Serratia marcescens bacteraemia outbreak in haemodialysis patients with tunnelled catheters due to colonisation of antiseptic solution. Experience at 4 hospitals

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"apellidos" => "Merino" "email" => array:1 [ 0 => "jluis.merino@salud.madrid.org" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Hanane" "apellidos" => "Bouarich" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Mª José" "apellidos" => "Pita" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "Patricia" "apellidos" => "Martínez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 4 => array:3 [ "nombre" => "Blanca" "apellidos" => "Bueno" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 5 => array:3 [ "nombre" => "Silvia" "apellidos" => "Caldés" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "d" "identificador" => "aff0020" ] ] ] 6 => array:3 [ "nombre" => "Elena" "apellidos" => "Corchete" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "e" "identificador" => "aff0025" ] ] ] 7 => array:3 [ "nombre" => "Mª Teresa" "apellidos" => "Jaldo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "f" "identificador" => "aff0030" ] ] ] 8 => array:3 [ "nombre" => "Beatriz" "apellidos" => "Espejo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 9 => array:3 [ "nombre" => "Vicente" "apellidos" => "Paraíso" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:6 [ 0 => array:3 [ "entidad" => "Sección de Nefrología, Hospital Universitario del Henares, Coslada (Madrid), Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Nefrología, Hospital Universitario Príncipe de Asturias, Alcalá de Henares (Madrid), Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Sección de Medicina Preventiva, Hospital Universitario del Henares, Coslada (Madrid), Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Sección de Nefrología, Hospital Universitario Infanta Sofía, San Sebastián de los Reyes (Madrid), Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Sección de Nefrología, Hospital Universitario Infanta Leonor, Madrid, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Servicio de Nefrología, Complejo Hospitalario de Jaén, Jaén, Spain" "etiqueta" => "f" "identificador" => "aff0030" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Brote de bacteriemia por Serratia marcescens en pacientes portadores de catéteres tunelizados en hemodiálisis secundario a colonización de la solución antiséptica. Experiencia en 4 centros" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 920 "Ancho" => 2636 "Tamanyo" => 69252 ] ] "descripcion" => array:1 [ "en" => "Timeline of the Serratia marcescens outbreak cases." ] ] ] "textoCompleto" => "IntroductionVenous catheters are the alternative for patients who do not have an arteriovenous fistula or functioning prosthesis for renal replacement therapy with haemodialysis. Although the design of the current tunnelled catheters (TCs) has improved, they continue to present higher morbidity and mortality and complication rates than other vascular accesses.<a class="elsevierStyleCrossRefs" href="#bib0140">1–3</a> Infections are the main problem, with a high risk of bacteraemia, which determines the life expectancy of patients on renal replacement therapy.<a class="elsevierStyleCrossRef" href="#bib0155">4</a> Prophylaxis measures for handling the catheters are crucial for preventing this type of complication. Applying an aseptic solution for TC handling is a recommended practice for decreasing the risks in patients with this type of catheter.<a class="elsevierStyleCrossRefs" href="#bib0160">5,6</a> The most common causative agent for catheter-associated bacteraemia is Staphylococcus aureus, with a high associated comorbidity. While other germs are more unusual, secondary bacteraemia with less conventional germs can also be observed.<a class="elsevierStyleCrossRefs" href="#bib0170">7–9</a> We present an unusual outbreak of Serratia marcescens (S. marcescens) bacteraemia in patients with TCs for haemodialysis in 4 hospitals in the Autonomous Community of Madrid.Material and methodsThe study was conducted at 4 sites where cases of S. marcescens bacteraemia were identified in patients with TCs for haemodialysis. On 17 December 2014, after identifying 2 patients with TCs with positive blood cultures for an uncommon germ (S. marcescens), prevention mechanisms were activated because of the possibility of a nosocomial outbreak. The entire haemodialysis unit, the staff, and the possible sites of infection were investigated, starting with using blood cultures to monitor the at-risk patients, those with catheters, prostheses, those using the button-hole technique. Cultures were taken from the lines, dialysis machines, and the aseptic solutions applied per protocol in the units. A retrospective, multi-centre, descriptive study was conducted of all the cases identified from the first event until the outcome was considered over. The objective was to identified the number affected, the patient characteristics, the treatment received, and the course. A case was considered any patient with S. marcescens identified by blood culture with a TC for haemodialysis, whether or not there were associated symptoms. No patients who were not on renal replacement therapy were included. The 4 sites that conducted a joint analysis along with the measures applied are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. The sites were independent, and the treatment regimens were personalised in each hospital. Each site had its own Nephrology and Preventive Medicine section. To establish whether it was the same strain of S. marcescens, genotyping was performed using pulsed-field gel electrophoresis: the blood cultures and the samples from the contaminated solutions had to coincide.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Statistical analysis: The results are expressed as the mean and standard deviation. The median and range are included when required by the series.FindingsThe first case confirmed by blood culture was on December 6th 2014. The outbreak was suspected on December 17th given the presence of 2 other patients with positive blood cultures for the same germ. The outbreak ended on 19 February 2015, the date of the last positive case. Once the outbreak was over, 21 total patients were identified, all with positive blood cultures for S. marcescens and using TCs. Once the first cases were confirmed in different haemodialysis units, it was reported to the heads of Preventative Medicine at each site. During this period, an epidemiological study of the potential sources of infection was conducted according to each site's protocol, including the healthcare staff, materials, and machinery. Preventative control measures were also ramped up. Lastly, 11 male and 10 female patients were affected, with a mean age of 72±10 years. The mean time on haemodialysis of the affected patients was 33±13 months (range: 3–83) and the mean time since the catheter implantation was 22±13 months. The patients did not all coincide in the shifts, dialysis site, or the staff who cared for them. The most common presentation was the onset of hypotension, general discomfort, and shivering, with no fever associated with the bacteraemia in 11 cases, during the dialysis session. Temperature over 38°C was recorded in 7 cases. Three (3) cases whose were diagnosed via positive cultures were asymptomatic. The blood cultures were extracted from the lines during the haemodialysis session, in both the symptomatic and asymptomatic patients. The distribution by site and TC location are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. The treatment regimen was different at the 2 sites with the most patients affected. One used a treatment with ceftazidime IV (2g) after dialysis and antibiotic lock therapy with a solution of the same antibiotic (1ml of 500mg ceftazidime in 50 cc of saline solution, with a heparin solution until completing the catheter branches) for 2 weeks (in 11 patients), after confirming sensitivity. Another site used a regimen with gentamicin IV at a dose of 1mg/kg/body weight after dialysis and antibiotic lock therapy using a solution of ciprofloxacin (3ml of antibiotic [vial 200mg/100ml]+3 cc heparin 5%) for 3 weeks, after verifying sensitivity via antibiogram. Three (3) cases were given oral quinolone given the rareness of the infection, 2 cases also received vancomycin IV (1g after dialysis), one patient received oral ciprofloxacin exclusively, and another ceftriaxone IV (2g after dialysis) along with a ceftazidime lock therapy. The attack rate in the sites with the most cases described was 36.8% (7 patients affected out of 19 with TC catheters) and 46.15% (12 S. marcescens infections in 26 patients with TCs). No patients with prostheses or using the button-hole technique presented bacteraemia and their blood culture screens were negative.Once the risk prevention measures were taken, the potential transmission vectors were reviewed and the healthcare authorities were notified. On December 19th 2014, a report was received regarding the presence of lots of the BohmClorh healthy skin chlorhexidine 2% aqueous solution (250 cc, lots I-33, I-34, and I-35) antiseptic colonised by S. marcescens. A few weeks later, the prohibition on using this solution was expanded to the 0.05% lots. Given that these formulations are routinely applied when handling catheters in these hospitals, this contaminated chlorhexidine was deemed the source of infection. After withdrawing the compromised lots, both the alcoholic and aqueous solution, no new cases were reported. The last recorded case was in February 2015. The timeline of the cases is shown in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>. Sites 3 and 4 presented one isolated episode. At site 1, after the first notification all chlorhexidine solution lots were withdrawn; at site 2 only the 2% lots were withdrawn after the first recommendation and later the 0.05% lots. To establish whether it was the same strain of S. marcescens, genotyping was performed: the blood cultures and the chlorhexidine sample from of the withdrawn lots coincided. The course was favourable in all cases, with no recurring fever, and none of the TCs needed to be removed because of the infection. The only TC removed was scheduled, since the patient recovered residual kidney function. The positive blood culture was detected a posteriori in this case, during the general unit screening. Given the absence of symptoms and that the focal point was removed, no associated antibiotic treatment was started. No patients died due to a complication secondary to the infection.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>DiscussionS. marcescens is a gram-negative bacilli included in the same Enterobacteriaceae family as Klebsiella, Proteus or Escherichia. It is a significant cause of nosocomial infections such as bacteraemia, pneumonia, and urinary tract infections. It commonly affects patients admitted to the ICU and in neonatal units.<a class="elsevierStyleCrossRefs" href="#bib0185">10–12</a> Nosocomial outbreaks in adults are commonly related to colonisation of the respiratory and urinary tracts. It has the ability to colonise the gastrointestinal tract, skin, and inorganic treatment vehicles, as well as to survive in disinfecting substances. Its presence in intensive care units has been described, and although there are descriptions of outbreaks more than 20 years ago in haemodialysis, finding it in dialysis units is rare.<a class="elsevierStyleCrossRefs" href="#bib0200">13,14</a> In a paper published in 1991, the colonisation of the dialysers used at that time was considered the source of the outbreak.<a class="elsevierStyleCrossRef" href="#bib0210">15</a> Presently this possibility is very low with the current control and sterilisation methods.Bacteraemia-associated morbidity and mortality secondary to catheter infection is high, and therefore the care measures for TCs are extreme in haemodialysis units.<a class="elsevierStyleCrossRefs" href="#bib0145">2,4</a> It is well known that the contamination rates were reduced in the equipment involved, with good training and periodic retraining; with special attention to hand washing, as different papers have made it clear.<a class="elsevierStyleCrossRefs" href="#bib0215">16,17</a> Nevertheless, despite these measures, bacteraemia occurs and accounts for one of the main causes of death in haemodialysis patients. Applying antiseptic solutions prior to handling the TCs is an accepted practice for decreasing the risks of infection.<a class="elsevierStyleCrossRefs" href="#bib0160">5,18</a> The high attack rate and the onset of cases in a short period of time at several sites at the same time suggested the presence of a common vehicle. Although all sites applied conventional prevention measures, the fact that the source of contamination was the antiseptic solution used resulted in a high infection rate. Initially, the withdrawal notice was only associated with a chlorhexidine concentration, although it was later extended to all concentrations, given the common origin. This fact is likely the one that led to the outbreak being prolonged. Although all concentrations in the haemodialysis unit were removed at site 1, at site 2 other formulations were kept, according to the recommendations from the healthcare authorities, until the definitive indication to completely withdraw all the dosage forms from the same brand.In turn, only the patients with TCs were affected, with no bacteraemia being detected in other patients who were also potentially at risk, such as the patients with PTFE prostheses or using the button-hole technique. This makes it clear that the TC patients had a higher exposure to the contaminated solutions.The most commonly implicated germ in TC-associated bacteraemia is Staphylococcus aureus, although bacteraemia can also be secondary to other gram-positive or gram-negative bacteria, and even of fungal origin.<a class="elsevierStyleCrossRef" href="#bib0170">7</a> In general, for any secondary bacteraemia in catheters, its removal is indicated as the main measure.<a class="elsevierStyleCrossRefs" href="#bib0230">19,20</a> Nevertheless, in haemodialysis patients with TCs, pharmacological treatment is acceptable if no severity criteria are met in order to avoid removing the TC, given its vital condition as a vascular access.<a class="elsevierStyleCrossRef" href="#bib0240">21</a> A situation of severe sepsis, haemodynamic instability, presence of infection elsewhere, evidence of complicated tunnel-associated infection, persistent fever for 48–72h after starting antibiotic therapy or finding infection by Pseudomonas, Candida, or other fungal infections, as well as detecting multi-resistant pathogens or resistant Staphylococcus aureus are criteria for removing a colonised TC.<a class="elsevierStyleCrossRef" href="#bib0245">22</a> In our series, the patients did not meet the severity criteria and pharmacological treatment was used. TC maintenance is a reasonable treatment option if the bacteraemia is not accompanied by severity criteria, as proposed by some guidelines. In these conditions, attempting IV antibiotic therapy for at least 2 weeks is acceptable.<a class="elsevierStyleCrossRef" href="#bib0250">23</a> This treatment should include, as some studies have previously demonstrated, along with systemic antibiotics (oral or IV), TC antibiotic lock therapy.<a class="elsevierStyleCrossRefs" href="#bib0240">21,24</a>It is known that the presence of a biofilm in the catheter can act as a reservoir; therefore, the treatment should include this antibiotic lock therapy.<a class="elsevierStyleCrossRef" href="#bib0260">25</a> In our series, the treatment was established with an IV regimen and catheter lock therapy based on the antibiogram, applying two different formulations that showed similar results. Both the ceftazidime and the gentamicin were effective with gram-negative bacteria, and although there is more experience with gentamicin in dialysis, it can cause more side effects.<a class="elsevierStyleCrossRefs" href="#bib0265">26,27</a> Although the antibiotic therapy regimens are usually advised for 2 weeks of treatment, site 1 opted to lengthen it to 3 weeks given the uncertainty of the course with an atypical germ.<a class="elsevierStyleCrossRefs" href="#bib0245">22,24</a> In our series, the course was favourable, without requiring the TC to be removed and with no significant associated complications. The early treatment and practice of using lock therapy probably enabled this outcome, once the source of contamination was removed from the haemodialysis units.ConclusionsThe appearance of bacteraemia caused by an unconventional germ like S. marcescens should put us on alert in haemodialysis units. Colonisation in aseptic solutions is rare, but it can occur. Therefore it should be a vector to be analysed in these situations. Treatment should be as early as possible and it should include TC antibiotic lock therapy. Removing the catheter may not be necessary if no severity criteria are present. Fast action, collaboration of all the facilities, and applying screening measures are key for interrupting the spread of the outbreak and achieving a favourable course for the infections. In this situation the main risk factor was using a TC. Therefore, as long as it is possible, it would be advisable to insist on reducing the number of TCs in the dialysis units.Conflicts of interestNone." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres803820" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec802009" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres803821" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec802010" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Material and methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Findings" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusions" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflicts of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-11-09" "fechaAceptado" => "2016-05-10" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec802009" "palabras" => array:4 [ 0 => "Bacteraemia" 1 => "Serratia" 2 => "Catheters" 3 => "Hemodialysis" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec802010" "palabras" => array:4 [ 0 => "Bacteriemia" 1 => "Serratia" 2 => "Catéteres" 3 => "Hemodiálisis" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "IntroductionThe application of antiseptic solution for handling tunnelled catheters is recommended in patients undergoing haemodialysis. These routine antiseptic procedures in handling catheters are crucial to avoid complications. We report an outbreak of Serratia marcescens (S. marcescens) bacteraemia in numerous haemodialysis units of the Community of Madrid. Material and methodsThe first cases of bacteraemia due to S. marcescens were isolated in December 2014. The Preventive Medicine Services were informed of the detection of an atypical pathogen in several patients, suspecting a probable nosocomial outbreak. Information from 4 centres with similar S. marcescens bacteraemia was analysed. ResultsTwenty-one cases of bacteraemia related to S. marcescens were identified. The mean age of affected patients was 72±10 years. The mean time on haemodialysis of affected patients was 33±13 months (range: 3–83 months), the median time of tunnelled catheter was 22±13 months. In 11 cases the clinical picture was similar, with hypotension and general malaise during the haemodialysis session. Fever was present in a further 7 cases. In 3 cases the presentation was asymptomatic and was detected by blood cultures. All patients had tunnelled catheters (12 patients with catheter in the right jugular vein, 5 in the left jugular, 2 in the right femoral artery and 2 in the left subclavian artery). Gentamicin intravenous doses (1mg/kg) with catheter lock solution with ciprofloxacin post-dialysis were administered for 3 weeks in 6 patients. In 12 patients the treatment was ceftazidime (2g IV) plus catheter lock solution with the same antibiotic, for 2 weeks. Four patients received oral ciprofloxacin for 2 weeks, in one case together with IV vancomycin. The patients were asymptomatic and without new episodes 48h after the treatment. No major complications were observed. The teams informed the health authorities of the situation, which then reported the presence of batches of antiseptic (chlorhexidine 0.05 and 2%) colonised by S. marcescens. Given the routine application of this antiseptic in handling catheters at these units, this was considered the source of contagion and new cases were not observed after the removal of the batches. ConclusionsThe presence of bacteraemia due to unconventional germs should alert us to a potential outbreak. The application of a solution contaminated by S. marcescens in haemodialysis catheters was the source of bacteraemia. The intravenous antibiotic treatment and the catheter lock solution allowed an excellent survival of patients and catheters." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "IntroducciónLa aplicación de una solución antiséptica previa al uso de los catéteres tunelizados es una práctica recomendada. Estas medidas habituales en la manipulación de los catéteres para hemodiálisis son cruciales para evitar complicaciones. Presentamos un brote de infección por Serratia marcescens (S. marcescens) en varias unidades de hemodiálisis de la Comunidad Autónoma de Madrid. Material y métodosLos primeros casos de bacteriemia por S. marcescens fueron aislados en diciembre de 2014. La detección de un germen infrecuente en varios pacientes se puso en conocimiento de los Servicios de Medicina Preventiva por sospecha de probable brote nosocomial. Se recogieron datos de 4 centros donde se detectaron episodios de bacteriemias similares por S. marcescens. ResultadosFueron detectados un total de 21 casos de bacteriemia por S. marcescens. La edad media de los pacientes era de 72±10 años. El tiempo medio en hemodiálisis de los pacientes afectados era de 33±13 meses (rango: 3–83), el tiempo medio del catéter tunelizado era de 22±13 meses. En 11 casos el cuadro clínico fue semejante, caracterizado por hipotensión y malestar general durante la sesión de hemodiálisis. En otros 7 pacientes se asoció fiebre. En 3 casos la forma de presentación fue asintomática y se detectó por hemocultivos. Todos eran portadores de catéteres tunelizados (12 pacientes con catéter en la vena yugular derecha, 5 en la yugular izquierda, 2en la femoral derecha y 2 en la subclavia izquierda). El tratamiento que se aplicó en 6 casos fue gentamicina posdiálisis intravenosa (1mg/kg) más sellado del catéter con solución de ciprofloxacino durante 3 semanas. En 12 pacientes el tratamiento fue ceftazidima 2g iv más sellado de catéter con el mismo antibiótico durante 2semanas. Cuatro pacientes recibieron dosis de ciprofloxacino oral, en un caso se asoció a vancomicina iv, durante 2semanas. A las 48h de iniciar el tratamiento, los pacientes quedaron asintomáticos y no presentaron nuevos episodios. No se observó ninguna complicación mayor. Esta situación fue comunicada por los equipos a las autoridades sanitarias. Posteriormente, se notificó la presencia de lotes de antiséptico de clorhexidina acuosa al 0,05 y 2% colonizados por S. marcescens. Dada la aplicación de forma rutinaria del antiséptico en el manejo de los catéteres en estas unidades, este fue considerado el foco de contagio. Tras la retirada de los lotes no acontecieron nuevos casos. ConclusionesLas bacteriemias por gérmenes no convencionales deben ponernos sobre aviso para investigar posibles brotes. La aplicación de una solución contaminada por S. marcescens en los catéteres en hemodiálisis fue la vía de bacteriemia. El tratamiento antibiótico intravenoso y el sellado de los catéteres permitió una excelente supervivencia tanto de los pacientes como de los catéteres." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Merino JL, Bouarich H, Pita S, Martínez P, Bueno B, Caldés S, et al. Brote de bacteriemia por Serratia marcescens en pacientes portadores de catéteres tunelizados en hemodiálisis secundario a colonización de la solución antiséptica. Experiencia en 4 centros. Nefrología. 2016;36:667–673." ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 920 "Ancho" => 2636 "Tamanyo" => 69252 ] ] "descripcion" => array:1 [ "en" => "Timeline of the Serratia marcescens outbreak cases." ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "Site 1: Hospital Univ. del Henares; Site 2: Hospital Univ. Príncipe de Asturias; Site 3: Hospital Univ. Infanta Leonor; Site 4: Hospital Univ. Infanta Sofía; F: Female; HD: haemodialysis; IV: intravenous; LJ: left jugular; LS: left subclavian; M: male; PO: oral; RF: right femoral; RJ: right jugular; TC: tunnelled catheter; Treatment A: Gentamicin IV (1mg/kg/body weight)+ciprofloxacin lock therapy; Treatment B: ceftazidime 2g IV+ceftazidime lock therapy; Treatment C: ciprofloxacin PO+vancomycin IV+gentamicin lock therapy." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Patient no. \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Site \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Sex \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Age \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">TC Position \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Time in HD (months) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Time with the TC (months) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Type of treatment \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Duration of treatment (days) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Dosage form \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">75 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">RJ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Ciprofloxacin PO+treatment A \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Bacteraemia with no fever \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">83 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">LJ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">83 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">83 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Ciprofloxacin PO+treatment A \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Fever \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">74 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">RF \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">54 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">37 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Levofloxacin PO+treatment A \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Fever \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">64 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">RJ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">24 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">23 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Treatment A \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Fever \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">59 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">RJ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Levofloxacin PO+treatment A \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Fever \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">82 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">RJ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">38 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">27 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Treatment A \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Asymptomatic \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">75 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">RJ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Withdrawal of TC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Asymptomatic \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">67 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">LS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">35 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">26 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Treatment B \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Asymptomatic \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">75 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">RJ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Vancomycin IV+treatment B \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Bacteraemia with no fever \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">65 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">LJ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">67 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">26 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Treatment B \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Bacteraemia with no fever \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">73 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">RJ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">37 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">36 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Treatment B \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Bacteraemia with no fever \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">50 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">RJ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Treatment B \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Bacteraemia with no fever \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">77 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">RJ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">47 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">26 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Treatment B \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Fever \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">78 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">LJ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">19 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Ceftriaxone IV+ceftazidime lock therapy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Fever \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">72 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">LJ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">25 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Treatment B \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Fever \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">58 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">RJ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Treatment B \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Bacteraemia with no fever \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">17 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">80 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">LJ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Treatment B \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Bacteraemia with no fever \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">81 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">RF \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">51 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Treatment B \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Bacteraemia with no fever \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">19 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">77 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">LS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">62 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">26 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Treatment B \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Bacteraemia with no fever \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">71 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">RJ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">48 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">45 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Ciprofloxacin PO \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Bacteraemia with no fever \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">89 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">RJ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">31 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">31 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Treatment C \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Bacteraemia with no fever \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1349412.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "Serratia marcescens identified after withdrawing TC due to recovering residual kidney function." ] ] ] "descripcion" => array:1 [ "en" => "Patient 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Original article

Brote de bacteriemia por Serratia marcescens en pacientes portadores de catéteres tunelizados en hemodiálisis secundario a colonización de la solución antiséptica. Experiencia en 4 centros

José L. Merinoa,

Corresponding author

jluis.merino@salud.madrid.org

Corresponding author.

, Hanane Bouarichb, Mª José Pitac, Patricia Martínezb, Blanca Buenoa, Silvia Caldésd, Elena Corchetee, Mª Teresa Jaldof, Beatriz Espejoa, Vicente Paraísoa

a Sección de Nefrología, Hospital Universitario del Henares, Coslada (Madrid), Spain

b Servicio de Nefrología, Hospital Universitario Príncipe de Asturias, Alcalá de Henares (Madrid), Spain

c Sección de Medicina Preventiva, Hospital Universitario del Henares, Coslada (Madrid), Spain

d Sección de Nefrología, Hospital Universitario Infanta Sofía, San Sebastián de los Reyes (Madrid), Spain

e Sección de Nefrología, Hospital Universitario Infanta Leonor, Madrid, Spain

f Servicio de Nefrología, Complejo Hospitalario de Jaén, Jaén, Spain

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    "titulo" => "<span class="elsevierStyleItalic">Serratia marcescens</span> bacteraemia outbreak in haemodialysis patients with tunnelled catheters due to colonisation of antiseptic solution&#46; Experience at 4 hospitals"
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        "titulo" => "Brote de bacteriemia por <span class="elsevierStyleItalic">Serratia marcescens</span> en pacientes portadores de cat&#233;teres tunelizados en hemodi&#225;lisis secundario a colonizaci&#243;n de la soluci&#243;n antis&#233;ptica&#46; Experiencia en 4 centros"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Timeline of the <span class="elsevierStyleItalic">Serratia marcescens</span> outbreak cases&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Venous catheters are the alternative for patients who do not have an arteriovenous fistula or functioning prosthesis for renal replacement therapy with haemodialysis&#46; Although the design of the current tunnelled catheters &#40;TCs&#41; has improved&#44; they continue to present higher morbidity and mortality and complication rates than other vascular accesses&#46;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">1&#8211;3</span></a> Infections are the main problem&#44; with a high risk of bacteraemia&#44; which determines the life expectancy of patients on renal replacement therapy&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">4</span></a> Prophylaxis measures for handling the catheters are crucial for preventing this type of complication&#46; Applying an aseptic solution for TC handling is a recommended practice for decreasing the risks in patients with this type of catheter&#46;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">5&#44;6</span></a> The most common causative agent for catheter-associated bacteraemia is <span class="elsevierStyleItalic">Staphylococcus aureus</span>&#44; with a high associated comorbidity&#46; While other germs are more unusual&#44; secondary bacteraemia with less conventional germs can also be observed&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">7&#8211;9</span></a> We present an unusual outbreak of <span class="elsevierStyleItalic">Serratia marcescens</span> &#40;<span class="elsevierStyleItalic">S&#46; marcescens</span>&#41; bacteraemia in patients with TCs for haemodialysis in 4 hospitals in the Autonomous Community of Madrid&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><p id="par0010" class="elsevierStylePara elsevierViewall">The study was conducted at 4 sites where cases of <span class="elsevierStyleItalic">S&#46; marcescens</span> bacteraemia were identified in patients with TCs for haemodialysis&#46; On 17 December 2014&#44; after identifying 2 patients with TCs with positive blood cultures for an uncommon germ &#40;<span class="elsevierStyleItalic">S&#46; marcescens</span>&#41;&#44; prevention mechanisms were activated because of the possibility of a nosocomial outbreak&#46; The entire haemodialysis unit&#44; the staff&#44; and the possible sites of infection were investigated&#44; starting with using blood cultures to monitor the at-risk patients&#44; those with catheters&#44; prostheses&#44; those using the <span class="elsevierStyleItalic">button-hole</span> technique&#46; Cultures were taken from the lines&#44; dialysis machines&#44; and the aseptic solutions applied per protocol in the units&#46; A retrospective&#44; multi-centre&#44; descriptive study was conducted of all the cases identified from the first event until the outcome was considered over&#46; The objective was to identified the number affected&#44; the patient characteristics&#44; the treatment received&#44; and the course&#46; A case was considered any patient with <span class="elsevierStyleItalic">S&#46; marcescens</span> identified by blood culture with a TC for haemodialysis&#44; whether or not there were associated symptoms&#46; No patients who were not on renal replacement therapy were included&#46; The 4 sites that conducted a joint analysis along with the measures applied are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; The sites were independent&#44; and the treatment regimens were personalised in each hospital&#46; Each site had its own Nephrology and Preventive Medicine section&#46; To establish whether it was the same strain of <span class="elsevierStyleItalic">S&#46; marcescens</span>&#44; genotyping was performed using pulsed-field gel electrophoresis&#58; the blood cultures and the samples from the contaminated solutions had to coincide&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Statistical analysis&#58; The results are expressed as the mean and standard deviation&#46; The median and range are included when required by the series&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Findings</span><p id="par0020" class="elsevierStylePara elsevierViewall">The first case confirmed by blood culture was on December 6<span class="elsevierStyleSup">th</span> 2014&#46; The outbreak was suspected on December 17<span class="elsevierStyleSup">th</span> given the presence of 2 other patients with positive blood cultures for the same germ&#46; The outbreak ended on 19 February 2015&#44; the date of the last positive case&#46; Once the outbreak was over&#44; 21 total patients were identified&#44; all with positive blood cultures for <span class="elsevierStyleItalic">S&#46; marcescens</span> and using TCs&#46; Once the first cases were confirmed in different haemodialysis units&#44; it was reported to the heads of Preventative Medicine at each site&#46; During this period&#44; an epidemiological study of the potential sources of infection was conducted according to each site&#39;s protocol&#44; including the healthcare staff&#44; materials&#44; and machinery&#46; Preventative control measures were also ramped up&#46; Lastly&#44; 11 male and 10 female patients were affected&#44; with a mean age of 72<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>10 years&#46; The mean time on haemodialysis of the affected patients was 33<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>13 months &#40;range&#58; 3&#8211;83&#41; and the mean time since the catheter implantation was 22<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>13 months&#46; The patients did not all coincide in the shifts&#44; dialysis site&#44; or the staff who cared for them&#46; The most common presentation was the onset of hypotension&#44; general discomfort&#44; and shivering&#44; with no fever associated with the bacteraemia in 11 cases&#44; during the dialysis session&#46; Temperature over 38<span class="elsevierStyleHsp" style=""></span>&#176;C was recorded in 7 cases&#46; Three &#40;3&#41; cases whose were diagnosed via positive cultures were asymptomatic&#46; The blood cultures were extracted from the lines during the haemodialysis session&#44; in both the symptomatic and asymptomatic patients&#46; The distribution by site and TC location are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; The treatment regimen was different at the 2 sites with the most patients affected&#46; One used a treatment with ceftazidime IV &#40;2<span class="elsevierStyleHsp" style=""></span>g&#41; after dialysis and antibiotic lock therapy with a solution of the same antibiotic &#40;1<span class="elsevierStyleHsp" style=""></span>ml of 500<span class="elsevierStyleHsp" style=""></span>mg ceftazidime in 50 cc of saline solution&#44; with a heparin solution until completing the catheter branches&#41; for 2 weeks &#40;in 11 patients&#41;&#44; after confirming sensitivity&#46; Another site used a regimen with gentamicin IV at a dose of 1<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;body weight after dialysis and antibiotic lock therapy using a solution of ciprofloxacin &#40;3<span class="elsevierStyleHsp" style=""></span>ml of antibiotic &#91;vial 200<span class="elsevierStyleHsp" style=""></span>mg&#47;100<span class="elsevierStyleHsp" style=""></span>ml&#93;<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>3 cc heparin 5&#37;&#41; for 3 weeks&#44; after verifying sensitivity via antibiogram&#46; Three &#40;3&#41; cases were given oral quinolone given the rareness of the infection&#44; 2 cases also received vancomycin IV &#40;1<span class="elsevierStyleHsp" style=""></span>g after dialysis&#41;&#44; one patient received oral ciprofloxacin exclusively&#44; and another ceftriaxone IV &#40;2<span class="elsevierStyleHsp" style=""></span>g after dialysis&#41; along with a ceftazidime lock therapy&#46; The attack rate in the sites with the most cases described was 36&#46;8&#37; &#40;7 patients affected out of 19 with TC catheters&#41; and 46&#46;15&#37; &#40;12 <span class="elsevierStyleItalic">S&#46; marcescens</span> infections in 26 patients with TCs&#41;&#46; No patients with prostheses or using the <span class="elsevierStyleItalic">button-hole</span> technique presented bacteraemia and their blood culture screens were negative&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Once the risk prevention measures were taken&#44; the potential transmission vectors were reviewed and the healthcare authorities were notified&#46; On December 19<span class="elsevierStyleSup">th</span> 2014&#44; a report was received regarding the presence of lots of the BohmClorh healthy skin chlorhexidine 2&#37; aqueous solution &#40;250 cc&#44; lots I-33&#44; I-34&#44; and I-35&#41; antiseptic colonised by <span class="elsevierStyleItalic">S&#46; marcescens</span>&#46; A few weeks later&#44; the prohibition on using this solution was expanded to the 0&#46;05&#37; lots&#46; Given that these formulations are routinely applied when handling catheters in these hospitals&#44; this contaminated chlorhexidine was deemed the source of infection&#46; After withdrawing the compromised lots&#44; both the alcoholic and aqueous solution&#44; no new cases were reported&#46; The last recorded case was in February 2015&#46; The timeline of the cases is shown in <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#46; Sites 3 and 4 presented one isolated episode&#46; At site 1&#44; after the first notification all chlorhexidine solution lots were withdrawn&#59; at site 2 only the 2&#37; lots were withdrawn after the first recommendation and later the 0&#46;05&#37; lots&#46; To establish whether it was the same strain of <span class="elsevierStyleItalic">S&#46; marcescens</span>&#44; genotyping was performed&#58; the blood cultures and the chlorhexidine sample from of the withdrawn lots coincided&#46; The course was favourable in all cases&#44; with no recurring fever&#44; and none of the TCs needed to be removed because of the infection&#46; The only TC removed was scheduled&#44; since the patient recovered residual kidney function&#46; The positive blood culture was detected a posteriori in this case&#44; during the general unit screening&#46; Given the absence of symptoms and that the focal point was removed&#44; no associated antibiotic treatment was started&#46; No patients died due to a complication secondary to the infection&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0030" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">S&#46; marcescens</span> is a gram-negative bacilli included in the same Enterobacteriaceae family as <span class="elsevierStyleItalic">Klebsiella&#44; Proteus</span> or <span class="elsevierStyleItalic">Escherichia</span>&#46; It is a significant cause of nosocomial infections such as bacteraemia&#44; pneumonia&#44; and urinary tract infections&#46; It commonly affects patients admitted to the ICU and in neonatal units&#46;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">10&#8211;12</span></a> Nosocomial outbreaks in adults are commonly related to colonisation of the respiratory and urinary tracts&#46; It has the ability to colonise the gastrointestinal tract&#44; skin&#44; and inorganic treatment vehicles&#44; as well as to survive in disinfecting substances&#46; Its presence in intensive care units has been described&#44; and although there are descriptions of outbreaks more than 20 years ago in haemodialysis&#44; finding it in dialysis units is rare&#46;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">13&#44;14</span></a> In a paper published in 1991&#44; the colonisation of the dialysers used at that time was considered the source of the outbreak&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">15</span></a> Presently this possibility is very low with the current control and sterilisation methods&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Bacteraemia-associated morbidity and mortality secondary to catheter infection is high&#44; and therefore the care measures for TCs are extreme in haemodialysis units&#46;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">2&#44;4</span></a> It is well known that the contamination rates were reduced in the equipment involved&#44; with good training and periodic retraining&#59; with special attention to hand washing&#44; as different papers have made it clear&#46;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">16&#44;17</span></a> Nevertheless&#44; despite these measures&#44; bacteraemia occurs and accounts for one of the main causes of death in haemodialysis patients&#46; Applying antiseptic solutions prior to handling the TCs is an accepted practice for decreasing the risks of infection&#46;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">5&#44;18</span></a> The high attack rate and the onset of cases in a short period of time at several sites at the same time suggested the presence of a common vehicle&#46; Although all sites applied conventional prevention measures&#44; the fact that the source of contamination was the antiseptic solution used resulted in a high infection rate&#46; Initially&#44; the withdrawal notice was only associated with a chlorhexidine concentration&#44; although it was later extended to all concentrations&#44; given the common origin&#46; This fact is likely the one that led to the outbreak being prolonged&#46; Although all concentrations in the haemodialysis unit were removed at site 1&#44; at site 2 other formulations were kept&#44; according to the recommendations from the healthcare authorities&#44; until the definitive indication to completely withdraw all the dosage forms from the same brand&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">In turn&#44; only the patients with TCs were affected&#44; with no bacteraemia being detected in other patients who were also potentially at risk&#44; such as the patients with PTFE prostheses or using the <span class="elsevierStyleItalic">button-hole</span> technique&#46; This makes it clear that the TC patients had a higher exposure to the contaminated solutions&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The most commonly implicated germ in TC-associated bacteraemia is <span class="elsevierStyleItalic">Staphylococcus aureus</span>&#44; although bacteraemia can also be secondary to other gram-positive or gram-negative bacteria&#44; and even of fungal origin&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">7</span></a> In general&#44; for any secondary bacteraemia in catheters&#44; its removal is indicated as the main measure&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">19&#44;20</span></a> Nevertheless&#44; in haemodialysis patients with TCs&#44; pharmacological treatment is acceptable if no severity criteria are met in order to avoid removing the TC&#44; given its vital condition as a vascular access&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">21</span></a> A situation of severe sepsis&#44; haemodynamic instability&#44; presence of infection elsewhere&#44; evidence of complicated tunnel-associated infection&#44; persistent fever for 48&#8211;72<span class="elsevierStyleHsp" style=""></span>h after starting antibiotic therapy or finding infection by <span class="elsevierStyleItalic">Pseudomonas</span>&#44; Candida&#44; or other fungal infections&#44; as well as detecting multi-resistant pathogens or resistant <span class="elsevierStyleItalic">Staphylococcus aureus</span> are criteria for removing a colonised TC&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">22</span></a> In our series&#44; the patients did not meet the severity criteria and pharmacological treatment was used&#46; TC maintenance is a reasonable treatment option if the bacteraemia is not accompanied by severity criteria&#44; as proposed by some guidelines&#46; In these conditions&#44; attempting IV antibiotic therapy for at least 2 weeks is acceptable&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">23</span></a> This treatment should include&#44; as some studies have previously demonstrated&#44; along with systemic antibiotics &#40;oral or IV&#41;&#44; TC antibiotic lock therapy&#46;<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">21&#44;24</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">It is known that the presence of a biofilm in the catheter can act as a reservoir&#59; therefore&#44; the treatment should include this antibiotic lock therapy&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">25</span></a> In our series&#44; the treatment was established with an IV regimen and catheter lock therapy based on the antibiogram&#44; applying two different formulations that showed similar results&#46; Both the ceftazidime and the gentamicin were effective with gram-negative bacteria&#44; and although there is more experience with gentamicin in dialysis&#44; it can cause more side effects&#46;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">26&#44;27</span></a> Although the antibiotic therapy regimens are usually advised for 2 weeks of treatment&#44; site 1 opted to lengthen it to 3 weeks given the uncertainty of the course with an atypical germ&#46;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">22&#44;24</span></a> In our series&#44; the course was favourable&#44; without requiring the TC to be removed and with no significant associated complications&#46; The early treatment and practice of using lock therapy probably enabled this outcome&#44; once the source of contamination was removed from the haemodialysis units&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conclusions</span><p id="par0055" class="elsevierStylePara elsevierViewall">The appearance of bacteraemia caused by an unconventional germ like <span class="elsevierStyleItalic">S&#46; marcescens</span> should put us on alert in haemodialysis units&#46; Colonisation in aseptic solutions is rare&#44; but it can occur&#46; Therefore it should be a vector to be analysed in these situations&#46; Treatment should be as early as possible and it should include TC antibiotic lock therapy&#46; Removing the catheter may not be necessary if no severity criteria are present&#46; Fast action&#44; collaboration of all the facilities&#44; and applying screening measures are key for interrupting the spread of the outbreak and achieving a favourable course for the infections&#46; In this situation the main risk factor was using a TC&#46; Therefore&#44; as long as it is possible&#44; it would be advisable to insist on reducing the number of TCs in the dialysis units&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflicts of interest</span><p id="par0060" class="elsevierStylePara elsevierViewall">None&#46;</p></span></span>"
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          "titulo" => "Keywords"
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          "titulo" => "Resumen"
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              "titulo" => "Introducci&#243;n"
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            1 => "Serratia"
            2 => "Catheters"
            3 => "Hemodialysis"
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            0 => "Bacteriemia"
            1 => "Serratia"
            2 => "Cat&#233;teres"
            3 => "Hemodi&#225;lisis"
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    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The application of antiseptic solution for handling tunnelled catheters is recommended in patients undergoing haemodialysis&#46; These routine antiseptic procedures in handling catheters are crucial to avoid complications&#46; We report an outbreak of <span class="elsevierStyleItalic">Serratia marcescens</span> &#40;<span class="elsevierStyleItalic">S&#46; marcescens</span>&#41; bacteraemia in numerous haemodialysis units of the Community of Madrid&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The first cases of bacteraemia due to <span class="elsevierStyleItalic">S&#46; marcescens</span> were isolated in December 2014&#46; The Preventive Medicine Services were informed of the detection of an atypical pathogen in several patients&#44; suspecting a probable nosocomial outbreak&#46; Information from 4 centres with similar <span class="elsevierStyleItalic">S&#46; marcescens</span> bacteraemia was analysed&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Twenty-one cases of bacteraemia related to <span class="elsevierStyleItalic">S&#46; marcescens</span> were identified&#46; The mean age of affected patients was 72<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>10 years&#46; The mean time on haemodialysis of affected patients was 33<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>13 months &#40;range&#58; 3&#8211;83 months&#41;&#44; the median time of tunnelled catheter was 22<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>13 months&#46; In 11 cases the clinical picture was similar&#44; with hypotension and general malaise during the haemodialysis session&#46; Fever was present in a further 7 cases&#46; In 3 cases the presentation was asymptomatic and was detected by blood cultures&#46; All patients had tunnelled catheters &#40;12 patients with catheter in the right jugular vein&#44; 5 in the left jugular&#44; 2 in the right femoral artery and 2 in the left subclavian artery&#41;&#46; Gentamicin intravenous doses &#40;1<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#41; with catheter lock solution with ciprofloxacin post-dialysis were administered for 3 weeks in 6 patients&#46; In 12 patients the treatment was ceftazidime &#40;2<span class="elsevierStyleHsp" style=""></span>g IV&#41; plus catheter lock solution with the same antibiotic&#44; for 2 weeks&#46; Four patients received oral ciprofloxacin for 2 weeks&#44; in one case together with IV vancomycin&#46; The patients were asymptomatic and without new episodes 48<span class="elsevierStyleHsp" style=""></span>h after the treatment&#46; No major complications were observed&#46; The teams informed the health authorities of the situation&#44; which then reported the presence of batches of antiseptic &#40;chlorhexidine 0&#46;05 and 2&#37;&#41; colonised by <span class="elsevierStyleItalic">S&#46; marcescens&#46;</span> Given the routine application of this antiseptic in handling catheters at these units&#44; this was considered the source of contagion and new cases were not observed after the removal of the batches&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The presence of bacteraemia due to unconventional germs should alert us to a potential outbreak&#46; The application of a solution contaminated by <span class="elsevierStyleItalic">S&#46; marcescens</span> in haemodialysis catheters was the source of bacteraemia&#46; The intravenous antibiotic treatment and the catheter lock solution allowed an excellent survival of patients and catheters&#46;</p></span>"
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          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Introduction"
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          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Material and methods"
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            "titulo" => "Results"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La aplicaci&#243;n de una soluci&#243;n antis&#233;ptica previa al uso de los cat&#233;teres tunelizados es una pr&#225;ctica recomendada&#46; Estas medidas habituales en la manipulaci&#243;n de los cat&#233;teres para hemodi&#225;lisis son cruciales para evitar complicaciones&#46; Presentamos un brote de infecci&#243;n por <span class="elsevierStyleItalic">Serratia marcescens</span> &#40;<span class="elsevierStyleItalic">S&#46; marcescens</span>&#41; en varias unidades de hemodi&#225;lisis de la Comunidad Aut&#243;noma de Madrid&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Los primeros casos de bacteriemia por <span class="elsevierStyleItalic">S&#46; marcescens</span> fueron aislados en diciembre de 2014&#46; La detecci&#243;n de un germen infrecuente en varios pacientes se puso en conocimiento de los Servicios de Medicina Preventiva por sospecha de probable brote nosocomial&#46; Se recogieron datos de 4 centros donde se detectaron episodios de bacteriemias similares por <span class="elsevierStyleItalic">S&#46; marcescens&#46;</span></p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Fueron detectados un total de 21 casos de bacteriemia por <span class="elsevierStyleItalic">S&#46; marcescens&#46;</span> La edad media de los pacientes era de 72<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>10 a&#241;os&#46; El tiempo medio en hemodi&#225;lisis de los pacientes afectados era de 33<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>13 meses &#40;rango&#58; 3&#8211;83&#41;&#44; el tiempo medio del cat&#233;ter tunelizado era de 22<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>13 meses&#46; En 11 casos el cuadro cl&#237;nico fue semejante&#44; caracterizado por hipotensi&#243;n y malestar general durante la sesi&#243;n de hemodi&#225;lisis&#46; En otros 7 pacientes se asoci&#243; fiebre&#46; En 3 casos la forma de presentaci&#243;n fue asintom&#225;tica y se detect&#243; por hemocultivos&#46; Todos eran portadores de cat&#233;teres tunelizados &#40;12 pacientes con cat&#233;ter en la vena yugular derecha&#44; 5 en la yugular izquierda&#44; 2<span class="elsevierStyleHsp" style=""></span>en la femoral derecha y 2 en la subclavia izquierda&#41;&#46; El tratamiento que se aplic&#243; en 6 casos fue gentamicina posdi&#225;lisis intravenosa &#40;1<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#41; m&#225;s sellado del cat&#233;ter con soluci&#243;n de ciprofloxacino durante 3 semanas&#46; En 12 pacientes el tratamiento fue ceftazidima 2<span class="elsevierStyleHsp" style=""></span>g iv m&#225;s sellado de cat&#233;ter con el mismo antibi&#243;tico durante 2<span class="elsevierStyleHsp" style=""></span>semanas&#46; Cuatro pacientes recibieron dosis de ciprofloxacino oral&#44; en un caso se asoci&#243; a vancomicina iv&#44; durante 2<span class="elsevierStyleHsp" style=""></span>semanas&#46; A las 48<span class="elsevierStyleHsp" style=""></span>h de iniciar el tratamiento&#44; los pacientes quedaron asintom&#225;ticos y no presentaron nuevos episodios&#46; No se observ&#243; ninguna complicaci&#243;n mayor&#46; Esta situaci&#243;n fue comunicada por los equipos a las autoridades sanitarias&#46; Posteriormente&#44; se notific&#243; la presencia de lotes de antis&#233;ptico de clorhexidina acuosa al 0&#44;05 y 2&#37; colonizados por <span class="elsevierStyleItalic">S&#46; marcescens</span>&#46; Dada la aplicaci&#243;n de forma rutinaria del antis&#233;ptico en el manejo de los cat&#233;teres en estas unidades&#44; este fue considerado el foco de contagio&#46; Tras la retirada de los lotes no acontecieron nuevos casos&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Las bacteriemias por g&#233;rmenes no convencionales deben ponernos sobre aviso para investigar posibles brotes&#46; La aplicaci&#243;n de una soluci&#243;n contaminada por <span class="elsevierStyleItalic">S&#46; marcescens</span> en los cat&#233;teres en hemodi&#225;lisis fue la v&#237;a de bacteriemia&#46; El tratamiento antibi&#243;tico intravenoso y el sellado de los cat&#233;teres permiti&#243; una excelente supervivencia tanto de los pacientes como de los cat&#233;teres&#46;</p></span>"
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            "titulo" => "Introducci&#243;n"
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          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "Material y m&#233;todos"
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          2 => array:2 [
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            "titulo" => "Resultados"
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            "titulo" => "Conclusiones"
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Please cite this article as&#58; Merino JL&#44; Bouarich H&#44; Pita S&#44; Mart&#237;nez P&#44; Bueno B&#44; Cald&#233;s S&#44; et al&#46; Brote de bacteriemia por <span class="elsevierStyleItalic">Serratia marcescens</span> en pacientes portadores de cat&#233;teres tunelizados en hemodi&#225;lisis secundario a colonizaci&#243;n de la soluci&#243;n antis&#233;ptica&#46; Experiencia en 4 centros&#46; Nefrolog&#237;a&#46; 2016&#59;36&#58;667&#8211;673&#46;</p>"
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        "etiqueta" => "Fig&#46; 1"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Timeline of the <span class="elsevierStyleItalic">Serratia marcescens</span> outbreak cases&#46;</p>"
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        "etiqueta" => "Table 1"
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          "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Site 1&#58; Hospital Univ&#46; del Henares&#59; Site 2&#58; Hospital Univ&#46; Pr&#237;ncipe de Asturias&#59; Site 3&#58; Hospital Univ&#46; Infanta Leonor&#59; Site 4&#58; Hospital Univ&#46; Infanta Sof&#237;a&#59; F&#58; Female&#59; HD&#58; haemodialysis&#59; IV&#58; intravenous&#59; LJ&#58; left jugular&#59; LS&#58; left subclavian&#59; M&#58; male&#59; PO&#58; oral&#59; RF&#58; right femoral&#59; RJ&#58; right jugular&#59; TC&#58; tunnelled catheter&#59; Treatment A&#58; Gentamicin IV &#40;1<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;body weight&#41;<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>ciprofloxacin lock therapy&#59; Treatment B&#58; ceftazidime 2<span class="elsevierStyleHsp" style=""></span>g IV<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>ceftazidime lock therapy&#59; Treatment C&#58; ciprofloxacin PO<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>vancomycin IV<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>gentamicin lock therapy&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Patient no&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Site&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Sex&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Age&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">TC Position&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Time in HD &#40;months&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Time with the TC &#40;months&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Type of treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Duration of treatment &#40;days&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Dosage form&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">75&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RJ&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Ciprofloxacin PO<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>treatment A&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Bacteraemia with no fever&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">83&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">LJ&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">83&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">83&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Ciprofloxacin PO<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>treatment A&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Fever&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">74&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">54&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">37&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Levofloxacin PO<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>treatment A&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Fever&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">64&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RJ&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Treatment A&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Fever&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">59&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RJ&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Levofloxacin PO<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>treatment A&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Fever&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">82&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RJ&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Treatment A&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Asymptomatic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">75&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RJ&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Withdrawal of TC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Asymptomatic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">67&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">LS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">26&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Treatment B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Asymptomatic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">75&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RJ&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Vancomycin IV<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>treatment B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Bacteraemia with no fever&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">65&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">LJ&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">67&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">26&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Treatment B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Bacteraemia with no fever&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">73&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RJ&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">37&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">36&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Treatment B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Bacteraemia with no fever&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RJ&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Treatment B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Bacteraemia with no fever&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">77&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RJ&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">47&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">26&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Treatment B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Fever&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">78&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">LJ&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Ceftriaxone IV<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>ceftazidime lock therapy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Fever&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">72&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">LJ&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Treatment B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Fever&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">58&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RJ&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Treatment B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Bacteraemia with no fever&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">80&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">LJ&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Treatment B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Bacteraemia with no fever&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">81&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">51&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Treatment B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Bacteraemia with no fever&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">77&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">LS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">62&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">26&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Treatment B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Bacteraemia with no fever&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">71&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RJ&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">48&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">45&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Ciprofloxacin PO&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Bacteraemia with no fever&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">89&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RJ&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Treatment C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Bacteraemia with no fever&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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Article information

ISSN: 20132514
Original language: English

DOI:10.1016/j.nefroe.2016.05.010

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2023 April	95	17	112
2023 March	95	23	118
2023 February	80	19	99
2023 January	88	23	111
2022 December	125	29	154
2022 November	123	35	158
2022 October	104	37	141
2022 September	74	32	106
2022 August	71	40	111
2022 July	87	45	132
2022 June	105	34	139
2022 May	95	37	132
2022 April	92	47	139
2022 March	100	41	141
2022 February	108	42	150
2022 January	120	47	167
2021 December	75	40	115
2021 November	86	41	127
2021 October	152	48	200
2021 September	96	39	135
2021 August	109	68	177
2021 July	79	34	113
2021 June	73	42	115
2021 May	112	48	160
2021 April	202	74	276
2021 March	447	39	486
2021 February	136	44	180
2021 January	93	20	113
2020 December	62	21	83
2020 November	69	13	82
2020 October	42	22	64
2020 September	53	27	80
2020 August	56	24	80
2020 July	61	25	86
2020 June	65	26	91
2020 May	86	15	101
2020 April	50	13	63
2020 March	54	23	77
2020 February	68	28	96
2020 January	98	27	125
2019 December	92	31	123
2019 November	87	27	114
2019 October	82	21	103
2019 September	78	26	104
2019 August	64	30	94
2019 July	50	22	72
2019 June	58	21	79
2019 May	40	27	67
2019 April	94	73	167
2019 March	49	33	82
2019 February	34	21	55
2019 January	40	23	63
2018 December	147	39	186
2018 November	268	27	295
2018 October	195	33	228
2018 September	127	23	150
2018 August	130	25	155
2018 July	59	15	74
2018 June	51	16	67
2018 May	82	17	99
2018 April	95	23	118
2018 March	75	9	84
2018 February	88	9	97
2018 January	116	7	123
2017 December	128	7	135
2017 November	75	18	93
2017 October	39	9	48
2017 September	64	33	97
2017 August	65	49	114
2017 July	108	48	156
2017 June	131	18	149
2017 May	126	17	143
2017 April	127	3089	3216
2017 March	105	11	116
2017 February	76	15	91
2017 January	73	13	86

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