Extended spectrum β-lactamase producers among nosocomial Enterobacteriaceae in Latin America | The Brazilian Journal of Infectious Diseases

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Copyright (2009) with permission from The American Journal of Tropical Medicine and Hygiene.<a class="elsevierStyleCrossRef" href="#bib0175">35</a>" "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1341 "Ancho" => 1400 "Tamanyo" => 446062 ] ] "descripcion" => array:1 [ "en" => "Renal amyloidosis in a patient with visceral leishmaniasis and HIV. (A) Abundant mesangial amyloid deposits (black arrowhead; enlarged in (B)) and interstitial fibrosis (white asterisk); FAOG stain; 100×, (B) almost complete obliteration of the glomerular architecture by mesangial amyloid deposits; FAOG stain; 600×, (C) amyloid deposits in arteriolar wall that are congophilic and produce apple-green birefringence; Congo red; 600×, (D) typical ultrastructural appearance of amyloid fibrils in the mesangium; transmission electron microscopy (uranyl acetate and lead citrate), and (E) amyloid fibrils are also seen in capillary membranes in a subendothelial location; transmission electron microscopy (uranyl acetate and lead citrate)." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Geraldo Bezerra da Silva Junior, Elvino José Guardão Barros, Elizabeth De Francesco Daher" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Geraldo Bezerra" "apellidos" => "da Silva Junior" ] 1 => array:2 [ "nombre" => "Elvino José" "apellidos" => "Guardão Barros" ] 2 => array:2 [ "nombre" => "Elizabeth" "apellidos" => "De Francesco Daher" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1413867014000580?idApp=UINPBA00003Y" "url" => "/14138670/0000001800000004/v8_201510050558/S1413867014000580/v8_201510050558/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S1413867014000609" "issn" => "14138670" "doi" => "10.1016/j.bjid.2014.01.007" "estado" => "S300" "fechaPublicacion" => "2014-07-01" "aid" => "322" "copyright" => "Elsevier Editora Ltda." "documento" => "article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "fla" "cita" => "Braz J Infect Dis. 2014;18:414-20" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 1402 "formatos" => array:3 [ "EPUB" => 187 "HTML" => 778 "PDF" => 437 ] ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "Original article" "titulo" => "Assessment of sexual risk behaviors and perception of vulnerability to sexually transmitted diseases/acquired immunodeficiency syndrome in women, 1999–2012: a population based survey in a medium-sized Brazilian city" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "414" "paginaFinal" => "420" ] ] "contieneResumen" => array:1 [ "en" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Marilia Arndt Mesenburg, Ludmila Correa Muniz, Mariângela Freitas Silveira" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Marilia Arndt" "apellidos" => "Mesenburg" ] 1 => array:2 [ "nombre" => "Ludmila Correa" "apellidos" => "Muniz" ] 2 => array:2 [ "nombre" => "Mariângela Freitas" "apellidos" => "Silveira" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1413867014000609?idApp=UINPBA00003Y" "url" => "/14138670/0000001800000004/v8_201510050558/S1413867014000609/v8_201510050558/en/main.assets" ] "en" => array:21 [ "idiomaDefecto" => true "cabecera" => "Review article" "titulo" => "Extended spectrum β-lactamase producers among nosocomial Enterobacteriaceae in Latin America" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "421" "paginaFinal" => "433" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Manuel Guzmán-Blanco, Jaime A. Labarca, Maria Virginia Villegas, Eduardo Gotuzzo" "autores" => array:5 [ 0 => array:4 [ "nombre" => "Manuel" "apellidos" => "Guzmán-Blanco" "email" => array:1 [ 0 => "mibeli03@gmail.com" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "1" "identificador" => "fn1" ] 2 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Jaime A." "apellidos" => "Labarca" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Maria Virginia" "apellidos" => "Villegas" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "Eduardo" "apellidos" => "Gotuzzo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "d" "identificador" => "aff0020" ] ] ] 4 => array:2 [ "colaborador" => "On behalf of the Latin America Working Group on Bacterial Resistance" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "2" "identificador" => "fn2" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Hospital Privado Centro Médico de Caracas and Hospital Vargas de Caracas, Caracas, Venezuela" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Department of Infectious Diseases, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Bacterial Resistance Group, International Center for Medical Research and Training (CIDEIM), Cali, Colombia" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Universidad Peruana Cayetano Heredia, Lima, Peru" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0020" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1702 "Ancho" => 2998 "Tamanyo" => 147918 ] ] "descripcion" => array:1 [ "en" => "Findings of the Pan-American Health Organization (PAHO) summarizing the frequency of nosocomial Escherichia coli and Klebsiella pneumoniae isolates resistant to cefepime in 2009.<a class="elsevierStyleCrossRef" href="#bib0175">35</a> NR, not reported." ] ] ] "textoCompleto" => "IntroductionHealth care-associated infections (HAIs) are particularly challenging in developing countries such as those of Latin America owing to their far higher rate of occurrence than in developed countries. For instance, the World Health Organization reported that the pooled prevalence of hospital-wide HAIs between 1995 and 2010 in low- and middle-income countries was 10.1 per 100 patients (95% confidence interval [CI], 8.4–12.2), which compares unfavorably with the corresponding rate in high-income countries (7.6 episodes per 100 patients; 95% CI, 6.9–8.5).<a class="elsevierStyleCrossRef" href="#bib0005">1</a> Most HAIs in developed and developing countries are by Gram-negative bacteria, predominantly species and subspecies from the Enterobacteriaceae family followed by nonfermenters such as Pseudomonas aeruginosa and Acinetobacter baumannii.<a class="elsevierStyleCrossRefs" href="#bib0005">1–4</a> The capacity of health care professionals to manage nosocomial infections by Enterobacteriaceae has diminished over the last decade because of the emergence and widespread dissemination of multidrug-resistant phenotypes.<a class="elsevierStyleCrossRefs" href="#bib0010">2,5–8</a>Production of β-lactamases is the primary mechanism of β-lactam resistance in these pathogens.<a class="elsevierStyleCrossRefs" href="#bib0045">9–15</a> ESBL, extended spectrum β-lactamase (ESBLs) can confer resistance to penicillins, first-, second-, and third-generation cephalosporins, and aztreonam (but not the cephamycins such as cefoxitin or carbapenems), and are usually inhibited by β-lactamase inhibitors such as clavulanic acid.<a class="elsevierStyleCrossRef" href="#bib0075">15</a> Most ESBLs can also hydrolyze fourth-generation cephalosporins (e.g., cefepime or cefpirome).<a class="elsevierStyleCrossRefs" href="#bib0080">16,17</a> It is important to note that AmpC β-lactamases differ from typical ESBLs in that AmpC β-lactamases, besides hydrolyzing third-generation cephalosporins, are not inhibited by β-lactamase inhibitors.<a class="elsevierStyleCrossRef" href="#bib0075">15</a> Furthermore, Enterobacteriaceae harboring ESBLs are often co-resistant to fluoroquinolones, aminoglycosides, and trimethoprim/sulfamethoxazole.<a class="elsevierStyleCrossRefs" href="#bib0075">15,18</a> Thus, infections by these multidrug-resistant pathogens are a major public health threat, as there are limited treatment options available.The purpose of this review is to provide an updated epidemiology of ESBL-producing Enterobacteriaceae in the Latin American hospital setting, with a focus on antimicrobial susceptibilities of Escherichia coli and Klebsiella pneumoniae strains throughout the region. We include in this review data from the Spanish- and Portuguese-speaking countries of the Americas, including Mexico.Background: emergence of extended spectrum β-lactamase-producing Enterobacteriaceae in Latin America before 2005During the period from 1987 to 1989, K. pneumoniae expressing sulfhydryl variant (SHV)-5 and SHV-2 were responsible for infection outbreaks in a Buenos Aires intensive care unit (ICU).<a class="elsevierStyleCrossRef" href="#bib0070">14</a> Retrospective analysis of a lyophilized strain of K. pneumoniae recovered in 1982 from the urine of a patient with an indwelling urinary catheter detected SHV-5, making this the earliest detected ESBL-producing bacterium in South America.<a class="elsevierStyleCrossRefs" href="#bib0070">14,19</a> Cefotaxime-resistant (CTX-M) β-lactamase was first described in an outbreak of neonatal infection with Salmonella typhymurium during 1989 in Argentina, Bolivia, and Paraguay.<a class="elsevierStyleCrossRef" href="#bib0070">14</a> Further outbreaks of infections in neonates caused by ESBL-producing Klebsiella spp. were reported in the late 1990s in Mexico and Brazil.<a class="elsevierStyleCrossRefs" href="#bib0100">20,21</a>By the late 1990s, ESBL expression by Enterobacteriaceae in Latin American hospitals became endemic. During SENTRY antimicrobial surveillance conducted between 1997 and 2002, the prevalence of Klebsiella spp. expressing ESBLs in blood cultures from hospitalized patients was greater in Latin America than in Europe and North America (43% vs. 22% and 6%, respectively, p<0.001).<a class="elsevierStyleCrossRef" href="#bib0045">9</a> SENTRY data for urine isolates revealed that ∼45% of Klebsiella spp. exhibited an ESBL phenotype in 2000 (compared with ∼30% during 1997–1999) and ∼5% of E. coli exhibited an ESBL phenotype during both testing periods.<a class="elsevierStyleCrossRef" href="#bib0065">13</a> The percentage of Enterobacteriaceae producing ESBLs was also very high in Brazilian hospitals (SENTRY, 1997–1999), with 50% of all K. pneumoniae isolates and 9% of all E. coli isolates suspected of harboring ESBLs.<a class="elsevierStyleCrossRef" href="#bib0110">22</a> Over a slightly later timeframe, findings of the Meropenem Yearly Susceptibility Test Information Collection (MYSTIC) study (1997–2003) showed that 52% of K. pneumoniae isolates from Latin America (vs. 12% from North America), 18% of E. coli isolates (vs. 8% from North America), and 6% of Proteus mirabilis isolates (vs. 4% from North America) were ESBL-positive.<a class="elsevierStyleCrossRef" href="#bib0115">23</a>CTX-M-type β-lactamases eventually replaced TEM and SHV variants as the most common type of ESBL globally.<a class="elsevierStyleCrossRefs" href="#bib0090">18,24</a> In 2000, CTX-M-2 was the most prevalent type of ESBL in Latin America (especially in the southern part of the continent),<a class="elsevierStyleCrossRef" href="#bib0125">25</a> and in 2002, CTX-M-12 from a strain of K. pneumoniae was detected in Colombia, representing the first description of a CTX-M in this country.<a class="elsevierStyleCrossRef" href="#bib0130">26</a> While ESBLs are found predominantly in Klebsiella spp. and E. coli, they have also been described in other genera of Enterobacteriaceae including species of Citrobacter, Serratia, Proteus, Morganella, Salmonella, and Enterobacter.<a class="elsevierStyleCrossRef" href="#bib0070">14</a>MethodsTo review the published clinical data relating to epidemiology of ESBL-producing Enterobacteriaceae in the Latin American hospital setting, a systematic search of the biomedical literature was conducted. Medline (via PubMed) was searched limited by the dates 1 January 2005 to 15 July 2013 for articles using the following terms and Boolean logic: (Extended spectrum beta lactamase OR ESBL) AND (Enterobacteriaceae OR coli OR Klebsiella OR Shigella OR Salmonella OR Proteus) AND (“Latin America” OR “South America” OR “Central America” OR Mexico OR Guatemala OR Honduras OR Nicaragua OR “Costa Rica” OR Cuba OR “Dominican Republic” OR Panama OR Colombia OR Venezuela OR Guyana OR Suriname OR “French Guiana” OR Brazil OR Ecuador OR Peru OR Bolivia OR Paraguay OR Uruguay OR Chile OR Argentina). Selected additional references were identified by authors.Prevalence and type of extended spectrum β-lactamasesRegional dataSeveral regional surveillance studies monitor drug resistance in Latin America, most with a small number of participating centers in each country. The number of centers from each country participating in surveillance efforts is shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.<a class="elsevierStyleCrossRefs" href="#bib0135">27–35</a> According to data from the Study for Monitoring Antimicrobial Resistance Trends (SMART), Tigecycline Evaluation and Surveillance Trial (TEST), and Doripenem International Surveillance Network (DISN), the prevalence of ESBL-producing K. pneumoniae was far higher in Latin America than in other world regions (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).<a class="elsevierStyleCrossRefs" href="#bib0040">8,27,28,31,36</a> Similarly, only the Asia/Pacific region had higher rates of ESBL production in E. coli. <a class="elsevierStyleCrossRefs" href="#bib0040">8,27,28,31,36</a> Furthermore, prevalence of ESBL-producing E. coli and Klebsiella spp. appears to have steadily increased over the last decade (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).<a class="elsevierStyleCrossRefs" href="#bib0040">8,27–33,36</a> A greater proportion of Klebsiella spp. than E. coli produce ESBLs, although ESBL production by E. coli has increased since the period before 2005.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Country-specific dataSurveillance studiesIn the SENTRY 2008–2010, SMART 2008–2009, and TEST 2004–2010 reports, the frequencies of E. coli producing ESBLs were highest in Chile, Ecuador, Guatemala, Honduras, and Mexico (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>a).<a class="elsevierStyleCrossRefs" href="#bib0150">30,32,33</a> Among Klebsiella spp., ESBL phenotype rates of 50% or greater were observed in Argentina, Brazil, Chile, and Honduras (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>b).<a class="elsevierStyleCrossRefs" href="#bib0160">32,33</a><elsevierMultimedia ident="fig0010"></elsevierMultimedia>Cohort studiesAs in the surveillance studies, independent cohort data revealed that a greater proportion of K. pneumoniae than E. coli clinical isolates produce ESBLs throughout the continent (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).<a class="elsevierStyleCrossRefs" href="#bib0185">37–48</a> The range of ESBL production among K. pneumoniae isolates varied from 24% (in Cuba, 2009–2010)<a class="elsevierStyleCrossRef" href="#bib0220">44</a> to 58% (in Curitiba, Brazil, 2003–2004)<a class="elsevierStyleCrossRef" href="#bib0230">46</a> whereas ESBL production among E. coli isolates varied from 7% (in southern Brazil)<a class="elsevierStyleCrossRef" href="#bib0225">45</a> to 32% (in Sonoro, Mexico, 2008–2009).<a class="elsevierStyleCrossRef" href="#bib0210">42</a> Care must be taken when interpreting these data because of inter-study differences with respect to the time, method (i.e., consecutive or random), and anatomical site of sample collection, as well as the microbiological techniques and standards used. Nevertheless, data collected by independent cohort studies on the frequency of ESBL production among E. coli clinical isolates (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>) compared favorably with data collected by SMART, SENTRY, and TEST (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>a) for Brazil (range, 7–24% vs. 13–17%, respectively), Mexico (16–32% vs. 38–48%) and Venezuela (16–27% vs 15–30%). Regarding the frequency of ESBL production among K. pneumoniae clinical isolates, general agreement was observed between independent cohort (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>) and surveillance data (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>b) for Brazil (44–58% vs. 49–50%, respectively), and Mexico (27–36% vs. 25–33%), but not Venezuela (46–48% vs. 17%). Limited prevalence data were available for Bolivia (Santa Cruz de la Sierra, 2004) wherein 150–642 (23%) consecutively collected Gram-negative isolates were putative ESBL producers, but this statistic encompassed strains of P. aeruginosa and Acinetobacter spp. in addition to Enterobacteriaceae.<a class="elsevierStyleCrossRef" href="#bib0245">49</a><elsevierMultimedia ident="fig0015"></elsevierMultimedia>The molecular characteristics of the ESBL isolates detected in surveillance studies were not described in those publications. Most of our knowledge about specific ESBLs circulating in Latin American hospitals comes from independent cohort studies. <a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a> shows that CTX-Ms have infiltrated most countries to various extents, with CTX-M-15 commonly found in the northern part of the continent. The endemicity of CTX-M-15 is challenging because this enzyme, unlike other ESBLs, can hydrolyze ceftazidime.<a class="elsevierStyleCrossRef" href="#bib0250">50</a> CTX-M-2 was the most common subtype in Argentina (52% of 50 ESBL producers), and data indicated emergence of CTX-M-15 (38%) along with CTX-M-8 (2%) and CTX-M-9 (6%).<a class="elsevierStyleCrossRef" href="#bib0240">48</a> SHV enzymes (particularly SHV-5 and SHV-12) were highly prevalent in Mexico, Colombia, and Brazil (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).These prevalence findings are supported by results of studies that examined the genotype distribution among ESBL producers. Of 127 ESBL-producing Enterobacteriaceae isolated over one year from inpatients and outpatients at a public teaching hospital at São Paulo, Brazil, blaCTX-M and blaSHV were highly prevalent (in 34% and 63% of strains, respectively).<a class="elsevierStyleCrossRef" href="#bib0255">51</a> In Colombia (Bogota, 2003–2005), computational sequencing analysis revealed that CTX-M-12 (56%) and SHV-12 (33%) were the most prevalent ESBLs produced among 177 K. pneumoniae isolates harboring bla genes.<a class="elsevierStyleCrossRef" href="#bib0260">52</a> In Bolivia, blaCTX-M-2 (71%), and to a lesser extent blaCTX-M-43 (21%), were the most prevalent genes encoding ESBL production in 150 Gram-negative clinical isolates collected from four hospitals in Santa Cruz de la Sierra during a 4-month period in 2004.<a class="elsevierStyleCrossRef" href="#bib0245">49</a> In addition, blaPER-2 was reported among 31% of 122 ESBL+ K. pneumoniae isolates collected in 10 hospitals in Chile in 1998–2004 (40% were blaCTX-M and 13% were blaGES),<a class="elsevierStyleCrossRef" href="#bib0265">53</a> and 15% of 47 ESBL+ K. pneumoniae isolates collected in eight hospitals in Caracas, Venezuela in 2009-2010 were type PER.<a class="elsevierStyleCrossRef" href="#bib0200">40</a>Antimicrobial susceptibilityRegional dataData on antimicrobial susceptibilities are reported for the Latin American region by the SMART, TEST, and SENTRY surveillance efforts, and for individual Latin American countries by The Pan-American Health Organization (PAHO) (see <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> for countries participating in each effort).From a regional perspective, E. coli strains were more often susceptible (75–89%) to third-generation cephalosporins than strains of K. pneumoniae (47–55%, referring to strains that were not distinguished as ESBL+ or ESBL−).<a class="elsevierStyleCrossRefs" href="#bib0140">28–33</a> Susceptibilities of E. coli and K. pneumoniae to the fourth-generation cephalosporin cefepime were not markedly greater than their susceptibilities to third-generation cephalosporins. As expected, susceptibility to third-generation cephalosporins and cefepime was much lower among ESBL-positive E. coli and K. pneumoniae strains than among ESBL-negative or unspecified isolates (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>).<a class="elsevierStyleCrossRefs" href="#bib0145">29–32</a> Antimicrobial co-resistance was a recurring feature among these isolates, particularly those expressing ESBLs. In SENTRY 2008–2010, E. coli (all isolates) were most susceptible to the carbapenems (99–100%), amikacin (97–100%), piperacillin/tazobactam (82–94%), and colistin (100%), whereas low rates of susceptibility to ciprofloxacin (35–73%) were observed.<a class="elsevierStyleCrossRef" href="#bib0165">33</a> Susceptibility of Klebsiella spp. was appreciably lower than that of E. coli to all of these drug classes, with susceptibility rates of 89–99% for carbapenems, 78–92% for amikacin, 49–81% for piperacillin/tazobactam, and 95–99% for colistin across four countries (Argentina, Brazil, Chile, and Mexico).<a class="elsevierStyleCrossRef" href="#bib0165">33</a> Even lower susceptibility rates across the commonly used drug classes were observed for ESBL-producing E. coli and K. pneumoniae isolates collected in SMART 2008, 2008–2009, and TEST 2004–2010.<a class="elsevierStyleCrossRefs" href="#bib0145">29,30,32</a> Although susceptibility of ESBL-producing E. coli to carbapenems and tigecycline was >95% in all of these studies, susceptibility to amikacin (85–90%), piperacillin/tazobactam (74–80%), and fluoroquinolones (12–19%) dropped markedly.<a class="elsevierStyleCrossRefs" href="#bib0145">29,30,32</a> Likewise, susceptibility of ESBL-producing K. pneumoniae to carbapenems (in TEST 2004–2010 and SMART 2008) and tigecycline (in TEST 2004–2010) was high (≥89%), but susceptibility was low to amikacin (71–72%), levofloxacin (35–38%), and piperacillin/tazobactam (34–40%) in both surveillance studies.<a class="elsevierStyleCrossRefs" href="#bib0145">29,32</a><elsevierMultimedia ident="tbl0015"></elsevierMultimedia>Country-specific dataPAHO established a surveillance program in 2000 to collect country-specific data on selected organisms, both from nosocomial and community-acquired infections. In 2006 and 2009, there was large variability in Enterobacteriaceae resistance rates to third-generation cephalosporins (cefotaxime and ceftazidime), even after accounting for countries with small isolate numbers (<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>)<a class="elsevierStyleCrossRefs" href="#bib0170">34,35</a> and few collecting centers (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). In 2009, the resistance rate of E. coli to third-generation cephalosporins was highest in Bolivia (37%) and lowest in Nicaragua (0–0.5%; <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>). PAHO data for K. pneumoniae nosocomial isolates in 2009 showed high levels of resistance to third-generation cephalosporins, consistent with the high prevalence of ESBL-producing strains in Latin American countries. The resistance rate of Klebsiella spp. to third-generation cephalosporins in 2009 was highest in Peru (66%) and lowest in Nicaragua (0.3%). A high rate of resistance to cefepime in nosocomial isolates of E. coli and K. pneumoniae was also reported in PAHO 2009 data (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>).<a class="elsevierStyleCrossRef" href="#bib0175">35</a> The PAHO data for Klebsiella spp. were similar to findings of the Asociación Panamericana de Infectología, showing that the proportion of cefotaxime-resistant strains ranged from 17% (in Ecuador and Panama) to 60% (in Brazil), resistance rates to ceftazidime ranged from 13% (in Venezuela) to 40% (in Argentina, Brazil, and Paraguay), and resistance to cefepime ranged from 10% (in Colombia) to 50% (in Argentina and Brazil).<a class="elsevierStyleCrossRef" href="#bib0270">54</a><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia>Data collected by the SENTRY Antimicrobial Surveillance Program between 2008 and 2010 reported country-specific data in addition to regional data. They showed that the susceptibility rate of healthcare-acquired E. coli isolates to third-generation cephalosporins was low in Mexico (52–53%) and modest in Argentina, Brazil, and Chile (76–88%).<a class="elsevierStyleCrossRef" href="#bib0165">33</a> Again, Klebsiella spp. exhibited unacceptably low susceptibility rates to cephalosporins in all four countries (40–67%). The susceptibilities of E. coli and Klebsiella spp. were modestly higher to cefepime than to third-generation cephalosporins.<a class="elsevierStyleCrossRef" href="#bib0165">33</a>In agreement with SENTRY, a consolidated 2009 network analysis involving 14 hospitals in Chile revealed that 78% and 79% of E. coli blood and urine cultures, respectively, were susceptible to cefotaxime.<a class="elsevierStyleCrossRef" href="#bib0275">55</a> Remarkable susceptibility rates were observed for carbapenems (≥99.9%) while susceptibility rates were ≥90% for piperacillin/tazobactam and amikacin and lower for ciprofloxacin (61–64%).<a class="elsevierStyleCrossRef" href="#bib0275">55</a>Surveillance was conducted in 2006–2008 by the Colombian Nosocomial Resistance Study Group, consisting of 14 tertiary-care hospitals in seven major cities.<a class="elsevierStyleCrossRef" href="#bib0280">56</a> Among E. coli isolates from general wards (N>2300 each year) and adult ICUs (N>550 each year), resistance to third-generation cephalosporins was low and stable at rates ranging from 2% to 8%. Among isolates from adult ICUs, resistance to cefepime was also stable at 4–5% during this period. For K. pneumoniae, resistance rates to third-generation cephalosporins (ceftazidime and ceftriaxone) among isolates from general wards were 19–20% in 2006 (N=948); 24–29% in 2007 (N=1244), and 15% in 2008 (N=1038). Among K. pneumoniae isolates from adult ICUs, resistance to third-generation cephalosporins was 24–25% in 2006 (N=497), 20–31% in 2007 (N=800), and 9–24% in 2008 (N=602). Among isolates from adult ICUs, resistance to cefepime was 12% in 2006, 18% in 2007, and 11% in 2008.<a class="elsevierStyleCrossRef" href="#bib0280">56</a>In the independent cohort studies that reported quantitative susceptibility data on Enterobacteriaceae harboring ESBLs, co-resistance to multiple commonly used antimicrobial agents besides resistance to third-generation cephalosporins was evident.<a class="elsevierStyleCrossRefs" href="#bib0185">37–39,52</a> Moderate to high resistance rates (>15% to <81%) were observed for aminoglycosides, trimethoprim/sulfamethoxazole, piperacillin/tazobactam, and quinolones, whereas low resistance rates (<10%) were observed for carbapenems and tigecycline.<a class="elsevierStyleCrossRefs" href="#bib0185">37–41,52</a>Risk factorsStudies conducted in locations throughout the world have identified multiple risk factors for infection with ESBL-producing Enterobacteriaceae in hospitalized patients.<a class="elsevierStyleCrossRefs" href="#bib0285">57–61</a> In multivariate analyses in these studies, the following risk factors were identified: previous antibiotic use (specifically, quinolones,<a class="elsevierStyleCrossRef" href="#bib0295">59</a> cephalosporins,<a class="elsevierStyleCrossRef" href="#bib0285">57</a> oxyimino-cephalosporins,<a class="elsevierStyleCrossRef" href="#bib0290">58</a> piperacillin/tazobactam,<a class="elsevierStyleCrossRef" href="#bib0285">57</a> or β-lactams with an oxyimino group<a class="elsevierStyleCrossRef" href="#bib0300">60</a>), recurrent infections,<a class="elsevierStyleCrossRef" href="#bib0295">59</a> hemodialysis,<a class="elsevierStyleCrossRef" href="#bib0305">61</a> urinary catheterization,<a class="elsevierStyleCrossRef" href="#bib0290">58</a> artificial nutrition,<a class="elsevierStyleCrossRef" href="#bib0295">59</a> and residence in a nursing home.<a class="elsevierStyleCrossRef" href="#bib0305">61</a>There are few studies of risk factors for ESBL-producing Enterobacteriaceae in Latin America. Potential risk factors for the occurrence of invasive infections arising from ESBL- and non-ESBL-producing E. coli and Klebsiella spp. were assessed in an international, prospective, observational study conducted by the SENTRY Antimicrobial Surveillance Program, which included 11 Latin American hospitals, from 2001–2002.<a class="elsevierStyleCrossRef" href="#bib0310">62</a> Although underlying comorbidities and potential risk factors were generally similar between ESBL and non-ESBL cases, a higher proportion of ESBL cases had a gastrostomy or jejunostomy tube (30.3% vs. 6.7%, p=0.008), required ventilation assistance (64.8% vs. 38.2%, p=0.005), or had been admitted to ICU (65.6% vs. 41.0%, p=0.006) compared with non-ESBL cases.<a class="elsevierStyleCrossRef" href="#bib0310">62</a>Among single-center studies, multivariate analysis of retrospective case-control data (n=121 patients) pertaining to all episodes of K. pneumoniae bacteremia for the period 1993–2002 in a Mexican referral center revealed prior use of cephalosporins (Odds ratio [OR] 7.6, 95% CI 1.1–53.5; p=0.039) and admission to ICU (OR 5.6, 95% CI 1.1–27.9; p=0.033) as significant risk factors.<a class="elsevierStyleCrossRef" href="#bib0315">63</a> Use of broad-spectrum cephalosporins also featured as the only independent predictor of ESBL-producing enterobacteriaceae strains (n=90) causing bacteremia in a recently published Mexican study,<a class="elsevierStyleCrossRef" href="#bib0320">64</a> and use of third-generation cephalosporins (p=0.008) was a risk factor for colonization of ESBL-producing strains of Klebsiella spp in a pediatric ICU in Brazil in 2008.<a class="elsevierStyleCrossRef" href="#bib0325">65</a> Another Latin American study found a relationship between use of ciprofloxacin and prevalence of ESBL-producing K. pneumoniae in a hospital setting.<a class="elsevierStyleCrossRef" href="#bib0330">66</a>DiscussionSince the first cases and outbreaks of infections by ESBL-producing Enterobacteriaceae were reported in Latin American hospitals, there has been a steady increase in the overall prevalence and in the number of types of ESBLs detected. According to region-wide surveillance data (ie, SENTRY, TEST, SMART, PAHO, and API) and findings from independent country-specific cohort studies, ESBL production among Klebsiella spp. can be considered endemic in Latin America. The balance of data indicates that rates of nosocomial infection caused by ESBL-producing Enterobacteriaceae, particularly K. pneumoniae, are high in Latin America compared with other world regions (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). More specifically, there has been a rapid spread of CTX-M enzymes throughout Latin American hospitals, which has been facilitated by horizontal transfer of encoding plasmids and successful clones. While we observed a geographical trend in the prevalence of a finite number of CTX-M enzyme subtypes in Latin America (i.e CTX-M-15 in the North; CTX-M-2 in the South), there was clear evidence that this regional association is weakening as CTX-Ms become even more widespread and evolve locally.In surveillance data reviewed for this article (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>), 45–53% of K. pneumoniae isolates are nonsusceptible to third-generation cephalosporins, compared with 21–27% resistance associated with K. pneumoniae HAIs in the United States.<a class="elsevierStyleCrossRef" href="#bib0335">67</a> The northern countries of Guatemala, Honduras, and Mexico have high rates of cephalosporin-resistant E. coli, while Argentina, Brazil, Colombia, and Panama have lower rates. For Klebsiella spp., Argentina, Brazil, Chile, Guatemala, and Honduras are experiencing especially high rates of cephalosporin-resistant strains, while Colombia, Panama, and Venezuela have lower rates. Independent cohort data showed that it is not uncommon in Latin America to encounter ESBL-producing Enterobacteriaceae that are nonsusceptible to cefepime, exhibit high rates of resistance to fluoroquinolones and ampicillin/sulbactam, and have appreciable rates of resistance to aminoglycosides and piperacillin/tazobactam. Susceptibility of ESBL-producing Enterobacteriaceae to the carbapenems, tigecycline, and colistin remains much higher (>90%).There are many possible explanations for the observed differences between countries and regions. Reported susceptibility rates may have differed because of selection of centers (public versus private) or other biases in study design, small numbers of isolates collected in some settings, differing laboratory methods, or quality control in some laboratories. Reported resistance rates may also reflect real differences in prevalence of resistant pathogens arising from local outbreaks, differences in antimicrobial prescribing practices (including use of cephalosporins), differences in facilities (e.g., rooms with multiple beds or overcrowded conditions), and local infection control measures (or the lack thereof). Unfortunately there are no studies that systematically investigate these differences between countries and facilities in Latin America and their effect on prevalence of ESBL-producing pathogens. Surveillance data must also be read carefully because some sources report resistance rates, while others report susceptibility rates—and because nonsusceptibility is not the same as resistance. Furthermore, data may over-represent tertiary care hospitals with more complicated patient populations receiving more intensive care than the general hospital population.The expanding geographic spread of ESBL-producing Enterobacteriaceae in the community and hospital setting underscores the importance of clinical and microbiologic recognition of these enzymes at multiple levels of health care. Surveillance data collected regionally in Latin America may be used to guide empiric treatment of patients suspected of multidrug-resistant infection, based on their individual risk level. For example, it has been shown that patients with age 65 years or older, recent use of antibiotics, recent hospitalization or stay in long-term care facility, and male sex have a greater likelihood of infection by ESBL-producing Enterobacteriaceae;<a class="elsevierStyleCrossRef" href="#bib0120">24</a> such patients may be suspected of infection with resistant pathogens and treated accordingly. However, knowledge of regional surveillance data and patient risk level is not adequate to guide optimal choice of therapy. Physicians should be aware of local data regarding the prevalence and antimicrobial susceptibilities of ESBL-producing bacterial strains in their particular city and hospital, information that can help guide treatment choices for patients in a particular facility. When possible, pathogen identification (at the genus and species level) and information about the in vitro antimicrobial resistance profile of the pathogen infecting the individual patient can guide the choice and adjustment of antimicrobials during the course of treatment.<a class="elsevierStyleCrossRef" href="#bib0340">68</a> Prospective observational data have shown that patients have a survival advantage when the correct antimicrobial agent is chosen as initial therapy rather than empiric agents that provide no coverage against the responsible pathogen.<a class="elsevierStyleCrossRef" href="#bib0345">69</a>Collaborative institutional, local, national, and regional surveillance of ESBL-producing Enterobacteriaceae is required to assist diagnosis, support treatment decisions, and guide antimicrobial stewardship and infection control efforts.<a class="elsevierStyleCrossRef" href="#bib0340">68</a> The US Clinical and Laboratory Standards Institute (CLSI) and the UK Health Protection Agency (HPA) have published guidelines for the detection of ESBL-producing organisms.<a class="elsevierStyleCrossRef" href="#bib0350">70</a> Following PAHO surveillance system recommendations, CLSI guidelines are followed in most Latin American countries to detect the presence of ESBL-mediated resistance. The difficulty in detecting and classifying specific ESBLs in the local setting is demonstrated by the fact that hundreds of different ESBLs have been described, including more than 145 β-lactamases in the CTX-M class alone (<a href="http://www.lahey.org/studies/other.asp">http://www.lahey.org/studies/other.asp</a>). More than 890 unique protein sequences for β-lactamases were determined by late 2009.<a class="elsevierStyleCrossRef" href="#bib0080">16</a> However, findings from Latin American studies show that molecular biology techniques can be useful in characterizing virulent K. pneumoniae clones isolated from patients and health care workers.<a class="elsevierStyleCrossRefs" href="#bib0105">21,71,72</a> The technology to identify genes conferring resistance is improving quickly and is becoming more automated. Ideally, surveillance programs in cities and hospitals should provide real-time information about phenotype and mechanism of resistance in a rapid, accurate, and reproducible manner.Antimicrobial stewardship in conjunction with local surveillance is also required to preserve the antimicrobial integrity of a limited arsenal of agents. More research is required to elucidate the risk factors for acquiring ESBL-producing Enterobacteriaceae, although it can be stated that antimicrobial treatment is the primary cause. Encouragingly, a 2002–2006 study in Colombia showed that restriction of third-generation cephalosporins can result in significant (5-fold) reduction in the number of ESBL-producing isolates.<a class="elsevierStyleCrossRef" href="#bib0365">73</a> However, treatment with cefepime is not recommended in areas where there is a high prevalence of circulating CTX-Ms since clinical failures often result in patients with high inoculum infections.<a class="elsevierStyleCrossRef" href="#bib0360">72</a> Carbapenems are a treatment of choice for infections caused by ESBL-producing Enterobacteriaceae, but an undesirable consequence of their use may be selection of carbapenem-resistant non-fermenter Gram-negative bacilli and Enterobacteriaceae.<a class="elsevierStyleCrossRefs" href="#bib0360">72,74–76</a> Instructions on how to restrict and cycle certain antimicrobial agents for specific indications, framed within a real-time surveillance-based drug formulary, offer the best conditions for rational drug use.Patient-to-patient transmission of ESBL-producing pathogens has been reported; this is likely a more important mode of infection with K. pneumoniae than with E. coli.<a class="elsevierStyleCrossRefs" href="#bib0385">77,78</a> However, this issue has not been studied in Latin America beyond nosocomial outbreaks. Because of difficulties with infection control, patient-to-patient transmission could play an important role in Latin American healthcare institutions. Therefore, infection control efforts are crucial in reducing the prevalence of drug-resistant pathogens. Local outbreaks of ESBL-producing Klebsiella spp. strains have been successfully addressed in Latin American settings through standard infection control practices, including disinfection of the unit, re-enforcing hand hygiene and barrier control measures, and adjusting antimicrobial prescribing practices.<a class="elsevierStyleCrossRefs" href="#bib0105">21,72,79</a>In summary, the problem of high infection rates by ESBL-producing Enterobacteriaceae in hospitals of Latin America is exacerbated by the spread of multidrug-resistant strains. Antimicrobial surveillance at the unit, hospital, city, national, and regional level is recommended to guide decision making about infection control efforts and appropriate antimicrobial treatment.Conflicts of interestManuel Guzmán Blanco is or has been a member of advisory boards of Merck, Pfizer, Becton and Dickinson. He has received research funds from Pfizer, Merck, Glaxo and Novartis. Jaime A. Labarca has been a member of advisory boards of Merck Sharp & Dhome and Pfizer, has received research funds from Merck Sharp & Dhome, and has participated in clinical studies for Sanofi Pasteur. Maria Virginia Villegas has been a member of advisory boards of Merck and Pfizer and has received research funds from Pfizer, Merck, Novartis, AstraZeneca, Merck S.A, Bayer, Janssen Cilag and Biomeriux. Eduardo Gotuzzo has been a consultant to Pfizer and has received research funds from Johnson & Johnson." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres566362" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec583704" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 3 => array:2 [ "identificador" => "sec0010" "titulo" => "Background: emergence of extended spectrum β-lactamase-producing Enterobacteriaceae in Latin America before 2005" ] 4 => array:2 [ "identificador" => "sec0015" "titulo" => "Methods" ] 5 => array:3 [ "identificador" => "sec0020" "titulo" => "Prevalence and type of extended spectrum β-lactamases" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Regional data" ] 1 => array:3 [ "identificador" => "sec0030" "titulo" => "Country-specific data" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0035" "titulo" => "Surveillance studies" ] ] ] 2 => array:2 [ "identificador" => "sec0040" "titulo" => "Cohort studies" ] ] ] 6 => array:3 [ "identificador" => "sec0045" "titulo" => "Antimicrobial susceptibility" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0050" "titulo" => "Regional data" ] 1 => array:2 [ "identificador" => "sec0055" "titulo" => "Country-specific data" ] ] ] 7 => array:2 [ "identificador" => "sec0060" "titulo" => "Risk factors" ] 8 => array:2 [ "identificador" => "sec0065" "titulo" => "Discussion" ] 9 => array:2 [ "identificador" => "sec0070" "titulo" => "Conflicts of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2013-05-10" "fechaAceptado" => "2013-10-29" "PalabrasClave" => array:1 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec583704" "palabras" => array:4 [ 0 => "Escherichia coli" 1 => "Klebsiella" 2 => "Latin America" 3 => "Bacterial resistance" ] ] ] ] "tieneResumen" => true "resumen" => array:1 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "To review the epidemiology of nosocomial extended spectrum β-lactamase-producing Enterobacteriaceae in Latin America, a systematic search of the biomedical literature (PubMed) was performed for articles published since 2005. Rates of nosocomial infections caused by extended spectrum β-lactamase-producing Enterobacteriaceae in Latin America have increased since 2005. Up to 32% of Escherichia coli and up to 58% of Klebsiella pneumoniae isolates are extended spectrum β-lactamase-positive, rates that are higher than in other world regions. From a region-wide perspective, 11–25% of E. coli isolates and 45–53% of K. pneumoniae isolates were nonsusceptible to third-generation cephalosporins. At the country level, there was a wide range in Enterobacteriaceae resistance rates to third-generation cephalosporins, with especially high rates of resistance to E. coli in Guatemala, Honduras, and Mexico, and high resistance rates to Klebsiella spp. in Argentina, Brazil, Chile, Guatemala, Honduras, and Paraguay. Susceptibility of extended spectrum β-lactamase-producing Enterobacteriaceae to cefepime, fluoroquinolones, ampicillin/sulbactam, aminoglycosides, and piperacillin/tazobactam has also been compromised, leaving the carbapenems, tigecycline, and colistin as the only antibiotics with >90% susceptibility rates. There is a steady increase in the prevalence and types of extended spectrum β-lactamases produced by Enterobacteriaceae isolates in Latin American hospitals (particularly CTX-Ms), suggesting endemic conditions overlaid by clonal outbreaks. Appropriate treatment decisions and infection control strategies informed by surveillance of regional and local susceptibilities and mechanisms of resistance are required to mitigate this major public health concern." ] ] "NotaPie" => array:2 [ 0 => array:3 [ "etiqueta" => "1" "nota" => "The authors dedicate this work to the memory of José María Casellas." "identificador" => "fn1" ] 1 => array:3 [ "etiqueta" => "2" "nota" => "See Appendix A for the members of the Working Group." "identificador" => "fn2" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:3 [ "apendice" => "Latin America Working Group on Bacterial Resistance: Carlos Alvarez (Hospital Universitario San Ignacio and Pontificia Universidad Javeriana, Bogotá, Colombia), Luis Bavestrello (Clinica Reñaca, Viña Del Mar, Chile), Eitan Berezin (Santa Casa de São Paulo School of Medicine, Brazil), Eduardo Gotuzzo (Universidad Peruana Cayetano Heredia, Lima, Peru), Manuel Guzmán-Blanco (Hospital Privado Centro Médico de Caracas, Venezuela), Jaime A. Labarca (Pontificia Universidad Católica de Chile, Santiago, Chile), Carlos M. Luna (Hospital de Clínicas José de San Martin Hospital, Universidad de Buenos Aires, Argentina), Carlos Mejía (Hospital Roosevelt, Guatemala City, Guatemala), Simone Nouer (Hospital Universitário Clementino Fraga Filho, Rio de Janeiro, Brazil), Eduardo Rodríguez-Noriega (Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Mexico), Mauro José Costa Salles (Hospital Irmandade da Santa Casa de Misericórdia de São Paulo, Brazil), Carlos Seas (Universidad Peruana Cayetano Heredia, Lima, Peru), Fortino Solórzano Santos (Hospital de Pediatría Centro Médico Nacional Siglo XXI, Mexico City, Mexico), Maria Virginia Villegas (International Center for Medical Research and Training [CIDEIM], Cali, Colombia), Jeannete Zurita (Hospital Vozandes and Pontificia Universidad Católica del Ecuador, Quito, Ecuador)." "etiqueta" => "Appendix A" "identificador" => "sec0075" ] ] ] ] "multimedia" => array:8 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1693 "Ancho" => 2999 "Tamanyo" => 189910 ] ] "descripcion" => array:1 [ "en" => "Frequency of ESBL producers among E. coli and K. pneumoniae isolates in the SMART and TEST antimicrobial surveillance programs.<a class="elsevierStyleCrossRefs" href="#bib0040">8,27,28,31,36</a> *United States data only. DISN, Doripenem International Surveillance Network; ESBL, extended spectrum β-lactamase; SMART, Study for Monitoring Antimicrobial Resistance Trends; TEST, Tigecycline Evaluation and Surveillance Trial." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 3427 "Ancho" => 2996 "Tamanyo" => 285274 ] ] "descripcion" => array:1 [ "en" => "National frequencies of ESBL producers among (a) Escherichia coli and (b) Klebsiella pneumoniae isolates in Latin American hospitals.<a class="elsevierStyleCrossRefs" href="#bib0150">30,32,33</a> ESBL, extended spectrum β-lactamase; SMART, Study for Monitoring Antimicrobial Resistance Trends; TEST, Tigecycline Evaluation and Surveillance Trial. In SENTRY 2008–2010 report, only the 4 countries with highest rates of ESBL production were reported." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 2702 "Ancho" => 3167 "Tamanyo" => 621178 ] ] "descripcion" => array:1 [ "en" => "Representation of the frequency of ESBL production (no. of isolates tested) and types of ESBLs produced by Enterobaceriaceae isolated from Latin American hospitals reporting >100 isolates.<a class="elsevierStyleCrossRefs" href="#bib0185">37–47</a> The distribution of ESBLs was not available for all studies reporting prevalence data. All isolates were resistant to oxyimino-cephalosporins. ESBL, extended spectrum β-lactamase." ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1702 "Ancho" => 2998 "Tamanyo" => 147918 ] ] "descripcion" => array:1 [ "en" => "Findings of the Pan-American Health Organization (PAHO) summarizing the frequency of nosocomial Escherichia coli and Klebsiella pneumoniae isolates resistant to cefepime in 2009.<a class="elsevierStyleCrossRef" href="#bib0175">35</a> NR, not reported." ] ] 4 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:3 [ "leyenda" => "PAHO, Pan-American Health Organization; SMART, Study for Monitoring Antimicrobial Resistance Trends; TEST, Tigecycline Evaluation and Surveillance Trial." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col">Country \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="9" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Surveillance program and collection period</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col">SMART<a class="elsevierStyleCrossRef" href="#bib0135">27</a> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col">SMART<a class="elsevierStyleCrossRef" href="#bib0140">28</a> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col">SMART<a class="elsevierStyleCrossRef" href="#bib0145">29</a> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col">SMART<a class="elsevierStyleCrossRef" href="#bib0150">30</a> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col">TEST<a class="elsevierStyleCrossRef" href="#bib0155">31</a> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col">TEST<a class="elsevierStyleCrossRef" href="#bib0160">32</a> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col">SENTRY<a class="elsevierStyleCrossRef" href="#bib0165">33</a> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col">PAHO<a class="elsevierStyleCrossRef" href="#bib0170">34</a>,<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col">PAHO<a class="elsevierStyleCrossRef" href="#bib0175">35</a>,<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">2004 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">2005 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">2008 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">2008–2009 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">2004–2006 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">2004–2010 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">2008–2010 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">2006 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">2009 \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Argentina \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">59 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">72 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Bolivia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">19 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">30 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Brazil \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Chile \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Colombia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">147 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Dominican Republic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Ecuador \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">22 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">El Salvador \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">33 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">33 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Guatemala \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Honduras \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Mexico \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Nicaragua \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Panama \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">24 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">24 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Paraguay \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">21 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Peru \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">22 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">40 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Puerto Rico \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Venezuela \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">34 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">24 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab920845.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "Including only countries reporting data on Enterobacteriaceae in hospital settings." ] ] ] "descripcion" => array:1 [ "en" => "Number of study sites by country for key surveillance reports." ] ] 5 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:3 [ "leyenda" => "ESBL, extended spectrum β-lactamase; DISN, Doripenem International Surveillance Network; NR, not reported; SMART, Study for Monitoring Antimicrobial Resistance Trends; TEST, Tigecycline Evaluation and Surveillance Trial." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col">Surveillance program \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col">Collection period \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col">Anatomical collection site \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Proportion ESBL-positive (total no. isolates)</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">E. coli \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Klebsiella spp. \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">SMART<a class="elsevierStyleCrossRef" href="#bib0135">27</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2004 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Intra-abdominal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">28% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">SMART<a class="elsevierStyleCrossRef" href="#bib0140">28</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2005 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Intra-abdominal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">16% (395) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">27% (121) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">TEST<a class="elsevierStyleCrossRef" href="#tblfn0010">a</a>,<a class="elsevierStyleCrossRef" href="#bib0155">31</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2004–2006 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Blood, respiratory tract, urine, skin, wound, fluids and other defined sources \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">14% (326) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">44% (282)<a class="elsevierStyleCrossRef" href="#tblfn0015">b</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">TEST<a class="elsevierStyleCrossRef" href="#bib0160">32</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2004–2010 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Blood, respiratory tract, urine, skin, wound, fluids \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">24% (3581) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">35% (2962)<a class="elsevierStyleCrossRef" href="#tblfn0015">b</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">DISN<a class="elsevierStyleCrossRef" href="#bib0040">8</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2007 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Blood, respiratory tract, skin and skin structure, urine \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">14% (493) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">44% (350)<a class="elsevierStyleCrossRef" href="#tblfn0015">b</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">SMART<a class="elsevierStyleCrossRef" href="#bib0145">29</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2008 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Intra-abdominal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">27% (504) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">38% (151)<a class="elsevierStyleCrossRef" href="#tblfn0015">b</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">SMART<a class="elsevierStyleCrossRef" href="#bib0150">30</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2008–2009 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Intra-abdominal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">24% (1366) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NR \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">SENTRY<a class="elsevierStyleCrossRef" href="#bib0165">33</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2008–2010 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Blood, skin and soft tissue, lower respiratory tract \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">25% (1517) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">53% (1052) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">SMART<a class="elsevierStyleCrossRef" href="#tblfn0020">c</a>,<a class="elsevierStyleCrossRef" href="#bib0180">36</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2009–2010 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Urine \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">23% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab920848.png" ] ] ] "notaPie" => array:3 [ 0 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "a" "nota" => "Most data were collected from intensive care units." ] 1 => array:3 [ "identificador" => "tblfn0015" "etiqueta" => "b" "nota" => "K. pneumoniae only." ] 2 => array:3 [ "identificador" => "tblfn0020" "etiqueta" => "c" "nota" => "Data collected from 15 sites in Latin America; countries where sites located not specified.<a class="elsevierStyleCrossRef" href="#bib0180">36</a>" ] ] ] "descripcion" => array:1 [ "en" => "Temporal prevalences of healthcare-acquired ESBL-positive Enterobacteriaceae in hospitals of Latin America." ] ] 6 => array:7 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:3 [ "leyenda" => "NR, not reported; SMART, Study for Monitoring Antimicrobial Resistance Trends; TEST, Tigecycline Evaluation and Surveillance Trial." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pathogen \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">SMART 2005<a class="elsevierStyleCrossRef" href="#bib0140">28</a> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">TEST 2004–2006<a class="elsevierStyleCrossRef" href="#bib0155">31</a> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">TEST 2004–2010<a class="elsevierStyleCrossRef" href="#bib0160">32</a> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">SMART 2008<a class="elsevierStyleCrossRef" href="#bib0145">29</a> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">SMART 2008–2009<a class="elsevierStyleCrossRef" href="#bib0150">30</a> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">SENTRY 2008–2010<a class="elsevierStyleCrossRef" href="#bib0165">33</a> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " rowspan="3" align="left" valign="top">E. coli</td><td class="td" title="table-entry " align="left" valign="top">83–84% (84%<a class="elsevierStyleCrossRef" href="#tblfn0025">a</a>)n=395 isolates \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">82–89% (86%)n=326 isolates \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">82% (94%)n=2711non-ESBL isolates \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">96% (100%)n>50non-ESBL isolates \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">94–95% (100%)n=1043non-ESBL isolates \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">75–82% (84%)n=1517 isolates \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="6" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1% (28%)n=870 ESBL isolates \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2%–28% (7%)n>50 ESBL isolates \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1%-21% (12%)n=323 ESBL isolates \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="3" align="left" valign="top">K. pneumoniae</td><td class="td" title="table-entry " align="left" valign="top">NR \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">53–55% (58%)n=282 isolates \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">77% (88%)n=1917non-ESBL isolates \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">96–97% (97%)n>50non-ESBL isolates \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NR \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">47–55% (59%)n=1052 isolates<a class="elsevierStyleCrossRef" href="#tblfn0030">b</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="6" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0% (0%)n=124 ESBLK. pneumoniae isolates \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1% (29%)n=1045 ESBLK. pneumoniae isolates \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2%–28% (7%)n>50 ESBLK. pneumoniae isolates \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">S. marcescens \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NR \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">77% (82%)n=124 isolates \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">68% (84%) n=1126 isolates \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NR \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NR \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NR \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab920847.png" ] ] ] "notaPie" => array:2 [ 0 => array:3 [ "identificador" => "tblfn0025" "etiqueta" => "a" "nota" => "Throughout table, figures in parentheses are proportions susceptible to cefepime, a fourth-generation cephalosporin." ] 1 => array:3 [ "identificador" => "tblfn0030" "etiqueta" => "b" "nota" => "Klebsiella spp." ] ] ] "descripcion" => array:1 [ "en" => "Proportion of healthcare-acquired Enterobacteriaceae isolates susceptible to third-generation cephalosporins (and cefepime) in Latin American hospitals." ] ] 7 => array:7 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col">Country \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="4" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">% Resistance (total no. isolates)</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">E. coli</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">K. pneumoniae</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">2006 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">2009 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">2006 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">2009 \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Argentina \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 (12001) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">18 (1659) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">57 (3278)<a class="elsevierStyleCrossRef" href="#tblfn0035">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">58 (1518) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Bolivia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">33 (1079) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">37 (2923) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">14–47 (646)<a class="elsevierStyleCrossRef" href="#tblfn0035">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">27–50 (984) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Colombia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8-9 (9607) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">30 (3607) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Dominican Republic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">35–40 (516) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">23 (3061) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">30 (828) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">26 (2510) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Ecuador \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10–13 (2582) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">18–20 (2736) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">14–18 (457) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">42–48 (890) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">El Salvador \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 (1306) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">18–32 (2498) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">14–15 (421) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">46–50 (1007) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Guatemala \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">67–70 (1729) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">24 (4921) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">68–75 (1456) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">52–53 (3001) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Honduras \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">21–32 (524) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">30–32 (1273) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">44–54 (449) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">58–67 (871) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Nicaragua \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">19 (508) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0–0.5 (1081) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">65 (312) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.3 (383) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Panama \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4–8 (2522) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8 (3040) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">23–37 (1263) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">26–39 (1749) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Paraguay \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6–15 (1119) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">16 (694) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">37–55 (1055) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">57–59 (721) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Peru \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">43–56 (463/282) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">32 (1401/1766) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">68–71 (185/169) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">66 (583) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Venezuela \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4–10 (11316) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">13–14 (1450) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">38–39 (2666)<a class="elsevierStyleCrossRef" href="#tblfn0035">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">60 (377) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab920846.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0035" "etiqueta" => "a" "nota" => "Klebsiella spp." ] ] ] "descripcion" => array:1 [ "en" => "Findings of the Pan-American Health Organization (PAHO) summarizing the frequency of nosocomial Enterobacteriaceae isolates resistant to third-generation cephalosporins in 2006 and 2009.<a class="elsevierStyleCrossRefs" href="#bib0170">34,35</a>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:79 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => 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Extended spectrum β-lactamase producers among nosocomial Enterobacteriaceae in Latin America

Manuel Guzmán-Blancoa,1,

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mibeli03@gmail.com

Corresponding author.

, Jaime A. Labarcab, Maria Virginia Villegasc, Eduardo Gotuzzod, On behalf of the Latin America Working Group on Bacterial Resistance 2

a Hospital Privado Centro Médico de Caracas and Hospital Vargas de Caracas, Caracas, Venezuela

b Department of Infectious Diseases, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile

c Bacterial Resistance Group, International Center for Medical Research and Training (CIDEIM), Cali, Colombia

d Universidad Peruana Cayetano Heredia, Lima, Peru

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    "titulo" => "Extended spectrum &#946;-lactamase producers among nosocomial <span class="elsevierStyleItalic">Enterobacteriaceae</span> in Latin America"
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Findings of the Pan-American Health Organization &#40;PAHO&#41; summarizing the frequency of nosocomial <span class="elsevierStyleItalic">Escherichia coli</span> and <span class="elsevierStyleItalic">Klebsiella pneumoniae</span> isolates resistant to cefepime in 2009&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> NR&#44; not reported&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Health care-associated infections &#40;HAIs&#41; are particularly challenging in developing countries such as those of Latin America owing to their far higher rate of occurrence than in developed countries&#46; For instance&#44; the World Health Organization reported that the pooled prevalence of hospital-wide HAIs between 1995 and 2010 in low- and middle-income countries was 10&#46;1 per 100 patients &#40;95&#37; confidence interval &#91;CI&#93;&#44; 8&#46;4&#8211;12&#46;2&#41;&#44; which compares unfavorably with the corresponding rate in high-income countries &#40;7&#46;6 episodes per 100 patients&#59; 95&#37; CI&#44; 6&#46;9&#8211;8&#46;5&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Most HAIs in developed and developing countries are by Gram-negative bacteria&#44; predominantly species and subspecies from the <span class="elsevierStyleItalic">Enterobacteriaceae</span> family followed by nonfermenters such as <span class="elsevierStyleItalic">Pseudomonas aeruginosa</span> and <span class="elsevierStyleItalic">Acinetobacter baumannii</span>&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;4</span></a> The capacity of health care professionals to manage nosocomial infections by <span class="elsevierStyleItalic">Enterobacteriaceae</span> has diminished over the last decade because of the emergence and widespread dissemination of multidrug-resistant phenotypes&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;5&#8211;8</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Production of &#946;-lactamases is the primary mechanism of &#946;-lactam resistance in these pathogens&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#8211;15</span></a> ESBL&#44; extended spectrum &#946;-lactamase &#40;ESBLs&#41; can confer resistance to penicillins&#44; first-&#44; second-&#44; and third-generation cephalosporins&#44; and aztreonam &#40;but not the cephamycins such as cefoxitin or carbapenems&#41;&#44; and are usually inhibited by &#946;-lactamase inhibitors such as clavulanic acid&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> Most ESBLs can also hydrolyze fourth-generation cephalosporins &#40;e&#46;g&#46;&#44; cefepime or cefpirome&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;17</span></a> It is important to note that AmpC &#946;-lactamases differ from typical ESBLs in that AmpC &#946;-lactamases&#44; besides hydrolyzing third-generation cephalosporins&#44; are not inhibited by &#946;-lactamase inhibitors&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> Furthermore&#44; <span class="elsevierStyleItalic">Enterobacteriaceae</span> harboring ESBLs are often co-resistant to fluoroquinolones&#44; aminoglycosides&#44; and trimethoprim&#47;sulfamethoxazole&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#44;18</span></a> Thus&#44; infections by these multidrug-resistant pathogens are a major public health threat&#44; as there are limited treatment options available&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The purpose of this review is to provide an updated epidemiology of ESBL-producing <span class="elsevierStyleItalic">Enterobacteriaceae</span> in the Latin American hospital setting&#44; with a focus on antimicrobial susceptibilities of <span class="elsevierStyleItalic">Escherichia coli</span> and <span class="elsevierStyleItalic">Klebsiella pneumoniae</span> strains throughout the region&#46; We include in this review data from the Spanish- and Portuguese-speaking countries of the Americas&#44; including Mexico&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Background&#58; emergence of extended spectrum &#946;-lactamase-producing <span class="elsevierStyleItalic">Enterobacteriaceae</span> in Latin America before 2005</span><p id="par0020" class="elsevierStylePara elsevierViewall">During the period from 1987 to 1989&#44; <span class="elsevierStyleItalic">K&#46; pneumoniae</span> expressing sulfhydryl variant &#40;SHV&#41;-5 and SHV-2 were responsible for infection outbreaks in a Buenos Aires intensive care unit &#40;ICU&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> Retrospective analysis of a lyophilized strain of <span class="elsevierStyleItalic">K&#46; pneumoniae</span> recovered in 1982 from the urine of a patient with an indwelling urinary catheter detected SHV-5&#44; making this the earliest detected ESBL-producing bacterium in South America&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14&#44;19</span></a> Cefotaxime-resistant &#40;CTX-M&#41; &#946;-lactamase was first described in an outbreak of neonatal infection with <span class="elsevierStyleItalic">Salmonella typhymurium</span> during 1989 in Argentina&#44; Bolivia&#44; and Paraguay&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> Further outbreaks of infections in neonates caused by ESBL-producing <span class="elsevierStyleItalic">Klebsiella</span> spp&#46; were reported in the late 1990s in Mexico and Brazil&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">20&#44;21</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">By the late 1990s&#44; ESBL expression by <span class="elsevierStyleItalic">Enterobacteriaceae</span> in Latin American hospitals became endemic&#46; During SENTRY antimicrobial surveillance conducted between 1997 and 2002&#44; the prevalence of <span class="elsevierStyleItalic">Klebsiella</span> spp&#46; expressing ESBLs in blood cultures from hospitalized patients was greater in Latin America than in Europe and North America &#40;43&#37; vs&#46; 22&#37; and 6&#37;&#44; respectively&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> SENTRY data for urine isolates revealed that &#8764;45&#37; of <span class="elsevierStyleItalic">Klebsiella</span> spp&#46; exhibited an ESBL phenotype in 2000 &#40;compared with &#8764;30&#37; during 1997&#8211;1999&#41; and &#8764;5&#37; of <span class="elsevierStyleItalic">E&#46; coli</span> exhibited an ESBL phenotype during both testing periods&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> The percentage of <span class="elsevierStyleItalic">Enterobacteriaceae</span> producing ESBLs was also very high in Brazilian hospitals &#40;SENTRY&#44; 1997&#8211;1999&#41;&#44; with 50&#37; of all <span class="elsevierStyleItalic">K&#46; pneumoniae</span> isolates and 9&#37; of all <span class="elsevierStyleItalic">E&#46; coli</span> isolates suspected of harboring ESBLs&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> Over a slightly later timeframe&#44; findings of the Meropenem Yearly Susceptibility Test Information Collection &#40;MYSTIC&#41; study &#40;1997&#8211;2003&#41; showed that 52&#37; of <span class="elsevierStyleItalic">K&#46; pneumoniae</span> isolates from Latin America &#40;vs&#46; 12&#37; from North America&#41;&#44; 18&#37; of <span class="elsevierStyleItalic">E&#46; coli</span> isolates &#40;vs&#46; 8&#37; from North America&#41;&#44; and 6&#37; of <span class="elsevierStyleItalic">Proteus mirabilis</span> isolates &#40;vs&#46; 4&#37; from North America&#41; were ESBL-positive&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">CTX-M-type &#946;-lactamases eventually replaced TEM and SHV variants as the most common type of ESBL globally&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#44;24</span></a> In 2000&#44; CTX-M-2 was the most prevalent type of ESBL in Latin America &#40;especially in the southern part of the continent&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> and in 2002&#44; CTX-M-12 from a strain of <span class="elsevierStyleItalic">K&#46; pneumoniae</span> was detected in Colombia&#44; representing the first description of a CTX-M in this country&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> While ESBLs are found predominantly in <span class="elsevierStyleItalic">Klebsiella</span> spp&#46; and <span class="elsevierStyleItalic">E&#46; coli</span>&#44; they have also been described in other genera of <span class="elsevierStyleItalic">Enterobacteriaceae</span> including species of <span class="elsevierStyleItalic">Citrobacter</span>&#44; <span class="elsevierStyleItalic">Serratia</span>&#44; <span class="elsevierStyleItalic">Proteus</span>&#44; <span class="elsevierStyleItalic">Morganella</span>&#44; <span class="elsevierStyleItalic">Salmonella</span>&#44; and <span class="elsevierStyleItalic">Enterobacter</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Methods</span><p id="par0035" class="elsevierStylePara elsevierViewall">To review the published clinical data relating to epidemiology of ESBL-producing <span class="elsevierStyleItalic">Enterobacteriaceae</span> in the Latin American hospital setting&#44; a systematic search of the biomedical literature was conducted&#46; Medline &#40;via PubMed&#41; was searched limited by the dates 1 January 2005 to 15 July 2013 for articles using the following terms and Boolean logic&#58; &#40;Extended spectrum beta lactamase OR ESBL&#41; AND &#40;<span class="elsevierStyleItalic">Enterobacteriaceae</span> OR <span class="elsevierStyleItalic">coli</span> OR <span class="elsevierStyleItalic">Klebsiella</span> OR <span class="elsevierStyleItalic">Shigella</span> OR <span class="elsevierStyleItalic">Salmonella</span> OR <span class="elsevierStyleItalic">Proteus</span>&#41; AND &#40;&#8220;Latin America&#8221; OR &#8220;South America&#8221; OR &#8220;Central America&#8221; OR Mexico OR Guatemala OR Honduras OR Nicaragua OR &#8220;Costa Rica&#8221; OR Cuba OR &#8220;Dominican Republic&#8221; OR Panama OR Colombia OR Venezuela OR Guyana OR Suriname OR &#8220;French Guiana&#8221; OR Brazil OR Ecuador OR Peru OR Bolivia OR Paraguay OR Uruguay OR Chile OR Argentina&#41;&#46; Selected additional references were identified by authors&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Prevalence and type of extended spectrum &#946;-lactamases</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Regional data</span><p id="par0040" class="elsevierStylePara elsevierViewall">Several regional surveillance studies monitor drug resistance in Latin America&#44; most with a small number of participating centers in each country&#46; The number of centers from each country participating in surveillance efforts is shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">27&#8211;35</span></a> According to data from the Study for Monitoring Antimicrobial Resistance Trends &#40;SMART&#41;&#44; Tigecycline Evaluation and Surveillance Trial &#40;TEST&#41;&#44; and Doripenem International Surveillance Network &#40;DISN&#41;&#44; the prevalence of ESBL-producing <span class="elsevierStyleItalic">K&#46; pneumoniae</span> was far higher in Latin America than in other world regions &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;27&#44;28&#44;31&#44;36</span></a> Similarly&#44; only the Asia&#47;Pacific region had higher rates of ESBL production in <span class="elsevierStyleItalic">E&#46; coli</span>&#46; <a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;27&#44;28&#44;31&#44;36</span></a> Furthermore&#44; prevalence of ESBL-producing <span class="elsevierStyleItalic">E&#46; coli</span> and <span class="elsevierStyleItalic">Klebsiella</span> spp&#46; appears to have steadily increased over the last decade &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;27&#8211;33&#44;36</span></a> A greater proportion of <span class="elsevierStyleItalic">Klebsiella</span> spp&#46; than <span class="elsevierStyleItalic">E&#46; coli</span> produce ESBLs&#44; although ESBL production by <span class="elsevierStyleItalic">E&#46; coli</span> has increased since the period before 2005&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Country-specific data</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Surveillance studies</span><p id="par0045" class="elsevierStylePara elsevierViewall">In the SENTRY 2008&#8211;2010&#44; SMART 2008&#8211;2009&#44; and TEST 2004&#8211;2010 reports&#44; the frequencies of <span class="elsevierStyleItalic">E&#46; coli</span> producing ESBLs were highest in Chile&#44; Ecuador&#44; Guatemala&#44; Honduras&#44; and Mexico &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>a&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">30&#44;32&#44;33</span></a> Among <span class="elsevierStyleItalic">Klebsiella</span> spp&#46;&#44; ESBL phenotype rates of 50&#37; or greater were observed in Argentina&#44; Brazil&#44; Chile&#44; and Honduras &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>b&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">32&#44;33</span></a></p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Cohort studies</span><p id="par0050" class="elsevierStylePara elsevierViewall">As in the surveillance studies&#44; independent cohort data revealed that a greater proportion of <span class="elsevierStyleItalic">K&#46; pneumoniae</span> than <span class="elsevierStyleItalic">E&#46; coli</span> clinical isolates produce ESBLs throughout the continent &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">37&#8211;48</span></a> The range of ESBL production among <span class="elsevierStyleItalic">K&#46; pneumoniae</span> isolates varied from 24&#37; &#40;in Cuba&#44; 2009&#8211;2010&#41;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a> to 58&#37; &#40;in Curitiba&#44; Brazil&#44; 2003&#8211;2004&#41;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">46</span></a> whereas ESBL production among <span class="elsevierStyleItalic">E&#46; coli</span> isolates varied from 7&#37; &#40;in southern Brazil&#41;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">45</span></a> to 32&#37; &#40;in Sonoro&#44; Mexico&#44; 2008&#8211;2009&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">42</span></a> Care must be taken when interpreting these data because of inter-study differences with respect to the time&#44; method &#40;i&#46;e&#46;&#44; consecutive or random&#41;&#44; and anatomical site of sample collection&#44; as well as the microbiological techniques and standards used&#46; Nevertheless&#44; data collected by independent cohort studies on the frequency of ESBL production among <span class="elsevierStyleItalic">E&#46; coli</span> clinical isolates &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41; compared favorably with data collected by SMART&#44; SENTRY&#44; and TEST &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>a&#41; for Brazil &#40;range&#44; 7&#8211;24&#37; vs&#46; 13&#8211;17&#37;&#44; respectively&#41;&#44; Mexico &#40;16&#8211;32&#37; vs&#46; 38&#8211;48&#37;&#41; and Venezuela &#40;16&#8211;27&#37; vs 15&#8211;30&#37;&#41;&#46; Regarding the frequency of ESBL production among <span class="elsevierStyleItalic">K&#46; pneumoniae</span> clinical isolates&#44; general agreement was observed between independent cohort &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41; and surveillance data &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>b&#41; for Brazil &#40;44&#8211;58&#37; vs&#46; 49&#8211;50&#37;&#44; respectively&#41;&#44; and Mexico &#40;27&#8211;36&#37; vs&#46; 25&#8211;33&#37;&#41;&#44; but not Venezuela &#40;46&#8211;48&#37; vs&#46; 17&#37;&#41;&#46; Limited prevalence data were available for Bolivia &#40;Santa Cruz de la Sierra&#44; 2004&#41; wherein 150&#8211;642 &#40;23&#37;&#41; consecutively collected Gram-negative isolates were putative ESBL producers&#44; but this statistic encompassed strains of <span class="elsevierStyleItalic">P&#46; aeruginosa</span> and <span class="elsevierStyleItalic">Acinetobacter</span> spp&#46; in addition to <span class="elsevierStyleItalic">Enterobacteriaceae</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">49</span></a></p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">The molecular characteristics of the ESBL isolates detected in surveillance studies were not described in those publications&#46; Most of our knowledge about specific ESBLs circulating in Latin American hospitals comes from independent cohort studies&#46; <a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a> shows that CTX-Ms have infiltrated most countries to various extents&#44; with CTX-M-15 commonly found in the northern part of the continent&#46; The endemicity of CTX-M-15 is challenging because this enzyme&#44; unlike other ESBLs&#44; can hydrolyze ceftazidime&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">50</span></a> CTX-M-2 was the most common subtype in Argentina &#40;52&#37; of 50 ESBL producers&#41;&#44; and data indicated emergence of CTX-M-15 &#40;38&#37;&#41; along with CTX-M-8 &#40;2&#37;&#41; and CTX-M-9 &#40;6&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">48</span></a> SHV enzymes &#40;particularly SHV-5 and SHV-12&#41; were highly prevalent in Mexico&#44; Colombia&#44; and Brazil &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">These prevalence findings are supported by results of studies that examined the genotype distribution among ESBL producers&#46; Of 127 ESBL-producing <span class="elsevierStyleItalic">Enterobacteriaceae</span> isolated over one year from inpatients and outpatients at a public teaching hospital at S&#227;o Paulo&#44; Brazil&#44; <span class="elsevierStyleItalic">bla</span><span class="elsevierStyleInf">CTX-M</span> and <span class="elsevierStyleItalic">bla</span><span class="elsevierStyleInf">SHV</span> were highly prevalent &#40;in 34&#37; and 63&#37; of strains&#44; respectively&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">51</span></a> In Colombia &#40;Bogota&#44; 2003&#8211;2005&#41;&#44; computational sequencing analysis revealed that CTX-M-12 &#40;56&#37;&#41; and SHV-12 &#40;33&#37;&#41; were the most prevalent ESBLs produced among 177 <span class="elsevierStyleItalic">K&#46; pneumoniae</span> isolates harboring <span class="elsevierStyleItalic">bla</span> genes&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">52</span></a> In Bolivia&#44; <span class="elsevierStyleItalic">bla</span><span class="elsevierStyleInf">CTX-M-2</span> &#40;71&#37;&#41;&#44; and to a lesser extent <span class="elsevierStyleItalic">bla</span><span class="elsevierStyleInf">CTX-M-43</span> &#40;21&#37;&#41;&#44; were the most prevalent genes encoding ESBL production in 150 Gram-negative clinical isolates collected from four hospitals in Santa Cruz de la Sierra during a 4-month period in 2004&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">49</span></a> In addition&#44; <span class="elsevierStyleItalic">bla</span><span class="elsevierStyleInf">PER-2</span> was reported among 31&#37; of 122 ESBL&#43; <span class="elsevierStyleItalic">K&#46; pneumoniae</span> isolates collected in 10 hospitals in Chile in 1998&#8211;2004 &#40;40&#37; were <span class="elsevierStyleItalic">bla</span><span class="elsevierStyleInf">CTX-M</span> and 13&#37; were <span class="elsevierStyleItalic">bla</span><span class="elsevierStyleInf">GES</span>&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">53</span></a> and 15&#37; of 47 ESBL&#43; <span class="elsevierStyleItalic">K&#46; pneumoniae</span> isolates collected in eight hospitals in Caracas&#44; Venezuela in 2009-2010 were type PER&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a></p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Antimicrobial susceptibility</span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Regional data</span><p id="par0065" class="elsevierStylePara elsevierViewall">Data on antimicrobial susceptibilities are reported for the Latin American region by the SMART&#44; TEST&#44; and SENTRY surveillance efforts&#44; and for individual Latin American countries by The Pan-American Health Organization &#40;PAHO&#41; &#40;see <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> for countries participating in each effort&#41;&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">From a regional perspective&#44; <span class="elsevierStyleItalic">E&#46; coli</span> strains were more often susceptible &#40;75&#8211;89&#37;&#41; to third-generation cephalosporins than strains of <span class="elsevierStyleItalic">K&#46; pneumoniae</span> &#40;47&#8211;55&#37;&#44; referring to strains that were not distinguished as ESBL&#43; or ESBL&#8722;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">28&#8211;33</span></a> Susceptibilities of <span class="elsevierStyleItalic">E&#46; coli</span> and <span class="elsevierStyleItalic">K&#46; pneumoniae</span> to the fourth-generation cephalosporin cefepime were not markedly greater than their susceptibilities to third-generation cephalosporins&#46; As expected&#44; susceptibility to third-generation cephalosporins and cefepime was much lower among ESBL-positive <span class="elsevierStyleItalic">E&#46; coli</span> and <span class="elsevierStyleItalic">K&#46; pneumoniae</span> strains than among ESBL-negative or unspecified isolates &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">29&#8211;32</span></a> Antimicrobial co-resistance was a recurring feature among these isolates&#44; particularly those expressing ESBLs&#46; In SENTRY 2008&#8211;2010&#44; <span class="elsevierStyleItalic">E&#46; coli</span> &#40;all isolates&#41; were most susceptible to the carbapenems &#40;99&#8211;100&#37;&#41;&#44; amikacin &#40;97&#8211;100&#37;&#41;&#44; piperacillin&#47;tazobactam &#40;82&#8211;94&#37;&#41;&#44; and colistin &#40;100&#37;&#41;&#44; whereas low rates of susceptibility to ciprofloxacin &#40;35&#8211;73&#37;&#41; were observed&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> Susceptibility of <span class="elsevierStyleItalic">Klebsiella</span> spp&#46; was appreciably lower than that of <span class="elsevierStyleItalic">E&#46; coli</span> to all of these drug classes&#44; with susceptibility rates of 89&#8211;99&#37; for carbapenems&#44; 78&#8211;92&#37; for amikacin&#44; 49&#8211;81&#37; for piperacillin&#47;tazobactam&#44; and 95&#8211;99&#37; for colistin across four countries &#40;Argentina&#44; Brazil&#44; Chile&#44; and Mexico&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> Even lower susceptibility rates across the commonly used drug classes were observed for ESBL-producing <span class="elsevierStyleItalic">E&#46; coli</span> and <span class="elsevierStyleItalic">K&#46; pneumoniae</span> isolates collected in SMART 2008&#44; 2008&#8211;2009&#44; and TEST 2004&#8211;2010&#46;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">29&#44;30&#44;32</span></a> Although susceptibility of ESBL-producing <span class="elsevierStyleItalic">E&#46; coli</span> to carbapenems and tigecycline was &#62;95&#37; in all of these studies&#44; susceptibility to amikacin &#40;85&#8211;90&#37;&#41;&#44; piperacillin&#47;tazobactam &#40;74&#8211;80&#37;&#41;&#44; and fluoroquinolones &#40;12&#8211;19&#37;&#41; dropped markedly&#46;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">29&#44;30&#44;32</span></a> Likewise&#44; susceptibility of ESBL-producing <span class="elsevierStyleItalic">K&#46; pneumoniae</span> to carbapenems &#40;in TEST 2004&#8211;2010 and SMART 2008&#41; and tigecycline &#40;in TEST 2004&#8211;2010&#41; was high &#40;&#8805;89&#37;&#41;&#44; but susceptibility was low to amikacin &#40;71&#8211;72&#37;&#41;&#44; levofloxacin &#40;35&#8211;38&#37;&#41;&#44; and piperacillin&#47;tazobactam &#40;34&#8211;40&#37;&#41; in both surveillance studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">29&#44;32</span></a></p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Country-specific data</span><p id="par0075" class="elsevierStylePara elsevierViewall">PAHO established a surveillance program in 2000 to collect country-specific data on selected organisms&#44; both from nosocomial and community-acquired infections&#46; In 2006 and 2009&#44; there was large variability in <span class="elsevierStyleItalic">Enterobacteriaceae</span> resistance rates to third-generation cephalosporins &#40;cefotaxime and ceftazidime&#41;&#44; even after accounting for countries with small isolate numbers &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">34&#44;35</span></a> and few collecting centers &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; In 2009&#44; the resistance rate of <span class="elsevierStyleItalic">E&#46; coli</span> to third-generation cephalosporins was highest in Bolivia &#40;37&#37;&#41; and lowest in Nicaragua &#40;0&#8211;0&#46;5&#37;&#59; <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46; PAHO data for <span class="elsevierStyleItalic">K&#46; pneumoniae</span> nosocomial isolates in 2009 showed high levels of resistance to third-generation cephalosporins&#44; consistent with the high prevalence of ESBL-producing strains in Latin American countries&#46; The resistance rate of <span class="elsevierStyleItalic">Klebsiella</span> spp&#46; to third-generation cephalosporins in 2009 was highest in Peru &#40;66&#37;&#41; and lowest in Nicaragua &#40;0&#46;3&#37;&#41;&#46; A high rate of resistance to cefepime in nosocomial isolates of <span class="elsevierStyleItalic">E&#46; coli</span> and <span class="elsevierStyleItalic">K&#46; pneumoniae</span> was also reported in PAHO 2009 data &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> The PAHO data for <span class="elsevierStyleItalic">Klebsiella</span> spp&#46; were similar to findings of the Asociaci&#243;n Panamericana de Infectolog&#237;a&#44; showing that the proportion of cefotaxime-resistant strains ranged from 17&#37; &#40;in Ecuador and Panama&#41; to 60&#37; &#40;in Brazil&#41;&#44; resistance rates to ceftazidime ranged from 13&#37; &#40;in Venezuela&#41; to 40&#37; &#40;in Argentina&#44; Brazil&#44; and Paraguay&#41;&#44; and resistance to cefepime ranged from 10&#37; &#40;in Colombia&#41; to 50&#37; &#40;in Argentina and Brazil&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">54</span></a></p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">Data collected by the SENTRY Antimicrobial Surveillance Program between 2008 and 2010 reported country-specific data in addition to regional data&#46; They showed that the susceptibility rate of healthcare-acquired <span class="elsevierStyleItalic">E&#46; coli</span> isolates to third-generation cephalosporins was low in Mexico &#40;52&#8211;53&#37;&#41; and modest in Argentina&#44; Brazil&#44; and Chile &#40;76&#8211;88&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> Again&#44; <span class="elsevierStyleItalic">Klebsiella</span> spp&#46; exhibited unacceptably low susceptibility rates to cephalosporins in all four countries &#40;40&#8211;67&#37;&#41;&#46; The susceptibilities of <span class="elsevierStyleItalic">E&#46; coli</span> and <span class="elsevierStyleItalic">Klebsiella</span> spp&#46; were modestly higher to cefepime than to third-generation cephalosporins&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">In agreement with SENTRY&#44; a consolidated 2009 network analysis involving 14 hospitals in Chile revealed that 78&#37; and 79&#37; of <span class="elsevierStyleItalic">E&#46; coli</span> blood and urine cultures&#44; respectively&#44; were susceptible to cefotaxime&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">55</span></a> Remarkable susceptibility rates were observed for carbapenems &#40;&#8805;99&#46;9&#37;&#41; while susceptibility rates were &#8805;90&#37; for piperacillin&#47;tazobactam and amikacin and lower for ciprofloxacin &#40;61&#8211;64&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">55</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Surveillance was conducted in 2006&#8211;2008 by the Colombian Nosocomial Resistance Study Group&#44; consisting of 14 tertiary-care hospitals in seven major cities&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">56</span></a> Among <span class="elsevierStyleItalic">E&#46; coli</span> isolates from general wards &#40;<span class="elsevierStyleItalic">N</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>2300 each year&#41; and adult ICUs &#40;<span class="elsevierStyleItalic">N</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>550 each year&#41;&#44; resistance to third-generation cephalosporins was low and stable at rates ranging from 2&#37; to 8&#37;&#46; Among isolates from adult ICUs&#44; resistance to cefepime was also stable at 4&#8211;5&#37; during this period&#46; For <span class="elsevierStyleItalic">K&#46; pneumoniae</span>&#44; resistance rates to third-generation cephalosporins &#40;ceftazidime and ceftriaxone&#41; among isolates from general wards were 19&#8211;20&#37; in 2006 &#40;<span class="elsevierStyleItalic">N</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>948&#41;&#59; 24&#8211;29&#37; in 2007 &#40;<span class="elsevierStyleItalic">N</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1244&#41;&#44; and 15&#37; in 2008 &#40;<span class="elsevierStyleItalic">N</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1038&#41;&#46; Among <span class="elsevierStyleItalic">K&#46; pneumoniae</span> isolates from adult ICUs&#44; resistance to third-generation cephalosporins was 24&#8211;25&#37; in 2006 &#40;<span class="elsevierStyleItalic">N</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>497&#41;&#44; 20&#8211;31&#37; in 2007 &#40;<span class="elsevierStyleItalic">N</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>800&#41;&#44; and 9&#8211;24&#37; in 2008 &#40;<span class="elsevierStyleItalic">N</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>602&#41;&#46; Among isolates from adult ICUs&#44; resistance to cefepime was 12&#37; in 2006&#44; 18&#37; in 2007&#44; and 11&#37; in 2008&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">56</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">In the independent cohort studies that reported quantitative susceptibility data on <span class="elsevierStyleItalic">Enterobacteriaceae</span> harboring ESBLs&#44; co-resistance to multiple commonly used antimicrobial agents besides resistance to third-generation cephalosporins was evident&#46;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">37&#8211;39&#44;52</span></a> Moderate to high resistance rates &#40;&#62;15&#37; to &#60;81&#37;&#41; were observed for aminoglycosides&#44; trimethoprim&#47;sulfamethoxazole&#44; piperacillin&#47;tazobactam&#44; and quinolones&#44; whereas low resistance rates &#40;&#60;10&#37;&#41; were observed for carbapenems and tigecycline&#46;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">37&#8211;41&#44;52</span></a></p></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Risk factors</span><p id="par0100" class="elsevierStylePara elsevierViewall">Studies conducted in locations throughout the world have identified multiple risk factors for infection with ESBL-producing <span class="elsevierStyleItalic">Enterobacteriaceae</span> in hospitalized patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">57&#8211;61</span></a> In multivariate analyses in these studies&#44; the following risk factors were identified&#58; previous antibiotic use &#40;specifically&#44; quinolones&#44;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">59</span></a> cephalosporins&#44;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">57</span></a> oxyimino-cephalosporins&#44;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">58</span></a> piperacillin&#47;tazobactam&#44;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">57</span></a> or &#946;-lactams with an oxyimino group<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">60</span></a>&#41;&#44; recurrent infections&#44;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">59</span></a> hemodialysis&#44;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">61</span></a> urinary catheterization&#44;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">58</span></a> artificial nutrition&#44;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">59</span></a> and residence in a nursing home&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">61</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">There are few studies of risk factors for ESBL-producing <span class="elsevierStyleItalic">Enterobacteriaceae</span> in Latin America&#46; Potential risk factors for the occurrence of invasive infections arising from ESBL- and non-ESBL-producing <span class="elsevierStyleItalic">E&#46; coli</span> and <span class="elsevierStyleItalic">Klebsiella</span> spp&#46; were assessed in an international&#44; prospective&#44; observational study conducted by the SENTRY Antimicrobial Surveillance Program&#44; which included 11 Latin American hospitals&#44; from 2001&#8211;2002&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">62</span></a> Although underlying comorbidities and potential risk factors were generally similar between ESBL and non-ESBL cases&#44; a higher proportion of ESBL cases had a gastrostomy or jejunostomy tube &#40;30&#46;3&#37; vs&#46; 6&#46;7&#37;&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;008&#41;&#44; required ventilation assistance &#40;64&#46;8&#37; vs&#46; 38&#46;2&#37;&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;005&#41;&#44; or had been admitted to ICU &#40;65&#46;6&#37; vs&#46; 41&#46;0&#37;&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;006&#41; compared with non-ESBL cases&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">62</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">Among single-center studies&#44; multivariate analysis of retrospective case-control data &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>121 patients&#41; pertaining to all episodes of <span class="elsevierStyleItalic">K&#46; pneumoniae</span> bacteremia for the period 1993&#8211;2002 in a Mexican referral center revealed prior use of cephalosporins &#40;Odds ratio &#91;OR&#93; 7&#46;6&#44; 95&#37; CI 1&#46;1&#8211;53&#46;5&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;039&#41; and admission to ICU &#40;OR 5&#46;6&#44; 95&#37; CI 1&#46;1&#8211;27&#46;9&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;033&#41; as significant risk factors&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">63</span></a> Use of broad-spectrum cephalosporins also featured as the only independent predictor of ESBL-producing enterobacteriaceae strains &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>90&#41; causing bacteremia in a recently published Mexican study&#44;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">64</span></a> and use of third-generation cephalosporins &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;008&#41; was a risk factor for colonization of ESBL-producing strains of <span class="elsevierStyleItalic">Klebsiella</span> spp in a pediatric ICU in Brazil in 2008&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">65</span></a> Another Latin American study found a relationship between use of ciprofloxacin and prevalence of ESBL-producing <span class="elsevierStyleItalic">K&#46; pneumoniae</span> in a hospital setting&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">66</span></a></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Discussion</span><p id="par0115" class="elsevierStylePara elsevierViewall">Since the first cases and outbreaks of infections by ESBL-producing <span class="elsevierStyleItalic">Enterobacteriaceae</span> were reported in Latin American hospitals&#44; there has been a steady increase in the overall prevalence and in the number of types of ESBLs detected&#46; According to region-wide surveillance data &#40;ie&#44; SENTRY&#44; TEST&#44; SMART&#44; PAHO&#44; and API&#41; and findings from independent country-specific cohort studies&#44; ESBL production among <span class="elsevierStyleItalic">Klebsiella</span> spp&#46; can be considered endemic in Latin America&#46; The balance of data indicates that rates of nosocomial infection caused by ESBL-producing <span class="elsevierStyleItalic">Enterobacteriaceae</span>&#44; particularly <span class="elsevierStyleItalic">K&#46; pneumoniae</span>&#44; are high in Latin America compared with other world regions &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; More specifically&#44; there has been a rapid spread of CTX-M enzymes throughout Latin American hospitals&#44; which has been facilitated by horizontal transfer of encoding plasmids and successful clones&#46; While we observed a geographical trend in the prevalence of a finite number of CTX-M enzyme subtypes in Latin America &#40;i&#46;e CTX-M-15 in the North&#59; CTX-M-2 in the South&#41;&#44; there was clear evidence that this regional association is weakening as CTX-Ms become even more widespread and evolve locally&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">In surveillance data reviewed for this article &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#44; 45&#8211;53&#37; of <span class="elsevierStyleItalic">K&#46; pneumoniae</span> isolates are nonsusceptible to third-generation cephalosporins&#44; compared with 21&#8211;27&#37; resistance associated with <span class="elsevierStyleItalic">K&#46; pneumoniae</span> HAIs in the United States&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">67</span></a> The northern countries of Guatemala&#44; Honduras&#44; and Mexico have high rates of cephalosporin-resistant <span class="elsevierStyleItalic">E&#46; coli</span>&#44; while Argentina&#44; Brazil&#44; Colombia&#44; and Panama have lower rates&#46; For <span class="elsevierStyleItalic">Klebsiella</span> spp&#46;&#44; Argentina&#44; Brazil&#44; Chile&#44; Guatemala&#44; and Honduras are experiencing especially high rates of cephalosporin-resistant strains&#44; while Colombia&#44; Panama&#44; and Venezuela have lower rates&#46; Independent cohort data showed that it is not uncommon in Latin America to encounter ESBL-producing <span class="elsevierStyleItalic">Enterobacteriaceae</span> that are nonsusceptible to cefepime&#44; exhibit high rates of resistance to fluoroquinolones and ampicillin&#47;sulbactam&#44; and have appreciable rates of resistance to aminoglycosides and piperacillin&#47;tazobactam&#46; Susceptibility of ESBL-producing <span class="elsevierStyleItalic">Enterobacteriaceae</span> to the carbapenems&#44; tigecycline&#44; and colistin remains much higher &#40;&#62;90&#37;&#41;&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">There are many possible explanations for the observed differences between countries and regions&#46; Reported susceptibility rates may have differed because of selection of centers &#40;public versus private&#41; or other biases in study design&#44; small numbers of isolates collected in some settings&#44; differing laboratory methods&#44; or quality control in some laboratories&#46; Reported resistance rates may also reflect real differences in prevalence of resistant pathogens arising from local outbreaks&#44; differences in antimicrobial prescribing practices &#40;including use of cephalosporins&#41;&#44; differences in facilities &#40;e&#46;g&#46;&#44; rooms with multiple beds or overcrowded conditions&#41;&#44; and local infection control measures &#40;or the lack thereof&#41;&#46; Unfortunately there are no studies that systematically investigate these differences between countries and facilities in Latin America and their effect on prevalence of ESBL-producing pathogens&#46; Surveillance data must also be read carefully because some sources report resistance rates&#44; while others report susceptibility rates&#8212;and because nonsusceptibility is not the same as resistance&#46; Furthermore&#44; data may over-represent tertiary care hospitals with more complicated patient populations receiving more intensive care than the general hospital population&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">The expanding geographic spread of ESBL-producing <span class="elsevierStyleItalic">Enterobacteriaceae</span> in the community and hospital setting underscores the importance of clinical and microbiologic recognition of these enzymes at multiple levels of health care&#46; Surveillance data collected regionally in Latin America may be used to guide empiric treatment of patients suspected of multidrug-resistant infection&#44; based on their individual risk level&#46; For example&#44; it has been shown that patients with age 65 years or older&#44; recent use of antibiotics&#44; recent hospitalization or stay in long-term care facility&#44; and male sex have a greater likelihood of infection by ESBL-producing <span class="elsevierStyleItalic">Enterobacteriaceae</span>&#59;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> such patients may be suspected of infection with resistant pathogens and treated accordingly&#46; However&#44; knowledge of regional surveillance data and patient risk level is not adequate to guide optimal choice of therapy&#46; Physicians should be aware of local data regarding the prevalence and antimicrobial susceptibilities of ESBL-producing bacterial strains in their particular city and hospital&#44; information that can help guide treatment choices for patients in a particular facility&#46; When possible&#44; pathogen identification &#40;at the genus and species level&#41; and information about the <span class="elsevierStyleItalic">in vitro</span> antimicrobial resistance profile of the pathogen infecting the individual patient can guide the choice and adjustment of antimicrobials during the course of treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">68</span></a> Prospective observational data have shown that patients have a survival advantage when the correct antimicrobial agent is chosen as initial therapy rather than empiric agents that provide no coverage against the responsible pathogen&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">69</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">Collaborative institutional&#44; local&#44; national&#44; and regional surveillance of ESBL-producing <span class="elsevierStyleItalic">Enterobacteriaceae</span> is required to assist diagnosis&#44; support treatment decisions&#44; and guide antimicrobial stewardship and infection control efforts&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">68</span></a> The US Clinical and Laboratory Standards Institute &#40;CLSI&#41; and the UK Health Protection Agency &#40;HPA&#41; have published guidelines for the detection of ESBL-producing organisms&#46;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">70</span></a> Following PAHO surveillance system recommendations&#44; CLSI guidelines are followed in most Latin American countries to detect the presence of ESBL-mediated resistance&#46; The difficulty in detecting and classifying specific ESBLs in the local setting is demonstrated by the fact that hundreds of different ESBLs have been described&#44; including more than 145 &#946;-lactamases in the CTX-M class alone &#40;<a href="http://www.lahey.org/studies/other.asp">http&#58;&#47;&#47;www&#46;lahey&#46;org&#47;studies&#47;other&#46;asp</a>&#41;&#46; More than 890 unique protein sequences for &#946;-lactamases were determined by late 2009&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> However&#44; findings from Latin American studies show that molecular biology techniques can be useful in characterizing virulent <span class="elsevierStyleItalic">K&#46; pneumoniae</span> clones isolated from patients and health care workers&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21&#44;71&#44;72</span></a> The technology to identify genes conferring resistance is improving quickly and is becoming more automated&#46; Ideally&#44; surveillance programs in cities and hospitals should provide real-time information about phenotype and mechanism of resistance in a rapid&#44; accurate&#44; and reproducible manner&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Antimicrobial stewardship in conjunction with local surveillance is also required to preserve the antimicrobial integrity of a limited arsenal of agents&#46; More research is required to elucidate the risk factors for acquiring ESBL-producing <span class="elsevierStyleItalic">Enterobacteriaceae</span>&#44; although it can be stated that antimicrobial treatment is the primary cause&#46; Encouragingly&#44; a 2002&#8211;2006 study in Colombia showed that restriction of third-generation cephalosporins can result in significant &#40;5-fold&#41; reduction in the number of ESBL-producing isolates&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">73</span></a> However&#44; treatment with cefepime is not recommended in areas where there is a high prevalence of circulating CTX-Ms since clinical failures often result in patients with high inoculum infections&#46;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">72</span></a> Carbapenems are a treatment of choice for infections caused by ESBL-producing <span class="elsevierStyleItalic">Enterobacteriaceae</span>&#44; but an undesirable consequence of their use may be selection of carbapenem-resistant non-fermenter Gram-negative bacilli and <span class="elsevierStyleItalic">Enterobacteriaceae</span>&#46;<a class="elsevierStyleCrossRefs" href="#bib0360"><span class="elsevierStyleSup">72&#44;74&#8211;76</span></a> Instructions on how to restrict and cycle certain antimicrobial agents for specific indications&#44; framed within a real-time surveillance-based drug formulary&#44; offer the best conditions for rational drug use&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Patient-to-patient transmission of ESBL-producing pathogens has been reported&#59; this is likely a more important mode of infection with <span class="elsevierStyleItalic">K&#46; pneumoniae</span> than with <span class="elsevierStyleItalic">E&#46; coli&#46;</span><a class="elsevierStyleCrossRefs" href="#bib0385"><span class="elsevierStyleSup">77&#44;78</span></a> However&#44; this issue has not been studied in Latin America beyond nosocomial outbreaks&#46; Because of difficulties with infection control&#44; patient-to-patient transmission could play an important role in Latin American healthcare institutions&#46; Therefore&#44; infection control efforts are crucial in reducing the prevalence of drug-resistant pathogens&#46; Local outbreaks of ESBL-producing <span class="elsevierStyleItalic">Klebsiella</span> spp&#46; strains have been successfully addressed in Latin American settings through standard infection control practices&#44; including disinfection of the unit&#44; re-enforcing hand hygiene and barrier control measures&#44; and adjusting antimicrobial prescribing practices&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21&#44;72&#44;79</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">In summary&#44; the problem of high infection rates by ESBL-producing <span class="elsevierStyleItalic">Enterobacteriaceae</span> in hospitals of Latin America is exacerbated by the spread of multidrug-resistant strains&#46; Antimicrobial surveillance at the unit&#44; hospital&#44; city&#44; national&#44; and regional level is recommended to guide decision making about infection control efforts and appropriate antimicrobial treatment&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Conflicts of interest</span><p id="par0155" class="elsevierStylePara elsevierViewall">Manuel Guzm&#225;n Blanco is or has been a member of advisory boards of Merck&#44; Pfizer&#44; Becton and Dickinson&#46; He has received research funds from Pfizer&#44; Merck&#44; Glaxo and Novartis&#46; Jaime A&#46; Labarca has been a member of advisory boards of Merck Sharp &#38; Dhome and Pfizer&#44; has received research funds from Merck Sharp &#38; Dhome&#44; and has participated in clinical studies for Sanofi Pasteur&#46; Maria Virginia Villegas has been a member of advisory boards of Merck and Pfizer and has received research funds from Pfizer&#44; Merck&#44; Novartis&#44; AstraZeneca&#44; Merck S&#46;A&#44; Bayer&#44; Janssen Cilag and Biomeriux&#46; Eduardo Gotuzzo has been a consultant to Pfizer and has received research funds from Johnson &#38; Johnson&#46;</p></span></span>"
    "textoCompletoSecciones" => array:1 [
      "secciones" => array:11 [
        0 => array:3 [
          "identificador" => "xres566362"
          "titulo" => "Abstract"
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            0 => array:1 [
              "identificador" => "abst0005"
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        1 => array:2 [
          "identificador" => "xpalclavsec583704"
          "titulo" => "Keywords"
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        2 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Introduction"
        ]
        3 => array:2 [
          "identificador" => "sec0010"
          "titulo" => "Background&#58; emergence of extended spectrum &#946;-lactamase-producing Enterobacteriaceae in Latin America before 2005"
        ]
        4 => array:2 [
          "identificador" => "sec0015"
          "titulo" => "Methods"
        ]
        5 => array:3 [
          "identificador" => "sec0020"
          "titulo" => "Prevalence and type of extended spectrum &#946;-lactamases"
          "secciones" => array:3 [
            0 => array:2 [
              "identificador" => "sec0025"
              "titulo" => "Regional data"
            ]
            1 => array:3 [
              "identificador" => "sec0030"
              "titulo" => "Country-specific data"
              "secciones" => array:1 [
                0 => array:2 [
                  "identificador" => "sec0035"
                  "titulo" => "Surveillance studies"
                ]
              ]
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            2 => array:2 [
              "identificador" => "sec0040"
              "titulo" => "Cohort studies"
            ]
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        6 => array:3 [
          "identificador" => "sec0045"
          "titulo" => "Antimicrobial susceptibility"
          "secciones" => array:2 [
            0 => array:2 [
              "identificador" => "sec0050"
              "titulo" => "Regional data"
            ]
            1 => array:2 [
              "identificador" => "sec0055"
              "titulo" => "Country-specific data"
            ]
          ]
        ]
        7 => array:2 [
          "identificador" => "sec0060"
          "titulo" => "Risk factors"
        ]
        8 => array:2 [
          "identificador" => "sec0065"
          "titulo" => "Discussion"
        ]
        9 => array:2 [
          "identificador" => "sec0070"
          "titulo" => "Conflicts of interest"
        ]
        10 => array:1 [
          "titulo" => "References"
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      ]
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    "pdfFichero" => "main.pdf"
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    "fechaRecibido" => "2013-05-10"
    "fechaAceptado" => "2013-10-29"
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec583704"
          "palabras" => array:4 [
            0 => "<span class="elsevierStyleItalic">Escherichia coli</span>"
            1 => "<span class="elsevierStyleItalic">Klebsiella</span>"
            2 => "Latin America"
            3 => "Bacterial resistance"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To review the epidemiology of nosocomial extended spectrum &#946;-lactamase-producing <span class="elsevierStyleItalic">Enterobacteriaceae</span> in Latin America&#44; a systematic search of the biomedical literature &#40;PubMed&#41; was performed for articles published since 2005&#46; Rates of nosocomial infections caused by extended spectrum &#946;-lactamase-producing <span class="elsevierStyleItalic">Enterobacteriaceae</span> in Latin America have increased since 2005&#46; Up to 32&#37; of <span class="elsevierStyleItalic">Escherichia coli</span> and up to 58&#37; of <span class="elsevierStyleItalic">Klebsiella pneumoniae</span> isolates are extended spectrum &#946;-lactamase-positive&#44; rates that are higher than in other world regions&#46; From a region-wide perspective&#44; 11&#8211;25&#37; of <span class="elsevierStyleItalic">E&#46; coli</span> isolates and 45&#8211;53&#37; of <span class="elsevierStyleItalic">K&#46; pneumoniae</span> isolates were nonsusceptible to third-generation cephalosporins&#46; At the country level&#44; there was a wide range in <span class="elsevierStyleItalic">Enterobacteriaceae</span> resistance rates to third-generation cephalosporins&#44; with especially high rates of resistance to <span class="elsevierStyleItalic">E&#46; coli</span> in Guatemala&#44; Honduras&#44; and Mexico&#44; and high resistance rates to <span class="elsevierStyleItalic">Klebsiella</span> spp&#46; in Argentina&#44; Brazil&#44; Chile&#44; Guatemala&#44; Honduras&#44; and Paraguay&#46; Susceptibility of extended spectrum &#946;-lactamase-producing <span class="elsevierStyleItalic">Enterobacteriaceae</span> to cefepime&#44; fluoroquinolones&#44; ampicillin&#47;sulbactam&#44; aminoglycosides&#44; and piperacillin&#47;tazobactam has also been compromised&#44; leaving the carbapenems&#44; tigecycline&#44; and colistin as the only antibiotics with &#62;90&#37; susceptibility rates&#46; There is a steady increase in the prevalence and types of extended spectrum &#946;-lactamases produced by <span class="elsevierStyleItalic">Enterobacteriaceae</span> isolates in Latin American hospitals &#40;particularly CTX-Ms&#41;&#44; suggesting endemic conditions overlaid by clonal outbreaks&#46; Appropriate treatment decisions and infection control strategies informed by surveillance of regional and local susceptibilities and mechanisms of resistance are required to mitigate this major public health concern&#46;</p></span>"
      ]
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    "NotaPie" => array:2 [
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0040">The authors dedicate this work to the memory of Jos&#233; Mar&#237;a Casellas&#46;</p>"
        "identificador" => "fn1"
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        "etiqueta" => "2"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0045">See Appendix A for the members of the Working Group&#46;</p>"
        "identificador" => "fn2"
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            "apendice" => "<p id="par0165" class="elsevierStylePara elsevierViewall">Latin America Working Group on Bacterial Resistance&#58;</p> <p id="par0170" class="elsevierStylePara elsevierViewall">Carlos Alvarez &#40;Hospital Universitario San Ignacio and Pontificia Universidad Javeriana&#44; Bogot&#225;&#44; Colombia&#41;&#44; Luis Bavestrello &#40;Clinica Re&#241;aca&#44; Vi&#241;a Del Mar&#44; Chile&#41;&#44; Eitan Berezin &#40;Santa Casa de S&#227;o Paulo School of Medicine&#44; Brazil&#41;&#44; Eduardo Gotuzzo &#40;Universidad Peruana Cayetano Heredia&#44; Lima&#44; Peru&#41;&#44; Manuel Guzm&#225;n-Blanco &#40;Hospital Privado Centro M&#233;dico de Caracas&#44; Venezuela&#41;&#44; Jaime A&#46; Labarca &#40;Pontificia Universidad Cat&#243;lica de Chile&#44; Santiago&#44; Chile&#41;&#44; Carlos M&#46; Luna &#40;Hospital de Cl&#237;nicas Jos&#233; de San Martin Hospital&#44; Universidad de Buenos Aires&#44; Argentina&#41;&#44; Carlos Mej&#237;a &#40;Hospital Roosevelt&#44; Guatemala City&#44; Guatemala&#41;&#44; Simone Nouer &#40;Hospital Universit&#225;rio Clementino Fraga Filho&#44; Rio de Janeiro&#44; Brazil&#41;&#44; Eduardo Rodr&#237;guez-Noriega &#40;Hospital Civil de Guadalajara Fray Antonio Alcalde&#44; Guadalajara&#44; Mexico&#41;&#44; Mauro Jos&#233; Costa Salles &#40;Hospital Irmandade da Santa Casa de Miseric&#243;rdia de S&#227;o Paulo&#44; Brazil&#41;&#44; Carlos Seas &#40;Universidad Peruana Cayetano Heredia&#44; Lima&#44; Peru&#41;&#44; Fortino Sol&#243;rzano Santos &#40;Hospital de Pediatr&#237;a Centro M&#233;dico Nacional Siglo XXI&#44; Mexico City&#44; Mexico&#41;&#44; Maria Virginia Villegas &#40;International Center for Medical Research and Training &#91;CIDEIM&#93;&#44; Cali&#44; Colombia&#41;&#44; Jeannete Zurita &#40;Hospital Vozandes and Pontificia Universidad Cat&#243;lica del Ecuador&#44; Quito&#44; Ecuador&#41;&#46;</p>"
            "etiqueta" => "Appendix A"
            "identificador" => "sec0075"
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Frequency of ESBL producers among <span class="elsevierStyleItalic">E&#46; coli</span> and <span class="elsevierStyleItalic">K&#46; pneumoniae</span> isolates in the SMART and TEST antimicrobial surveillance programs&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;27&#44;28&#44;31&#44;36</span></a> &#42;United States data only&#46; DISN&#44; Doripenem International Surveillance Network&#59; ESBL&#44; extended spectrum &#946;-lactamase&#59; SMART&#44; Study for Monitoring Antimicrobial Resistance Trends&#59; TEST&#44; Tigecycline Evaluation and Surveillance Trial&#46;</p>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">National frequencies of ESBL producers among &#40;a&#41; <span class="elsevierStyleItalic">Escherichia coli</span> and &#40;b&#41; <span class="elsevierStyleItalic">Klebsiella pneumoniae</span> isolates in Latin American hospitals&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">30&#44;32&#44;33</span></a> ESBL&#44; extended spectrum &#946;-lactamase&#59; SMART&#44; Study for Monitoring Antimicrobial Resistance Trends&#59; TEST&#44; Tigecycline Evaluation and Surveillance Trial&#46; In SENTRY 2008&#8211;2010 report&#44; only the 4 countries with highest rates of ESBL production were reported&#46;</p>"
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Representation of the frequency of ESBL production &#40;no&#46; of isolates tested&#41; and types of ESBLs produced by <span class="elsevierStyleItalic">Enterobaceriaceae</span> isolated from Latin American hospitals reporting &#62;100 isolates&#46;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">37&#8211;47</span></a> The distribution of ESBLs was not available for all studies reporting prevalence data&#46; All isolates were resistant to oxyimino-cephalosporins&#46; ESBL&#44; extended spectrum &#946;-lactamase&#46;</p>"
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Findings of the Pan-American Health Organization &#40;PAHO&#41; summarizing the frequency of nosocomial <span class="elsevierStyleItalic">Escherichia coli</span> and <span class="elsevierStyleItalic">Klebsiella pneumoniae</span> isolates resistant to cefepime in 2009&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> NR&#44; not reported&#46;</p>"
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          "leyenda" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">PAHO&#44; Pan-American Health Organization&#59; SMART&#44; Study for Monitoring Antimicrobial Resistance Trends&#59; TEST&#44; Tigecycline Evaluation and Surveillance Trial&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col">Country&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="9" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Surveillance program and collection period</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col">SMART<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col">SMART<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col">SMART<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col">SMART<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col">TEST<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col">TEST<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col">SENTRY<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col">PAHO<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col">PAHO<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">2004&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">2005&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">2008&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">2008&#8211;2009&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">2004&#8211;2006&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">2004&#8211;2010&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">2008&#8211;2010&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">2006&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">2009&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Argentina&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">59&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">72&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Bolivia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Brazil&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Chile&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Colombia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">147&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Dominican Republic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Ecuador&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">El Salvador&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">33&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">33&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Guatemala&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Honduras&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Mexico&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Nicaragua&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Panama&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Paraguay&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Peru&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Puerto Rico&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Venezuela&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">34&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab920845.png"
              ]
            ]
          ]
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            0 => array:3 [
              "identificador" => "tblfn0005"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Including only countries reporting data on <span class="elsevierStyleItalic">Enterobacteriaceae</span> in hospital settings&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Number of study sites by country for key surveillance reports&#46;</p>"
        ]
      ]
      5 => array:7 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:3 [
          "leyenda" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">ESBL&#44; extended spectrum &#946;-lactamase&#59; DISN&#44; Doripenem International Surveillance Network&#59; NR&#44; not reported&#59; SMART&#44; Study for Monitoring Antimicrobial Resistance Trends&#59; TEST&#44; Tigecycline Evaluation and Surveillance Trial&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col">Surveillance program&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col">Collection period&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col">Anatomical collection site&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Proportion ESBL-positive &#40;total no&#46; isolates&#41;</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">E&#46; coli</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">Klebsiella</span> spp&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">SMART<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2004&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Intra-abdominal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">28&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">SMART<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2005&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Intra-abdominal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">16&#37; &#40;395&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">27&#37; &#40;121&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">TEST<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">a</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2004&#8211;2006&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Blood&#44; respiratory tract&#44; urine&#44; skin&#44; wound&#44; fluids and other defined sources&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">14&#37; &#40;326&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">44&#37; &#40;282&#41;<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">TEST<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2004&#8211;2010&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Blood&#44; respiratory tract&#44; urine&#44; skin&#44; wound&#44; fluids&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">24&#37; &#40;3581&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">35&#37; &#40;2962&#41;<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">DISN<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2007&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Blood&#44; respiratory tract&#44; skin and skin structure&#44; urine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">14&#37; &#40;493&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">44&#37; &#40;350&#41;<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">SMART<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2008&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Intra-abdominal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">27&#37; &#40;504&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">38&#37; &#40;151&#41;<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">SMART<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2008&#8211;2009&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Intra-abdominal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">24&#37; &#40;1366&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">SENTRY<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2008&#8211;2010&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Blood&#44; skin and soft tissue&#44; lower respiratory tract&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">25&#37; &#40;1517&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">53&#37; &#40;1052&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">SMART<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">c</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2009&#8211;2010&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Urine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">23&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab920848.png"
              ]
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          "notaPie" => array:3 [
            0 => array:3 [
              "identificador" => "tblfn0010"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Most data were collected from intensive care units&#46;</p>"
            ]
            1 => array:3 [
              "identificador" => "tblfn0015"
              "etiqueta" => "b"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0015"><span class="elsevierStyleItalic">K&#46; pneumoniae</span> only&#46;</p>"
            ]
            2 => array:3 [
              "identificador" => "tblfn0020"
              "etiqueta" => "c"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0020">Data collected from 15 sites in Latin America&#59; countries where sites located not specified&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a></p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Temporal prevalences of healthcare-acquired ESBL-positive <span class="elsevierStyleItalic">Enterobacteriaceae</span> in hospitals of Latin America&#46;</p>"
        ]
      ]
      6 => array:7 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:3 [
          "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">NR&#44; not reported&#59; SMART&#44; Study for Monitoring Antimicrobial Resistance Trends&#59; TEST&#44; Tigecycline Evaluation and Surveillance Trial&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pathogen&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">SMART 2005<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">TEST 2004&#8211;2006<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">TEST 2004&#8211;2010<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">SMART 2008<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">SMART 2008&#8211;2009<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">SENTRY 2008&#8211;2010<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " rowspan="3" align="left" valign="top"><span class="elsevierStyleItalic">E&#46; coli</span></td><td class="td" title="table-entry  " align="left" valign="top">83&#8211;84&#37; &#40;84&#37;<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">a</span></a>&#41;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>395 isolates&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">82&#8211;89&#37; &#40;86&#37;&#41;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>326 isolates&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">82&#37; &#40;94&#37;&#41;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2711non-ESBL isolates&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">96&#37; &#40;100&#37;&#41;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>50non-ESBL isolates&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">94&#8211;95&#37; &#40;100&#37;&#41;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1043non-ESBL isolates&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">75&#8211;82&#37; &#40;84&#37;&#41;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1517 isolates&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="6" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#37; &#40;28&#37;&#41;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>870 ESBL isolates&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#37;&#8211;28&#37; &#40;7&#37;&#41;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>50 ESBL isolates&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#37;-21&#37; &#40;12&#37;&#41;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>323 ESBL isolates&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="3" align="left" valign="top"><span class="elsevierStyleItalic">K&#46; pneumoniae</span></td><td class="td" title="table-entry  " align="left" valign="top">NR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">53&#8211;55&#37; &#40;58&#37;&#41;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>282 isolates&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">77&#37; &#40;88&#37;&#41;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1917non-ESBL isolates&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">96&#8211;97&#37; &#40;97&#37;&#41;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>50non-ESBL isolates&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">47&#8211;55&#37; &#40;59&#37;&#41;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1052 isolates<a class="elsevierStyleCrossRef" href="#tblfn0030"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="6" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#37; &#40;0&#37;&#41;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>124 ESBL<span class="elsevierStyleItalic">K&#46; pneumoniae</span> isolates&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#37; &#40;29&#37;&#41;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1045 ESBL<span class="elsevierStyleItalic">K&#46; pneumoniae</span> isolates&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#37;&#8211;28&#37; &#40;7&#37;&#41;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>50 ESBL<span class="elsevierStyleItalic">K&#46; pneumoniae</span> isolates&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">S&#46; marcescens</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">77&#37; &#40;82&#37;&#41;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>124 isolates&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">68&#37; &#40;84&#37;&#41; <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1126 isolates&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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              "identificador" => "tblfn0025"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0025">Throughout table&#44; figures in parentheses are proportions susceptible to cefepime&#44; a fourth-generation cephalosporin&#46;</p>"
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            1 => array:3 [
              "identificador" => "tblfn0030"
              "etiqueta" => "b"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Proportion of healthcare-acquired <span class="elsevierStyleItalic">Enterobacteriaceae</span> isolates susceptible to third-generation cephalosporins &#40;and cefepime&#41; in Latin American hospitals&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col">Country&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="4" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">&#37; Resistance &#40;total no&#46; isolates&#41;</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">E&#46; coli</span></th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">K&#46; pneumoniae</span></th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">2006&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">2009&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">2006&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">2009&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Argentina&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4 &#40;12001&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">18 &#40;1659&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">57 &#40;3278&#41;<a class="elsevierStyleCrossRef" href="#tblfn0035"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">58 &#40;1518&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Bolivia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">33 &#40;1079&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">37 &#40;2923&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">14&#8211;47 &#40;646&#41;<a class="elsevierStyleCrossRef" href="#tblfn0035"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">27&#8211;50 &#40;984&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Colombia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8-9 &#40;9607&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">30 &#40;3607&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Dominican Republic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">35&#8211;40 &#40;516&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">23 &#40;3061&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">30 &#40;828&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">26 &#40;2510&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Ecuador&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10&#8211;13 &#40;2582&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">18&#8211;20 &#40;2736&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">14&#8211;18 &#40;457&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">42&#8211;48 &#40;890&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">El Salvador&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4 &#40;1306&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">18&#8211;32 &#40;2498&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">14&#8211;15 &#40;421&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">46&#8211;50 &#40;1007&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Guatemala&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">67&#8211;70 &#40;1729&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">24 &#40;4921&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">68&#8211;75 &#40;1456&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">52&#8211;53 &#40;3001&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Honduras&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">21&#8211;32 &#40;524&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">30&#8211;32 &#40;1273&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">44&#8211;54 &#40;449&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">58&#8211;67 &#40;871&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Nicaragua&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">19 &#40;508&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#8211;0&#46;5 &#40;1081&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">65 &#40;312&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;3 &#40;383&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Panama&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&#8211;8 &#40;2522&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8 &#40;3040&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">23&#8211;37 &#40;1263&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">26&#8211;39 &#40;1749&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Paraguay&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6&#8211;15 &#40;1119&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">16 &#40;694&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">37&#8211;55 &#40;1055&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">57&#8211;59 &#40;721&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Peru&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">43&#8211;56 &#40;463&#47;282&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">32 &#40;1401&#47;1766&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">68&#8211;71 &#40;185&#47;169&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">66 &#40;583&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Venezuela&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&#8211;10 &#40;11316&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">13&#8211;14 &#40;1450&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">38&#8211;39 &#40;2666&#41;<a class="elsevierStyleCrossRef" href="#tblfn0035"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">60 &#40;377&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Findings of the Pan-American Health Organization &#40;PAHO&#41; summarizing the frequency of nosocomial <span class="elsevierStyleItalic">Enterobacteriaceae</span> isolates resistant to third-generation cephalosporins in 2006 and 2009&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">34&#44;35</span></a></p>"
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    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:79 [
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Report on the burden of endemic health care-associated infection worldwide"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "World Health Organization"
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                      "Libro" => array:1 [
                        "fecha" => "2011"
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Article information

ISSN: 14138670
Original language: English

DOI:10.1016/j.bjid.2013.10.005

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2021 July	34	19	53
2021 June	25	21	46
2021 May	43	37	80
2021 April	87	55	142
2021 March	43	32	75
2021 February	32	13	45
2021 January	41	23	64
2020 December	21	15	36
2020 November	31	11	42
2020 October	13	13	26
2020 September	16	11	27
2020 August	40	14	54
2020 July	13	7	20
2020 June	31	14	45
2020 May	31	21	52
2020 April	24	12	36
2020 March	37	23	60
2020 February	62	54	116
2020 January	27	17	44
2019 December	45	19	64
2019 November	27	30	57
2019 October	33	8	41
2019 September	38	23	61
2019 August	52	35	87
2019 July	34	24	58
2019 June	36	20	56
2019 May	59	57	116
2019 April	45	34	79
2019 March	27	20	47
2019 February	42	17	59
2019 January	19	15	34
2018 December	48	30	78
2018 November	189	23	212
2018 October	505	33	538
2018 September	84	15	99
2018 July	0	0	0
2018 June	1	1	2
2018 May	12	10	22
2018 April	39	21	60
2018 March	29	9	38
2018 February	29	17	46
2018 January	28	10	38
2017 December	28	15	43
2017 November	26	7	33
2017 October	31	11	42
2017 September	23	13	36
2017 August	24	10	34
2017 July	28	14	42
2017 June	30	9	39
2017 May	31	9	40
2017 April	26	23	49
2017 March	34	20	54
2017 February	34	9	43
2017 January	18	6	24
2016 December	50	19	69
2016 November	41	6	47
2016 October	56	14	70
2016 September	66	6	72
2016 August	48	5	53
2016 July	32	11	43
2016 June	2	0	2
2016 February	1	0	1
2015 December	3	0	3

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