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How I diagnose and manage ventilator-associated tracheobronchitis
Cómo diagnostico y trato la traqueobronquitis asociada al ventilador
M.H. Kollef
Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, MO, United States
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Hidalgo, D. Mas, M. Rubio, P. Garcia-Hierro" "autores" => array:4 [ 0 => array:2 [ "nombre" => "F." "apellidos" => "Hidalgo" ] 1 => array:2 [ "nombre" => "D." "apellidos" => "Mas" ] 2 => array:2 [ "nombre" => "M." "apellidos" => "Rubio" ] 3 => array:2 [ "nombre" => "P." "apellidos" => "Garcia-Hierro" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S021056911600053X?idApp=WMIE" "url" => "/02105691/0000004000000003/v1_201604080110/S021056911600053X/v1_201604080110/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S0210569115002508" "issn" => "02105691" "doi" => "10.1016/j.medin.2015.11.006" "estado" => "S300" "fechaPublicacion" => "2016-04-01" "aid" => "866" "copyright" => "Elsevier España, S.L.U. and SEMICYUC" "documento" => "article" "crossmark" => 1 "subdocumento" => "ssu" "cita" => "Med Intensiva. 2016;40:169-75" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 57436 "formatos" => array:3 [ "EPUB" => 333 "HTML" => 43675 "PDF" => 13428 ] ] "es" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">REVISIÓN</span>" "titulo" => "Distrés respiratorio agudo: del síndrome a la enfermedad" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "169" "paginaFinal" => "175" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Acute Respiratory Distress: from syndrome to disease" ] ] "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" => 819 "Ancho" => 3333 "Tamanyo" => 893248 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Daño alveolar difuso.</p> <p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Caso 1: paciente de 42 años que ingresa en la UCI con diagnóstico de shock séptico asociado a una neumonía aguda hospitalaria. Fallece a los 2 días de ventilación mecánica por hipoxemia refractaria. El estudio autópsico de la paciente (figura a, HE, ×5) mostró un patrón histológico heterogéneo con áreas de DAD en fase exudativa, destacándose la presencia de membranas hialinas y edema intersticial y alveolar, la vasocongestión de los tabiques interalveolares y la descamación e hiperplasia de los neumocitos tipo <span class="elsevierStyleSmallCaps">ii</span>. En otras áreas (figura b, HE, ×5) se aprecia DAD en fase organizativa con fibrosis laxa intersticial e intraalveolar, además de membranas hialinas y el resto de los hallazgos mencionados previamente.</p> <p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Caso 2: paciente de 28 años que ingresa en la UCI por un SDRA secundario a una sepsis respiratoria por influenza H1N1. Fallece por hipoxemia refractaria a los 48 días de ventilación mecánica. En la microfotografía de tejido pulmonar (figura c, HE, ×5) obtenida en la autopsia se aprecia DAD evolucionado, en etapa de fibrosis, con una gran distorsión del parénquima pulmonar y sustitución prácticamente total de los espacios alveolares por tejido fibrótico.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "P. Cardinal-Fernández, E. Correger, J. Villanueva, F. Rios" "autores" => array:4 [ 0 => array:2 [ "nombre" => "P." "apellidos" => "Cardinal-Fernández" ] 1 => array:2 [ "nombre" => "E." "apellidos" => "Correger" ] 2 => array:2 [ "nombre" => "J." "apellidos" => "Villanueva" ] 3 => array:2 [ "nombre" => "F." "apellidos" => "Rios" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2173572716000187" "doi" => "10.1016/j.medine.2015.11.002" "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/S2173572716000187?idApp=WMIE" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0210569115002508?idApp=WMIE" "url" => "/02105691/0000004000000003/v1_201604080110/S0210569115002508/v1_201604080110/es/main.assets" ] "en" => array:17 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Point of view</span>" "titulo" => "How I diagnose and manage ventilator-associated tracheobronchitis" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "176" "paginaFinal" => "178" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "M.H. Kollef" "autores" => array:1 [ 0 => array:3 [ "nombre" => "M.H." "apellidos" => "Kollef" "email" => array:1 [ 0 => "mkollef@dom.wustl.edu" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, MO, United States" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Cómo diagnostico y trato la traqueobronquitis asociada al ventilador" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1734 "Ancho" => 2353 "Tamanyo" => 308977 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The continuum of ventilator-associated lower respiratory tract infections progressing from bronchial colonization to ventilator-associated tracheobronchitis and ventilator-associated pneumonia. Selective decontamination of the digestive tract (SDD) and selective oropharyngeal (the mouth and throat) decontamination (SOD) would only be recommended in locations with a low prevalence of colonization with multidrug-resistant bacteria.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Ventilator-associated lower respiratory tract infections (VALRTIs) in mechanically ventilated patients include ventilator-associated pneumonia (VAP) and ventilator-associated tracheobronchitis (VAT). It is important to recognize that one of the major clinical issues related to the management of VALRTIs is the increasing occurrence of multi-drug resistant (MDR) or extremely-drug resistant (XDR) pathogens.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,2</span></a> The available evidence suggests that the overall prevalence of nosocomial infections attributed to MDR/XDR pathogens, as well as the global use of antibiotics in the hospital setting is on the rise despite efforts to curb these infections.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> VAP and VAT are recognized to be among the most common infections associated with MDR/XDR bacteria including <span class="elsevierStyleItalic">Pseudomonas aeruginosa</span>, <span class="elsevierStyleItalic">Acinetobacter</span> species, and KPC (<span class="elsevierStyleItalic">Klebsiella pneumoniae</span> carbapenemase) containing <span class="elsevierStyleItalic">Enterobacteriaceae</span>. Moreover, the recent recognition of colisitin resistance among MDR/XDR Gram-negative bacteria raises the real possibility of endemic spread of common enteric bacteria possessing resistance to all currently available antibacterial agents. However, it is paramount for clinicians to be aware of the pathogens within their local hospitals associated with VALRTIs in order to optimize treatment strategies and avoid unnecessary use of broad-spectrum antibiotics.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Traditionally the goal for clinicians has been to understand local patient characteristics that increase the risk for infection due to MDR/XDR pathogens above a threshold where broader empiric antibiotics would be needed. However, in the face of rising resistance the focus has shifted in many centers toward excluding patients at minimal risk for MDR/XDR bacteria. Within the hospital where I practice the prevalence of MDR/XDR bacteria associated with VAP and VAT is high enough to warrant initial coverage with broad-spectrum empiric antibiotics targeting methicillin-resistant <span class="elsevierStyleItalic">Staphylococcus aureus</span> and <span class="elsevierStyleItalic">Pseudomonas aeruginosa</span>, the two most common pathogens for these infections. However, I also aggressively practice antimicrobial de-escalation in order to limit the unnecessary use of broad-spectrum agents.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a><a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a> provides an overview of my strategy for the assessment and treatment of VALRTIs. Establishing an accurate diagnosis of VALRTIs is important in order to target antimicrobial therapy to patients who are most likely to benefit from it.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">I define VAT as the presence of all of the following in a patient receiving mechanical ventilation for >48<span class="elsevierStyleHsp" style=""></span>h: body temperature >38.3<span class="elsevierStyleHsp" style=""></span>°C or <36.0<span class="elsevierStyleHsp" style=""></span>°C, new or increased purulent tracheal secretions, positive culture of tracheal secretions at a concentration of ≥10<span class="elsevierStyleSup">5</span><span class="elsevierStyleHsp" style=""></span>cfu/mL, and no new or progressive infiltrate on portable chest radiograph.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> I define VAP as the presence of a new or progressive pulmonary infiltrate and two of the following: temperature >38.3<span class="elsevierStyleHsp" style=""></span>°C or <36.0<span class="elsevierStyleHsp" style=""></span>°C, leukocyte count >12,000/μL or <4000/μL, or purulent tracheal secretions. I consider the diagnosis of VAP to be microbiologically confirmed if cultures, preferentially quantitative bronchoalveolar lavage cultures, demonstrate significant growth at ≥10<span class="elsevierStyleSup">4</span><span class="elsevierStyleHsp" style=""></span>cfu/mL. Unfortunately, portable chest radiographs often are of poor quality for assessing the presence of new or progressive infiltrates making it difficult to differentiate VAP and VAT. Nevertheless, the microbiologic confirmation of VAT and VAP is necessary in order to distinguish these infections from other noninfectious causes in mechanically ventilated patients such as congestive heart failure, atelectasis, pulmonary emboli, or neoplastic disease. It is my experience that when I obtain computed tomography in mechanically ventilated patients I frequently identify infiltrates or consolidated lung, especially at the lung bases, that was not seen on the portable films. The definition for VAT that I employ, requiring systemic evidence of infection, is similar to that of Martin-Loeches et al. describing their recent cohort of patients with VALRTIs.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">At the present time I do not routinely perform surveillance cultures from the respiratory tract in mechanically ventilated patients. I only obtain cultures when patients have systemic signs of infection as noted above. The rationale for this is to avoid the unnecessary use of antibiotics and to avoid treating simple colonization. In my published experience over a one year period, 2060 patients admitted to the medical and surgical ICUs of Barnes-Jewish Hospital required mechanical ventilation for >48<span class="elsevierStyleHsp" style=""></span>h of which 111 (5.4%) were identified as having either VAT or VAP.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> There were 28 (25.2%) with VAT and 83 (74.8%) with VAP. VAT progressed to VAP in nine patients (32.1%) despite concurrent therapy with appropriate antibiotics. Martin-Loeches et al. performed a multicenter study in 114 ICUs in Spain, France, Portugal, Brazil, Argentina, Ecuador, Bolivia, and Colombia over ten months.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> They obtained data from 2960 patients receiving mechanical ventilation for >48<span class="elsevierStyleHsp" style=""></span>h, of whom 689 (23%) developed VALRTIs. The incidence of VAT and VAP were 11% and 12% respectively. They also found that twelve percent of patients with VAT progressed to VAP and that patients with VAT who received appropriate antibiotic therapy were significantly less likely to progress to VAP. The data from these two studies suggest that VAT and VAP clearly overlap and that some patients with VAT may actually have early VAP. Moreover, appropriate and timely antibiotic therapy seems to be an important element in improving patient outcomes.</p><p id="par0025" class="elsevierStylePara elsevierViewall">I traditionally have employed systemic antibiotics for the treatment of VAT and VAP avoiding the use of aerosolized antibiotics (AAs) due to the limitations of the available delivery devices. However, over the past ten years I have increasingly employed AAs for difficult to treat pathogens such as <span class="elsevierStyleItalic">Pseudomonas aeruginosa</span> and <span class="elsevierStyleItalic">Acinetobacter baumannii</span> in VAP.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> I have also progressively more considered the use of AAs for VAT due to similar pathogens. I have strictly avoided antibiotic therapy for colonization without systemic signs of infection. However, emerging data suggests that this paradigm, and my practices, may be changing in the future with the advent of improved aerosol delivery devices.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Palmer et al. recently performed a randomized study in critically ill intubated patients receiving AAs or saline using a jet nebulizer aerosol delivery system for 14 days or until extubation.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> They demonstrated that AAs were successful in eradicating existing MDR/XDR bacteria and reducing the emergence of subsequent resistance from systemically administered antibiotics.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> Advances in the design of aerosol generators has allowed for the delivery of high antibiotic concentrations into the lung. Niederman et al. studied an investigational drug-device combination (BAY41-6551) of amikacin formulated for inhalation using a primary endpoint of 25 times the MIC of 256<span class="elsevierStyleHsp" style=""></span>μg/ml, representing a tracheal aspirate amikacin maximal concentration greater than or equal to 6400<span class="elsevierStyleHsp" style=""></span>μg/ml.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> Response rates for this endpoint were 50% for amikacin delivered every twelve hours. Similarly, the administration of 300<span class="elsevierStyleHsp" style=""></span>mg/120<span class="elsevierStyleHsp" style=""></span>mg amikacin/fosfomycin combination to mechanically ventilated adults using an investigational vibrating mesh nebulizer achieved tracheal aspirate amikacin concentrations of 12,390<span class="elsevierStyleHsp" style=""></span>μg/g and fosfomycin concentrations of 6174<span class="elsevierStyleHsp" style=""></span>μg/g.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">VAP and VAT are important infections requiring appropriate treatment in order to maximize outcomes. However, clinicians must also me mindful of the excessive use of antibiotics, to include AAs, for fear of generating greater resistance. From my perspective, VALRTIs should be managed according to the algorithm in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>. However, the findings of ongoing trials could change the way AAs are employed for the treatment and possibly prevention of VALRTIs.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of interest</span><p id="par0040" class="elsevierStylePara elsevierViewall">Dr. Kollef's efforts are supported by the Barnes-Jewish Hospital Foundation.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflict of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-12-16" "fechaAceptado" => "2015-12-22" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">This work was supported by the Barnes-Jewish Hospital Foundation.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1734 "Ancho" => 2353 "Tamanyo" => 308977 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The continuum of ventilator-associated lower respiratory tract infections progressing from bronchial colonization to ventilator-associated tracheobronchitis and ventilator-associated pneumonia. Selective decontamination of the digestive tract (SDD) and selective oropharyngeal (the mouth and throat) decontamination (SOD) would only be recommended in locations with a low prevalence of colonization with multidrug-resistant bacteria.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Is this patient at risk for infection with multidrug resistant bacteria?" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "C. Vazquez Guillamet" 1 => "M.H. 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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 10 | 18 | 28 |
| 2024 Octubre | 63 | 54 | 117 |
| 2024 Septiembre | 104 | 47 | 151 |
| 2024 Agosto | 116 | 55 | 171 |
| 2024 Julio | 120 | 45 | 165 |
| 2024 Junio | 127 | 100 | 227 |
| 2024 Mayo | 101 | 65 | 166 |
| 2024 Abril | 114 | 49 | 163 |
| 2024 Marzo | 97 | 55 | 152 |
| 2024 Febrero | 74 | 64 | 138 |
| 2024 Enero | 118 | 45 | 163 |
| 2023 Diciembre | 99 | 46 | 145 |
| 2023 Noviembre | 112 | 57 | 169 |
| 2023 Octubre | 104 | 31 | 135 |
| 2023 Septiembre | 96 | 45 | 141 |
| 2023 Agosto | 77 | 29 | 106 |
| 2023 Julio | 92 | 27 | 119 |
| 2023 Junio | 75 | 22 | 97 |
| 2023 Mayo | 84 | 46 | 130 |
| 2023 Abril | 89 | 34 | 123 |
| 2023 Marzo | 112 | 43 | 155 |
| 2023 Febrero | 85 | 38 | 123 |
| 2023 Enero | 100 | 40 | 140 |
| 2022 Diciembre | 92 | 39 | 131 |
| 2022 Noviembre | 72 | 52 | 124 |
| 2022 Octubre | 87 | 38 | 125 |
| 2022 Septiembre | 73 | 44 | 117 |
| 2022 Agosto | 92 | 49 | 141 |
| 2022 Julio | 74 | 38 | 112 |
| 2022 Junio | 66 | 35 | 101 |
| 2022 Mayo | 74 | 49 | 123 |
| 2022 Abril | 72 | 54 | 126 |
| 2022 Marzo | 81 | 71 | 152 |
| 2022 Febrero | 93 | 44 | 137 |
| 2022 Enero | 106 | 56 | 162 |
| 2021 Diciembre | 100 | 58 | 158 |
| 2021 Noviembre | 109 | 61 | 170 |
| 2021 Octubre | 109 | 87 | 196 |
| 2021 Septiembre | 74 | 55 | 129 |
| 2021 Agosto | 88 | 50 | 138 |
| 2021 Julio | 95 | 42 | 137 |
| 2021 Junio | 79 | 46 | 125 |
| 2021 Mayo | 149 | 47 | 196 |
| 2021 Abril | 240 | 99 | 339 |
| 2021 Marzo | 171 | 50 | 221 |
| 2021 Febrero | 161 | 51 | 212 |
| 2021 Enero | 118 | 43 | 161 |
| 2020 Diciembre | 110 | 38 | 148 |
| 2020 Noviembre | 101 | 22 | 123 |
| 2020 Octubre | 68 | 46 | 114 |
| 2020 Septiembre | 91 | 33 | 124 |
| 2020 Agosto | 64 | 23 | 87 |
| 2020 Julio | 74 | 25 | 99 |
| 2020 Junio | 67 | 31 | 98 |
| 2020 Mayo | 74 | 24 | 98 |
| 2020 Abril | 104 | 32 | 136 |
| 2020 Marzo | 82 | 11 | 93 |
| 2020 Febrero | 165 | 38 | 203 |
| 2020 Enero | 66 | 43 | 109 |
| 2019 Diciembre | 120 | 30 | 150 |
| 2019 Noviembre | 127 | 43 | 170 |
| 2019 Octubre | 591 | 44 | 635 |
| 2019 Septiembre | 86 | 34 | 120 |
| 2019 Agosto | 82 | 29 | 111 |
| 2019 Julio | 68 | 26 | 94 |
| 2019 Junio | 55 | 21 | 76 |
| 2019 Mayo | 80 | 39 | 119 |
| 2019 Abril | 56 | 38 | 94 |
| 2019 Marzo | 61 | 41 | 102 |
| 2019 Febrero | 61 | 37 | 98 |
| 2019 Enero | 50 | 42 | 92 |
| 2018 Diciembre | 61 | 51 | 112 |
| 2018 Noviembre | 182 | 97 | 279 |
| 2018 Octubre | 113 | 20 | 133 |
| 2018 Septiembre | 44 | 17 | 61 |
| 2018 Agosto | 38 | 7 | 45 |
| 2018 Julio | 39 | 9 | 48 |
| 2018 Junio | 49 | 15 | 64 |
| 2018 Mayo | 33 | 11 | 44 |
| 2018 Abril | 76 | 12 | 88 |
| 2018 Marzo | 55 | 13 | 68 |
| 2018 Febrero | 62 | 10 | 72 |
| 2018 Enero | 61 | 25 | 86 |
| 2017 Diciembre | 63 | 14 | 77 |
| 2017 Noviembre | 54 | 21 | 75 |
| 2017 Octubre | 45 | 9 | 54 |
| 2017 Septiembre | 60 | 13 | 73 |
| 2017 Agosto | 784 | 17 | 801 |
| 2017 Julio | 38 | 27 | 65 |
| 2017 Junio | 34 | 41 | 75 |
| 2017 Mayo | 63 | 32 | 95 |
| 2017 Abril | 35 | 26 | 61 |
| 2017 Marzo | 36 | 18 | 54 |
| 2017 Febrero | 33 | 22 | 55 |
| 2017 Enero | 32 | 8 | 40 |
| 2016 Diciembre | 44 | 31 | 75 |
| 2016 Noviembre | 56 | 41 | 97 |
| 2016 Octubre | 54 | 60 | 114 |
| 2016 Septiembre | 70 | 76 | 146 |
| 2016 Agosto | 65 | 248 | 313 |
| 2016 Julio | 41 | 45 | 86 |
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