Bacteriemia a Staphylococcus aureus meticilino resistente
Palabras clave:
Bacteriemia, Staphylococcus aureus meticilino resistente, Staphylococcus aureus meticilino resistente adquirido en la comunidadResumen
Introducción: La bacteriemia por Staphylococcus aureus meticilino resistente (SAMR) en una infección frecuente que representa un problema de salud pública creciente. El objetivo de este estudio es describir las características de las bacteriemias a SAMR y analizar los factores asociados con el origen de esta y su evolución. Material y métodos: Estudio descriptivo y analítico, retrospectivo; realizado entre 2014 y 2018 que incluyó pacientes con bacteriemia a SAMR hospitalizados en sala de clínica médica. Se clasificaron las bacteriemias por un lado según el origen de su adquisición en bacteriemia comunitaria, asociada a cuidados de la salud (ACS) e intrahospitalaria (IH).Por otro lado, según la sensibilidad del germen, se definió SAMR adquirido en la comunidad (SAMR-AC) versus SAMR adquirido en hospital (SAMR-AH). Resultados: Se incluyeron 56 episodios de bacteriemia a SAMR. El origen de la bacteriemia fue comunitaria en 41%, ACS en 32% e IH en 27%.La edad media fue de 43 (± 15) años, siendo menor en los casos comunitarios (p 0,027). El 83% eran de sexo masculino. Los factores de riesgo clásicos para adquisición de SAMR–AC se encontraron en un 56% de los casos con origen comunitario. El principal foco infectivo fueron los tejidos de piel y partes blandas (IPPB). Según la sensibilidad del germen, se aisló SAMR-AC en 88% y SAMR-AH en 12%.La demora hasta el inicio del tratamiento dirigido en el grupo comunitario fue 2,3 (± 2,2) días versus 0,9 (± 1,7) días en los otros (p 0,014). La bacteriemia fue complicada en el 64% delos episodios. La estadía hospitalaria fue de 29 (± 16) días. El 55% presentó falla clínica sistémica. La mortalidad fue del 7%. La edad y el foco neumónico se asociaron significativamente con mala evolución (p 0,04 y 0,015) y mortalidad (p 0,02 y 0,036). Conclusiones: Se sugiere mantener la sospecha de bacteriemia por SAMR ante infecciones originadas en la comunidad, aunque los factores de riesgo clásicos para resistencia se encuentren ausentes.
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1. Ardura M. Staphylococcus aureus: Vieja bacteria con nuevos trucos. Rev Chil Infect; 26 : 401-405,2009.
2. Álvarez I, Ponce Bittar J; Staphylococcus aureus, evolución de un viejo patógeno. Rev Cubana de Pediatría; 84: 383-391,2012.
3. Arroyave Rivera S, Atehortúa Barragán D, Jaimes Barragán F. Actualización en Bacteriemia por Staphylococcus Aureus. MEDICINA U.P.B. 33: 48-55, 2014.
4. Naber CK, Baddour L ,Giamarellos-Bourboulis E y col. Clinical Consensus Conference: Survey on Gram- Positive Bloodstream Infections with a Focus on Staphylococcus aureus. Clin Infect Dis15;48 S260-70, 2009.
5. Arias C, Reyes J, Carvajal L y col. Molecular Epidemiology and Phylogenomics of Staphylococcus aureus Bacteremia in Latin-America: A Prospective Cohort Multicenter Study in Nine Countries. Antimicrob Agents Chemother. 61 (10) e00816-17; DOI: https://doi.org/10.1128/AAC.00816-17 , 2017.
6. Ribeiro A, Dias C, Silva-Carvalho MC y col. First Report of Infection with Community-Acquired Methicillin- Resistant Staphylococcus aureus in South America .J Clin Microbiol43:1985–1988, 2005.
7. Egea AL, Gagettib P, Lamberghinic R y col. New patterns of methicillin-resistant Staphylococcus aureus (MRSA) clones, community-associated MRSA genotypes behave like healthcare-associated MRSA genotypes within hospitals, Argentina. International Journal of Medical Microbiology.304:1086–1099, 2014.
8. Stryjewski M, Ralph Corey G. Methicillin-Resistant Staphylococcus aureus: An Evolving Pathogen. Clin Infect Dis 58: (Suppl 1):S10-9, 2014.
9. Sanabria G. Evolución de la resistencia en el Staphylococcus aureus. Rev Inst Med Trop Vol 3: 27-39, 2014.
10. Gordon RJ, Lowy FD. Pathogenesis of Methicillin-Resistant Staphylococcus aureus Infection. Clin Infect Dis.46 (Suppl 5): S350–S359, 2008.
11.Tong SY, Davis JS, Eichenberger E y col. Staphylococcus aureus Infections: Epidemiology, Pathophysiology,ClinicalManifestations, and Management. Clin Microbiol Rev 28:603-61, 2015.
12. Ortwine JK , Bhavan K. Morbidity, mortality, and management of methicillin-resistant S. aureus bacteremia in the US: update on antibacterial choices and understanding, Hospital Practice, 46:74-2, 2018.
13. Gudiol C, Cuervo G, Shaw E, Pujol M, Carratalà J. Pharmacotherapeutic options for treating Staphylococcus aureus bacteremia. Expert Opin Pharmacother 18:1947- 1963, 2017.
14. Loewen K, Schreiber Y, Kirlew M y col. Community- associated methicillin-resistant Staphylococcus aureus infection. Literature review and clinical update. Can Fam Physician. 63:512-520, 2017.
15. Bassetti M, Peghin M, Trecarichi EM y col. Characteristics of Staphylococcus aureus Bacteremia and Predictors of Early and Late Mortality. PLoS ONE Feb 2;12(2):e0170236. DOI: https://doi.org/10.1371/journal.pone.0170236. 2017.
16. Garau J, Ostermann H, Medina J y col.Current management of patients hospitalized with complicated skin and soft tissue infections across Europe (2010– 2011): assessment of clinical practice patternsand real-life effectiveness of antibiotics from the REACH study .Clin Microbiol Infect ; 19: E377–E385,2013.
17. Casapao AM, Jacobs DM, Bowers DR y col. Early administration of adjuvant b-lactamic therapy in combination with vancomicyn among patients with meticilin resistant Staphylococcus aureus bloodstream infections: a retrospective, multicenter analysis. Pharmacotherapy 37:1347-1356, 2017
18. Van Hal SJ, Jensen SO, Vaska VL y col. Predictors of Mortality in Staphylococcus aureus Bacteremia. Clin Microbiol Rev 25:362,2012.
19. Kaasch AJ, Barlow G, Edgeworth JD y col. Staphylococcus aureus bloodstream infection: A pooled analysis of five prospective, observational studies. J Infect 68: 242-251, 2014.
20. Jokinen E, Laine J, Huttunen R y col. Trends in incidence and resistance patterns of Staphylococcus aureus bacteremia. Infect Dis (Lond). 50:52-58, 2018.
21. Seymour CW ,Liu VX, Iwashyna TJ y col. Assessment of Clinical Criteria for Sepsis For the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA 315:762-774, 2016.
22. Kang CI, Song JH, Chung DR. Clinical impact of methicillin resistance on outcome of patients with Staphylococcus aureus infection: a stratified analysis according to underlying diseases and sites of infection in a large prospective cohort. J. Infect 61:299 –306, 2010.
23. Tibavizco D, Rodríguez J, Silva E, Isabel Cuervo E y col. Enfoque terapéutico de la bacteriemia por Staphylococcus aureus. Biomédica.27:29-307, 2007.
24. Klevens RM ,Morrison MA, Nadle J y “col.”Invasive Methicillin-Resistant Staphylococcus aureus Infections in the United States. JAMA. 29(15):1763-71,2007.
25. Khatib R ,Saeed S,Sharma M y col. Impact of initial antibiotic choice and delayed appropriate treatment on the outcome of Staphylococcus aureus bacteremia. Eur J Clin Microbiol Infect Dis 25: 181–85, 2006.
26. Mermel LA, Farr BM, Sherertz RJ y col. Guidelines for the Management of Intravascular Catheter–Related Infections. Clin Infec Dis 32:1249–72, 2001.
27. Esteban J, Marín M, Meseguer MA, Sánchez Somolinos M. Procedimientos en Microbiología Clínica Recomendaciones de la Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica. Editores: Cercenado E y Rafael Cantón.2009.
28. Kim SH, Park W, Lee C y col. Outcomes of inappropriate empirical antibiotic therapy in patients with Staphylococcus aureus bacteraemia: analytical strategy using propensity scores. Clin Microbiol Infect 12:13–21, 2006.
29. Fowler VJ ,Olsen MK, Corey GR y col. Clinical identifiers of complicated bacteriemia. Arch Intern Med 163:2066- 2072, 2003.
30. Del Rio A, Cervera C, Moreno A y col. Patients at Risk of Complications of Staphylococcus aureus Bloodstream Infection. Clin Infect Dis 48: S246–S253, 2009.
31. Fowler VJ .Complications of Staphylococcus aureus bacteremia. Up to Date. 2013.
32. Khatib R, Johnson LB, Fakih MJ y col. Persistence in Staphylococcus aureus bacteremia: incidence, characteristics of patients and outcome. Scand J Infect Dis 38:7–14, 2006.
33. JungN, Rieg S. Essentials in the management of S. aureus bloodstream infection. Infection 46:441-442, 2018.
34. Fang CT. Early empirical glycopeptide therapy for patients with methicillin-resistant Staphylococcus aureus bacteraemia: impact on the outcome. J Antimicrob Chemother57:511–519, 2006.
35. Guilarde AO, Turchi MD, Martelli CM, Primo MG. Staphylococcus aureus bacteraemia: incidence, risk factors and predictors for death in a Brazilian teaching hospital. J Hosp Infect 63:330 –336, 2006.
36. Wang JT. Risk factors for mortality of nosocomial methicillin resistant Staphylococcus aureus (MRSA) bloodstream infection with investigation of the potential role of community-associated MRSA strains. J Infect 61:449– 457, 2010.
37. Park SY, Son JS, Oh IHb y col. Clinical impact of methicillin-resistant Staphylococcus aureus bacteremia based on propensity scores. Infection 39:141–147, 2011.
38. Perencevich EN. Excess shock and mortality in Staphylococcus aureus related to methicillin resistance. Clin Infect Dis 31:1311–1313, 2000.
39. Turnidge JD, Kotsanas D, Munckhof W y col. Staphylococcus aureus bacteraemia: a major cause of mortality in Australia and New Zealand. Med J Aust 191:368–373, 2009.
40. Cosgrove SE, Qi Y, Kaye KS y col. The impact of methicillin resistance in Staphylococcus aureus bacteremia on patient outcomes: mortality, length of stay, and hospital charges. Infect Control Hosp Epidemiol 26:166 –174, 2005.
41. Hewagama S, Spelman T , Einsiedel LJ. Staphylococcus aureus bacteraemia at Alice Springs Hospital, Central Australia, 2003–2006. Intern Med J 42:505-512, 2012.
42. Van Hal SJ, Jones M, Gosbell IB y col. Vancomycin heteroresistance is associated with reduced mortality in ST239 methicillin- resistant Staphylococcus aureus blood stream infections. PLoS One 6:e21217, 2011.
43. Truong J, Veillette JJ, Forlanda SC. -lactam versus vancomycin only for theOutcomes of vancomycin plus a treatment of methicillin-resistant Staphylococcus aureus bacteremia. Antimicrob Agents Chemother 62: e01554- 17, 2018.
44. Lesens O, Methlin C, Hansmann Y y col. Role of comorbidity in mortality related to Staphylococcus aureus bacteremia: a prospective study using the Charlson weighted index of comorbidity. Infect. Control Hosp Epidemiol 24: 890–896, 2003.
45. Big C, Malani PN. Staphylococcus aureus bloodstream infections in older adults: clinical outcomes and risk factors for in-hospital mortality .J Am Geriatr Soc 58:300 –305, 2010.
46. Chen SY, Wang JT, Chen TH y col. Impact of traditional hospital strain of methicillinresistant Staphylococcus aureus (MRSA) and community strain of MRSA on mortality in patients with community-onset S aureus bacteremia. Medicine (Baltimore) 89:285–294, 2010.
47. Ammerlaan H, Seifert H, Harbarth S y col. Adequacy of antimicrobial treatment and outcome of Staphylococcus aureus bacteremia in 9 Western European countries. Clin Infect Dis 49:997–1005, 2009.
48. Prybylski JP. Vancomycin Trough Concentration as a Predictor of Clinical Outcomes in Patients with Staphylococcus aureus Bacteremia: A Meta-analysis of Observational Studies. Pharmacotherapy 35:889–898, 2015.
49. Ruiz J, Ramirez P, Concha P y col. Vancomycin and Daptomycin Minimum Inhibitory Concentration as a predictor of methicillin-resistant Staphylococcus aureus Bacteremia outcome. J Glob Antimicrob Resist. 2018 14:141-144, 2018.
50. Kalil AC, Van Schooneveld TC ,Fey PD, Rupp ME. Association Between Vancomycin Minimum Inhibitor Concentration and Mortality Among Patients With Staphylococcus aureus Bloodstream Infection A Systematic Review and Meta-analysis. JAMA.312:1552-1564, 2014.
51. Welsh KJ, Skrobarcek KA, Abbott AN y col. Predictors of Relapse of Methicillin-Resistant Staphylococcus aureus Bacteremia after Treatment with Vancomycin. J Clin Mirocbiol 49;3669–3672, 2011.
2. Álvarez I, Ponce Bittar J; Staphylococcus aureus, evolución de un viejo patógeno. Rev Cubana de Pediatría; 84: 383-391,2012.
3. Arroyave Rivera S, Atehortúa Barragán D, Jaimes Barragán F. Actualización en Bacteriemia por Staphylococcus Aureus. MEDICINA U.P.B. 33: 48-55, 2014.
4. Naber CK, Baddour L ,Giamarellos-Bourboulis E y col. Clinical Consensus Conference: Survey on Gram- Positive Bloodstream Infections with a Focus on Staphylococcus aureus. Clin Infect Dis15;48 S260-70, 2009.
5. Arias C, Reyes J, Carvajal L y col. Molecular Epidemiology and Phylogenomics of Staphylococcus aureus Bacteremia in Latin-America: A Prospective Cohort Multicenter Study in Nine Countries. Antimicrob Agents Chemother. 61 (10) e00816-17; DOI: https://doi.org/10.1128/AAC.00816-17 , 2017.
6. Ribeiro A, Dias C, Silva-Carvalho MC y col. First Report of Infection with Community-Acquired Methicillin- Resistant Staphylococcus aureus in South America .J Clin Microbiol43:1985–1988, 2005.
7. Egea AL, Gagettib P, Lamberghinic R y col. New patterns of methicillin-resistant Staphylococcus aureus (MRSA) clones, community-associated MRSA genotypes behave like healthcare-associated MRSA genotypes within hospitals, Argentina. International Journal of Medical Microbiology.304:1086–1099, 2014.
8. Stryjewski M, Ralph Corey G. Methicillin-Resistant Staphylococcus aureus: An Evolving Pathogen. Clin Infect Dis 58: (Suppl 1):S10-9, 2014.
9. Sanabria G. Evolución de la resistencia en el Staphylococcus aureus. Rev Inst Med Trop Vol 3: 27-39, 2014.
10. Gordon RJ, Lowy FD. Pathogenesis of Methicillin-Resistant Staphylococcus aureus Infection. Clin Infect Dis.46 (Suppl 5): S350–S359, 2008.
11.Tong SY, Davis JS, Eichenberger E y col. Staphylococcus aureus Infections: Epidemiology, Pathophysiology,ClinicalManifestations, and Management. Clin Microbiol Rev 28:603-61, 2015.
12. Ortwine JK , Bhavan K. Morbidity, mortality, and management of methicillin-resistant S. aureus bacteremia in the US: update on antibacterial choices and understanding, Hospital Practice, 46:74-2, 2018.
13. Gudiol C, Cuervo G, Shaw E, Pujol M, Carratalà J. Pharmacotherapeutic options for treating Staphylococcus aureus bacteremia. Expert Opin Pharmacother 18:1947- 1963, 2017.
14. Loewen K, Schreiber Y, Kirlew M y col. Community- associated methicillin-resistant Staphylococcus aureus infection. Literature review and clinical update. Can Fam Physician. 63:512-520, 2017.
15. Bassetti M, Peghin M, Trecarichi EM y col. Characteristics of Staphylococcus aureus Bacteremia and Predictors of Early and Late Mortality. PLoS ONE Feb 2;12(2):e0170236. DOI: https://doi.org/10.1371/journal.pone.0170236. 2017.
16. Garau J, Ostermann H, Medina J y col.Current management of patients hospitalized with complicated skin and soft tissue infections across Europe (2010– 2011): assessment of clinical practice patternsand real-life effectiveness of antibiotics from the REACH study .Clin Microbiol Infect ; 19: E377–E385,2013.
17. Casapao AM, Jacobs DM, Bowers DR y col. Early administration of adjuvant b-lactamic therapy in combination with vancomicyn among patients with meticilin resistant Staphylococcus aureus bloodstream infections: a retrospective, multicenter analysis. Pharmacotherapy 37:1347-1356, 2017
18. Van Hal SJ, Jensen SO, Vaska VL y col. Predictors of Mortality in Staphylococcus aureus Bacteremia. Clin Microbiol Rev 25:362,2012.
19. Kaasch AJ, Barlow G, Edgeworth JD y col. Staphylococcus aureus bloodstream infection: A pooled analysis of five prospective, observational studies. J Infect 68: 242-251, 2014.
20. Jokinen E, Laine J, Huttunen R y col. Trends in incidence and resistance patterns of Staphylococcus aureus bacteremia. Infect Dis (Lond). 50:52-58, 2018.
21. Seymour CW ,Liu VX, Iwashyna TJ y col. Assessment of Clinical Criteria for Sepsis For the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA 315:762-774, 2016.
22. Kang CI, Song JH, Chung DR. Clinical impact of methicillin resistance on outcome of patients with Staphylococcus aureus infection: a stratified analysis according to underlying diseases and sites of infection in a large prospective cohort. J. Infect 61:299 –306, 2010.
23. Tibavizco D, Rodríguez J, Silva E, Isabel Cuervo E y col. Enfoque terapéutico de la bacteriemia por Staphylococcus aureus. Biomédica.27:29-307, 2007.
24. Klevens RM ,Morrison MA, Nadle J y “col.”Invasive Methicillin-Resistant Staphylococcus aureus Infections in the United States. JAMA. 29(15):1763-71,2007.
25. Khatib R ,Saeed S,Sharma M y col. Impact of initial antibiotic choice and delayed appropriate treatment on the outcome of Staphylococcus aureus bacteremia. Eur J Clin Microbiol Infect Dis 25: 181–85, 2006.
26. Mermel LA, Farr BM, Sherertz RJ y col. Guidelines for the Management of Intravascular Catheter–Related Infections. Clin Infec Dis 32:1249–72, 2001.
27. Esteban J, Marín M, Meseguer MA, Sánchez Somolinos M. Procedimientos en Microbiología Clínica Recomendaciones de la Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica. Editores: Cercenado E y Rafael Cantón.2009.
28. Kim SH, Park W, Lee C y col. Outcomes of inappropriate empirical antibiotic therapy in patients with Staphylococcus aureus bacteraemia: analytical strategy using propensity scores. Clin Microbiol Infect 12:13–21, 2006.
29. Fowler VJ ,Olsen MK, Corey GR y col. Clinical identifiers of complicated bacteriemia. Arch Intern Med 163:2066- 2072, 2003.
30. Del Rio A, Cervera C, Moreno A y col. Patients at Risk of Complications of Staphylococcus aureus Bloodstream Infection. Clin Infect Dis 48: S246–S253, 2009.
31. Fowler VJ .Complications of Staphylococcus aureus bacteremia. Up to Date. 2013.
32. Khatib R, Johnson LB, Fakih MJ y col. Persistence in Staphylococcus aureus bacteremia: incidence, characteristics of patients and outcome. Scand J Infect Dis 38:7–14, 2006.
33. JungN, Rieg S. Essentials in the management of S. aureus bloodstream infection. Infection 46:441-442, 2018.
34. Fang CT. Early empirical glycopeptide therapy for patients with methicillin-resistant Staphylococcus aureus bacteraemia: impact on the outcome. J Antimicrob Chemother57:511–519, 2006.
35. Guilarde AO, Turchi MD, Martelli CM, Primo MG. Staphylococcus aureus bacteraemia: incidence, risk factors and predictors for death in a Brazilian teaching hospital. J Hosp Infect 63:330 –336, 2006.
36. Wang JT. Risk factors for mortality of nosocomial methicillin resistant Staphylococcus aureus (MRSA) bloodstream infection with investigation of the potential role of community-associated MRSA strains. J Infect 61:449– 457, 2010.
37. Park SY, Son JS, Oh IHb y col. Clinical impact of methicillin-resistant Staphylococcus aureus bacteremia based on propensity scores. Infection 39:141–147, 2011.
38. Perencevich EN. Excess shock and mortality in Staphylococcus aureus related to methicillin resistance. Clin Infect Dis 31:1311–1313, 2000.
39. Turnidge JD, Kotsanas D, Munckhof W y col. Staphylococcus aureus bacteraemia: a major cause of mortality in Australia and New Zealand. Med J Aust 191:368–373, 2009.
40. Cosgrove SE, Qi Y, Kaye KS y col. The impact of methicillin resistance in Staphylococcus aureus bacteremia on patient outcomes: mortality, length of stay, and hospital charges. Infect Control Hosp Epidemiol 26:166 –174, 2005.
41. Hewagama S, Spelman T , Einsiedel LJ. Staphylococcus aureus bacteraemia at Alice Springs Hospital, Central Australia, 2003–2006. Intern Med J 42:505-512, 2012.
42. Van Hal SJ, Jones M, Gosbell IB y col. Vancomycin heteroresistance is associated with reduced mortality in ST239 methicillin- resistant Staphylococcus aureus blood stream infections. PLoS One 6:e21217, 2011.
43. Truong J, Veillette JJ, Forlanda SC. -lactam versus vancomycin only for theOutcomes of vancomycin plus a treatment of methicillin-resistant Staphylococcus aureus bacteremia. Antimicrob Agents Chemother 62: e01554- 17, 2018.
44. Lesens O, Methlin C, Hansmann Y y col. Role of comorbidity in mortality related to Staphylococcus aureus bacteremia: a prospective study using the Charlson weighted index of comorbidity. Infect. Control Hosp Epidemiol 24: 890–896, 2003.
45. Big C, Malani PN. Staphylococcus aureus bloodstream infections in older adults: clinical outcomes and risk factors for in-hospital mortality .J Am Geriatr Soc 58:300 –305, 2010.
46. Chen SY, Wang JT, Chen TH y col. Impact of traditional hospital strain of methicillinresistant Staphylococcus aureus (MRSA) and community strain of MRSA on mortality in patients with community-onset S aureus bacteremia. Medicine (Baltimore) 89:285–294, 2010.
47. Ammerlaan H, Seifert H, Harbarth S y col. Adequacy of antimicrobial treatment and outcome of Staphylococcus aureus bacteremia in 9 Western European countries. Clin Infect Dis 49:997–1005, 2009.
48. Prybylski JP. Vancomycin Trough Concentration as a Predictor of Clinical Outcomes in Patients with Staphylococcus aureus Bacteremia: A Meta-analysis of Observational Studies. Pharmacotherapy 35:889–898, 2015.
49. Ruiz J, Ramirez P, Concha P y col. Vancomycin and Daptomycin Minimum Inhibitory Concentration as a predictor of methicillin-resistant Staphylococcus aureus Bacteremia outcome. J Glob Antimicrob Resist. 2018 14:141-144, 2018.
50. Kalil AC, Van Schooneveld TC ,Fey PD, Rupp ME. Association Between Vancomycin Minimum Inhibitor Concentration and Mortality Among Patients With Staphylococcus aureus Bloodstream Infection A Systematic Review and Meta-analysis. JAMA.312:1552-1564, 2014.
51. Welsh KJ, Skrobarcek KA, Abbott AN y col. Predictors of Relapse of Methicillin-Resistant Staphylococcus aureus Bacteremia after Treatment with Vancomycin. J Clin Mirocbiol 49;3669–3672, 2011.
Publicado
2019-12-20
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Stephanie de Araujo Otero, Mariana Lagrutta, Liliana Negro Marquínez, Roberto Parodi, Jorgelina Perez, Gabriela Falco y Alcides Greca (2019) «Bacteriemia a Staphylococcus aureus meticilino resistente», Revista Médica de Rosario, 85(3), pp. 113-125. Disponible en: https://revistamedicaderosario.org/index.php/rm/article/view/45 (Accedido: 23noviembre2024).
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