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Brief report
Penicillin-susceptible Staphylococcus aureus bacteremia: Epidemiological and clinical relevance. Possible therapeutic implications
Bacteriemia por Staphylococcus aureus sensible a penicilina. Importancia epidemiológica, clínica y posibles implicaciones terapéuticas
Carmen Aspiroza,
Corresponding author
carmenaspiroz@gmail.com

Corresponding author.
, Olouwafemi Mistourath Mamab, Rosa M. Martínez-Álvarezc, Laura Ruiz-Ripab, Sara Ceballosb, Carmen Torresb
a Sección de Microbiología, Hospital Royo Villanova, Zaragoza, Spain
b Área de Bioquímica y Biología Molecular, Universidad de La Rioja, Logroño, La Rioja, Spain
c Servicio de Enfermedades Infecciosas, Hospital Miguel Servet, Zaragoza, Spain
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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"><span class="elsevierStyleItalic">Staphylococcus aureus</span> &#40;SA&#41; bacteraemia is an entity with special relevance due to its frequency&#44; severity and high mortality&#46; In the treatment of Methicillin-susceptible SA &#40;MSSA&#41; bacteraemia&#44; the timeliness of suitable treatment is very important&#46; In targeted therapy there is controversy about the use of different beta-lactams&#44; with cloxacillin and cefazolin as first-line&#44; and poorer results with second and third generation cephalosporins and beta-lactams with beta-lactamase inhibitors&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Regarding penicillin&#44; due to its high resistance&#44; it is not generally used for these treatments&#44; especially in bacteraemia&#46; However&#44; in addition to the vast experience with this antibiotic over decades&#44; recent works indicate that it still has points in its favour for even standing as a treatment of choice for SA infections susceptible to this antibiotic &#40;SA-Pen<span class="elsevierStyleSup">S</span>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;4</span></a> These points include&#58; 1&#41; MIC values 10&#8211;50 times lower and a lower percentage of protein binding than cloxacillin&#59; 2&#41; the time above the MIC is longer than other antimicrobials&#44; including cefazolin<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>&#59; 3&#41; narrower spectrum than other options&#44; including first-generation cephalosporins &#40;thus related to fewer infections by <span class="elsevierStyleItalic">Clostridium difficile</span>&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> and 4&#41; less selection of <span class="elsevierStyleItalic">mecA</span> and <span class="elsevierStyleItalic">mecC</span>-mediated methicillin resistance&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In various countries around the world there is a growing trend in penicillin-sensitive SA&#44; especially in invasive infections like bacteraemia&#46; Data from the USA&#44;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;8&#8211;10</span></a> Canada&#44;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Europe &#40;Sweden&#44;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;11</span></a> Finland<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> and Denmark<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&#41; or from Australia and New Zealand<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> exemplify this phenomenon&#44; including penicillin in a kind of &#34;second chance&#34;&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Penicillin resistance in <span class="elsevierStyleItalic">mecA</span>-negative SA strains is due to the production of beta-lactamases encoded by the <span class="elsevierStyleItalic">bla</span>Z gene&#46; There are several phenotypic methods for its detection&#44; such as the nitrocefin test or the reading of the halo edge of penicillin on disk-diffusion&#44; but compared with PCR detection of the <span class="elsevierStyleItalic">bla</span>Z gene they have less sensitivity&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;9&#44;11</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The objective of this work was to understand the situation of penicillin sensitivity in cases of bacteriaemia caused by SA and its characteristics in our environment&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><p id="par0025" class="elsevierStylePara elsevierViewall">During the study period &#40;July 2015-December 2017&#41; SA strains isolated from bacteraemia &#40;both MSSA and methicillin-resistant <span class="elsevierStyleItalic">Staphylococcus aureus</span> &#91;MRSA&#93;&#41; were analysed&#44; in adult patients at the Hospital Royo Villanova &#91;Royo Villanova Hospital&#93;&#44; Zaragoza&#46; The blood cultures &#40;Bactec&#44; Becton&#44; Dickinson&#174;&#41; and the sensitivity study &#40;MicroScan&#44; Beckman&#174; Combo 31 panel&#41; were performed following the usual <span class="elsevierStyleItalic">European Committe for Antimicrobial Susceptibility Testing</span> protocols and cut-off points&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">In all the SA strains &#40;one per patient&#41; the presence of the <span class="elsevierStyleItalic">bla</span>Z and <span class="elsevierStyleItalic">mecA</span>genes was analysed&#44; as well as the Panton-Valentine leukocidin &#40;PVL&#41; gene&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The characterisation of the <span class="elsevierStyleItalic">bla</span>Z-negative &#40;<span class="elsevierStyleItalic">bla</span>Z<span class="elsevierStyleSup">negative</span>&#41; isolates was obtained through&#58; 1&#41; <span class="elsevierStyleItalic">spa</span> typing by PCR and sequencing<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a>&#59; 2&#41; determination of the sequence type &#40;ST&#41; and clonal complex &#40;CC&#41; by the multilocus-sequence typing &#40;MLST&#41; technique from a representative isolate of each of the different <span class="elsevierStyleItalic">spa</span>-types detected&#44; assuming the ST for all the isolates of the same<span class="elsevierStyleItalic">spa&#44;</span><a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> and 3&#41; PCR study of non-beta-lactam antibiotic resistance genes&#58; macrolides &#40;<span class="elsevierStyleItalic">ermA</span>&#47;<span class="elsevierStyleItalic">ermB</span>&#47;<span class="elsevierStyleItalic">ermC&#47;msrA&#47;msrB</span> y <span class="elsevierStyleItalic">ermT</span>&#41;&#44; tobramycin &#40;<span class="elsevierStyleItalic">ant&#40;4&#41;&#8217;-Ia</span>&#41; or mupirocin <span class="elsevierStyleItalic">&#40;mupA&#41;</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0040" class="elsevierStylePara elsevierViewall">Over the 30 months of study there were 84 patients with SA bacteraemia &#40;30 with MRSA &#91;35&#46;7&#37;&#93; and 54 with MSSA &#91;64&#46;3&#37;&#93;&#41;&#46; Of the MSSA isolates&#44; 12 were susceptible to penicillin &#40;MSSA-Pen<span class="elsevierStyleSup">S</span>&#41;&#44; representing 22&#46;2&#37; of MSSA and 14&#46;3&#37; of SA&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Of the total of 84 SA&#44; 77 isolates were recovered for characterisation &#40;27 MRSA and 50 MSSA&#41;&#46; The 27 MRSA isolates were resistant to penicillin &#40;MIC&#58; &#62;0&#46;12mcg&#47;m&#41;&#44; carried the <span class="elsevierStyleItalic">mecA</span> and <span class="elsevierStyleItalic">bla</span>Z genes&#44; and were negative for the PVL gene&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The 50 MSSA isolates lacked <span class="elsevierStyleItalic">mecA</span>&#44; and in relation to penicillin&#58; a&#41; 39 of them showed phenotypic resistance to penicillin &#40;MIC&#58; &#62;0&#46;25&#8239;&#956;g&#47;mL&#41; and contained the <span class="elsevierStyleItalic">bla</span>Z gene &#40;MSSA-Pen<span class="elsevierStyleSup">R</span>-<span class="elsevierStyleItalic">bla</span>Z<span class="elsevierStyleSup">positive</span>&#41;&#44; and b&#41; 11 were susceptible to penicillin and lacked the <span class="elsevierStyleItalic">bla</span>Z gene &#40;MSSA-Pen<span class="elsevierStyleSup">S</span>-<span class="elsevierStyleItalic">bla</span>Z<span class="elsevierStyleSup">negative</span>&#41;&#44; all of them showing an MIC-Pen&#8804;0&#46;3&#8239;&#956;g&#47;mL &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">The 11 MSSA-Pen<span class="elsevierStyleSup">S</span>-<span class="elsevierStyleItalic">bla</span>Z<span class="elsevierStyleSup">negative</span> isolates were assigned to 8 different <span class="elsevierStyleItalic">spa</span> -types &#40;t002 the most frequent&#41;&#44; associated with 8 STs and 7 CCs &#40;CC5&#44; CC8&#44; CC22&#44; CC45&#44; CC59&#44; CC97 y CC398&#41;&#46; Six of the 11 MSSA-Pen<span class="elsevierStyleSup">S</span>-<span class="elsevierStyleItalic">bla</span>Z<span class="elsevierStyleSup">negative</span> isolates were susceptible to all the antibiotics tested and the remaining 5 presented resistance to macrolides&#44; lincosamides&#44; tobramycin&#44; mupirocin and&#47;or fluoroquinolones &#40;genes <span class="elsevierStyleItalic">ermA</span>&#44; <span class="elsevierStyleItalic">ermT</span>&#44; <span class="elsevierStyleItalic">msrA</span>&#44; <span class="elsevierStyleItalic">msrB</span>&#44; <span class="elsevierStyleItalic">ant&#40;4&#41;&#8217;-Ia</span> or <span class="elsevierStyleItalic">mupA</span>being detected&#41;&#46; Lastly&#44; one of the MSSA-Pen<span class="elsevierStyleSup">S</span>-<span class="elsevierStyleItalic">bla</span>Z<span class="elsevierStyleSup">negative</span> strains was a carrier of the PVL gene &#40;t121-ST8&#47;CC8&#41;&#44; and only resistant to fluoroquinolones&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0060" class="elsevierStylePara elsevierViewall">In this study of SA bacteraemia&#44; a MRSA prevalence of 35&#46;7&#37; was detected with 22&#46;2&#37; susceptibility to penicillin among MSSA isolates &#40;14&#46;3&#37; of total SA&#41;&#46; The percentage of MRSA is higher than that of other European countries and that of most Spanish hospitals &#40;<a href="https://ecdc.europa.eu/en/about-us/partnerships-and-networks/disease-and-laboratory-networks/ears-net">https&#58;&#47;&#47;ecdc&#46;europa&#46;eu&#47;en&#47;about-us&#47;partnerships-and-networks&#47;disease-and-laboratory-networks&#47;ears-net</a>&#41;&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Regarding the MSSA-Pen<span class="elsevierStyleSup">S</span>isolates&#44; published figures are between 20 and 33&#37; in northern European countries&#44;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;11</span></a> USA<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;14</span></a> or Canada&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;10</span></a> In Spain we have not found any recent data&#44; but in a multicentre study<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> with 20-year evolution data &#40;1986&#8211;2006&#41; the results of 6 prevalence studies in Spanish hospitals were analysed and it was observed that there was an increase in global susceptibility to penicillin in SA isolates from different clinical samples&#44; with the lowest figures in 1991 &#40;2&#46;9&#37;&#41; and a sustained increase up to 2006 &#40;11&#46;0&#37;&#41;&#46; The data of our series of 14&#46;3&#37; global and 22&#46;2&#37; in MSSA would be in line with an increase in global susceptibility to penicillin in SA&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Of all the Pen<span class="elsevierStyleSup">S</span> strains characterised&#44; &#40;n&#8239;&#61;&#8239;11&#41;&#44; all presented MIC-Pen&#8804;0&#46;3&#8239;&#956;g&#47;mL values and lacked the <span class="elsevierStyleItalic">bla</span>Z gene&#46; This observation contributes to simplifying the microbiological diagnosis of penicillin susceptibility determination&#44; since PCR detection of the <span class="elsevierStyleItalic">bla</span>Z gene is not available in most laboratories&#44; the interpretation of susceptibility by disk-diffusion is not very objective and other tests such as nitrocefin are not recommended&#46; Our data coincide with other authors that demonstrate that in strains with high susceptibility to penicillin &#40;&#60;0&#46;03&#8239;&#956;g&#47;mL&#41; the presence of beta-lactamases mediated by <span class="elsevierStyleItalic">bla</span>Z<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;9</span></a> can be reliably ruled out&#46; Clonal complexes CC5&#44; CC8&#44; CC45 y CC22 associated with our MSSA-Pen<span class="elsevierStyleSup">S</span>-<span class="elsevierStyleItalic">bla</span>Z<span class="elsevierStyleSup">negative</span> were also detected in a similar study in Sweden&#44; with CC5-t002<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> also predominant&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">An explanation for the increased susceptibility to penicillin in SA could be attributed to a lower selective pressure due to its lower use&#46; In fact&#44; there is a trend in this regard in the first years of the 21&#8239;st century compared to previous years&#44; which is especially marked in the USA and Canada&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;10</span></a> The only country reporting a downward trend is Sweden&#44;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> a country with an antibiotic policy that has prioritised narrow-spectrum antibiotics for years&#44; which went from 57&#37; susceptibility in 2008&#8722;09 to 29&#37; in 2014&#8722;15&#46; Perhaps it could be interpreted as an increasing phenomenon in countries where penicillin is not consumed and decreasing in those where it is used&#44; with both situations coinciding with figures of 20-30&#37; at the present time&#46; Another possible explanation is that new&#44; more epidemiologically successful SA clones are coming in to replace the previous ones&#44; and among these some lack <span class="elsevierStyleItalic">bla</span>Z&#46; This aspect should be monitored in the future&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">One of the limitations of our study is that of being single-centre&#46; It would be interesting to see if this prevalence of penicillin susceptibility &#40;with absence of <span class="elsevierStyleItalic">bla</span>Z&#41; in SA exists in other hospitals in our country&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">There are no randomised studies comparing benzylpenicillin with other antistaphylococcal penicillins &#40;cloxacillin&#41; or with cefazolin&#44; and its use has been so low since the end of the last century &#40;due to increased resistance&#41; that sufficient data has not been collected in retrospective studies&#46; In some studies that analyse the use of penicillin&#44; a higher mortality has not been observed compared with comparators such as dicloxacillin&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;6</span></a> In one study&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> the use of penicillin went from 0 to 50&#37; of susceptible cases&#44; with good results&#46; Another recent article<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> shows a slightly higher mortality of flucloxacillin compared to benzylpenicillin&#44; although with methodological limitations&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Pencillin susceptibility in MSSA expands targeted treatment options&#46; The limited data on its usefulness is favourable&#44; but randomised studies are needed to determine the most appropriate treatment&#46; The narrowest of spectrums is one of the aspects that must take precedence in the treatment of infections&#44; without ruling out other aspects such as administration dosage difficulties&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Funding</span><p id="par0100" class="elsevierStylePara elsevierViewall">This work was funded in part by the <span class="elsevierStyleGrantSponsor" id="gs0005">Agencia Estatal de Investigaci&#243;n &#40;AEI&#41; &#91;State Bureau of Investigation&#93; of Spain</span> and <span class="elsevierStyleGrantSponsor" id="gs0010">the EU European Regional Development Fund</span><span class="elsevierStyleGrantNumber" refid="gs0010">SAF2016-76571-R</span> project&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">O&#46;M&#46; Mama has a predoctoral scholarship from Mujeres por &#193;frica &#91;Women for Africa&#93;-Universidad de La Rioja &#91;La Rioja University&#93; and L&#46; Ruiz-Ripa has a predoctoral scholarship from the Universidad de La Rioja&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conflicts of interest</span><p id="par0095" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The increase in penicillin susceptibility among <span class="elsevierStyleItalic">Staphylococcus aureus</span> &#40;SA-Pen<span class="elsevierStyleSup">S</span>&#41; might have therapeutic relevance&#46; We aimed to study the current situation in our environment&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Over a 2&#46;5 years period&#44; all SA isolates from bacteraemia were analysed&#46; For all isolates&#44; antimicrobial susceptibility profile&#44; beta-lactam resistance genes &#40;<span class="elsevierStyleItalic">blaZ&#44; mecA</span>&#41; and Panton-Valentine leucocidine encoding-genes were studied&#46; For SA-Pen<span class="elsevierStyleSup">S</span>-<span class="elsevierStyleItalic">blaZ</span><span class="elsevierStyleSup">negative</span> isolates&#44; <span class="elsevierStyleItalic">spa</span>-type&#44; MLST and the presence of other resistance genes were studied&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Among 84 patients with SA bacteraemia &#40;35&#46;7&#37; MRSA and 64&#46;3&#37; MSSA&#41;&#44; 77 were analysed&#59; 22&#46;2&#37; of MSSA isolates were Pen<span class="elsevierStyleSup">S</span> and <span class="elsevierStyleItalic">blaZ</span><span class="elsevierStyleSup">negative</span> &#40;Pen-MIC &#8804;0&#46;03&#8239;&#181;g&#47;mL&#41; corresponding to 14&#46;3&#37; of the total SA&#46; In MSSA-Pen<span class="elsevierStyleSup">S</span>-<span class="elsevierStyleItalic">bla</span>Z<span class="elsevierStyleSup">negative</span> isolates&#44; eight <span class="elsevierStyleItalic">spa</span>-types corresponding to seven clonal complexes were detected&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">A high prevalence of MRSA&#47;SA and MSSA-Pen<span class="elsevierStyleSup">S</span>-<span class="elsevierStyleItalic">bla</span>Z<span class="elsevierStyleSup">negative</span>&#47;MSSA was detected in blood cultures&#46; Pen-MIC &#8804;0&#44;3&#8239;&#181;g&#47;mL corresponded to MSSA-Pen<span class="elsevierStyleSup">S</span>-<span class="elsevierStyleItalic">bla</span>Z<span class="elsevierStyleSup">negative</span>&#46; This situation raises therapeutic options which should be further evaluated in larger studies and clinical trials&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">El aumento de la sensibilidad a penicilina en <span class="elsevierStyleItalic">Staphylococcus aureus</span> &#40;SA-Pen<span class="elsevierStyleSup">S</span>&#41; podr&#237;a tener relevancia terap&#233;utica&#46; Pretendemos conocer esta situaci&#243;n en nuestro medio&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todos</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Se analizaron bacteriemias por SA durante 2&#44;5 a&#241;os &#40;2015&#8211;2017&#41;&#46; Estudiamos la sensibilidad a antimicrobianos&#44; genes de resistencia a beta-lact&#225;micos &#40;<span class="elsevierStyleItalic">blaZ&#44; mecA</span>&#41; y presencia de leucocidina de Panton-Valentine&#46; En aislados SA-Pen<span class="elsevierStyleSup">S</span>-<span class="elsevierStyleItalic">bla</span>Z<span class="elsevierStyleSup">negativo</span> se determin&#243; el tipo de <span class="elsevierStyleItalic">spa</span>&#44; MLST y genes de resistencia a antimicrobianos no-beta-lact&#225;micos&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Hubo 84 pacientes con bacteriemia por SA &#40;35&#44;7&#37; SARM y 64&#44;3&#37; SASM&#41;&#44; se analizaron 77&#46; El 22&#37; de los SASM estudiados &#40;n&#8239;&#61;&#8239;11&#41; fueron Pen<span class="elsevierStyleSup">S</span>- <span class="elsevierStyleItalic">bla</span>Z<span class="elsevierStyleSup">negativo</span> &#40;CMI-Pen &#8804;0&#44;3&#8239;&#181;g&#47;mL&#41;&#44; correspondiendo a 14&#44;3&#37; del total de SA&#46; En SASM-Pen<span class="elsevierStyleSup">S</span>-<span class="elsevierStyleItalic">bla</span>Z<span class="elsevierStyleSup">negativo</span> se detectaron ocho tipos de <span class="elsevierStyleItalic">spa</span> asociados a siete complejos clonales&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusi&#243;n</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Detectamos alta prevalencia de SARM&#47;SA y de SASM-Pen<span class="elsevierStyleSup">S</span>-<span class="elsevierStyleItalic">bla</span>Z<span class="elsevierStyleSup">negativo</span>&#47;SASM en hemocultivos&#46; Una CMI-Pen &#8804;0&#44;3&#8239;&#181;g&#47;mL se correspondi&#243; con SASM-Pen<span class="elsevierStyleSup">S</span>-<span class="elsevierStyleItalic">bla</span>Z<span class="elsevierStyleSup">negativo</span>&#46; Esta situaci&#243;n plantea opciones terap&#233;uticas que deber&#225;n reevaluarse con estudios m&#225;s amplios y ensayos cl&#237;nicos&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Introducci&#243;n"
          ]
          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "Material y m&#233;todos"
          ]
          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusi&#243;n"
          ]
        ]
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Please cite this article as&#58; Aspiroz C&#44; Mama OM&#44; Mart&#237;nez-&#193;lvarez RM&#44; Ruiz-Ripa L&#44; Ceballos S&#44; Torres C&#46; Bacteriemia por <span class="elsevierStyleItalic">Staphylococcus aureus</span> sensible a penicilina&#46; Importancia epidemiol&#243;gica&#44; cl&#237;nica y posibles implicaciones terap&#233;uticas&#46; Enferm Infecc Microbiol Clin&#46; 2020&#59;38&#58;434&#8211;437&#46;</p>"
      ]
    ]
    "multimedia" => array:1 [
      0 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0005"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:3 [
          "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">&#63;&#58; probable&#44; unproven infection&#59; BAC&#58; catheter-related bacteriaemia&#59; CIP&#58; ciprofloxacin&#59; CLI&#58; clindamycin&#59; ERI&#58; erythromycin&#59; SSTI&#58; skin and soft tissue infections&#59; HAI&#58; health care-associated infections&#59; RTI&#58; respiratory tract infection&#59; UTI&#58; urinary tract infection&#59; LEVO&#58; levofloxacin&#59; MUP&#58; mupirocin&#59; TOB&#58; tobramycin&#59; PUI&#58; pressure ulcer infection&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Antibiotic resistance</th><th class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr><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">Isolate code&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">ST&#47;CC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">Spa</span> -type&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Resistance phenotype&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Resistance genes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Virulence genes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Clinical picture&#47;focus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Origin of the infection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-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">X797&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">ST5&#47;CC5&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">t002&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">ERI-CLI<span class="elsevierStyleSup">a</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">msrA&#47;msrB&#44; ermA</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">&#8212;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">RTI&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">HAI&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">X748&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">ST5&#47;CC5&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">t002&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">ERI-CIP-LEVO-MUP&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"><span class="elsevierStyleItalic">msrA&#47;msrB</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">&#8212;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">SSTI&#46; Cellulitis&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">Community&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">X728&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">ST5&#47;CC5&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">t002&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">Pansusceptible<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&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"><span class="elsevierStyleItalic">&#8212;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">&#8212;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">UTI&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">HAI&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">X770&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">ST1099&#47;CC5&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">t2450&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">ERI-CIP-LEVO-MUP-TOB&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"><span class="elsevierStyleItalic">msrA&#47;msrB&#44; mupA&#44; ant&#40;4&#769;&#41;-Ia</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">&#8212;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">UTI&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">HAI&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">X737&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">ST8&#47;CC8&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">t121&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">CIP-LEVO&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"><span class="elsevierStyleItalic">&#8212;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">lukF&#47;lukS-PV</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">SSTI&#46; Abscesses&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">Community&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">X749&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">ST22&#47;CC22&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">t2816&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">Pansusceptible<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&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"><span class="elsevierStyleItalic">&#8212;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">&#8212;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">SSTI&#63;&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">HAI&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">X727&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">ST45&#47;CC45&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">Non-identifiable&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">Pansusceptible<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&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"><span class="elsevierStyleItalic">&#8212;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">&#8212;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">BAC&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">Nosocomial&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">X756&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">ST59&#47;CC59&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">t216&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">Pansusceptible<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&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"><span class="elsevierStyleItalic">&#8212;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">&#8212;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Fever without a focus&#46; SSTI-PUI&#63;&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">HAI&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">X766&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">ST97&#47;CC97&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">t359&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">Pansusceptible<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&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"><span class="elsevierStyleItalic">&#8212;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">&#8212;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Fever without a focus&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">HAI&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">X787&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">ST97&#47;CC97&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">t1236&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">Pansusceptible<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&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"><span class="elsevierStyleItalic">&#8212;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">&#8212;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">RTI&#63; SSTI-PUI&#63;&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">HAI&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">X746&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">ST398&#47;CC398&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">t571&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">ERI-CLI<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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">msrA&#47;msrB&#44; ermT</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">&#8212;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">BAC&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">Nosocomial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                0 => "xTab2417669.png"
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              "identificador" => "tblfn0005"
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              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Inducible resistance phenotype&#46;</p>"
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            1 => array:3 [
              "identificador" => "tblfn0010"
              "etiqueta" => "b"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Susceptible to the following antimicrobials&#58; cefoxitin&#44; oxacillin&#44; penicillin&#44; phosphomycin&#44; rifampin&#44; mupirocin&#44; fusidic acid&#44; gentamicin&#44; tobramycin&#44; amikacin&#44; ciprofloxacin&#44; levofloxacin&#44; cotrimoxazole&#44; vancomycin&#44; teicoplanin&#44; daptomycin&#44; linezolid&#44; and tetracycline&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Phenotypic and genetic characteristics of 11 strains of <span class="elsevierStyleItalic">Staphylococcus aureus</span> Pen<span class="elsevierStyleSup">&#8722;S</span><span class="elsevierStyleItalic">-blaZ</span><span class="elsevierStyleSup">negative</span> isolated from blood cultures&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:15 [
            0 => array:3 [
              "identificador" => "bib0005"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Are all beta-lactams similarly effective in the treatment of methicillin-sensitive <span class="elsevierStyleItalic">Staphylococcus aureus</span> bacteraemia&#63;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "M&#46; Paul"
                            1 => "N&#46; Zemer-Wassercug"
                            2 => "O&#46; Talker"
                            3 => "Y&#46; Lishtzinsky"
                            4 => "B&#46; Lev"
                            5 => "Z&#46; Samra"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1469-0691.2010.03425.x"
                      "Revista" => array:5 [
                        "tituloSerie" => "Clin Microbiol Infect&#46;"
                        "fecha" => "2011"
                        "volumen" => "17"
                        "paginaInicial" => "1581"
                        "paginaFinal" => "1586"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0010"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Effectiveness of penicillin&#44; dicloxacillin and cefuroxime for penicillin-susceptible <span class="elsevierStyleItalic">Staphylococcus aureus</span> bacteraemia&#58; a retrospective&#44; propensity-score-adjusted case-control and cohort analysis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "J&#46;L&#46; Nissen"
                            1 => "R&#46; Skov"
                            2 => "J&#46;D&#46; Knudsen"
                            3 => "C&#46; Ostergaard"
                            4 => "H&#46;C&#46; Sch&#248;nheyder"
                            5 => "N&#46; Frimodt-M&#248;ller"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1093/jac/dkt108"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Antimicrob Chemother&#46;"
                        "fecha" => "2013"
                        "volumen" => "68"
                        "paginaInicial" => "1894"
                        "paginaFinal" => "1900"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23599360"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0015"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Benzylpenicillin versus flucloxacillin for penicillin susceptible <span class="elsevierStyleItalic">Staphylococcus aureus</span> bloodstream infections from a large retrospective cohort study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "A&#46; Henderson"
                            1 => "P&#46; Harris"
                            2 => "G&#46; Hartel"
                            3 => "D&#46; Paterson"
                            4 => "J&#46; Turnidge"
                            5 => "J&#46;S&#46; Davis"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.ijantimicag.2019.05.020"
                      "Revista" => array:2 [
                        "tituloSerie" => "Int J of Antimicrob Agents&#46;"
                        "fecha" => "2019"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0020"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Back to the Future&#58; Penicillin-Susceptible <span class="elsevierStyleItalic">Staphylococcus aureus</span>"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "M&#46;P&#46; Cheng"
                            1 => "P&#46; Ren&#233;"
                            2 => "A&#46;P&#46; Cheng"
                            3 => "T&#46;C&#46; Lee"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.amjmed.2016.01.048"
                      "Revista" => array:5 [
                        "tituloSerie" => "Am J Med&#46;"
                        "fecha" => "2016"
                        "volumen" => "129"
                        "paginaInicial" => "1331"
                        "paginaFinal" => "1333"
                      ]
                    ]
                  ]
                ]
              ]
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos