring to improve what needs to be improved
Monitorización adecuada de antibióticos para mejorar lo que necesita mejorarse
R. Amaya-Villar
Jefa de Servicio, UGC Cuidados Intensivos, Hospital Universitario Virgen del Rocío, Avda. Manuel Siurot s/n, Sevilla 41013, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The World Health Organization &#40;WHO&#41; defines that patients receive appropriate medications to their clinical needs if they are prescribed in doses that meet their own individual requirements&#44; for an adequate period of time&#44; and at the lowest cost to them and their community&#46; These general principles are obviously applicable to antimicrobial use in general and to the administration of antimicrobials in the critical care setting&#46; Many parameters of importance for optimal quality of antimicrobial therapy have already been defined&#46; Maximal efficacy of the treatment should be combined with minimal toxicity at the lowest cost&#46; Quality of antimicrobial drug use is dependent on knowledge of many aspects of infectious diseases and patient characteristics&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Inappropriate use of antimicrobial drugs is the major determinant of antimicrobial resistance development increasing the costs of care&#44; morbidity and mortality&#46; Critically ill patients are especially complex suffering profound pathophysiological changes that can affect PK&#47;PD properties of antibiotics&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Institutional programs aiming at reducing the inappropriate use of antibiotics have been launched worldwide&#46; These activities require accurate comparators of antibiotic consumption to benchmark antimicrobial drug use&#46; The three more common metrics for measuring aggregate antimicrobial use are the defined daily dose &#40;DDD&#41;&#44; the prescribed daily doses &#40;PDD&#41;&#44; and the days of therapy &#40;DOT&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The DDD is the measure endorsed by the WHO&#44; and nowadays&#44; the metric most widely used for comparisons of antibiotic use in primary care and in hospitals&#46; The consensus document of the Spanish programs for optimizing the use of antibiotics &#40;PROA&#41; in hospitals recommends DDD as the basic meter for monitoring antibiotic consumption considering DOT and DDP as metrics of excellence&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">4</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">However&#44; many studies have documented that DDD does not accurately reflect the antibiotic consumption and the quality of antibiotic prescription&#46; One of the major drawbacks of DDD measurement is that it underestimates antibiotic consumption when the WHO-consigned DDD is greater than the administered dose as occurs in patients with renal insufficiency or in pediatric populations&#46; Conversely&#44; DDD overestimates antibiotic consumption when reference DDD is lower than the administered dose as occurs very frequently in the critical care setting&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">In this issue&#44; the study by Vall&#232;s et al&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">5</span></a> has documented that DDD misjudges antibiotic use in adult critically ill patients overestimating the utilization of the majority of antibacterial and antifungal drugs&#46; Previous studies have shown discordant measurements between DDD and DOT&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">6&#8211;8</span></a> The measurement of DOT favors those situations where broad spectrum monotherapy is used&#44; independently of the dosages administered&#46; DOT punishes the use of combination therapy including those with narrow spectrum antimicrobials&#46; DOT is more difficult to measure requiring patient-level antibiotic use data&#44; but it has been demonstrated to be a superior measurement methodology than DDD&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">9</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">These differences may be even greater in burns or neurocritical care units&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">7</span></a> Severe burn injury results in a complex physiological derangement that significantly alters drug PK&#47;PD&#46; Burns patients require higher and more frequent dosing to reach and maintain therapeutic levels&#46; Similarly&#44; antibiotic doses are higher for central nervous system &#40;CNS&#41; infections than for other infections in order to achieve therapeutic levels in the CNS&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Nowadays&#44; high doses of antimicrobials are used appropriately in the ICUs&#46; The advent of therapeutic drug monitoring has revealed that up to 50&#37; of critically ill patients have suboptimal antibiotic plasma concentrations &#40;beta lactam&#44; aminoglycosides&#44; etc&#46;&#41;&#44; especially those with augmented renal clearance or high volume of distribution&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">10</span></a> The dramatic increase in bacterial resistance is the other factor that forces clinicians to increase antibiotic dosing to prevent therapeutic failure and death&#46; Therefore&#44; in this scenario&#44; DDD will not accurately reflect the quality of antibiotic prescription punishing hospital with routine use of TDM or those with outbreaks or endemics of multi-drug resistant bacteria&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">In the study by Vall&#232;s and colleagues&#44;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">5</span></a> discrepancies between DDDs and DOTs were major &#40;&#62;25&#37;&#41; in nine antibiotics and in three antifungals&#46; It is true that in 2019&#44; WHO has modified the DDD of several critical antibiotics to bring DDD closer to the usual dose of antibiotics&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">11</span></a> This modification affects only to four of the antimicrobials including in the list of &#8220;major differences&#8221; &#40;amoxicillin&#8211;clavulanic&#44; cefepime&#44; ciprofloxacin&#44; and meropenem&#41; and none of the antifungals&#46; Moreover&#44; these updated DDD are still lower than the doses used in many critically ill patients&#46; As examples&#44; 3<span class="elsevierStyleHsp" style=""></span>g a day of meropenem may be clearly insufficient in hyperdynamic critically ill patients as occurs with de new DDD of ampicillin &#40;6<span class="elsevierStyleHsp" style=""></span>g a day&#41; for the treatment of a bacteremia caused by <span class="elsevierStyleItalic">Enterococcus faecalis</span>&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The study by Vall&#232;s et al&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">5</span></a> is not absent of some limitations&#46; It is a single center study so their findings cannot be extrapolated to other Units with different levels of complexity&#46; However&#44; its compelling data should be taken into account to consider DOT as the standard measurement to monitor antibiotic use in the critical care setting&#46; In fact&#44; the new Infectious Diseases Society of America &#40;IDSA&#41; antibiotic stewardship guidelines suggests the use of DOT over the DDD for antibiotic consumption monitoring&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">12</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">There is room for improvement in antibiotic prescriptions in all hospitals and obviously in the ICUs&#46; However&#44; validated antibiotic use data are needed to provide correct feedback to clinicians&#46; The DOT method should be also used to carry out national and international comparisons among different Units&#46; In critical care units&#44; DOT&#44; undoubtfully with its limitations&#44; reflects more appropriately the quality of antibiotic prescription and ecological antibiotic pressure&#46;</p></span>"
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              "identificador" => "bib0070"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Antibiotic dose optimization in critically ill patients"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "M&#46;O&#46; Cotta"
                            1 => "J&#46;A&#46; Roberts"
                            2 => "J&#46; Lipman"
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                    0 => array:2 [
                      "doi" => "10.1016/j.medin.2015.07.009"
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                        "tituloSerie" => "Med Intensiva"
                        "fecha" => "2015"
                        "volumen" => "39"
                        "paginaInicial" => "563"
                        "paginaFinal" => "572"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26415688"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0075"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Antimicrobial use metrics and benchmarking to improve stewardship outcomes&#58; methodology&#44; opportunities&#44; and challenges"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "O&#46;M&#46; Ibrahim"
                            1 => "R&#46;E&#46; Polk"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.idc.2014.01.006"
                      "Revista" => array:6 [
                        "tituloSerie" => "Infect Dis Clin North Am"
                        "fecha" => "2014"
                        "volumen" => "28"
                        "paginaInicial" => "195"
                        "paginaFinal" => "214"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24857388"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "&#91;Programs for optimizing the use of antibiotics &#40;PROA&#41; in Spanish hospitals&#58; GEIH-SEIMC&#44; SEFH and SEMPSPH consensus document&#93;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
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                            1 => "J&#46;R&#46; Pa&#241;o-Pardo"
                            2 => "L&#46; Alvarez-Rocha"
                            3 => "A&#46; Asensio"
                            4 => "E&#46; Calbo"
                            5 => "E&#46; Cercenado"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:3 [
                        "tituloSerie" => "Enferm Infecc Microbiol Clin"
                        "fecha" => "2012"
                        "volumen" => "30"
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "identificador" => "bib0085"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Comparison of the defined daily dose and days of treatment methods for evaluating the consumption of antibiotics and antifungals in the intensive care unit"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "J&#46; Vall&#232;s"
                            1 => "S&#46; Fern&#225;ndez"
                            2 => "E&#46; Cort&#233;s"
                            3 => "A&#46; Mor&#243;n"
                            4 => "E&#46; Fondevilla"
                            5 => "J&#46;C&#46; Oliva"
                          ]
                        ]
                      ]
                    ]
                  ]
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                    0 => array:1 [
                      "Revista" => array:2 [
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                        "fecha" => "2019"
                      ]
                    ]
                  ]
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              ]
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              "identificador" => "bib0090"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Discrepancies between prescribed daily doses and WHO defined daily doses of antibacterials at a university hospital"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "A&#46; Muller"
                            1 => "D&#46;L&#46; Monnet"
                            2 => "D&#46; Talon"
                            3 => "T&#46; H&#233;non"
                            4 => "X&#46; Bertrand"
                          ]
                        ]
                      ]
                    ]
                  ]
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                    0 => array:2 [
                      "doi" => "10.1111/j.1365-2125.2006.02605.x"
                      "Revista" => array:6 [
                        "tituloSerie" => "Br J Clin Pharmacol"
                        "fecha" => "2006"
                        "volumen" => "61"
                        "paginaInicial" => "585"
                        "paginaFinal" => "591"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16669851"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Antimicrobial consumption in five adult intensive care units&#58; a 33-month surveillance study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "H&#46;H&#46; Balkhy"
                            1 => "A&#46; El-Saed"
                            2 => "A&#46; El-Metwally"
                            3 => "Y&#46;M&#46; Arabi"
                            4 => "S&#46;M&#46; Aljohany"
                            5 => "M&#46; Al Zaibag"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1186/s13756-018-0451-9"
                      "Revista" => array:5 [
                        "tituloSerie" => "Antimicrob Resist Infect Control"
                        "fecha" => "2018"
                        "volumen" => "7"
                        "paginaInicial" => "156"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/30598819"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "etiqueta" => "8"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "How to measure quantitative antibiotic use in order to support antimicrobial stewardship in acute care hospitals&#58; a retrospective observational study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
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                  ]
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              ]
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