First bacteremia outbreak due Achromobacter spp. in hemodialysis patients in Mexico

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(Periodic acid-Schiff stain (PAS) stain, 200×), (B) Immunofluorescence microscopy showing small granular deposits of complement (C3), mainly in the glomerula mesangium (×200). (C) Electron microscopy revealing electron dense deposits in the mesangial matrix (×8000)." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Filipa Silva, Joana Tavares, Rita Pinho Peixeiro, João Oliveira, Diana Fernandes, Ana Castro, Sofia Santos, Rita Coutinho, Cristina Freitas, Josefina Santos, João Pedro Pimentel, Jorge Coutinho, António Cabrita" "autores" => array:13 [ 0 => array:2 [ "nombre" => "Filipa" "apellidos" => "Silva" ] 1 => array:2 [ "nombre" => "Joana" "apellidos" => "Tavares" ] 2 => array:2 [ "nombre" => "Rita Pinho" "apellidos" => "Peixeiro" ] 3 => array:2 [ "nombre" => "João" "apellidos" => "Oliveira" ] 4 => array:2 [ "nombre" => "Diana" "apellidos" => "Fernandes" ] 5 => array:2 [ "nombre" => "Ana" "apellidos" => "Castro" ] 6 => array:2 [ "nombre" => "Sofia" "apellidos" => "Santos" ] 7 => array:2 [ "nombre" => "Rita" "apellidos" => "Coutinho" ] 8 => array:2 [ "nombre" => "Cristina" "apellidos" => "Freitas" ] 9 => array:2 [ "nombre" => "Josefina" "apellidos" => "Santos" ] 10 => array:2 [ "nombre" => "João Pedro" "apellidos" => "Pimentel" ] 11 => array:2 [ "nombre" => "Jorge" "apellidos" => "Coutinho" ] 12 => array:2 [ "nombre" => "António" "apellidos" => "Cabrita" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2013251422000244?idApp=UINPBA000064" "url" => "/20132514/0000004200000001/v1_202204270522/S2013251422000244/v1_202204270522/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S2013251422000207" "issn" => "20132514" "doi" => "10.1016/j.nefroe.2022.02.005" "estado" => "S300" "fechaPublicacion" => "2022-01-01" "aid" => "781" "documento" => "simple-article" "crossmark" => 0 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "cor" "cita" => "Nefrologia (English Version). 2022;42:99-100" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "en" => array:10 [ "idiomaDefecto" => true "cabecera" => "Letter to the Editor" "titulo" => "Story of two sisters with kidney disease: Genetics command" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "99" "paginaFinal" => "100" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Historia de dos hermanas con enfermedad renal: la genética manda" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Mikel Barral-Juez, Carmen García-Rabaneda, Antonio Miguel Poyatos-Andújar, Margarita Martínez-Atienza, Ana Isabel Morales-García, Sonia Morales-Santana, María Luz Bellido-Díaz, Juan Antonio Bravo-Soto, Rafael José Esteban-de la Rosa" "autores" => array:9 [ 0 => array:2 [ "nombre" => "Mikel" "apellidos" => "Barral-Juez" ] 1 => array:2 [ "nombre" => "Carmen" "apellidos" => "García-Rabaneda" ] 2 => array:2 [ "nombre" => "Antonio Miguel" "apellidos" => "Poyatos-Andújar" ] 3 => array:2 [ "nombre" => "Margarita" "apellidos" => "Martínez-Atienza" ] 4 => array:2 [ "nombre" => "Ana Isabel" "apellidos" => "Morales-García" ] 5 => array:2 [ "nombre" => "Sonia" "apellidos" => "Morales-Santana" ] 6 => array:2 [ "nombre" => "María Luz" "apellidos" => "Bellido-Díaz" ] 7 => array:2 [ "nombre" => "Juan Antonio" "apellidos" => "Bravo-Soto" ] 8 => array:2 [ "nombre" => "Rafael José" "apellidos" => "Esteban-de la Rosa" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S021169952030151X" "doi" => "10.1016/j.nefro.2020.09.001" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S021169952030151X?idApp=UINPBA000064" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2013251422000207?idApp=UINPBA000064" "url" => "/20132514/0000004200000001/v1_202204270522/S2013251422000207/v1_202204270522/en/main.assets" ] "en" => array:16 [ "idiomaDefecto" => true "cabecera" => "Letter to the Editor" "titulo" => "First bacteremia outbreak due Achromobacter spp. in hemodialysis patients in Mexico" "tieneTextoCompleto" => true "saludo" => "Dear Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "101" "paginaFinal" => "103" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "José Luis Vázquez Castellanos, Edgar Daniel Copado Villagrana, Blanca Miriam Guadalupe Torres Mendoza, Diana Lizeth Gallegos Durazo, Juana González Plascencia, Adriana Karina Mejía-Zárate" "autores" => array:6 [ 0 => array:3 [ "nombre" => "José Luis" "apellidos" => "Vázquez Castellanos" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 1 => array:4 [ "nombre" => "Edgar Daniel" "apellidos" => "Copado Villagrana" "email" => array:1 [ 0 => "edcovi92@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 2 => array:3 [ "nombre" => "Blanca Miriam Guadalupe" "apellidos" => "Torres Mendoza" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "Diana Lizeth" "apellidos" => "Gallegos Durazo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 4 => array:3 [ "nombre" => "Juana" "apellidos" => "González Plascencia" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 5 => array:3 [ "nombre" => "Adriana Karina" "apellidos" => "Mejía-Zárate" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Hospital General Regional Núm. 110, Instituto Mexicano del Seguro Social, Guadalajara, Jalisco, Mexico" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Unidad de Medicina Familiar Núm. 53, Instituto Mexicano del Seguro Social, Zapopan, Jalisco, Mexico" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Centro de Investigación Biomédica de Occidente, Instituto Mexicano del Seguro Social, Guadalajara, Jalisco, Mexico" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Primer brote de bacteriemia por Achromobacter spp. en pacientes de hemodiálisis en México" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 711 "Ancho" => 1518 "Tamanyo" => 58071 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Epidemic curve graph of cases, according to the date confirmed." ] ] ] "textoCompleto" => "Nosocomial infections are potentially preventable conditions, with a high socioeconomic cost.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> Vascular access for haemodialysis is constantly subjected to manipulation by health personnel, so in these patients the risk of bloodstream infections increases considerably.<a class="elsevierStyleCrossRef" href="#bib0010">2</a>Achromobacter is a non-fermentative, gram-negative aerobic bacillus of the Burkholderiales order, widely distributed in nature.<a class="elsevierStyleCrossRef" href="#bib0015">3</a> It has been obtained from various types of environmental samples from surfaces in hospital units.<a class="elsevierStyleCrossRef" href="#bib0020">4</a> In the context of haemodialysis patients, few cases of infection by this microorganism have been described.<a class="elsevierStyleCrossRefs" href="#bib0025">5,6</a> It has been identified in outbreaks in other patient cohorts, and is often associated with medical care or the use of antiseptic solutions.<a class="elsevierStyleCrossRefs" href="#bib0035">7–10</a> To date, there have been no epidemic outbreaks associated with this bacterium in any type of patient in Mexico.We present an outbreak of bacteraemia caused by two species of Achromobacter in haemodialysis patients at a hospital in Guadalajara, Mexico. The objective was to identify the source of infection to establish measures for its control and to characterise the clinical charactreristics of these cases.The outbreak study was developed between April and July 2019, and all patients assigned to the Haemodialysis Unit (HU) of the hospital were included. Suspected cases were patients who received haemodialysis sessions in the HU during that period and who had a fever or chills after a session. A blood sample was taken from all of them for blood culture.To identify the source of contagion among the patients, samples were collected from surfaces with potential risk of contamination: sinks, haemodialysis machines and chairs, and antiseptic solutions from the catheter insertion site.Of the 207 patients assigned to the HU, 34 (16%) presented with symptoms compatible with bacteraemia. In 17 of these patients, the diagnosis of Achromobacter bacteraemia was confirmed, in 10 cases (59%) Achromobacter xylosoxidans was isolated, and in seven (41%) Achromobacter denitrificans was isolated.All confirmed cases presented chills during the sessions, but in the telephone interview they reported having presented other signs and symptoms. These included fever in six of the cases (35%), tachycardia in 12 (71%), hypotension in four (24%), and tachypnoea in one (6%).It should be noted that all the cases had a temporary catheter for haemodialysis, and 16 of them (94%) had it for more than six months. The main clinical and demographic characteristics are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>On 5 May, the HU reported to the Epidemiological Surveillance Unit (USE) the presence of several apparently associated cases of bacteraemia. The microbiology laboratory (ML) reported the presence of a previously unreported microorganism on the same day. On 15 May, the USE integrated this information and declared the presence of the outbreak in the HU with nine confirmed cases, for which vigilance of hand hygiene measures was intensified and exhaustive cleaning routines were carried out to contain the outbreak without suspending activities. <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a> shows the epidemic curve, according to the date of confirmation of the cases.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>The results of the environmental bacteriological sampling reported the presence of Achromobacter xylosoxidans and Achromobacter denitrificans in the benzalkonium chloride disinfectant solution used, obtained from the bottles used in the haemodialysis area, and in unopened containers from one of the product batches that were found in the unit's warehouse, and the suspension of its use was ordered. In the cultures of the surface samples and other solutions, no growth of any organisms was observed.The confirmed cases were exclusively concentrated in the haemodialysis area, because the disinfectant solution was used only in this service.After the withdrawal of the disinfectant solution from the hospital, there were no more cases. The last case was identified on 18 June and the incident was deemed ended on 1 July.In all cases, the infection was resolved. However, nine patients (53%) were hospitalised to continue with the bacteraemia study protocol, and in three of them the catheter was removed and repositioned the same day. All patients survived the infection and continued with renal replacement therapy without complications.It was concluded that the benzalkonium chloride solution, contaminated at origin, was responsible for the outbreak. In 2015, this solution from the same brand was associated with an outbreak of Serratia marcescens in another HU of a hospital in the same city.FundingNo funding was received for this study.Conflicts of interestThe authors declare that they have no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Funding" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Conflicts of interest" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Vázquez Castellanos JL, Copado Villagrana ED, Torres Mendoza BMG, Gallegos Durazo DL, González Plascencia J, Mejía-Zárate AK. Primer brote de bacteriemia por Achromobacter spp. en pacientes de hemodiálisis en México. Nefrologia. 2022;42:101–103." ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 711 "Ancho" => 1518 "Tamanyo" => 58071 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Epidemic curve graph of cases, according to the date confirmed." ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "SD: standard deviation." "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="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Variable \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Cases of bacteraemia due to Achromobacter spp. \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">N \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">17 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Gender, male/female \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8/9 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Age in years (mean ± SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">52 ± 18 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Vascular access, temporary catheter/arteriovenous fistula \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">17/0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Months since the placement of the vascular access \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">31 ± 33 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Temporary catheter for more than 6 months (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">16 (94) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Diabetes mellitus (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9 (53) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Haemoglobin, g/dl (mean ± SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9 ± 2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Leukocytes, 103/l (mean ± SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 ± 3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Leukocytosis (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 (18) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Leukopenia (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 (18) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Platelets, 103/l (mean ± SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">203 ± 74 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Lymphocytes, 104/μl (mean ± SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 ± 0.6 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Monocytes, 104/μl (mean ± SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.5 ± 0.2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Eosinophils, 104/μl (mean ± SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.2 ± 0.2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Neutrophils, 104/μl (mean ± SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 ± 0.3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Creatinine, mg/dl (mean ± SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9 ± 4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Glucose, mg/dl (mean ± SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">102 ± 65.6 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Urea, mg/dl (mean ± SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">96 ± 50.8 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2885052.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Main clinical and biochemical characteristics of the cases of bacteraemia due to Achromobacter spp." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Infecciones relacionadas con el uso de los catéteres vasculares" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "C. 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Letter to the Editor

Primer brote de bacteriemia por Achromobacter spp. en pacientes de hemodiálisis en México

José Luis Vázquez Castellanosa, Edgar Daniel Copado Villagranab,

Corresponding author

edcovi92@gmail.com

Corresponding author.

, Blanca Miriam Guadalupe Torres Mendozac, Diana Lizeth Gallegos Durazob, Juana González Plascenciaa, Adriana Karina Mejía-Záratea

a Hospital General Regional Núm. 110, Instituto Mexicano del Seguro Social, Guadalajara, Jalisco, Mexico

b Unidad de Medicina Familiar Núm. 53, Instituto Mexicano del Seguro Social, Zapopan, Jalisco, Mexico

c Centro de Investigación Biomédica de Occidente, Instituto Mexicano del Seguro Social, Guadalajara, Jalisco, Mexico

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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Nosocomial infections are potentially preventable conditions&#44; with a high socioeconomic cost&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Vascular access for haemodialysis is constantly subjected to manipulation by health personnel&#44; so in these patients the risk of bloodstream infections increases considerably&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Achromobacter</span> is a non-fermentative&#44; gram-negative aerobic bacillus of the <span class="elsevierStyleItalic">Burkholderiales</span> order&#44; widely distributed in nature&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> It has been obtained from various types of environmental samples from surfaces in hospital units&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> In the context of haemodialysis patients&#44; few cases of infection by this microorganism have been described&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a> It has been identified in outbreaks in other patient cohorts&#44; and is often associated with medical care or the use of antiseptic solutions&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#8211;10</span></a> To date&#44; there have been no epidemic outbreaks associated with this bacterium in any type of patient in Mexico&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">We present an outbreak of bacteraemia caused by two species of <span class="elsevierStyleItalic">Achromobacter</span> in haemodialysis patients at a hospital in Guadalajara&#44; Mexico&#46; The objective was to identify the source of infection to establish measures for its control and to characterise the clinical charactreristics of these cases&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The outbreak study was developed between April and July 2019&#44; and all patients assigned to the Haemodialysis Unit &#40;HU&#41; of the hospital were included&#46; Suspected cases were patients who received haemodialysis sessions in the HU during that period and who had a fever or chills after a session&#46; A blood sample was taken from all of them for blood culture&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">To identify the source of contagion among the patients&#44; samples were collected from surfaces with potential risk of contamination&#58; sinks&#44; haemodialysis machines and chairs&#44; and antiseptic solutions from the catheter insertion site&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Of the 207 patients assigned to the HU&#44; 34 &#40;16&#37;&#41; presented with symptoms compatible with bacteraemia&#46; In 17 of these patients&#44; the diagnosis of <span class="elsevierStyleItalic">Achromobacter</span> bacteraemia was confirmed&#44; in 10 cases &#40;59&#37;&#41; <span class="elsevierStyleItalic">Achromobacter xylosoxidans</span> was isolated&#44; and in seven &#40;41&#37;&#41; <span class="elsevierStyleItalic">Achromobacter denitrificans</span> was isolated&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">All confirmed cases presented chills during the sessions&#44; but in the telephone interview they reported having presented other signs and symptoms&#46; These included fever in six of the cases &#40;35&#37;&#41;&#44; tachycardia in 12 &#40;71&#37;&#41;&#44; hypotension in four &#40;24&#37;&#41;&#44; and tachypnoea in one &#40;6&#37;&#41;&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">It should be noted that all the cases had a temporary catheter for haemodialysis&#44; and 16 of them &#40;94&#37;&#41; had it for more than six months&#46; The main clinical and demographic characteristics are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">On 5 May&#44; the HU reported to the Epidemiological Surveillance Unit &#40;USE&#41; the presence of several apparently associated cases of bacteraemia&#46; The microbiology laboratory &#40;ML&#41; reported the presence of a previously unreported microorganism on the same day&#46; On 15 May&#44; the USE integrated this information and declared the presence of the outbreak in the HU with nine confirmed cases&#44; for which vigilance of hand hygiene measures was intensified and exhaustive cleaning routines were carried out to contain the outbreak without suspending activities&#46; <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a> shows the epidemic curve&#44; according to the date of confirmation of the cases&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">The results of the environmental bacteriological sampling reported the presence of Achromobacter <span class="elsevierStyleItalic">xylosoxidans</span> and <span class="elsevierStyleItalic">Achromobacter denitrificans</span> in the benzalkonium chloride disinfectant solution used&#44; obtained from the bottles used in the haemodialysis area&#44; and in unopened containers from one of the product batches that were found in the unit&#39;s warehouse&#44; and the suspension of its use was ordered&#46; In the cultures of the surface samples and other solutions&#44; no growth of any organisms was observed&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The confirmed cases were exclusively concentrated in the haemodialysis area&#44; because the disinfectant solution was used only in this service&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">After the withdrawal of the disinfectant solution from the hospital&#44; there were no more cases&#46; The last case was identified on 18 June and the incident was deemed ended on 1 July&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">In all cases&#44; the infection was resolved&#46; However&#44; nine patients &#40;53&#37;&#41; were hospitalised to continue with the bacteraemia study protocol&#44; and in three of them the catheter was removed and repositioned the same day&#46; All patients survived the infection and continued with renal replacement therapy without complications&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">It was concluded that the benzalkonium chloride solution&#44; contaminated at origin&#44; was responsible for the outbreak&#46; In 2015&#44; this solution from the same brand was associated with an outbreak of <span class="elsevierStyleItalic">Serratia marcescens</span> in another HU of a hospital in the same city&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0075" class="elsevierStylePara elsevierViewall">No funding was received for this study&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflicts of interest</span><p id="par0080" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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                  \t\t\t\t">Months since the placement of the vascular access&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">31&#8201;&#177;&#8201;33&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Temporary catheter for more than 6 months &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16 &#40;94&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Diabetes mellitus &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9 &#40;53&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Haemoglobin&#44; g&#47;dl &#40;mean&#8201;&#177;&#8201;SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&#8201;&#177;&#8201;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Leukocytes&#44; 10<span class="elsevierStyleSup">3</span>&#47;l &#40;mean&#8201;&#177;&#8201;SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#8201;&#177;&#8201;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Leukocytosis &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;18&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Leukopenia &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;18&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Platelets&#44; 10<span class="elsevierStyleSup">3</span>&#47;l &#40;mean&#8201;&#177;&#8201;SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">203&#8201;&#177;&#8201;74&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Lymphocytes&#44; 10<span class="elsevierStyleSup">4</span>&#47;&#956;l &#40;mean&#8201;&#177;&#8201;SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#8201;&#177;&#8201;0&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Monocytes&#44; 10<span class="elsevierStyleSup">4</span>&#47;&#956;l &#40;mean&#8201;&#177;&#8201;SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;5&#8201;&#177;&#8201;0&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Eosinophils&#44; 10<span class="elsevierStyleSup">4</span>&#47;&#956;l &#40;mean&#8201;&#177;&#8201;SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;2&#8201;&#177;&#8201;0&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Neutrophils&#44; 10<span class="elsevierStyleSup">4</span>&#47;&#956;l &#40;mean&#8201;&#177;&#8201;SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#8201;&#177;&#8201;0&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Creatinine&#44; mg&#47;dl &#40;mean&#8201;&#177;&#8201;SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&#8201;&#177;&#8201;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Glucose&#44; mg&#47;dl &#40;mean&#8201;&#177;&#8201;SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">102&#8201;&#177;&#8201;65&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Urea&#44; mg&#47;dl &#40;mean&#8201;&#177;&#8201;SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">96&#8201;&#177;&#8201;50&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Main clinical and biochemical characteristics of the cases of bacteraemia due to <span class="elsevierStyleItalic">Achromobacter</span> spp&#46;</p>"
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    "bibliografia" => array:2 [
      "titulo" => "References"
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            3 => array:3 [
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                    0 => array:2 [
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                            0 => "P&#46; Justo-Avila"
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                            2 => "M&#46;T&#46; Compte-Jove"
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                      "doi" => "10.3265/Nefrologia.pre2014.May.12141"
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                          "etal" => false
                          "autores" => array:5 [
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                          "etal" => true
                          "autores" => array:6 [
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                            2 => "E&#46; Hosaf"
                            3 => "S&#46; Ozbek"
                            4 => "E&#46; Aldemir"
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                        "volumen" => "17"
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                  "contribucion" => array:1 [
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
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                            2 => "A&#46; Gonz&#225;lez-Garc&#237;a"
                            3 => "A&#46; Bordes-Ben&#237;tez"
                            4 => "I&#46; Horcajada"
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                      "doi" => "10.1007/s10096-007-0311-7"
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                        "tituloSerie" => "Eur J Clin Microbiol Infect Dis"
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            9 => array:3 [
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                      "titulo" => "Nosocomial Colonization and Infection by Achromobacter Xylosoxidans"
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                            0 => "M&#46;E&#46; Reverdy"
                            1 => "J&#46; Freney"
                            2 => "J&#46; Fleurette"
                            3 => "M&#46; Coulet"
                            4 => "M&#46; Surgot"
                            5 => "D&#46; Marmet"
                          ]
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                        "fecha" => "1984"
                        "volumen" => "19"
                        "paginaInicial" => "140"
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Article information

ISSN: 20132514
Original language: English

DOI:10.1016/j.nefroe.2022.03.003

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Year/Month	Html	Pdf	Total

2024 November	12	12	24
2024 October	70	41	111
2024 September	67	32	99
2024 August	89	76	165
2024 July	89	40	129
2024 June	81	52	133
2024 May	90	54	144
2024 April	60	50	110
2024 March	73	50	123
2024 February	74	54	128
2024 January	62	55	117
2023 December	58	46	104
2023 November	82	62	144
2023 October	59	103	162
2023 September	71	72	143
2023 August	51	45	96
2023 July	68	57	125
2023 June	79	40	119
2023 May	71	65	136
2023 April	43	43	86
2023 March	82	30	112
2023 February	63	33	96
2023 January	49	47	96
2022 December	70	51	121
2022 November	69	67	136
2022 October	94	97	191
2022 September	72	49	121
2022 August	74	52	126
2022 July	81	65	146
2022 June	83	54	137
2022 May	76	44	120
2022 April	75	51	126

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