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          "en" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Practice of initial antimicrobial therapy &#40;AMT&#41; decision&#46; ICU&#44; Intensive Care Unit&#59; HICs&#44; high-income countries&#59; LMICs&#44; low- and middle-income countries&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Half of patients in Intensive Care Units &#40;ICU&#41; suffer infection while 30&#37; die secondary to it&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">1</span></a> Both ICU-acquired infection and antibiotic resistance are associated with an increased risk of death&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">1</span></a> It follows that 70&#37; of ICU patients are receiving antimicrobial therapy &#40;AMT&#41; representing a burden to healthcare costs&#44; predisposing to antimicrobial resistance &#40;AMR&#41; and worsening patients&#8217; outcome&#46;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">1&#44;2</span></a> AMR is more prevalent in low- to middle-income countries &#40;LMICs&#41; than high-income countries &#40;HICs&#41; and feared to cause millions of deaths by 2050&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Antimicrobial stewardship programme &#40;ASP&#41; is a mean of limiting AMR while improving patients&#8217; outcome&#46; It is defined as &#8220;the coordinated interventions designed to improve and measure the appropriate use of AMT by promoting the selection of the optimal drug regimen including dosing&#44; duration of therapy&#44; and route of administration&#8255;&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">3</span></a> It is recommended as a core competency for intensivists and for all ICUs integrating clinicians&#44; pharmacists&#44; infectious disease &#40;ID&#41; physicians and clinical microbiologists &#40;CM&#41; into one multidisciplinary team&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">3&#44;4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Understanding ICU ID practice remains essential for identifying gaps and opportunities&#44; but is generally lacking&#46; We conducted an international online survey &#40;PRACT-INF-ICU&#41; to explore from intensivists&#8217; perspective&#59; &#40;1&#41; the practice of ID in the ICU&#44; &#40;2&#41; their satisfaction with ID training&#44; and &#40;3&#41; the impact of defensive medicine on ICU ID practice&#46; Variability in responses were explored regarding settings &#40;HICs vs LMICs&#41;&#44; background training and experience&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Survey design</span><p id="par0020" class="elsevierStylePara elsevierViewall">PRACT-INF-ICU was an international cross sectional descriptive and analytical internet-based open survey of intensivists&#46; The questionnaire was developed by the survey steering committee then pre-tested for clarity&#44; reliability and validity by 2 non-experts and 2 ICU ID experts&#46; It gained approval by the infection section of the European Society of Intensive Care Medicine &#40;ESICM&#41; then endorsed by the ESICM research committee&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The survey consisted of 26 closed and open-ended questions&#44; including Likert scales and adaptive questioning&#44; divided into 4 sections&#59; &#40;1&#41; respondents&#8217; characteristics &#40;questions 1&#8211;9&#41;&#44; &#40;2&#41; practice of ID management &#40;questions 10&#8211;20&#41;&#44; &#40;3&#41; respondents&#8217; perceptions regarding adequacy of training &#40;questions 21&#8211;24&#41;&#44; and impact of defensive medicine on AMT &#40;questions 24 and 25&#41; in addition to a free text annotation &#40;<a class="elsevierStyleCrossRef" href="#sec0100">eAppendix-1 in the Electronic Supplementary Material &#91;ESM&#93;</a>&#41;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Survey dissemination</span><p id="par0030" class="elsevierStylePara elsevierViewall">The survey used an online platform &#40;SurveyMonkey&#174;&#59; California&#44; USA&#41; from July 30&#44; 2019 to October 19&#44; 2019 &#40;82 days&#41;&#46; It was displayed on the survey page of the ESICM website&#46; ESICM infection section sent 2 invitation emails to all members&#46; Two authors &#40;AR and AE&#41; shared invitations through social media &#40;Facebook and LinkedIn&#41; targeting ICU doctors&#46; All invitations and the ESICM page included a link to the survey page&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The survey was administered anonymously&#44; and the Internet protocol &#40;IP&#41; addresses and identity information were not collected&#46; Unique visitors were determined via IP address but no cookies were used to assign a unique user identifier&#46; IP addresses were not used to identify duplicate entries&#46; The survey consisted of 4 pages &#40;page 1&#59; questions 1&#8211;4&#44; page 2&#59; questions 5&#8211;9&#44; page 3&#59; questions 10&#8211;25 and page 4&#59; question 26&#41;&#46; Respondents were able to change their answers on any page until they completed the survey&#46; Completeness check was displayed as question number&#47;total questions&#46; Submitted data were exported as excel spreadsheet and one copy will be kept in ESICM archives for 5 years &#40;accessible only by ESICM employees and protected by its network security system&#41;&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The survey was voluntary with no incentives for respondents&#44; and consent was implied by participation&#46; Ethical approval was not required due to the anonymous voluntary nature of the study&#46; This report was constructed according to the Checklist for Reporting Results of Internet E-Surveys &#40;CHERRIES&#41; guidelines &#40;<a class="elsevierStyleCrossRef" href="#sec0100">eAppendix-2&#44; ESM</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">5</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Statistical analysis</span><p id="par0045" class="elsevierStylePara elsevierViewall">Only completed surveys were included in the final analyses&#46; Descriptive statistics are presented as either percentage or median &#40;interquartile range &#91;IQR&#93;&#41;&#44; as appropriate&#46; Imputation of missing data was not performed&#46; For descriptive statistics&#44; valid percentages &#40;i&#46;e&#46;&#44; not including missing data&#41; were used&#46; Comparisons between categorical data were done by chi-square test or Fisher&#39;s exact test&#44; as appropriate&#46; Mann&#8211;Whitney <span class="elsevierStyleItalic">U</span> test was used for continuous data&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Practice variations were assessed according to respondents&#8217; countries income class &#40;HICs versus LMICs&#41;&#44; background training &#40;critical care only&#44; anaesthesia and critical care&#44; or medicine and critical care&#41;&#44; and years of practice &#40;categorized as&#59; more experienced &#91;&#62;10 years&#93; or less experienced &#91;&#8804;10 years&#93;&#41;&#46; Respondents&#8217; countries income classes were according to the 2019 gross national income per capita using thresholds defined by the World Bank atlas method&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">6</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">To estimate associations between respondents&#8217; characteristics and their perceptions regarding adequacy of training&#44; we utilized the ordinal logistic regression &#40;OLR&#41; where the five-point Likert-type responses &#40;&#8216;strongly agree&#8217; is the highest response&#41; as the dependent variable&#46; Only characteristics that had a <span class="elsevierStyleItalic">p</span> value &#60;0&#46;1 in the univariate analysis were included in the multivariate analyses&#46; OLR results are given as cumulative odds ratios &#40;ORs&#41; and 95&#37; confidence intervals &#40;CIs&#41;&#46; Reported <span class="elsevierStyleItalic">p</span> values are 2-sided and a <span class="elsevierStyleItalic">p</span> value &#60;0&#46;05 was considered statistically significance&#46; The statistical analysis was performed using SPSS&#174; version 21&#46;0 &#40;IBM&#41;&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Results</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Respondents&#8217; characteristics</span><p id="par0060" class="elsevierStylePara elsevierViewall">The survey was initiated by 561 respondents from 82 countries&#46; Four respondents were not ICU physicians and were excluded&#46; Among the remaining 557 respondents&#44; 446 &#40;83&#46;7&#37;&#41; completed the survey &#40;<a class="elsevierStyleCrossRef" href="#sec0100">eTable 1&#44; ESM</a>&#41; from 74 countries &#40;<a class="elsevierStyleCrossRef" href="#sec0100">eFig&#46; 1</a>&#41; including 26 respondents from Spain&#46; Respondents were from Europe &#40;58&#46;8&#37;&#41;&#44; Asia &#40;23&#37;&#41;&#44; Africa &#40;6&#37;&#41;&#44; South America &#40;5&#46;4&#37;&#41;&#44; North America &#40;3&#46;4&#37;&#41;&#44; and Oceania &#40;3&#46;4&#37;&#41;&#44; including 34&#46;3&#37; from LMICs&#46; They were divided nearly equally into those trained solely in Critical Care Medicine &#40;CCM&#41;&#44; or dually along with medicine or anaesthesia &#40;30&#46;3&#37;&#44; 35&#46;6&#37; and 30&#46;5&#37; respectively&#41;&#46; The median duration of clinical practice was 10 years &#40;IQR&#44; 5&#8211;19&#41;&#44; and 77&#37; were working in mixed ICUs &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Knowledge about hospitals&#8217; microbiological diagnostic capabilities&#58; &#40;<a class="elsevierStyleCrossRef" href="#sec0100">eTable 2&#44; ESM</a>&#41;</span><p id="par0065" class="elsevierStylePara elsevierViewall">Two-thirds of respondents reported good knowledge of their hospitals&#8217; microbiological diagnostic capabilities&#44; which was lower in LMICs compared to HICs &#40;54&#37; vs 73&#37;&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#44; and among less experienced compared to more experienced intensivists &#40;57&#37; vs 76&#37;&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Initial AMT decision&#58; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a> and <a class="elsevierStyleCrossRef" href="#sec0100">eTable 3&#44; ESM</a>&#41;</span><p id="par0070" class="elsevierStylePara elsevierViewall">The majority &#40;70&#37;&#41; of intensivists based their initial AMT decision on guidelines and protocols&#46; An expert opinion within 1 hour was available for 83&#37; of them&#44; yet less frequently in LMICs than HICs &#40;73&#37; vs 88&#37;&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; Initial AMT decision was almost always done by intensivists while non-ICU specialities were less frequently involved &#40;35&#37;&#44; 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and 10&#37; of the less experienced intensivists did not know whether they have ASP in their unit or not&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Perceptions regarding the need of non-ICU expertise&#58; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a> and <a class="elsevierStyleCrossRef" href="#sec0100">eTable 5&#44; ESM</a>&#41;</span><p id="par0080" class="elsevierStylePara elsevierViewall">Intensivists felt a greater need for non-ICU expertise on reviewing AMT &#40;48&#47;72<span class="elsevierStyleHsp" style=""></span>h review&#58; 32&#37;&#44; adjustment to culture&#58; 39&#37; and AMT discontinuation&#58; 21&#37;&#41;&#44; however 20&#37; never requiring non-ICU expertise&#46; More experienced intensivists reported significantly less need for non-ICU expertise and 29&#37; of them never asking for such expertise&#46; Only 11&#37; of intensivists with background training in anaesthesia never required non-ICU expertise compared to 26&#37; with medical training background&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Intensivists were more probably asking for expert non-ICU opinion for immunocompromised patients &#40;63&#37;&#41;&#44; central nervous system infections &#40;49&#37;&#41;&#44; non-surgical soft tissue infection &#40;41&#37;&#41;&#44; followed by abdominal sepsis&#44; blood stream and surgical site infections&#46; For bacterial infections&#44; the more resistant the organism&#44; the more often intensivists asked for external advice &#40;55&#37;&#44; 43&#37; and 25&#46;5&#37; of pan-resistant&#44; extended-resistant and multi-resistant organisms&#44; respectively&#41;&#46; In general&#44; intensivists were most likely to ask for secondary opinion when facing resistant bacterial infections than fungal &#40;32&#37;&#41; or viral ones &#40;27&#37;&#41;&#46; The more experienced intensivists and those with sole CCM training or dually with medicine were less likely asking for second ID opinion&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Adequacy of training&#58; &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a> and <a class="elsevierStyleCrossRef" href="#sec0100">eTable 6&#44; ESM</a>&#41;</span><p id="par0090" class="elsevierStylePara elsevierViewall">Only 42&#37; of intensivists agreed the level of knowledge and training in ID in their countries is adequate&#46; Satisfaction was significantly lower in LMICs compared to HICs &#40;29&#37; vs 51&#37;&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; and in less experienced compared to more experienced intensivists &#40;36&#37; vs 51&#37;&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; Doctors trained in CCM as sole specialty are more satisfied with ID training than doctors trained dually along with anaesthesia or medicine &#40;56&#37;&#44; 39&#37; and 36&#37;&#44; respectively&#41;&#46; Almost all respondents &#40;96&#37;&#41; thought there is a need for more training to decrease AMR &#40;85&#37;&#41;&#44; improve patients&#8217; outcome &#40;79&#37;&#41;&#44; and decrease cost &#40;64&#37;&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">Univariate OLR analysis showed that income class&#44; practice years&#44; background training&#44; CCM working time&#44; and ESICM membership were associated with respondents&#8217; perspective regarding adequacy of training&#46; Multivariate analysis showed that LMICs &#40;cumulative odds ratio &#91;OR&#93;&#58; 0&#46;41&#44; 95&#37; CI&#58; 0&#46;28&#8211;0&#46;61&#41;&#44; practice years &#8804;10 years &#40;OR&#58; 0&#46;55&#44; 95&#37; CI&#58; 0&#46;39&#8211;0&#46;79&#41;&#44; and dual CCM training with anaesthesia &#40;OR&#58; 0&#46;52&#44; 95&#37; CI&#58; 0&#46;34&#8211;0&#46;79&#41; or medicine &#40;OR&#58; 0&#46;49&#44; 95&#37; CI&#58; 0&#46;32&#8211;0&#46;76&#41; were independently associated with less ID training satisfaction &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165">Impact of defensive medicine on AMT&#58; &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a> and <a class="elsevierStyleCrossRef" href="#sec0100">eTable 7&#44; ESM</a>&#41;</span><p id="par0100" class="elsevierStylePara elsevierViewall">The majority &#40;71&#37;&#41; of respondents agreed that medicolegal issues and defensive medicine are impacting AMT prescription which was higher in LMICs than HICs &#40;77&#46;5&#37; vs&#46;67&#46;6&#37;&#41;&#46; Defensive practices reduce the threshold to prescribe antibiotics &#40;55&#37;&#41;&#44; and leads to more antibiotic combinations &#40;43&#37;&#41;&#44; longer courses &#40;44&#37;&#41;&#44; less frequent de-escalation &#40;ADE&#41; &#40;46&#37;&#41; and seeking non-ICU expertise &#40;21&#37;&#41;&#46;</p></span></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0170">Discussion</span><p id="par0105" class="elsevierStylePara elsevierViewall">Our survey highlights shortfalls and heterogeneity in managing infectious diseases in the ICU&#46; ASPs are variously implemented and intensivists reported a need for more ID education&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">ASP aims to reduce AMT exposure and to improve patients&#8217; outcomes&#46; Despite valued by most intensivists&#44; ASP implementation remains short&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">7</span></a> In 2012&#44; it was applied in just 58&#37; of hospitals worldwide&#44; with significant variability in policies&#44; strategies&#44; priorities and programmes maturity&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">8</span></a> ASP can vary within the single hospital and while our survey focusses on ICU settings&#44; it draws a similar picture to other hospital settings &#40;1&#47;3 of intensivists reported no ASP&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">8</span></a> Even in developed countries&#44; less than half of French intensivists were aware of ASP&#44; and only 74&#37; of Canadian intensivists reported ASP in their institutions&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">7&#44;9</span></a> A Spanish survey indifferently showed ASP to be implemented nationally in only 37&#37; of ICUs&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">10</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">It is becoming crucial to study the barriers impeding ASP in the ICU&#46; While some are shared across all healthcare settings &#40;e&#46;g&#46;&#44; funds&#44; staffing&#44; clinicians&#8217; resistance and lack of data technology&#41;&#44; others remain ICU specific&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">7</span></a> Most importantly may be the lack of ICU specific ASP studies and guidance&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">4</span></a> Furthermore&#44; conflicts can arise between intensivists&#8217; goals &#40;patient cure&#41; and some perceived ASP targets &#40;AMT use or cost&#41;&#46; A local leadership within the ICU can mitigate most conflicts&#44; compensate for staff shortage and provide the support needed for a successful&#44; sustainable and effective ASP&#46; ICU ID champions were shown also to be associated with better ASP implementation&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">9</span></a> In this context&#44; it is noteworthy the high participation of Spanish intensivists in their units&#8217; ASP programmes&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">10</span></a> Such training in addition to participation in audits and research can provide better insight and unify goals &#40;e&#46;g&#46;&#44; drug toxicity&#44; AMR and long-term impact&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">4</span></a> However&#44; auditing and feedback are known to be among the least applied ASP measures&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">7</span></a> Last&#44; tele-ASP can be the answer for smaller and remote units suffering staff or expertise shortage&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Heterogeneity in ICU ID&#47;ASP practice is not new to report&#44; and our survey is another confirmation&#46;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">9&#44;11</span></a> LMICs intensivists are less exposed to ASP&#44; have less expert opinion and declared greater knowledge gap and need for training&#46; This may reflect inadequate training or be institutional in origin &#40;e&#46;g&#46;&#44; part-time work&#44; smaller or private hospitals&#44; less administrative awareness&#44; lack of data technology and auditing culture&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">8</span></a> ASP was previously shown to be implemented in only 12&#37; of African versus 77&#37; of European hospitals&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">8</span></a> While limited access to AMT risks higher mortality&#44; it also limits choices and proper usage&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">2</span></a> This should raise global concerns as ID and AMR are difficult to contain and a local substandard practice can progress easily across borders&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Despite the availability of expert opinion&#44; intensivists preferred a protocolized over a personalized approach when initiating AMT&#46; An independent AMT prescribers should be able to recognize the need for expertise and co-operate as appropriate&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">12</span></a> However&#44; routine ID consultation is practiced in only 11&#37; of Italian ICUs&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">13</span></a> In Spain&#44; the reference expert is intensivist or anaesthesiologist in 91&#37; of ICUs compared to ID specialist in only 7&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">10</span></a> Lack of expertise risks prescribing higher tier and broader spectrum antibiotics due to diagnostic uncertainty and higher risk of deterioration in the critically ill&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">14</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">While adherence to guidelines is one of the ASP goals&#44; AMR may spread fast and guidelines become outdated&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">15</span></a> Furthermore&#44; guidelines are usually issued in HICs reflecting different resources&#44; staffing&#44; training&#44; and AMR patterns&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">16</span></a> The American Thoracic Society &#40;ATS&#41; acknowledged better AMT optimization through individualization rather than rigid guidelines adherence&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">4</span></a> One observational work suggested adherence to guidelines may be associated with increased mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">17</span></a> If local AMR is monitored&#44; Individualized AMT can be preferred &#40;e&#46;g&#46; hospital acquired infections&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">4</span></a> ICUs are sometimes exempt from AMT restriction &#40;an ASP intervention&#41; while surveillance cultures can further blur the boundaries between colonization and infection&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">4&#44;8</span></a> Novel AMT methods may prove challenging for inexperienced prescribers &#40;e&#46;g&#46;&#44; therapeutic drug monitoring &#91;TDM&#93;&#44; pharmacokinetics&#47;pharmacodynamics &#91;PK&#47;PD&#93; concept&#44; continuous&#47;extended infusion&#44; nebulized AMT&#41;&#46; Holding AMT in stable patients had also been suggested but needs expert support&#44; monitoring and rapid diagnostic tests&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">18</span></a> For all the aforementioned reasons&#44; and while guidelines can provide the minimal satisfactory standard&#44; and unless ICU senior team has a high level of expertise&#44; the role of pharmacist and ID specialists remains indispensable for a tailored management&#44; however difficult to achieve&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Review and ADE usually follow 48&#8211;72<span class="elsevierStyleHsp" style=""></span>h after AMT initiation&#46; Such refinement is a precision decision&#58; Individualizing AMT based on microbiological results&#44; imaging and clinical course&#46; In the present survey&#44; intensivists sought non-ICU expertise more frequently on reviewing compared to initiation&#46; However&#44; the practice remained modest in best description &#40;48&#47;72<span class="elsevierStyleHsp" style=""></span>h review&#44; adjustment to culture and discontinuation in 32&#37;&#44; 39&#37; and 21&#37; respectively&#41;&#46; The DIANA study already showed ADE to be an exceptional ICU practice &#40;16&#37; of cases&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">14</span></a> Feedback during AMT review represents an ASP learning strategy and we can point up here a lost educational opportunity&#46; However&#44; a meta-analysis demonstrated no impact of feedback on ICU mortality despite reduction of AMT use&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">19</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">Traditional microbiological results are usually available 12&#8211;72<span class="elsevierStyleHsp" style=""></span>h after AMT initiation&#46; Molecular diagnostic tests provide faster identification of the causative micro-organism and&#44; possibly&#44; antibiotic susceptibility &#40;e&#46;g&#46;&#44; genetic testing&#41;&#46; If applied along with ASP&#44; such tests can improve mortality while reducing AMT use&#44; costs&#44; toxicity and resistance&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">20</span></a> Only two-thirds of respondents reported good knowledge about hospitals&#8217; microbiological diagnostic capabilities&#44; which was even lower in LMICs&#44; and for the less experienced&#46; Such inadequate understanding&#44; may hinder a proper initial timely testing and make subsequent review harder&#46; Our findings suggest the need for proper orientation of such new technology&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">4</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">Collaboration between ID specialists and intensivists may impact patients&#8217; outcome&#46;<a class="elsevierStyleCrossRefs" href="#bib0295"><span class="elsevierStyleSup">21&#8211;23</span></a> A previous survey highlighted the intensivists&#8217; inclination for expert opinion especially where ASP is not in place&#46; However&#44; a considerable percentage of respondents in our work reported the absence of regular ID rounds and variable need for non-ICU expertise according to the settings&#44; background training&#44; and expertise&#46; The involvement of ID specialist in managing <span class="elsevierStyleItalic">Staphylococcus aureus</span> bacteraemia<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">24</span></a> and candidemia<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">25</span></a> were previously shown to be associated with reduction in AMT duration and mortality&#46; However&#44; only one-third of respondents think blood stream or fungal infections require non-ICU expertise&#46; Again&#44; only a quarter considered consultation for viral infections&#46; Taking into account the diagnostic and therapeutic complexity of those infections&#44; we are not sure if the answers reflect an appropriate level of knowledge&#46; To note that only 20&#37; of UK ICUs had intensivists with special interest in fungal diseases&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">26</span></a> This situation may get worse with the emergence of new infections&#44; increasingly complex AMR and the introduction of novel AMT and microbial tests&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">AMR awareness and strengthening knowledge &#40;through training and research&#41; are 2 of 5 objectives of the 2015 WHO global action plan on AMR&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">27</span></a> Both AMR and ASP were recommended as CCM core training competencies&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">4&#44;27</span></a> However&#44; only 42&#37; of intensivists consider their ID training and knowledge adequate&#46; Multivariate analysis showed that LMICs&#44; practice &#8804;10 years&#44; and dual CCM training with anaesthesia or medicine to be independently associated with less training satisfaction&#46; Nevertheless&#44; the insight of a knowledge gap is positive considering previous reports showing absent acknowledgement of the problem&#46;<a class="elsevierStyleCrossRefs" href="#bib0330"><span class="elsevierStyleSup">28&#44;29</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">Competencies recommended by ICU societies<a class="elsevierStyleCrossRefs" href="#bib0340"><span class="elsevierStyleSup">30&#44;31</span></a> are becoming short to meet the evolving threat of ID and AMR &#40;e&#46;g&#46;&#44; COVID-19&#41; and generally lack an updated detailed cover for ICU ID specificities&#46; The &#8216;Competency-Based Training in Intensive Care Medicine in Europe&#8217; &#40;CoBaTrICE&#41; comprises 4 ID&#47;AMT competencies addressing microbiological sampling&#44; managing sepsis&#44; AMT and infection control&#46;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">32</span></a> UK&#44; USA and China issued also their national recommendations covering a variety of AMT&#44; microbial testing&#44; infection control and management&#46;<a class="elsevierStyleCrossRefs" href="#bib0345"><span class="elsevierStyleSup">31&#44;33&#44;34</span></a> However&#44; they remain generally missing in LMICs&#46; Intensivists act usually as independent prescribers and should be able to fulfil the 35 competencies recommended by the European Society of Clinical Microbiology and Infectious Diseases &#40;ESCMID&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">12</span></a> More recently&#44; an ATS workshop recommended ASP as a core ICU competency&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">4</span></a> Pragmatically&#44; 2 tiers of knowledge may be needed&#58; Basic knowledge for every intensivist&#44; and more advanced one for ID-subspecialised intensivists leading ASP&#44; ID research and education&#46; Alternatively&#44; focused ASP training can be implemented when ID expertise is absent &#40;e&#46;g&#46;&#44; LMICs&#41;&#46; Integrating ID&#47;ASP into daily ICU rounds can improve knowledge and awareness while setting ASP as a daily practice&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">4</span></a> Dual ID and ICM training was also proposed&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">35</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">CCM is a multi-disciplinary specialty where diversity and inclusiveness are considered points of strength&#46; Even in developed and closely related countries &#40;e&#46;g&#46;&#44; European Union&#41;&#44; the training pathways for intensivists are not unified&#46;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">36</span></a> Classically&#44; intensivists are initially trained as anaesthetists or internists &#40;or in any medical subspecialty&#41; before acquiring CCM as super-specialty&#46; Less frequently&#44; CCM is a standalone training&#46; Our data show that intensivists trained solely in CCM are seeking generally less non-ICU expertise and follow more personalized approach on initiating AMT&#46; They are also more confident to manage multi-resistant bacterial and viral infections and slightly more satisfied with their ID training&#46; These findings may reflect more profound practical and theoretical ID training for doctors solely trained as intensivists&#46; In this context&#44; Vidal-Cort&#233;s et al&#46; showed that CCM trainees in Spain to have more scheduled time in ID units compared to anaesthetic trainees&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">10</span></a> The different training pathways recently raised concerns about the flexibility of intensivists&#8217; movement across Europe in view of the COVID-19 pandemic&#46;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">36</span></a> We hope our survey by shedding lights on the ICU ID practice can help reforming and unifying ICU ID training&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">The fear of missing a causative pathogen leading to adverse outcome is a drive for excessive AMT rather than knowledge deficit&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">4</span></a> Such fear from legal liabilities &#40;i&#46;e&#46;&#44; defensive medicine&#41; is emerging to impact practice by the mean of unnecessary referrals&#44; unnecessary tests&#47;prescriptions and avoiding high risk procedures&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">37</span></a> In the AntibioLegalMap survey&#44; 75&#37; of ID and CM specialists reported engagement in some form of defensive behaviour&#46;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">38</span></a> 71&#37; of intensivists in our survey admitted a defensive attitude by lowering the threshold to start AMT&#44; or by prescribing longer courses or combinations of AMT &#40;55&#46;2&#37;&#44; 43&#46;8&#37; and 42&#46;7&#37; respectively&#41;&#46; Certain defensive behaviours &#40;e&#46;g&#46;&#44; over prescription or unnecessary invasive procedures&#41; impose risks to patients&#44; while others &#40;e&#46;g&#46;&#44; referral to more specialized physicians&#41; might improve quality of care&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">37</span></a> However&#44; only 21&#37; of respondents think defensive behaviour would lead to seeking non-ICU expertise&#46; Furthermore&#44; AMT may wrongly become a substitute for source control interventions reflecting inadequate awareness of the AMT associated harms&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">We admit many limitations of our work&#46; Surveys are subject to &#8220;response bias&#8255; with possible discrepancies between what is self-reported and actual practice&#46; Despite our aim was to explore the intensivists&#8217; insight and opinion&#44; we appreciate microbiologists&#44; ID doctors or pharmacists may have a different point of view and probably better insight for some aspects of the questionnaire&#46; The survey was focused on the practice of ID in the ICU&#59; however&#44; we did not revisit more complex principles like therapeutic drug monitoring and pharmacodynamics&#47;pharmacokinetics which may be of interest as standalone survey&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">A point of strength is the number of survey responders&#59; however&#44; the target population remains much bigger&#46; Furthermore&#44; there may be &#8220;a participation bias&#8255; where ID-interested intensivists more likely to participate&#46; Most respondents were from either Europe or Asia and the results might be more representative of these regions&#46; Furthermore&#44; the survey targeted intensivists as persons rather than being institutional&#44; so some respondents may be practicing in the same unit and answers were skewed&#46; Despite these limitations&#44; the diversity of respondents&#8217; countries&#44; settings&#44; experience and training are positive points and we believe our data are clearly highlighting a practice variability and gap of knowledge when managing ID in the ICU worldwide&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0175">Conclusions</span><p id="par0180" class="elsevierStylePara elsevierViewall">Infectious diseases practice is heterogeneous across ICUs underscoring the need for a common set of minimal standards&#46; Intensivists feel the need to improve their ID training and knowledge&#46; Such need is more evident in certain settings such in LMICs&#44; but also for part time and less experienced intensivists&#46; In contrast&#44; doctors with CCM as sole training were more satisfied with ID training&#46; This raises the point for a minimal standard set for ID CCM training&#46; There is also a need to issue ICU specific ASP guidance while encouraging a more precise ID approach&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0180">Authors&#8217; contributions</span><p id="par0185" class="elsevierStylePara elsevierViewall">AR and AE designed and disseminated the survey questionnaire&#44; AS reviewed the questionnaire for intellectual content and is responsible for the statistical analysis&#46; AR and AS wrote the first draft&#46; All authors critically revised the manuscript&#46; All authors read and approved the final manuscript&#46;</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0185">Conflict of interest</span><p id="par0190" class="elsevierStylePara elsevierViewall">Ashraf Roshdy declares owning shares in Astra Zeneca&#44; Pfizer and Merk pharmaceutical companies&#46; He gave also unpaid lecture for Pfizer Company&#46; Ahmad Sabry Saleh and Ahmad Samy Elsayed declares no conflict of interest&#46;</p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0190">Funding</span><p id="par0195" class="elsevierStylePara elsevierViewall">This research did not receive any specific grant from funding agencies in the public&#44; commercial&#44; or not-for-profit sectors&#46;</p></span></span>"
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              "identificador" => "sec0040"
              "titulo" => "Knowledge about hospitals&#8217; microbiological diagnostic capabilities&#58; &#40;eTable 2&#44; ESM&#41;"
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              "titulo" => "Initial AMT decision&#58; &#40;Fig&#46; 1 and eTable 3&#44; ESM&#41;"
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              "identificador" => "sec0050"
              "titulo" => "ASP and ID specialists&#8217; rounds&#58; &#40;Fig&#46; 2 and eTable 4&#44; ESM&#41;"
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              "identificador" => "sec0055"
              "titulo" => "Perceptions regarding the need of non-ICU expertise&#58; &#40;Fig&#46; 2 and eTable 5&#44; ESM&#41;"
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              "identificador" => "sec0060"
              "titulo" => "Adequacy of training&#58; &#40;Fig&#46; 3 and eTable 6&#44; ESM&#41;"
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              "identificador" => "sec0065"
              "titulo" => "Impact of defensive medicine on AMT&#58; &#40;Fig&#46; 3 and eTable 7&#44; ESM&#41;"
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          "titulo" => "Discussion"
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          "titulo" => "Conclusions"
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          "identificador" => "sec0080"
          "titulo" => "Authors&#8217; contributions"
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        10 => array:2 [
          "identificador" => "sec0085"
          "titulo" => "Conflict of interest"
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          "identificador" => "sec0090"
          "titulo" => "Funding"
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          "identificador" => "xack630890"
          "titulo" => "Acknowledgements"
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        13 => array:1 [
          "titulo" => "References"
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    "pdfFichero" => "main.pdf"
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    "fechaRecibido" => "2021-04-16"
    "fechaAceptado" => "2021-06-19"
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          "clase" => "keyword"
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            0 => "Antimicrobial stewardship"
            1 => "Antimicrobial therapy"
            2 => "Infection"
            3 => "Intensive Care Unit"
            4 => "Low- to middle-income countries"
            5 => "Survey"
            6 => "Infectious diseases training"
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          "palabras" => array:8 [
            0 => "Administraci&#243;n de antimicrobianos"
            1 => "Terapia antimicrobiana"
            2 => "Infecci&#243;n"
            3 => "Unidad de cuidados intensivos"
            4 => "Pa&#237;ses de ingresos bajos a medianos"
            5 => "Encuestas"
            6 => "Capacitaci&#243;n en enfermedades infecciosas"
            7 => "Medicina defensiva"
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    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Exploring infectious diseases &#40;ID&#41; practice in Intensive Care Unit &#40;ICU&#41; to identify gaps and opportunities&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Design</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Online international survey &#40;PRACT-INF-ICU&#41; endorsed by the ESICM and open from July 30&#44; 2019 to October 19&#44; 2019&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Setting</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">International study conducted in 78 countries&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Participants</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Physicians working in ICU&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Interventions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">None&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Main variables of interest</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Practice variations were assessed according to respondents&#8217; countries income class&#44; training&#44; and years of practice&#46; Univariate and multivariate ordinal logistic regression were used to estimate associations between respondents&#8217; characteristics and their perceptions regarding adequacy of training&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">466 intensivists with a median practice of 10 years &#40;interquartile range&#44; 5&#8211;19&#41; completed the survey&#46; A third reported no antimicrobial stewardship program and 40&#37; had no regular microbiological rounds in their ICUs&#46; Intensivists were mostly the decision makers for the initial antimicrobial therapy which in 70&#37; of cases were based on guidelines or protocols&#46; Non-ICU expertise were sought more frequently on reviewing &#40;48&#47;72<span class="elsevierStyleHsp" style=""></span>h&#44; culture adjustment and discontinuation in 32&#37;&#44; 39&#37; and 21&#37; respectively&#41; rather than antimicrobial therapy initiation &#40;16&#37;&#41;&#46; Only 42&#37; described ID training as adequate&#46; Multivariate ordinal logistic regression showed that low- to middle-income countries &#40;OR&#58; 0&#46;41&#44; 95&#37; CI&#58; 0&#46;28&#8211;0&#46;61&#41;&#44; ICU practice &#8804;10 years &#40;OR&#58; 0&#46;55&#44; 95&#37; CI&#58; 0&#46;39&#8211;0&#46;79&#41;&#44; and dual training with anaesthesia &#40;OR&#58; 0&#46;52&#44; 95&#37; CI&#58; 0&#46;34&#8211;0&#46;79&#41; or medicine &#40;OR&#58; 0&#46;49&#44; 95&#37; CI&#58; 0&#46;32&#8211;0&#46;76&#41; were associated with less training satisfaction&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conclusion</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">ID practice is heterogeneous across ICUs while antimicrobial stewardship program is not universally implemented&#46; From intensivists&#8217; perspective&#44; ID training and knowledge need improvement&#46;</p></span>"
        "secciones" => array:8 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Objective"
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          1 => array:2 [
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            "titulo" => "Design"
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            "identificador" => "abst0015"
            "titulo" => "Setting"
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          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Participants"
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            "identificador" => "abst0025"
            "titulo" => "Interventions"
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            "identificador" => "abst0030"
            "titulo" => "Main variables of interest"
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            "identificador" => "abst0035"
            "titulo" => "Results"
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            "identificador" => "abst0040"
            "titulo" => "Conclusion"
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Objetivo</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Explorar la pr&#225;ctica de enfermedades infecciosas &#40;EI&#41; en unidad de cuidados intensivos &#40;UCI&#41; para identificar lagunas y oportunidades&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Dise&#241;o</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Encuesta internacional online&#46;</p></span> <span id="abst0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">&#255;mbito</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Estudio internacional&#46;</p></span> <span id="abst0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Participantes</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">M&#233;dicos que trabajan en UCI&#46;</p></span> <span id="abst0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Intervenciones</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Ninguna&#46;</p></span> <span id="abst0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Principales variables de inter&#233;s</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Las variaciones de la pr&#225;ctica se evaluaron de acuerdo con la clase de ingresos de los pa&#237;ses encuestados&#44; la formaci&#243;n previa y los a&#241;os de pr&#225;ctica&#46; Se utilizaron an&#225;lisis de regresi&#243;n log&#237;stica ordinal para estimar las asociaciones entre las caracter&#237;sticas de los encuestados y sus percepciones con respecto a la adecuaci&#243;n de la capacitaci&#243;n&#46;</p></span> <span id="abst0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Resultados</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Cuatrocientos sesenta y seis intensivistas completaron la encuesta&#46; Un tercio de los intensivistas inform&#243; que no ten&#237;a un programa de optimizaci&#243;n de antimicrobianos y el 40&#37; no ten&#237;a rondas microbiol&#243;gicas regulares en su UCI&#46; Los intensivistas eran mayoritariamente los iniciadores de la terapia antibi&#243;tica inicial que en el 70&#37; de los casos estaba basada en gu&#237;as cl&#237;nicas y protocolos&#46; La regresi&#243;n log&#237;stica ordinal multivariante mostr&#243; que los pa&#237;ses de ingresos bajos a medianos &#40;OR&#58; 0&#44;41&#59; IC del 95&#37;&#58; 0&#44;28-0&#44;61&#41;&#44; pr&#225;ctica en la UCI &#8804;10 a&#241;os &#40;OR&#58; 0&#44;55&#59; IC del 95&#37;&#58; 0&#44;39-0&#44;79&#41; y entrenamiento dual con anestesiolog&#237;a &#40;OR&#58; 0&#44;52&#59; IC del 95&#37;&#58;0&#44;34&#8211;0&#44;79&#41; o medicina &#40;OR&#58; 0&#44;49&#59; IC del 95&#37;&#58; 0&#44;32&#8211;0&#44;76&#41; se asociaron con una menor satisfacci&#243;n con la capacitaci&#243;n en EI&#46;</p></span> <span id="abst0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conclusiones</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">La pr&#225;ctica en EI es heterog&#233;nea en todas las UCI&#44; mientras que el programa de optimizaci&#243;n de antimicrobianos no se implementa universalmente&#46; Desde la perspectiva de los intensivistas&#44; es necesario mejorar la formaci&#243;n y el conocimiento en EI&#46;</p></span>"
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            "identificador" => "abst0045"
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            "identificador" => "abst0050"
            "titulo" => "Dise&#241;o"
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          2 => array:2 [
            "identificador" => "abst0055"
            "titulo" => "&#255;mbito"
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          3 => array:2 [
            "identificador" => "abst0060"
            "titulo" => "Participantes"
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          4 => array:2 [
            "identificador" => "abst0065"
            "titulo" => "Intervenciones"
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          5 => array:2 [
            "identificador" => "abst0070"
            "titulo" => "Principales variables de inter&#233;s"
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          6 => array:2 [
            "identificador" => "abst0075"
            "titulo" => "Resultados"
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            "identificador" => "abst0080"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Parts of this report were presented at the 33rd annual congress of the European society of intensive care medicine &#40;LIVES DIGITAL 2020&#41;&#44; 6&#8211;9 December 2020&#46;</p>"
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            "titulo" => "Supplementary data"
            "identificador" => "sec0100"
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          "en" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Practice of initial antimicrobial therapy &#40;AMT&#41; decision&#46; ICU&#44; Intensive Care Unit&#59; HICs&#44; high-income countries&#59; LMICs&#44; low- and middle-income countries&#46;</p>"
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          "en" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Antimicrobial stewardship programme implementation &#40;A&#41;&#44; infectious diseases specialists&#8217; rounds per week &#40;B&#41;&#44; and respondents&#8217; perceptions regarding their need of non-ICU expertise &#40;C&#8211;F&#41;&#46; ICU&#44; Intensive Care Unit&#59; HICs&#44; high-income countries&#59; LMICs&#44; low- and middle-income countries&#59; IV&#44; intravenous&#59; AMT&#44; antimicrobial therapy&#59; CNS&#44; central nervous system&#59; MDR&#44; multidrug-resistant&#59; XDR&#44; extensively drug-resistant&#59; PDR&#44; Pandrug-Resistant&#46;</p>"
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          "en" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">Respondents perceptions regarding the adequacy of training in infectious diseases &#40;A and B&#41; and the impact of defensive medicine on AMT &#40;C and D&#41;&#46; ICU&#44; Intensive Care Unit&#59; HICs&#44; high-income countries&#59; LMICs&#44; low- and middle-income countries&#59; AMT&#44; antimicrobial therapy&#59; AMR&#44; antimicrobial resistance&#46;</p>"
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">35 &#40;21&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">North America</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16 &#40;3&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;1&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11 &#40;6&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Oceania</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16 &#40;3&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16 &#40;5&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">South America</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">25 &#40;5&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;0&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">23 &#40;14&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" 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-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Years of practice&#44; median &#40;IQR&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10 &#40;5&#8211;19&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10 &#40;5&#8211;20&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8 &#40;5&#8211;18&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;045&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" 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="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">ESICM membership&#44;</span><span class="elsevierStyleItalic"><span class="elsevierStyleBold">n</span></span><span class="elsevierStyleBold">&#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Member of ESICM</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">309 &#40;66&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">232 &#40;75&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">77 &#40;48&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="4" align="center" valign="middle">&#60;0&#46;001</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Member of infection section&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">181 &#40;38&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">136 &#40;44&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">45 &#40;28&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Not a member of infection section&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">128 &#40;27&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">96 &#40;31&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">32 &#40;20&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Not a member of ESICM</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">157 &#40;33&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">74 &#40;24&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">83 &#40;51&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" 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="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Training&#44;</span><span class="elsevierStyleItalic"><span class="elsevierStyleBold">n</span></span><span class="elsevierStyleBold">&#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Critical Care as sole specialty</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">141 &#40;30&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">79 &#40;25&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">62 &#40;38&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="4" align="center" valign="middle">0&#46;013</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Dual Anaesthesia &#38; Critical Care</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">166 &#40;35&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">122 &#40;39&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">44 &#40;27&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Dual Critical Care &#38; Medicine</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">142 &#40;30&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">95 &#40;31&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">47 &#40;29&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Other</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">17 &#40;3&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10 &#40;3&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7 &#40;4&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" 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="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">ICU time&#44;</span><span class="elsevierStyleItalic"><span class="elsevierStyleBold">n</span></span><span class="elsevierStyleBold">&#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Full time</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">356 &#40;76&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">247 &#40;80&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">109 &#40;68&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="2" align="center" valign="middle">0&#46;003</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Part time</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">110 &#40;23&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">59 &#40;19&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Public non-teaching hospital</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">75 &#40;24&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Private hospital</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Other</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">2 &#40;0&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">1 &#40;0&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">1 &#40;0&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Hospital beds&#44;</span><span class="elsevierStyleItalic"><span class="elsevierStyleBold">n</span></span><span class="elsevierStyleBold">&#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">66 &#40;41&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Critical care beds&#44;</span><span class="elsevierStyleItalic"><span class="elsevierStyleBold">n</span></span><span class="elsevierStyleBold">&#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="5" align="center" valign="middle">0&#46;111</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">11&#8211;15</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">20 &#40;12&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">49 &#40;16&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">33 &#40;10&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16 &#40;10&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#62;24</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">194 &#40;41&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">114 &#40;37&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">80 &#40;50&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">ICU type&#44;</span><span class="elsevierStyleItalic"><span class="elsevierStyleBold">n</span></span><span class="elsevierStyleBold">&#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Medical ICU</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">55 &#40;11&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
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        "texto" => "<p id="par0200" class="elsevierStylePara elsevierViewall">This survey was endorsed by the European Society of Intensive Care Medicine &#40;ESICM&#41;&#46; The participation of intensivists from around the globe in the survey&#44; without financial incentive&#44; is acknowledged gratefully&#46; The authors are indebted to thank Prof&#46; Pedro Povoa and Dr&#46; Andrew Conway Morris &#40;from the infection section of the ESICM&#41; for reviewing the survey questionnaire and for their continued support and guidance&#46; We also thank Ms&#46; Sherihane Bensemmane &#40;ESICM research office&#41; for her valuable support in creating and promoting the online survey&#59; Dr&#46; Ferial Moursi for the critical review of the questionnaire and Dr Jeronimo Moreno-Cuesta for his revision of the final draft&#46;</p>"
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Original article
Intensivists’ perceptions and attitudes towards infectious diseases management in the ICU: An international survey
Percepciones y actitudes de los intensivistas hacia el manejo de enfermedades infecciosas en la UCI: una encuesta internacional
A. Roshdya,b,
Autor para correspondencia
ashraf.roshdy@nhs.net

Corresponding author.
, A.S. Elsayedc, A.S. Salehd
a Intensive Care Unit, North Middlesex University Hospital, London, UK
b Critical Care Medicine Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
c Intensive Care Unit, King Fahd Military Medical Complex, Dhahran, Saudi Arabia
d Alhayat Clinic, Edku, el-Beheira, Egypt
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Half of patients in Intensive Care Units &#40;ICU&#41; suffer infection while 30&#37; die secondary to it&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">1</span></a> Both ICU-acquired infection and antibiotic resistance are associated with an increased risk of death&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">1</span></a> It follows that 70&#37; of ICU patients are receiving antimicrobial therapy &#40;AMT&#41; representing a burden to healthcare costs&#44; predisposing to antimicrobial resistance &#40;AMR&#41; and worsening patients&#8217; outcome&#46;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">1&#44;2</span></a> AMR is more prevalent in low- to middle-income countries &#40;LMICs&#41; than high-income countries &#40;HICs&#41; and feared to cause millions of deaths by 2050&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Antimicrobial stewardship programme &#40;ASP&#41; is a mean of limiting AMR while improving patients&#8217; outcome&#46; It is defined as &#8220;the coordinated interventions designed to improve and measure the appropriate use of AMT by promoting the selection of the optimal drug regimen including dosing&#44; duration of therapy&#44; and route of administration&#8255;&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">3</span></a> It is recommended as a core competency for intensivists and for all ICUs integrating clinicians&#44; pharmacists&#44; infectious disease &#40;ID&#41; physicians and clinical microbiologists &#40;CM&#41; into one multidisciplinary team&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">3&#44;4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Understanding ICU ID practice remains essential for identifying gaps and opportunities&#44; but is generally lacking&#46; We conducted an international online survey &#40;PRACT-INF-ICU&#41; to explore from intensivists&#8217; perspective&#59; &#40;1&#41; the practice of ID in the ICU&#44; &#40;2&#41; their satisfaction with ID training&#44; and &#40;3&#41; the impact of defensive medicine on ICU ID practice&#46; Variability in responses were explored regarding settings &#40;HICs vs LMICs&#41;&#44; background training and experience&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Survey design</span><p id="par0020" class="elsevierStylePara elsevierViewall">PRACT-INF-ICU was an international cross sectional descriptive and analytical internet-based open survey of intensivists&#46; The questionnaire was developed by the survey steering committee then pre-tested for clarity&#44; reliability and validity by 2 non-experts and 2 ICU ID experts&#46; It gained approval by the infection section of the European Society of Intensive Care Medicine &#40;ESICM&#41; then endorsed by the ESICM research committee&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The survey consisted of 26 closed and open-ended questions&#44; including Likert scales and adaptive questioning&#44; divided into 4 sections&#59; &#40;1&#41; respondents&#8217; characteristics &#40;questions 1&#8211;9&#41;&#44; &#40;2&#41; practice of ID management &#40;questions 10&#8211;20&#41;&#44; &#40;3&#41; respondents&#8217; perceptions regarding adequacy of training &#40;questions 21&#8211;24&#41;&#44; and impact of defensive medicine on AMT &#40;questions 24 and 25&#41; in addition to a free text annotation &#40;<a class="elsevierStyleCrossRef" href="#sec0100">eAppendix-1 in the Electronic Supplementary Material &#91;ESM&#93;</a>&#41;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Survey dissemination</span><p id="par0030" class="elsevierStylePara elsevierViewall">The survey used an online platform &#40;SurveyMonkey&#174;&#59; California&#44; USA&#41; from July 30&#44; 2019 to October 19&#44; 2019 &#40;82 days&#41;&#46; It was displayed on the survey page of the ESICM website&#46; ESICM infection section sent 2 invitation emails to all members&#46; Two authors &#40;AR and AE&#41; shared invitations through social media &#40;Facebook and LinkedIn&#41; targeting ICU doctors&#46; All invitations and the ESICM page included a link to the survey page&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The survey was administered anonymously&#44; and the Internet protocol &#40;IP&#41; addresses and identity information were not collected&#46; Unique visitors were determined via IP address but no cookies were used to assign a unique user identifier&#46; IP addresses were not used to identify duplicate entries&#46; The survey consisted of 4 pages &#40;page 1&#59; questions 1&#8211;4&#44; page 2&#59; questions 5&#8211;9&#44; page 3&#59; questions 10&#8211;25 and page 4&#59; question 26&#41;&#46; Respondents were able to change their answers on any page until they completed the survey&#46; Completeness check was displayed as question number&#47;total questions&#46; Submitted data were exported as excel spreadsheet and one copy will be kept in ESICM archives for 5 years &#40;accessible only by ESICM employees and protected by its network security system&#41;&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The survey was voluntary with no incentives for respondents&#44; and consent was implied by participation&#46; Ethical approval was not required due to the anonymous voluntary nature of the study&#46; This report was constructed according to the Checklist for Reporting Results of Internet E-Surveys &#40;CHERRIES&#41; guidelines &#40;<a class="elsevierStyleCrossRef" href="#sec0100">eAppendix-2&#44; ESM</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">5</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Statistical analysis</span><p id="par0045" class="elsevierStylePara elsevierViewall">Only completed surveys were included in the final analyses&#46; Descriptive statistics are presented as either percentage or median &#40;interquartile range &#91;IQR&#93;&#41;&#44; as appropriate&#46; Imputation of missing data was not performed&#46; For descriptive statistics&#44; valid percentages &#40;i&#46;e&#46;&#44; not including missing data&#41; were used&#46; Comparisons between categorical data were done by chi-square test or Fisher&#39;s exact test&#44; as appropriate&#46; Mann&#8211;Whitney <span class="elsevierStyleItalic">U</span> test was used for continuous data&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Practice variations were assessed according to respondents&#8217; countries income class &#40;HICs versus LMICs&#41;&#44; background training &#40;critical care only&#44; anaesthesia and critical care&#44; or medicine and critical care&#41;&#44; and years of practice &#40;categorized as&#59; more experienced &#91;&#62;10 years&#93; or less experienced &#91;&#8804;10 years&#93;&#41;&#46; Respondents&#8217; countries income classes were according to the 2019 gross national income per capita using thresholds defined by the World Bank atlas method&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">6</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">To estimate associations between respondents&#8217; characteristics and their perceptions regarding adequacy of training&#44; we utilized the ordinal logistic regression &#40;OLR&#41; where the five-point Likert-type responses &#40;&#8216;strongly agree&#8217; is the highest response&#41; as the dependent variable&#46; Only characteristics that had a <span class="elsevierStyleItalic">p</span> value &#60;0&#46;1 in the univariate analysis were included in the multivariate analyses&#46; OLR results are given as cumulative odds ratios &#40;ORs&#41; and 95&#37; confidence intervals &#40;CIs&#41;&#46; Reported <span class="elsevierStyleItalic">p</span> values are 2-sided and a <span class="elsevierStyleItalic">p</span> value &#60;0&#46;05 was considered statistically significance&#46; The statistical analysis was performed using SPSS&#174; version 21&#46;0 &#40;IBM&#41;&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Results</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Respondents&#8217; characteristics</span><p id="par0060" class="elsevierStylePara elsevierViewall">The survey was initiated by 561 respondents from 82 countries&#46; Four respondents were not ICU physicians and were excluded&#46; Among the remaining 557 respondents&#44; 446 &#40;83&#46;7&#37;&#41; completed the survey &#40;<a class="elsevierStyleCrossRef" href="#sec0100">eTable 1&#44; ESM</a>&#41; from 74 countries &#40;<a class="elsevierStyleCrossRef" href="#sec0100">eFig&#46; 1</a>&#41; including 26 respondents from Spain&#46; Respondents were from Europe &#40;58&#46;8&#37;&#41;&#44; Asia &#40;23&#37;&#41;&#44; Africa &#40;6&#37;&#41;&#44; South America &#40;5&#46;4&#37;&#41;&#44; North America &#40;3&#46;4&#37;&#41;&#44; and Oceania &#40;3&#46;4&#37;&#41;&#44; including 34&#46;3&#37; from LMICs&#46; They were divided nearly equally into those trained solely in Critical Care Medicine &#40;CCM&#41;&#44; or dually along with medicine or anaesthesia &#40;30&#46;3&#37;&#44; 35&#46;6&#37; and 30&#46;5&#37; respectively&#41;&#46; The median duration of clinical practice was 10 years &#40;IQR&#44; 5&#8211;19&#41;&#44; and 77&#37; were working in mixed ICUs &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Knowledge about hospitals&#8217; microbiological diagnostic capabilities&#58; &#40;<a class="elsevierStyleCrossRef" href="#sec0100">eTable 2&#44; ESM</a>&#41;</span><p id="par0065" class="elsevierStylePara elsevierViewall">Two-thirds of respondents reported good knowledge of their hospitals&#8217; microbiological diagnostic capabilities&#44; which was lower in LMICs compared to HICs &#40;54&#37; vs 73&#37;&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#44; and among less experienced compared to more experienced intensivists &#40;57&#37; vs 76&#37;&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Initial AMT decision&#58; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a> and <a class="elsevierStyleCrossRef" href="#sec0100">eTable 3&#44; ESM</a>&#41;</span><p id="par0070" class="elsevierStylePara elsevierViewall">The majority &#40;70&#37;&#41; of intensivists based their initial AMT decision on guidelines and protocols&#46; An expert opinion within 1 hour was available for 83&#37; of them&#44; yet less frequently in LMICs than HICs &#40;73&#37; vs 88&#37;&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; Initial AMT decision was almost always done by intensivists while non-ICU specialities were less frequently involved &#40;35&#37;&#44; 33&#46;9&#37; and 17&#46;6&#37; for ID specialities&#44; microbiologists&#44; and pharmacists&#44; respectively&#41;&#46; Only 22&#37; of intensivists frequently sought non-ICU opinion &#40;&#62;50&#37; of cases&#41;&#44; which was less likely for more experienced than less experienced intensivists &#40;18&#37; vs 26&#37;&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">ASP and ID specialists&#8217; rounds&#58; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a> and <a class="elsevierStyleCrossRef" href="#sec0100">eTable 4&#44; ESM</a>&#41;</span><p id="par0075" class="elsevierStylePara elsevierViewall">Two-thirds of intensivists reported having ASP in their units and 40&#37; had no regular rounds by ID specialists&#8217;&#46; ASP was less reported in LMICs than HICs &#40;62&#37; vs 68&#37;&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;015&#41;&#44; and 10&#37; of the less experienced intensivists did not know whether they have ASP in their unit or not&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Perceptions regarding the need of non-ICU expertise&#58; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a> and <a class="elsevierStyleCrossRef" href="#sec0100">eTable 5&#44; ESM</a>&#41;</span><p id="par0080" class="elsevierStylePara elsevierViewall">Intensivists felt a greater need for non-ICU expertise on reviewing AMT &#40;48&#47;72<span class="elsevierStyleHsp" style=""></span>h review&#58; 32&#37;&#44; adjustment to culture&#58; 39&#37; and AMT discontinuation&#58; 21&#37;&#41;&#44; however 20&#37; never requiring non-ICU expertise&#46; More experienced intensivists reported significantly less need for non-ICU expertise and 29&#37; of them never asking for such expertise&#46; Only 11&#37; of intensivists with background training in anaesthesia never required non-ICU expertise compared to 26&#37; with medical training background&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Intensivists were more probably asking for expert non-ICU opinion for immunocompromised patients &#40;63&#37;&#41;&#44; central nervous system infections &#40;49&#37;&#41;&#44; non-surgical soft tissue infection &#40;41&#37;&#41;&#44; followed by abdominal sepsis&#44; blood stream and surgical site infections&#46; For bacterial infections&#44; the more resistant the organism&#44; the more often intensivists asked for external advice &#40;55&#37;&#44; 43&#37; and 25&#46;5&#37; of pan-resistant&#44; extended-resistant and multi-resistant organisms&#44; respectively&#41;&#46; In general&#44; intensivists were most likely to ask for secondary opinion when facing resistant bacterial infections than fungal &#40;32&#37;&#41; or viral ones &#40;27&#37;&#41;&#46; The more experienced intensivists and those with sole CCM training or dually with medicine were less likely asking for second ID opinion&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Adequacy of training&#58; &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a> and <a class="elsevierStyleCrossRef" href="#sec0100">eTable 6&#44; ESM</a>&#41;</span><p id="par0090" class="elsevierStylePara elsevierViewall">Only 42&#37; of intensivists agreed the level of knowledge and training in ID in their countries is adequate&#46; Satisfaction was significantly lower in LMICs compared to HICs &#40;29&#37; vs 51&#37;&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; and in less experienced compared to more experienced intensivists &#40;36&#37; vs 51&#37;&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; Doctors trained in CCM as sole specialty are more satisfied with ID training than doctors trained dually along with anaesthesia or medicine &#40;56&#37;&#44; 39&#37; and 36&#37;&#44; respectively&#41;&#46; Almost all respondents &#40;96&#37;&#41; thought there is a need for more training to decrease AMR &#40;85&#37;&#41;&#44; improve patients&#8217; outcome &#40;79&#37;&#41;&#44; and decrease cost &#40;64&#37;&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">Univariate OLR analysis showed that income class&#44; practice years&#44; background training&#44; CCM working time&#44; and ESICM membership were associated with respondents&#8217; perspective regarding adequacy of training&#46; Multivariate analysis showed that LMICs &#40;cumulative odds ratio &#91;OR&#93;&#58; 0&#46;41&#44; 95&#37; CI&#58; 0&#46;28&#8211;0&#46;61&#41;&#44; practice years &#8804;10 years &#40;OR&#58; 0&#46;55&#44; 95&#37; CI&#58; 0&#46;39&#8211;0&#46;79&#41;&#44; and dual CCM training with anaesthesia &#40;OR&#58; 0&#46;52&#44; 95&#37; CI&#58; 0&#46;34&#8211;0&#46;79&#41; or medicine &#40;OR&#58; 0&#46;49&#44; 95&#37; CI&#58; 0&#46;32&#8211;0&#46;76&#41; were independently associated with less ID training satisfaction &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165">Impact of defensive medicine on AMT&#58; &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a> and <a class="elsevierStyleCrossRef" href="#sec0100">eTable 7&#44; ESM</a>&#41;</span><p id="par0100" class="elsevierStylePara elsevierViewall">The majority &#40;71&#37;&#41; of respondents agreed that medicolegal issues and defensive medicine are impacting AMT prescription which was higher in LMICs than HICs &#40;77&#46;5&#37; vs&#46;67&#46;6&#37;&#41;&#46; Defensive practices reduce the threshold to prescribe antibiotics &#40;55&#37;&#41;&#44; and leads to more antibiotic combinations &#40;43&#37;&#41;&#44; longer courses &#40;44&#37;&#41;&#44; less frequent de-escalation &#40;ADE&#41; &#40;46&#37;&#41; and seeking non-ICU expertise &#40;21&#37;&#41;&#46;</p></span></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0170">Discussion</span><p id="par0105" class="elsevierStylePara elsevierViewall">Our survey highlights shortfalls and heterogeneity in managing infectious diseases in the ICU&#46; ASPs are variously implemented and intensivists reported a need for more ID education&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">ASP aims to reduce AMT exposure and to improve patients&#8217; outcomes&#46; Despite valued by most intensivists&#44; ASP implementation remains short&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">7</span></a> In 2012&#44; it was applied in just 58&#37; of hospitals worldwide&#44; with significant variability in policies&#44; strategies&#44; priorities and programmes maturity&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">8</span></a> ASP can vary within the single hospital and while our survey focusses on ICU settings&#44; it draws a similar picture to other hospital settings &#40;1&#47;3 of intensivists reported no ASP&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">8</span></a> Even in developed countries&#44; less than half of French intensivists were aware of ASP&#44; and only 74&#37; of Canadian intensivists reported ASP in their institutions&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">7&#44;9</span></a> A Spanish survey indifferently showed ASP to be implemented nationally in only 37&#37; of ICUs&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">10</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">It is becoming crucial to study the barriers impeding ASP in the ICU&#46; While some are shared across all healthcare settings &#40;e&#46;g&#46;&#44; funds&#44; staffing&#44; clinicians&#8217; resistance and lack of data technology&#41;&#44; others remain ICU specific&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">7</span></a> Most importantly may be the lack of ICU specific ASP studies and guidance&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">4</span></a> Furthermore&#44; conflicts can arise between intensivists&#8217; goals &#40;patient cure&#41; and some perceived ASP targets &#40;AMT use or cost&#41;&#46; A local leadership within the ICU can mitigate most conflicts&#44; compensate for staff shortage and provide the support needed for a successful&#44; sustainable and effective ASP&#46; ICU ID champions were shown also to be associated with better ASP implementation&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">9</span></a> In this context&#44; it is noteworthy the high participation of Spanish intensivists in their units&#8217; ASP programmes&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">10</span></a> Such training in addition to participation in audits and research can provide better insight and unify goals &#40;e&#46;g&#46;&#44; drug toxicity&#44; AMR and long-term impact&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">4</span></a> However&#44; auditing and feedback are known to be among the least applied ASP measures&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">7</span></a> Last&#44; tele-ASP can be the answer for smaller and remote units suffering staff or expertise shortage&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Heterogeneity in ICU ID&#47;ASP practice is not new to report&#44; and our survey is another confirmation&#46;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">9&#44;11</span></a> LMICs intensivists are less exposed to ASP&#44; have less expert opinion and declared greater knowledge gap and need for training&#46; This may reflect inadequate training or be institutional in origin &#40;e&#46;g&#46;&#44; part-time work&#44; smaller or private hospitals&#44; less administrative awareness&#44; lack of data technology and auditing culture&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">8</span></a> ASP was previously shown to be implemented in only 12&#37; of African versus 77&#37; of European hospitals&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">8</span></a> While limited access to AMT risks higher mortality&#44; it also limits choices and proper usage&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">2</span></a> This should raise global concerns as ID and AMR are difficult to contain and a local substandard practice can progress easily across borders&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Despite the availability of expert opinion&#44; intensivists preferred a protocolized over a personalized approach when initiating AMT&#46; An independent AMT prescribers should be able to recognize the need for expertise and co-operate as appropriate&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">12</span></a> However&#44; routine ID consultation is practiced in only 11&#37; of Italian ICUs&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">13</span></a> In Spain&#44; the reference expert is intensivist or anaesthesiologist in 91&#37; of ICUs compared to ID specialist in only 7&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">10</span></a> Lack of expertise risks prescribing higher tier and broader spectrum antibiotics due to diagnostic uncertainty and higher risk of deterioration in the critically ill&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">14</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">While adherence to guidelines is one of the ASP goals&#44; AMR may spread fast and guidelines become outdated&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">15</span></a> Furthermore&#44; guidelines are usually issued in HICs reflecting different resources&#44; staffing&#44; training&#44; and AMR patterns&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">16</span></a> The American Thoracic Society &#40;ATS&#41; acknowledged better AMT optimization through individualization rather than rigid guidelines adherence&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">4</span></a> One observational work suggested adherence to guidelines may be associated with increased mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">17</span></a> If local AMR is monitored&#44; Individualized AMT can be preferred &#40;e&#46;g&#46; hospital acquired infections&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">4</span></a> ICUs are sometimes exempt from AMT restriction &#40;an ASP intervention&#41; while surveillance cultures can further blur the boundaries between colonization and infection&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">4&#44;8</span></a> Novel AMT methods may prove challenging for inexperienced prescribers &#40;e&#46;g&#46;&#44; therapeutic drug monitoring &#91;TDM&#93;&#44; pharmacokinetics&#47;pharmacodynamics &#91;PK&#47;PD&#93; concept&#44; continuous&#47;extended infusion&#44; nebulized AMT&#41;&#46; Holding AMT in stable patients had also been suggested but needs expert support&#44; monitoring and rapid diagnostic tests&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">18</span></a> For all the aforementioned reasons&#44; and while guidelines can provide the minimal satisfactory standard&#44; and unless ICU senior team has a high level of expertise&#44; the role of pharmacist and ID specialists remains indispensable for a tailored management&#44; however difficult to achieve&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Review and ADE usually follow 48&#8211;72<span class="elsevierStyleHsp" style=""></span>h after AMT initiation&#46; Such refinement is a precision decision&#58; Individualizing AMT based on microbiological results&#44; imaging and clinical course&#46; In the present survey&#44; intensivists sought non-ICU expertise more frequently on reviewing compared to initiation&#46; However&#44; the practice remained modest in best description &#40;48&#47;72<span class="elsevierStyleHsp" style=""></span>h review&#44; adjustment to culture and discontinuation in 32&#37;&#44; 39&#37; and 21&#37; respectively&#41;&#46; The DIANA study already showed ADE to be an exceptional ICU practice &#40;16&#37; of cases&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">14</span></a> Feedback during AMT review represents an ASP learning strategy and we can point up here a lost educational opportunity&#46; However&#44; a meta-analysis demonstrated no impact of feedback on ICU mortality despite reduction of AMT use&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">19</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">Traditional microbiological results are usually available 12&#8211;72<span class="elsevierStyleHsp" style=""></span>h after AMT initiation&#46; Molecular diagnostic tests provide faster identification of the causative micro-organism and&#44; possibly&#44; antibiotic susceptibility &#40;e&#46;g&#46;&#44; genetic testing&#41;&#46; If applied along with ASP&#44; such tests can improve mortality while reducing AMT use&#44; costs&#44; toxicity and resistance&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">20</span></a> Only two-thirds of respondents reported good knowledge about hospitals&#8217; microbiological diagnostic capabilities&#44; which was even lower in LMICs&#44; and for the less experienced&#46; Such inadequate understanding&#44; may hinder a proper initial timely testing and make subsequent review harder&#46; Our findings suggest the need for proper orientation of such new technology&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">4</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">Collaboration between ID specialists and intensivists may impact patients&#8217; outcome&#46;<a class="elsevierStyleCrossRefs" href="#bib0295"><span class="elsevierStyleSup">21&#8211;23</span></a> A previous survey highlighted the intensivists&#8217; inclination for expert opinion especially where ASP is not in place&#46; However&#44; a considerable percentage of respondents in our work reported the absence of regular ID rounds and variable need for non-ICU expertise according to the settings&#44; background training&#44; and expertise&#46; The involvement of ID specialist in managing <span class="elsevierStyleItalic">Staphylococcus aureus</span> bacteraemia<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">24</span></a> and candidemia<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">25</span></a> were previously shown to be associated with reduction in AMT duration and mortality&#46; However&#44; only one-third of respondents think blood stream or fungal infections require non-ICU expertise&#46; Again&#44; only a quarter considered consultation for viral infections&#46; Taking into account the diagnostic and therapeutic complexity of those infections&#44; we are not sure if the answers reflect an appropriate level of knowledge&#46; To note that only 20&#37; of UK ICUs had intensivists with special interest in fungal diseases&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">26</span></a> This situation may get worse with the emergence of new infections&#44; increasingly complex AMR and the introduction of novel AMT and microbial tests&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">AMR awareness and strengthening knowledge &#40;through training and research&#41; are 2 of 5 objectives of the 2015 WHO global action plan on AMR&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">27</span></a> Both AMR and ASP were recommended as CCM core training competencies&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">4&#44;27</span></a> However&#44; only 42&#37; of intensivists consider their ID training and knowledge adequate&#46; Multivariate analysis showed that LMICs&#44; practice &#8804;10 years&#44; and dual CCM training with anaesthesia or medicine to be independently associated with less training satisfaction&#46; Nevertheless&#44; the insight of a knowledge gap is positive considering previous reports showing absent acknowledgement of the problem&#46;<a class="elsevierStyleCrossRefs" href="#bib0330"><span class="elsevierStyleSup">28&#44;29</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">Competencies recommended by ICU societies<a class="elsevierStyleCrossRefs" href="#bib0340"><span class="elsevierStyleSup">30&#44;31</span></a> are becoming short to meet the evolving threat of ID and AMR &#40;e&#46;g&#46;&#44; COVID-19&#41; and generally lack an updated detailed cover for ICU ID specificities&#46; The &#8216;Competency-Based Training in Intensive Care Medicine in Europe&#8217; &#40;CoBaTrICE&#41; comprises 4 ID&#47;AMT competencies addressing microbiological sampling&#44; managing sepsis&#44; AMT and infection control&#46;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">32</span></a> UK&#44; USA and China issued also their national recommendations covering a variety of AMT&#44; microbial testing&#44; infection control and management&#46;<a class="elsevierStyleCrossRefs" href="#bib0345"><span class="elsevierStyleSup">31&#44;33&#44;34</span></a> However&#44; they remain generally missing in LMICs&#46; Intensivists act usually as independent prescribers and should be able to fulfil the 35 competencies recommended by the European Society of Clinical Microbiology and Infectious Diseases &#40;ESCMID&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">12</span></a> More recently&#44; an ATS workshop recommended ASP as a core ICU competency&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">4</span></a> Pragmatically&#44; 2 tiers of knowledge may be needed&#58; Basic knowledge for every intensivist&#44; and more advanced one for ID-subspecialised intensivists leading ASP&#44; ID research and education&#46; Alternatively&#44; focused ASP training can be implemented when ID expertise is absent &#40;e&#46;g&#46;&#44; LMICs&#41;&#46; Integrating ID&#47;ASP into daily ICU rounds can improve knowledge and awareness while setting ASP as a daily practice&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">4</span></a> Dual ID and ICM training was also proposed&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">35</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">CCM is a multi-disciplinary specialty where diversity and inclusiveness are considered points of strength&#46; Even in developed and closely related countries &#40;e&#46;g&#46;&#44; European Union&#41;&#44; the training pathways for intensivists are not unified&#46;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">36</span></a> Classically&#44; intensivists are initially trained as anaesthetists or internists &#40;or in any medical subspecialty&#41; before acquiring CCM as super-specialty&#46; Less frequently&#44; CCM is a standalone training&#46; Our data show that intensivists trained solely in CCM are seeking generally less non-ICU expertise and follow more personalized approach on initiating AMT&#46; They are also more confident to manage multi-resistant bacterial and viral infections and slightly more satisfied with their ID training&#46; These findings may reflect more profound practical and theoretical ID training for doctors solely trained as intensivists&#46; In this context&#44; Vidal-Cort&#233;s et al&#46; showed that CCM trainees in Spain to have more scheduled time in ID units compared to anaesthetic trainees&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">10</span></a> The different training pathways recently raised concerns about the flexibility of intensivists&#8217; movement across Europe in view of the COVID-19 pandemic&#46;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">36</span></a> We hope our survey by shedding lights on the ICU ID practice can help reforming and unifying ICU ID training&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">The fear of missing a causative pathogen leading to adverse outcome is a drive for excessive AMT rather than knowledge deficit&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">4</span></a> Such fear from legal liabilities &#40;i&#46;e&#46;&#44; defensive medicine&#41; is emerging to impact practice by the mean of unnecessary referrals&#44; unnecessary tests&#47;prescriptions and avoiding high risk procedures&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">37</span></a> In the AntibioLegalMap survey&#44; 75&#37; of ID and CM specialists reported engagement in some form of defensive behaviour&#46;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">38</span></a> 71&#37; of intensivists in our survey admitted a defensive attitude by lowering the threshold to start AMT&#44; or by prescribing longer courses or combinations of AMT &#40;55&#46;2&#37;&#44; 43&#46;8&#37; and 42&#46;7&#37; respectively&#41;&#46; Certain defensive behaviours &#40;e&#46;g&#46;&#44; over prescription or unnecessary invasive procedures&#41; impose risks to patients&#44; while others &#40;e&#46;g&#46;&#44; referral to more specialized physicians&#41; might improve quality of care&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">37</span></a> However&#44; only 21&#37; of respondents think defensive behaviour would lead to seeking non-ICU expertise&#46; Furthermore&#44; AMT may wrongly become a substitute for source control interventions reflecting inadequate awareness of the AMT associated harms&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">We admit many limitations of our work&#46; Surveys are subject to &#8220;response bias&#8255; with possible discrepancies between what is self-reported and actual practice&#46; Despite our aim was to explore the intensivists&#8217; insight and opinion&#44; we appreciate microbiologists&#44; ID doctors or pharmacists may have a different point of view and probably better insight for some aspects of the questionnaire&#46; The survey was focused on the practice of ID in the ICU&#59; however&#44; we did not revisit more complex principles like therapeutic drug monitoring and pharmacodynamics&#47;pharmacokinetics which may be of interest as standalone survey&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">A point of strength is the number of survey responders&#59; however&#44; the target population remains much bigger&#46; Furthermore&#44; there may be &#8220;a participation bias&#8255; where ID-interested intensivists more likely to participate&#46; Most respondents were from either Europe or Asia and the results might be more representative of these regions&#46; Furthermore&#44; the survey targeted intensivists as persons rather than being institutional&#44; so some respondents may be practicing in the same unit and answers were skewed&#46; Despite these limitations&#44; the diversity of respondents&#8217; countries&#44; settings&#44; experience and training are positive points and we believe our data are clearly highlighting a practice variability and gap of knowledge when managing ID in the ICU worldwide&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0175">Conclusions</span><p id="par0180" class="elsevierStylePara elsevierViewall">Infectious diseases practice is heterogeneous across ICUs underscoring the need for a common set of minimal standards&#46; Intensivists feel the need to improve their ID training and knowledge&#46; Such need is more evident in certain settings such in LMICs&#44; but also for part time and less experienced intensivists&#46; In contrast&#44; doctors with CCM as sole training were more satisfied with ID training&#46; This raises the point for a minimal standard set for ID CCM training&#46; There is also a need to issue ICU specific ASP guidance while encouraging a more precise ID approach&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0180">Authors&#8217; contributions</span><p id="par0185" class="elsevierStylePara elsevierViewall">AR and AE designed and disseminated the survey questionnaire&#44; AS reviewed the questionnaire for intellectual content and is responsible for the statistical analysis&#46; AR and AS wrote the first draft&#46; All authors critically revised the manuscript&#46; All authors read and approved the final manuscript&#46;</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0185">Conflict of interest</span><p id="par0190" class="elsevierStylePara elsevierViewall">Ashraf Roshdy declares owning shares in Astra Zeneca&#44; Pfizer and Merk pharmaceutical companies&#46; He gave also unpaid lecture for Pfizer Company&#46; Ahmad Sabry Saleh and Ahmad Samy Elsayed declares no conflict of interest&#46;</p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0190">Funding</span><p id="par0195" class="elsevierStylePara elsevierViewall">This research did not receive any specific grant from funding agencies in the public&#44; commercial&#44; or not-for-profit sectors&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Exploring infectious diseases &#40;ID&#41; practice in Intensive Care Unit &#40;ICU&#41; to identify gaps and opportunities&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Design</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Online international survey &#40;PRACT-INF-ICU&#41; endorsed by the ESICM and open from July 30&#44; 2019 to October 19&#44; 2019&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Setting</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">International study conducted in 78 countries&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Participants</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Physicians working in ICU&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Interventions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">None&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Main variables of interest</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Practice variations were assessed according to respondents&#8217; countries income class&#44; training&#44; and years of practice&#46; Univariate and multivariate ordinal logistic regression were used to estimate associations between respondents&#8217; characteristics and their perceptions regarding adequacy of training&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">466 intensivists with a median practice of 10 years &#40;interquartile range&#44; 5&#8211;19&#41; completed the survey&#46; A third reported no antimicrobial stewardship program and 40&#37; had no regular microbiological rounds in their ICUs&#46; Intensivists were mostly the decision makers for the initial antimicrobial therapy which in 70&#37; of cases were based on guidelines or protocols&#46; Non-ICU expertise were sought more frequently on reviewing &#40;48&#47;72<span class="elsevierStyleHsp" style=""></span>h&#44; culture adjustment and discontinuation in 32&#37;&#44; 39&#37; and 21&#37; respectively&#41; rather than antimicrobial therapy initiation &#40;16&#37;&#41;&#46; Only 42&#37; described ID training as adequate&#46; Multivariate ordinal logistic regression showed that low- to middle-income countries &#40;OR&#58; 0&#46;41&#44; 95&#37; CI&#58; 0&#46;28&#8211;0&#46;61&#41;&#44; ICU practice &#8804;10 years &#40;OR&#58; 0&#46;55&#44; 95&#37; CI&#58; 0&#46;39&#8211;0&#46;79&#41;&#44; and dual training with anaesthesia &#40;OR&#58; 0&#46;52&#44; 95&#37; CI&#58; 0&#46;34&#8211;0&#46;79&#41; or medicine &#40;OR&#58; 0&#46;49&#44; 95&#37; CI&#58; 0&#46;32&#8211;0&#46;76&#41; were associated with less training satisfaction&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conclusion</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">ID practice is heterogeneous across ICUs while antimicrobial stewardship program is not universally implemented&#46; From intensivists&#8217; perspective&#44; ID training and knowledge need improvement&#46;</p></span>"
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        "resumen" => "<span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Objetivo</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Explorar la pr&#225;ctica de enfermedades infecciosas &#40;EI&#41; en unidad de cuidados intensivos &#40;UCI&#41; para identificar lagunas y oportunidades&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Dise&#241;o</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Encuesta internacional online&#46;</p></span> <span id="abst0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">&#255;mbito</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Estudio internacional&#46;</p></span> <span id="abst0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Participantes</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">M&#233;dicos que trabajan en UCI&#46;</p></span> <span id="abst0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Intervenciones</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Ninguna&#46;</p></span> <span id="abst0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Principales variables de inter&#233;s</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Las variaciones de la pr&#225;ctica se evaluaron de acuerdo con la clase de ingresos de los pa&#237;ses encuestados&#44; la formaci&#243;n previa y los a&#241;os de pr&#225;ctica&#46; Se utilizaron an&#225;lisis de regresi&#243;n log&#237;stica ordinal para estimar las asociaciones entre las caracter&#237;sticas de los encuestados y sus percepciones con respecto a la adecuaci&#243;n de la capacitaci&#243;n&#46;</p></span> <span id="abst0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Resultados</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Cuatrocientos sesenta y seis intensivistas completaron la encuesta&#46; Un tercio de los intensivistas inform&#243; que no ten&#237;a un programa de optimizaci&#243;n de antimicrobianos y el 40&#37; no ten&#237;a rondas microbiol&#243;gicas regulares en su UCI&#46; Los intensivistas eran mayoritariamente los iniciadores de la terapia antibi&#243;tica inicial que en el 70&#37; de los casos estaba basada en gu&#237;as cl&#237;nicas y protocolos&#46; La regresi&#243;n log&#237;stica ordinal multivariante mostr&#243; que los pa&#237;ses de ingresos bajos a medianos &#40;OR&#58; 0&#44;41&#59; IC del 95&#37;&#58; 0&#44;28-0&#44;61&#41;&#44; pr&#225;ctica en la UCI &#8804;10 a&#241;os &#40;OR&#58; 0&#44;55&#59; IC del 95&#37;&#58; 0&#44;39-0&#44;79&#41; y entrenamiento dual con anestesiolog&#237;a &#40;OR&#58; 0&#44;52&#59; IC del 95&#37;&#58;0&#44;34&#8211;0&#44;79&#41; o medicina &#40;OR&#58; 0&#44;49&#59; IC del 95&#37;&#58; 0&#44;32&#8211;0&#44;76&#41; se asociaron con una menor satisfacci&#243;n con la capacitaci&#243;n en EI&#46;</p></span> <span id="abst0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conclusiones</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">La pr&#225;ctica en EI es heterog&#233;nea en todas las UCI&#44; mientras que el programa de optimizaci&#243;n de antimicrobianos no se implementa universalmente&#46; Desde la perspectiva de los intensivistas&#44; es necesario mejorar la formaci&#243;n y el conocimiento en EI&#46;</p></span>"
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">HICs&#40;<span class="elsevierStyleItalic">N</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>306&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th 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" scope="col" style="border-bottom: 2px solid black">LMICs&#40;<span class="elsevierStyleItalic">N</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>160&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th 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" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Continent&#44;</span><span class="elsevierStyleItalic"><span class="elsevierStyleBold">n</span></span><span class="elsevierStyleBold">&#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Africa</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">28 &#40;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">28 &#40;17&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="6" align="center" valign="middle">&#60;0&#46;001</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Asia</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">107 &#40;23&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">44 &#40;14&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">63 &#40;39&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Europe</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">274 &#40;58&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">239 &#40;78&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">35 &#40;21&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">North America</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16 &#40;3&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;1&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11 &#40;6&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Oceania</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16 &#40;3&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16 &#40;5&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">South America</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">25 &#40;5&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;0&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">23 &#40;14&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" 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-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Years of practice&#44; median &#40;IQR&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10 &#40;5&#8211;19&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10 &#40;5&#8211;20&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8 &#40;5&#8211;18&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;045&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" 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="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">ESICM membership&#44;</span><span class="elsevierStyleItalic"><span class="elsevierStyleBold">n</span></span><span class="elsevierStyleBold">&#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Member of ESICM</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">309 &#40;66&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">232 &#40;75&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">77 &#40;48&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="4" align="center" valign="middle">&#60;0&#46;001</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Member of infection section&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">181 &#40;38&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">136 &#40;44&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">45 &#40;28&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Not a member of infection section&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">128 &#40;27&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">96 &#40;31&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">32 &#40;20&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Not a member of ESICM</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">157 &#40;33&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">74 &#40;24&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">83 &#40;51&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" 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="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Training&#44;</span><span class="elsevierStyleItalic"><span class="elsevierStyleBold">n</span></span><span class="elsevierStyleBold">&#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Critical Care as sole specialty</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">141 &#40;30&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">79 &#40;25&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">62 &#40;38&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="4" align="center" valign="middle">0&#46;013</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Dual Anaesthesia &#38; Critical Care</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">166 &#40;35&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">122 &#40;39&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">44 &#40;27&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Dual Critical Care &#38; Medicine</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">142 &#40;30&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">95 &#40;31&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">47 &#40;29&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Other</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">17 &#40;3&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10 &#40;3&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7 &#40;4&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" 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="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">ICU time&#44;</span><span class="elsevierStyleItalic"><span class="elsevierStyleBold">n</span></span><span class="elsevierStyleBold">&#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Full time</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">356 &#40;76&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">247 &#40;80&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">109 &#40;68&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="2" align="center" valign="middle">0&#46;003</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Part time</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">110 &#40;23&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">59 &#40;19&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">51 &#40;31&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" 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="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Hospital type&#44;</span><span class="elsevierStyleItalic"><span class="elsevierStyleBold">n</span></span><span class="elsevierStyleBold">&#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">University&#47;teaching hospital</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">295 &#40;63&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">205 &#40;67&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">90 &#40;56&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="4" align="center" valign="middle">&#60;0&#46;001</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Public non-teaching hospital</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">92 &#40;19&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">75 &#40;24&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">17 &#40;10&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Private hospital</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">77 &#40;16&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">25 &#40;8&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">52 &#40;32&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Other</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;0&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;0&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;0&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" 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="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Hospital beds&#44;</span><span class="elsevierStyleItalic"><span class="elsevierStyleBold">n</span></span><span class="elsevierStyleBold">&#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#60;200</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">64 &#40;13&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">27 &#40;8&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">37 &#40;23&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="4" align="center" valign="middle">&#60;0&#46;001</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">200&#8211;499</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">187 &#40;40&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">121 &#40;39&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">66 &#40;41&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">500&#8211;999</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">136 &#40;29&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">99 &#40;32&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">37 &#40;23&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#62;1000</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">79 &#40;17&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">59 &#40;19&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">20 &#40;12&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" 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="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Critical care beds&#44;</span><span class="elsevierStyleItalic"><span class="elsevierStyleBold">n</span></span><span class="elsevierStyleBold">&#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#8804;10 beds</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">91 &#40;19&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">65 &#40;21&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">26 &#40;16&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="5" align="center" valign="middle">0&#46;111</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">11&#8211;15</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">65 &#40;13&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">45 &#40;14&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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        "identificador" => "xack630890"
        "titulo" => "Acknowledgements"
        "texto" => "<p id="par0200" class="elsevierStylePara elsevierViewall">This survey was endorsed by the European Society of Intensive Care Medicine &#40;ESICM&#41;&#46; The participation of intensivists from around the globe in the survey&#44; without financial incentive&#44; is acknowledged gratefully&#46; The authors are indebted to thank Prof&#46; Pedro Povoa and Dr&#46; Andrew Conway Morris &#40;from the infection section of the ESICM&#41; for reviewing the survey questionnaire and for their continued support and guidance&#46; We also thank Ms&#46; Sherihane Bensemmane &#40;ESICM research office&#41; for her valuable support in creating and promoting the online survey&#59; Dr&#46; Ferial Moursi for the critical review of the questionnaire and Dr Jeronimo Moreno-Cuesta for his revision of the final draft&#46;</p>"
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