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Clostridium difficile in the ICU: Study of the incidence, recurrence, clinical characteristics and complications in a University Hospital
Clostridium difficile en UCI: estudio de la incidencia, recurrencias, características clínicas y complicaciones en un hospital universitario
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Salva, N. Duran, V. Rodriguez, L. Nieto, J. Serra, J. Rello" "autores" => array:7 [ 0 => array:2 [ "nombre" => "S." "apellidos" => "Salva" ] 1 => array:2 [ "nombre" => "N." "apellidos" => "Duran" ] 2 => array:2 [ "nombre" => "V." "apellidos" => "Rodriguez" ] 3 => array:2 [ "nombre" => "L." "apellidos" => "Nieto" ] 4 => array:2 [ "nombre" => "J." "apellidos" => "Serra" ] 5 => array:2 [ "nombre" => "J." "apellidos" => "Rello" ] 6 => array:1 [ "colaborador" => "CRIPS Investigators" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S0210569113000776" "doi" => "10.1016/j.medin.2013.03.012" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0210569113000776?idApp=WMIE" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173572714000228?idApp=WMIE" "url" => "/21735727/0000003800000003/v1_201405090035/S2173572714000228/v1_201405090035/en/main.assets" ] ] "itemSiguiente" => array:18 [ "pii" => "S0210569113001010" "issn" => "02105691" "doi" => "10.1016/j.medin.2013.03.014" "estado" => "S300" "fechaPublicacion" => "2014-04-01" "aid" => "589" "copyright" => "Elsevier España, S.L. y SEMICYUC" "documento" => "article" "crossmark" => 0 "subdocumento" => "fla" "cita" => "Med Intensiva. 2014;38:146-53" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 6971 "formatos" => array:3 [ "EPUB" => 193 "HTML" => 5410 "PDF" => 1368 ] ] "es" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original</span>" "titulo" => "Análisis de la lipocalina asociada a la gelatinasa de neutrófilos en el paciente crítico" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "146" "paginaFinal" => "153" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Analysis of neutrophil gelatinase-associated lipocalin in the critical patient" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figura 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1378 "Ancho" => 1508 "Tamanyo" => 49852 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Curva ROC. Para analizar el valor diagnóstico de NGAL (como variable continua) para la detección de la DRA definida como AKIN<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>1 se midió el AUC que fue de 0,775.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "C. Marti-Macia, T.M. Tomasa, A. Sancho, A. Galán, J. Fernández-Llamazares, V. Macias, J. Roca, R. Gonzalez-Celador, É. Amestoy, J. Klamburg" "autores" => array:11 [ 0 => array:2 [ "nombre" => "C." "apellidos" => "Marti-Macia" ] 1 => array:2 [ "nombre" => "T.M." "apellidos" => "Tomasa" ] 2 => array:2 [ "nombre" => "A." "apellidos" => "Sancho" ] 3 => array:2 [ "nombre" => "A." "apellidos" => "Galán" ] 4 => array:2 [ "nombre" => "J." "apellidos" => "Fernández-Llamazares" ] 5 => array:2 [ "nombre" => "V." "apellidos" => "Macias" ] 6 => array:2 [ "nombre" => "J." "apellidos" => "Roca" ] 7 => array:2 [ "nombre" => "R." "apellidos" => "Gonzalez-Celador" ] 8 => array:2 [ "nombre" => "É." "apellidos" => "Amestoy" ] 9 => array:2 [ "nombre" => "J." "apellidos" => "Klamburg" ] 10 => array:1 [ "colaborador" => "los investigadores del estudio COFRADE" ] ] ] ] ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0210569113001010?idApp=WMIE" "url" => "/02105691/0000003800000003/v1_201403210452/S0210569113001010/v1_201403210452/es/main.assets" ] "itemAnterior" => array:18 [ "pii" => "S0210569113000065" "issn" => "02105691" "doi" => "10.1016/j.medin.2013.01.003" "estado" => "S300" "fechaPublicacion" => "2014-04-01" "aid" => "557" "copyright" => "Elsevier España, S.L. and SEMICYUC" "documento" => "article" "crossmark" => 0 "subdocumento" => "fla" "cita" => "Med Intensiva. 2014;38:133-9" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 15039 "formatos" => array:3 [ "EPUB" => 206 "HTML" => 11860 "PDF" => 2973 ] ] "es" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original</span>" "titulo" => "Efecto de la insuflación de aire subglótico sobre la presión subglótica durante la deglución" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "133" "paginaFinal" => "139" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Effect of subglottic air insufflation on subglottic pressure during swallowing" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 563 "Ancho" => 1000 "Tamanyo" => 65211 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Sección sagital de la tráquea donde se puede observar la cánula de traqueostomía, el catéter subglótico conectado al flowmeter y el dispositivo de medición de la PSg conectado al puerto lateral del conector de la válvula fonatoria.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "M. Clarett, M.F. Andreu, I.G. Salvati, M.C. Donnianni, G.S. Montes, M.G. Rodríguez" "autores" => array:6 [ 0 => array:2 [ "nombre" => "M." "apellidos" => "Clarett" ] 1 => array:2 [ "nombre" => "M.F." "apellidos" => "Andreu" ] 2 => array:2 [ "nombre" => "I.G." "apellidos" => "Salvati" ] 3 => array:2 [ "nombre" => "M.C." "apellidos" => "Donnianni" ] 4 => array:2 [ "nombre" => "G.S." "apellidos" => "Montes" ] 5 => array:2 [ "nombre" => "M.G." "apellidos" => "Rodríguez" ] ] ] ] ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0210569113000065?idApp=WMIE" "url" => "/02105691/0000003800000003/v1_201403210452/S0210569113000065/v1_201403210452/es/main.assets" ] "en" => array:21 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original</span>" "titulo" => "<span class="elsevierStyleItalic">Clostridium difficile</span> in the ICU: Study of the incidence, recurrence, clinical characteristics and complications in a University Hospital" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "140" "paginaFinal" => "145" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "S. Salva, N. Duran, V. Rodriguez, L. Nieto, J. Serra, J. Rello" "autores" => array:7 [ 0 => array:3 [ "nombre" => "S." "apellidos" => "Salva" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 1 => array:3 [ "nombre" => "N." "apellidos" => "Duran" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "V." "apellidos" => "Rodriguez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "L." "apellidos" => "Nieto" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 4 => array:3 [ "nombre" => "J." "apellidos" => "Serra" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 5 => array:4 [ "nombre" => "J." "apellidos" => "Rello" "email" => array:1 [ 0 => "jrello@crips.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 6 => array:2 [ "colaborador" => "CRIPS Investigators" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">◊</span>" "identificador" => "fn0005" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Critical Care Department, Vall d’Hebron University Hospital, Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Microbiology Department, Vall d’Hebron University Hospital, Barcelona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Critical Care Department, Vall d’Hebron University Hospital, CIBERES & CRIPS, Universitat Autónoma de Barcelona, Barcelona, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "<span class="elsevierStyleItalic">Clostridium difficile</span> en UCI: estudio de la incidencia, recurrencias, características clínicas y complicaciones en un hospital universitario" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 974 "Ancho" => 2167 "Tamanyo" => 183466 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">Computerized axial tomography of abdomen, showing dilation of colon and wall thickening (panel A, arrow) with fluid levels (panel B, arrow).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Clostridium difficile</span> infection (CDI) is an important hospital-acquired (nosocomial) complication associated with the use of antibiotics. Some patients remain asymptomatic after exposure, while in others the disease can vary from mild diarrhea to fulminant colitis.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> Colonization of the intestinal tract occurs via the feco-oral route by disruption of normal intestinal flora, especially related to the use of antibiotics, in immunosuppressed situations or related to the use of proton pump inhibitors. Incidence of diarrhea in hospitalized patients associated with CDI has increased fourfold from 1991 till 2002 rising from 3 to 12 per 1000 people and from 25 to 43 per 1000 people in 2003–2004. In previous studies, cases were found to be serious and refractory to therapy with significant rates of toxic megacolon requiring colectomy. Ten percent of cases required admission to an intensive care unit (ICU) and 2.5% required emergent colectomy. Mortality was 16%. The CDI increase was reported primarily in individuals over 65 years.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a> After an outbreak in Canada, there was an increase in the incidence, severity and mortality associated with CDI in North America and Europe which was attributed to the emergence of the new strain NAP1/BI/0.27. The virulence of this new strain was defined by: increased production of A and B toxins, fluoroquinolone resistance and production of binary toxin.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a> Antibiotic use is the most widely recognized and modifiable risk factor for CDI. Other risk factors include hospitalization, advanced age and severe underlying disease.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Besides, gastric acid suppression, enteral feeding, gastrointestinal surgery, cancer chemotherapy and hematopoietic stem cell transplant could be considered as risk features too. Nevertheless, CDI can occur without the presence of risk factors.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Although several studies have established the association between antibiotics and CDI we lack of epidemiological studies that determine the incidence or the prevalence of CDI in European Intensive Care Units except during outbreaks and little is known about the real associated risk factors. Data on recurrence or relapse are also limited. The main objective of the study was to establish the incidence of <span class="elsevierStyleItalic">C. difficile</span> infection in a medical–surgical Intensive Care Unit, outside an epidemic outbreak period. Secondary objectives were to determine patient characteristics for this type of infection, to document complications, to identify the treatments used and to record the recurrences.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Patients and methods</span><p id="par0015" class="elsevierStylePara elsevierViewall">This study was conducted at Vall d’Hebron University Hospital, an urban tertiary referral academic center (1400 beds) in Barcelona, Spain. We included all patients admitted to the Medical/Surgical ICU (34 beds) between January 2010 and December 2011. The Vall d’Hebron University Hospital Clinical Research Ethics Committee approved the study, and the need for informed consent was waived (Number 54/2012). This retrospective study identifying ICU patients with CDI was based on information from the microbiology laboratory electronic database and a retrospective review of medical charts. All patients over 18 years old were included. Data were recorded on demographic characteristics of all patients and clinical manifestations for CDI. Previous antimicrobial exposure, immunosuppression and previous hospital admission in the last six months were also recorded. Patients included were identified by diarrhea and a positive <span class="elsevierStyleItalic">C. difficile</span> toxin result according to ICU protocol. Diarrhea was clinically defined as more than three watery stools per day and/or an increase in stool amount of more than 200 grams per day.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> A positive result for <span class="elsevierStyleItalic">C difficile</span> toxin was determined using immunochromatography methods for urgent cases (Immunocard EIA<span class="elsevierStyleSup">®</span> Toxins A & B, Meridian Bioscience<span class="elsevierStyleSup">®</span>, Inc., USA) and enzyme immunoassay for routine cases (Enzyme Immunoassay Premier<span class="elsevierStyleSup">®</span> Toxins A & B Meridian Bioscience).</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Statistical analysis</span><p id="par0020" class="elsevierStylePara elsevierViewall">The results were described as frequency (%) in the case of discrete variables. Variables with a normal distribution were described with the mean and standard deviation (SD) and those with a non-normal distribution with the median and interquartile range (IQR).</p></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Results</span><p id="par0025" class="elsevierStylePara elsevierViewall">A total of 1936 adult patients were admitted to the ICU from January 2010 to December 2011. Out of 177 patients with diarrhea >48<span class="elsevierStyleHsp" style=""></span>h, seven (0.36%) acquired CDI in this period (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>), all of which were diagnosed with Enzyme-Linked ImmunoSorbent Assay (ELISA) and one case was confirmed through immune-chromatography. Hence, the rate of infections per 10,000 bed-days was 3.1. The cumulative incidence rate was 3.6<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>1000, in two years. The median age was 61 (IQR 53–64). Four patients were men. Two of the seven patients with CDI infection had suffered gastrointestinal pathology characterized by either cancer or <span class="elsevierStyleItalic">Helicobacter pylori</span> infection. Six patients showed some degree of immunosuppression (86%), three secondary to pharmacology due to the treatment of organ transplantation or cystic fibrosis disease, one because of corticoid use, another one due to cancer and the last one caused by AIDS. Additionally, five of the cases were hospitalized (had past medical history of hospitalization) six months prior to CDI infection. None of the patients were from a long stay center. The reason for admission to the ICU was severe respiratory failure in three cases, shock in two and pulmonary transplant surgery also in two cases. None of the patients were admitted for elective surgery. The median time of ICU hospitalization previous to CDI infection was 33 days (IQR 4–19). APACHE II score (Acute Physiology and Chronic Health Evaluation) at ICU admission ranged between 10 and 25 with a median of 17 (IQR 13–24). Risk factors associated with CDI are shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 1</a>. Only two patients were over the age of 65. The median number of antibiotics prescribed per patient was two, the most commonly prescribed antibiotic was carbapenems (four) followed by cephalosporins (two), piperacillin/tazobactam (two) and quinolones or aminopenicillins (one). None of the cases received prior glycopeptides, metronidazole, tygecicline or linezolid. Four out of seven patients received two different antibiotics in the six months prior to the occurrence of CDI. In two cases only one kind of antibiotic was administered for CDI whereas in just one case three different antibiotics were used.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0015">Table 2</a> summarizes the different clinical manifestations of the CDI. Six out of the seven positive CDI diarrheas lasted less than a week. Five patients showed an increase in white blood cell count above 15,000 (above 60,000 in one). The mean white blood cell count was 26,250 (SD 18,500).</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Only one patient had toxic megacolon (14%). The mean albumin level was 2.61 (SD 0.33) mg/dL. Scan tomography was performed in three cases. All the patients in whom tomography was performed showed thickening of the colonic wall. In one case involvement of the pericolonic fat was observed (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Severe sepsis was reported in five cases, (71%) three of whom were in shock and showed multiorgan dysfunction when diagnosed. Three cases had renal impairment with a 50% increase in creatinine levels within the first 24<span class="elsevierStyleHsp" style=""></span>h. No cases of intestinal perforation were documented. All cases were treated with medical therapy and surgery was not required.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">The treatment schedule, oral or intravenous, comprised metronidazole in the majority of patients. In two cases a combined treatment was used with oral vancomycin plus intravenous metronidazole. One case (n° 5) received double therapy, rectal vancomycin plus intravenous metronidazole due to the large-scale impairment of the intestinal function. The mean treatment duration was 10 days (range 7–14 days).</p><p id="par0045" class="elsevierStylePara elsevierViewall">Four of our patients presented recurrence of the infection at least once during hospitalization and a second phase of antibiotics was necessary. Additionally, hospitalization was prolonged by a mean of 24 days (SD 17.8) after diagnosis. One of the seven patients who presented infection for <span class="elsevierStyleItalic">C. difficile</span>, died 30 days after discharge from the intensive care unit, secondary to multiple organ failure with limitation of therapeutic effort in the ward.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Discussion</span><p id="par0050" class="elsevierStylePara elsevierViewall">To the best of our knowledge, this is the first study describing the incidence, general characteristics, risk factors and complications of patients infected with <span class="elsevierStyleItalic">C. difficile</span> in a European medical–surgical intensive care unit outside a period of outbreak. Our findings suggest that the CDI in our ICU is not frequent (<1/100 admissions), but is associated with a significant rate of complications and a prolonged ICU and hospital stay. Only seven of all the patients admitted to the ICU were found to have an infection with <span class="elsevierStyleItalic">C. difficile</span>; the incidence was 0.36%, with a rate of infection of 3.1 per 10,000 bed-days in this two-year period. This incidence is low compared to other studies in the ICU which have reported incidences of up to 4%<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> or 8.3 per 10,000 bed-days in a neurocritical ICU in the United Kingdom.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Antibiotic exposure has been strongly associated with CDI, therefore emphasizing that their rational use may have a positive impact on CDI incidence in the ICU population. However, antibiotics are usually a cornerstone treatment in the ICU due to the high number of infections. In this case, the use of antibiotics like piperacillin/tazobactam when appropriate might be preferred in order to minimize the risk of CDI.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Moreover, the prevalence of ribotype O27 is low in Spain.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">A striking finding in this study was the low median age; 61 years old (IQR 53–64) compared with the median ages of 74 years old (IQR 68–77) in a surgical ICU<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> and 68.9 in a medical ICU.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> This result may be influenced by the fact that the underlying medical conditions (transplant and HIV) usually occur in younger people, but are associated with severe immunosuppression. In fact, the majority of our patients had immunosuppression secondary to their previous condition and the rates were higher than in other studies<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12–15</span></a> possibly due the characteristics of our hospital. Therefore, it seems that immunosuppression played a role in the development of CDI in our ICU. An important element described is the recurrence and complication of CDI. In our series, more than half of our patients (four out of seven) showed deterioration and recurrence of infection, showing a higher rate than the overall figure of 25% reported in the literature.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16–19</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">At the time of diagnosis, six patients had a severe infection according to the score classification proposed by Zar et al.,<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> presenting scores of 2 or more. In our study we did not identify differences in the rate of complications or recurrence according to this score. The extra period of mechanical ventilation (MV) after diagnosis of CDI was over twelve days. Additionally, hospitalization was prolonged by a median of 24 days after diagnosis, indicating the impact on the health care resources that CDI can cause. We must bear in mind that measures to reduce complications or recurrences may be associated with significant cost savings in an era of cost containment.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Some limitations of our study should be acknowledged. The first is its retrospective design. Second, we evaluated only follow-up during the duration of hospitalization in ICU: we cannot comment on long term follow-up, including relapse of diarrhea outside ICU. Third, the small number of cases precludes certain statistical comparisons and may thus lead to a type II error. However, it demonstrates that CDI is unlikely out of an epidemic outbreak. Fourth, the incidence of CDI can be influenced by the diagnostic methods and criteria. Alternative methods such as enzyme glutamate dehydrogenase antigen (GDH) are described in the United Kingdom National Health System guides in 2012, as the best option in combination with enzymatic immunoassay (EIA) tests for CDI detection.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> Therefore, our microbiology laboratory is working in the implementation of this technique. Finally, the prevalence of CDI in Spain, in particular, ribotype 027 is lower than in other countries such as the United Kingdom or the United States of America. As a conclusion, fewer than 1% of patients hospitalized in a medical–surgical ICU in a tertiary referral center in Spain developed CDI, but showed a high risk of recurrence/complications associated with prolonged ICU stay. In addition, our results suggest that immunosuppression plays an important role in patients younger than 65 years old. These differences must be considered when generalizing the findings from North America to Europe.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Funding support</span><p id="par0070" class="elsevierStylePara elsevierViewall">This study was supported in part by an unrestricted grant from <span class="elsevierStyleGrantSponsor" id="gs0005">Astellas and CIBERES Network (Instituto de Salud Carlos III), Spain</span>.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Conflict of interest</span><p id="par0075" class="elsevierStylePara elsevierViewall">Dr Rello is a consultant for Astellas. The rest of the authors have no conflict of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:2 [ "identificador" => "xres324512" "titulo" => array:9 [ 0 => "Abstract" 1 => "Objective" 2 => "Design" 3 => "Setting" 4 => "Patients" 5 => "Interventions" 6 => "Study variables" 7 => "Results" 8 => "Conclusions" ] ] 1 => array:2 [ "identificador" => "xpalclavsec305955" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres324513" "titulo" => array:9 [ 0 => "Resumen" 1 => "Objetivo" 2 => "Diseño" 3 => "Ámbito" 4 => "Pacientes o participantes" 5 => "Intervenciones" 6 => "Variables de interés principales" 7 => "Resultados" 8 => "Conclusiones" ] ] 3 => array:2 [ "identificador" => "xpalclavsec305952" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Patients and methods" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Statistical analysis" ] ] ] 6 => array:2 [ "identificador" => "sec0020" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0025" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0030" "titulo" => "Funding support" ] 9 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflict of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2012-12-05" "fechaAceptado" => "2013-03-27" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec305955" "palabras" => array:4 [ 0 => "<span class="elsevierStyleItalic">Clostridium difficile</span>" 1 => "ICU" 2 => "Recurrence" 3 => "Lung transplant" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec305952" "palabras" => array:4 [ 0 => "<span class="elsevierStyleItalic">Clostridium difficile</span>" 1 => "UCI" 2 => "Recurrencia" 3 => "Trasplante pulmonar" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0020">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Although several studies have established the association between antibiotics and <span class="elsevierStyleItalic">Clostridium difficile</span> infection (CDI), there is a lack of epidemiological studies on the incidence of CDI in European Intensive Care Units outside the context of infection outbreaks. The present study describes the incidence, patient characteristics, complications, and recurrence rates of CDI in a Spanish ICU.</p> <span class="elsevierStyleSectionTitle" id="sect0025">Design</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A retrospective study was carried out.</p> <span class="elsevierStyleSectionTitle" id="sect0030">Setting</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A clinical–surgical ICU with 34 beds, a tertiary referral hospital with 1400 beds.</p> <span class="elsevierStyleSectionTitle" id="sect0035">Patients</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">All patients over 18 years of age admitted to the ICU from January 2010 to December 2011 with diarrhea for more than 48<span class="elsevierStyleHsp" style=""></span>h.</p> <span class="elsevierStyleSectionTitle" id="sect0040">Interventions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">None.</p> <span class="elsevierStyleSectionTitle" id="sect0045">Study variables</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Underlying diseases, risk factors, fever, leukocyte count, complications, recurrence of infection.</p> <span class="elsevierStyleSectionTitle" id="sect0050">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">A total of 1936 adult patients were admitted. Seven patients acquired CDI (0.36%), representing an infection rate of 3.1 per 10,000 bed-days and a cumulative incidence rate of 3.6 in two years. The mean age was 61 years. Six patients showed some degree of immunosuppression. The mean APACHE II score at ICU admission was 17 (IQR 13–24). Severe sepsis was reported in 5 cases of CDI, three of which presented shock and multiorgan dysfunction. Four patients presented recurrence of CDI during hospitalization. ICU admission was prolonged for a mean of 24 days (SD 17.8) after diagnosis.</p> <span class="elsevierStyleSectionTitle" id="sect0055">Conclusions</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Less than 1% of the patients admitted to a clinical–surgical ICU in a large teaching institution in Spain developed CDI. However, a high risk of recurrence/complications was associated with prolonged ICU stay.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0065">Objetivo</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">El objetivo de este estudio es describir la incidencia, características de los pacientes, complicaciones y la recurrencia de infección por <span class="elsevierStyleItalic">Clostridium difficile</span> en una UCI de un hospital universitario en un período fuera de brote.</p> <span class="elsevierStyleSectionTitle" id="sect0070">Diseño</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Serie de casos.</p> <span class="elsevierStyleSectionTitle" id="sect0075">Ámbito</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">UCI médico-quirúrgica de 34 camas en hospital de referencia de 1.400 camas.</p> <span class="elsevierStyleSectionTitle" id="sect0080">Pacientes o participantes</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Todo paciente mayor de 18 años ingresado en la UCI desde enero de 2010 hasta diciembre de 2011 que tuviese diarrea durante más de 48<span class="elsevierStyleHsp" style=""></span>h.</p> <span class="elsevierStyleSectionTitle" id="sect0085">Intervenciones</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Sin intervención.</p> <span class="elsevierStyleSectionTitle" id="sect0090">Variables de interés principales</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Enfermedades de base, factores de riesgo, recurrencia de infección.</p> <span class="elsevierStyleSectionTitle" id="sect0095">Resultados</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Un total de 1.936 pacientes fueron ingresados en el periodo de estudio, de los cuales 177 presentaron diarrea durante más de 48<span class="elsevierStyleHsp" style=""></span>h y 7 cumplieron criterios de infección por <span class="elsevierStyleItalic">Clostridium difficile</span> (0,36%). Una tasa de infección de 3,1 pacientes por cada 10.000 camas/día y una incidencia acumulada de 3,6<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>1.000, en 2 años. La edad media fue de 61 años. Seis mostraron algún grado de inmunosupresión. La media del score APACHE II al ingreso fue de 17. Cinco casos presentaron sepsis grave, 3 de los cuales tuvieron shock y disfunción multiorgánica. Un paciente de los 7 (14%) falleció. Cuatro pacientes sufrieron recurrencia durante la hospitalización (57%). La estancia media se prolongó 24 días (DE 17,8) después del diagnóstico.</p> <span class="elsevierStyleSectionTitle" id="sect0100">Conclusiones</span><p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Menos del 1% de los pacientes hospitalizados en una UCI médico-quirúrgica desarrollaron infección por <span class="elsevierStyleItalic">Clostridium difficile</span>. Sin embargo, se asoció a un alto grado de recurrencia/complicaciones y a una larga estancia en la UCI.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "◊" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">The Clinical Research/Innovation in Pneumonia & Sepsis group (CRIPS). List of CRIPS Investigators in detailed at <a class="elsevierStyleCrossRef" href="#sec0040">Appendix A</a>.</p>" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0080" class="elsevierStylePara elsevierViewall">The Clinical Research/Innovation in Pneumonia & Sepsis group (CRIPS).<elsevierMultimedia ident="tbl0005"></elsevierMultimedia></p>" "etiqueta" => "Appendix A" "titulo" => "List of CRIPS investigators" "identificador" => "sec0040" ] ] ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1338 "Ancho" => 1588 "Tamanyo" => 82042 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Flowchart of critically ill patients enrolled in the study of <span class="elsevierStyleItalic">C. difficile</span> infection.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 974 "Ancho" => 2167 "Tamanyo" => 183466 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">Computerized axial tomography of abdomen, showing dilation of colon and wall thickening (panel A, arrow) with fluid levels (panel B, arrow).</p>" ] ] 2 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 1" "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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Total no. of patients (male patients:female 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"><span class="elsevierStyleItalic">n</span>/<span class="elsevierStyleItalic">N</span> \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, median (years)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">61 years (IQR 53–64) \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">Risk factor</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>Received antibiotic therapy prior to onset of CDI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7/7 \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"><span class="elsevierStyleHsp" style=""></span>Proton pump inhibitors \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7/7 \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"><span class="elsevierStyleHsp" style=""></span>Steroids \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3/7 \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"><span class="elsevierStyleHsp" style=""></span>Gastrointestinal stimulants \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3/7 \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"><span class="elsevierStyleHsp" style=""></span>Age<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>65 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2/7 \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"><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">Underlying disease</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>Heart 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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0/7 \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"><span class="elsevierStyleHsp" style=""></span>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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1/7 \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"><span class="elsevierStyleHsp" style=""></span>Chronic respiratory disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2/7 \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"><span class="elsevierStyleHsp" style=""></span>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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2/7 \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"><span class="elsevierStyleHsp" style=""></span>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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0/7 \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"><span class="elsevierStyleHsp" style=""></span>Obesity \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1/7 \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"><span class="elsevierStyleHsp" style=""></span>Immunosupression \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3/7 \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"><span class="elsevierStyleHsp" style=""></span>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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1/7 \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"><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">Physiologic characteristics</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>Median APACHE II score \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">17 (IQR 13–24) \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>Invasive MV \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3/7 \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"><span class="elsevierStyleHsp" style=""></span>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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3/7 \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"><span class="elsevierStyleHsp" style=""></span>MODS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3/7 \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"><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">CT results:</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>Scan positive \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3/3 \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"><span class="elsevierStyleHsp" style=""></span>Colon thickening \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3/3 \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"><span class="elsevierStyleHsp" style=""></span>Colon dilation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2/3 \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"><span class="elsevierStyleHsp" style=""></span>Pericolonic fat affectation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1/3 \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"><span class="elsevierStyleHsp" style=""></span>Free air \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0/3 \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"><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">Presence of pseudomembranous colitis</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1/7 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab472550.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">Baseline characteristics of patients with <span class="elsevierStyleItalic">Clostridium difficile</span>-associated diarrhea.</p>" ] ] 3 => array:7 [ "identificador" => "tbl0015" "etiqueta" => "Table 2" "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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Patient \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">1 \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">2 \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">3 \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">4 \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">5 \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">6 \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">7 \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">Abdominal pain (y/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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Y \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Y \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Y \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">Fever (y/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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Y \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Y \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Y \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Y \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">WBC (×109 per L) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8300 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">17,500 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">19,100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">22,000 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">46,600 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">61,200 \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">Albumin level (mg/dl) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.71 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.99 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.71 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.96 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.74 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.90 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.30 \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 intolerance (y/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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Y \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Y \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Y \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">Toxic megacolon (y/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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Y \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab472549.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0105" class="elsevierStyleSimplePara elsevierViewall">Clinical manifestations in <span class="elsevierStyleItalic">Clostridium difficile</span> infection.</p>" ] ] 4 => array:5 [ "identificador" => "tbl0005" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => false "mostrarDisplay" => true "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=""><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">Roser Anglès Coll \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">Joan Balcells Ramirez \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">Elisabet Gallart Vive \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">Rosa Maria Gracia Gozalo \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">César Laborda Soriano \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">Joan Ramon Masclans Enviz \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">Mercedes Palomar Martínez \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">Marcos Pérez Carrasco \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">Teresa Pont Castellana \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">Isabel Porta Pampalona \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">Maria Alba Riera Badia \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">Judith Sacanell Lacasa \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">Bárbara Borgatta \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">Melisa Fernandez Pinto \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">Alejandra García Roche \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">Simone Gattarello \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">Elisabeth Papiol Gallofré \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">Ana Parra Castillo \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">Purificación Perez Terán \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">Laura Ruano Burgos \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">Anna Sánchez Corral \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">Jessica Souto Higueras. \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab472548.png" ] ] ] ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:22 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prevalence and pathogenicity of <span class="elsevierStyleItalic">Clostridium difficile</span> in hospitalized patients: a French multicenter study" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "F. Barbut" 1 => "G. Corthier" 2 => "Y. Charpak" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Arch Intern Med" "fecha" => "1996" "volumen" => "156" "paginaInicial" => "1449" "paginaFinal" => "1454" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8678714" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "<span class="elsevierStyleItalic">Clostridium difficile</span>-associated diarrhea" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "S. Johnson" 1 => "D.N. Gerding" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Clin Infect Dis" "fecha" => "1998" "volumen" => "26" "paginaInicial" => "1027" "paginaFinal" => "1036" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9597221" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "<span class="elsevierStyleItalic">Clostridium difficile</span>-associated diarrhea in a region of Quebec from 1991 to 2003: a changing pattern of disease severity" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "J. Pépin" 1 => "L. Valiquette" 2 => "M.E. 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Michaud" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1056/NEJMoa051639" "Revista" => array:6 [ "tituloSerie" => "N Engl J Med" "fecha" => "2005" "volumen" => "353" "paginaInicial" => "2442" "paginaFinal" => "2449" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16322602" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "<span class="elsevierStyleItalic">Clostridium difficile</span> – more difficult than ever" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "C. Kelly" 1 => "J.T. LaMonte" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1056/NEJMra0707500" "Revista" => array:6 [ "tituloSerie" => "N Engl J Med" "fecha" => "2008" "volumen" => "359" "paginaInicial" => "1932" "paginaFinal" => "1940" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18971494" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0035" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clinical practice. Antibiotic-associated diarrhea" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "J.G. 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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 9 | 14 | 23 |
| 2024 Octubre | 56 | 55 | 111 |
| 2024 Septiembre | 65 | 30 | 95 |
| 2024 Agosto | 94 | 44 | 138 |
| 2024 Julio | 59 | 40 | 99 |
| 2024 Junio | 53 | 44 | 97 |
| 2024 Mayo | 48 | 44 | 92 |
| 2024 Abril | 52 | 37 | 89 |
| 2024 Marzo | 50 | 21 | 71 |
| 2024 Febrero | 45 | 41 | 86 |
| 2024 Enero | 41 | 26 | 67 |
| 2023 Diciembre | 45 | 43 | 88 |
| 2023 Noviembre | 37 | 35 | 72 |
| 2023 Octubre | 36 | 27 | 63 |
| 2023 Septiembre | 30 | 28 | 58 |
| 2023 Agosto | 30 | 22 | 52 |
| 2023 Julio | 38 | 25 | 63 |
| 2023 Junio | 21 | 24 | 45 |
| 2023 Mayo | 56 | 35 | 91 |
| 2023 Abril | 38 | 41 | 79 |
| 2023 Marzo | 50 | 33 | 83 |
| 2023 Febrero | 60 | 26 | 86 |
| 2023 Enero | 36 | 29 | 65 |
| 2022 Diciembre | 77 | 27 | 104 |
| 2022 Noviembre | 83 | 39 | 122 |
| 2022 Octubre | 80 | 40 | 120 |
| 2022 Septiembre | 46 | 36 | 82 |
| 2022 Agosto | 75 | 42 | 117 |
| 2022 Julio | 103 | 47 | 150 |
| 2022 Junio | 118 | 26 | 144 |
| 2022 Mayo | 114 | 52 | 166 |
| 2022 Abril | 65 | 48 | 113 |
| 2022 Marzo | 101 | 67 | 168 |
| 2022 Febrero | 95 | 40 | 135 |
| 2022 Enero | 75 | 55 | 130 |
| 2021 Diciembre | 63 | 45 | 108 |
| 2021 Noviembre | 50 | 47 | 97 |
| 2021 Octubre | 92 | 76 | 168 |
| 2021 Septiembre | 65 | 48 | 113 |
| 2021 Agosto | 51 | 55 | 106 |
| 2021 Julio | 65 | 48 | 113 |
| 2021 Junio | 44 | 25 | 69 |
| 2021 Mayo | 80 | 56 | 136 |
| 2021 Abril | 131 | 112 | 243 |
| 2021 Marzo | 74 | 27 | 101 |
| 2021 Febrero | 64 | 36 | 100 |
| 2021 Enero | 47 | 25 | 72 |
| 2020 Diciembre | 27 | 24 | 51 |
| 2020 Noviembre | 40 | 28 | 68 |
| 2020 Octubre | 28 | 33 | 61 |
| 2020 Septiembre | 37 | 18 | 55 |
| 2020 Agosto | 35 | 20 | 55 |
| 2020 Julio | 40 | 30 | 70 |
| 2020 Junio | 56 | 21 | 77 |
| 2020 Mayo | 48 | 12 | 60 |
| 2020 Abril | 48 | 22 | 70 |
| 2020 Marzo | 35 | 23 | 58 |
| 2020 Febrero | 52 | 60 | 112 |
| 2020 Enero | 43 | 37 | 80 |
| 2019 Diciembre | 48 | 19 | 67 |
| 2019 Noviembre | 80 | 28 | 108 |
| 2019 Octubre | 61 | 23 | 84 |
| 2019 Septiembre | 61 | 29 | 90 |
| 2019 Agosto | 48 | 37 | 85 |
| 2019 Julio | 42 | 38 | 80 |
| 2019 Junio | 37 | 11 | 48 |
| 2019 Mayo | 59 | 37 | 96 |
| 2019 Abril | 42 | 32 | 74 |
| 2019 Marzo | 35 | 36 | 71 |
| 2019 Febrero | 37 | 36 | 73 |
| 2019 Enero | 55 | 43 | 98 |
| 2018 Diciembre | 54 | 37 | 91 |
| 2018 Noviembre | 124 | 73 | 197 |
| 2018 Octubre | 68 | 25 | 93 |
| 2018 Septiembre | 64 | 13 | 77 |
| 2018 Agosto | 18 | 5 | 23 |
| 2018 Julio | 29 | 16 | 45 |
| 2018 Junio | 39 | 5 | 44 |
| 2018 Mayo | 16 | 5 | 21 |
| 2018 Abril | 33 | 7 | 40 |
| 2018 Marzo | 22 | 6 | 28 |
| 2018 Febrero | 30 | 6 | 36 |
| 2018 Enero | 50 | 24 | 74 |
| 2017 Diciembre | 49 | 8 | 57 |
| 2017 Noviembre | 51 | 16 | 67 |
| 2017 Octubre | 36 | 9 | 45 |
| 2017 Septiembre | 26 | 6 | 32 |
| 2017 Agosto | 23 | 11 | 34 |
| 2017 Julio | 28 | 15 | 43 |
| 2017 Junio | 40 | 20 | 60 |
| 2017 Mayo | 43 | 27 | 70 |
| 2017 Abril | 36 | 21 | 57 |
| 2017 Marzo | 25 | 13 | 38 |
| 2017 Febrero | 27 | 10 | 37 |
| 2017 Enero | 15 | 8 | 23 |
| 2016 Diciembre | 36 | 11 | 47 |
| 2016 Noviembre | 81 | 12 | 93 |
| 2016 Octubre | 84 | 21 | 105 |
| 2016 Septiembre | 60 | 10 | 70 |
| 2016 Agosto | 24 | 10 | 34 |
| 2016 Julio | 25 | 21 | 46 |
| 2015 Diciembre | 2 | 0 | 2 |
| 2015 Febrero | 1 | 0 | 1 |
| 2014 Noviembre | 1 | 0 | 1 |
| 2014 Septiembre | 2 | 0 | 2 |
| 2014 Agosto | 1 | 0 | 1 |
| 2014 Marzo | 2 | 3 | 5 |
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