Características Epidemiológicas, Clínicas y Microbiológicas de las Infecciones por Staphylococcus aureus en Pediatría en dos Instituciones de Salud de Santander - Colombia del 2018 al 2021
Digital
- Autores:
-
Becerra-Riaño, Karen Linceyth
- Tipo de recurso:
- Fecha de publicación:
- 2024
- Institución:
- Universidad de Santander
- Repositorio:
- Repositorio Universidad de Santander
- Idioma:
- spa
- OAI Identifier:
- oai:repositorio.udes.edu.co:001/10183
- Palabra clave:
- Staphylococcus aureus
Infecciones
Staphylococcus aureus Meticilino Resistente
Infección Adquirida en Comunidad
Infections,
Methicillin-Resistant Staphylococcus aureus
Community-Acquired Infection
- Rights
- openAccess
- License
- http://purl.org/coar/access_right/c_abf2
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Repositorio Universidad de Santander |
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dc.title.spa.fl_str_mv |
Características Epidemiológicas, Clínicas y Microbiológicas de las Infecciones por Staphylococcus aureus en Pediatría en dos Instituciones de Salud de Santander - Colombia del 2018 al 2021 |
dc.title.translated.none.fl_str_mv |
Epidemiological, Clinical and Microbiological Characteristics of Staphylococcus aureus Infections in Pediatrics in two Health Institutions of Santander - Colombia from 2018 to 2021 |
title |
Características Epidemiológicas, Clínicas y Microbiológicas de las Infecciones por Staphylococcus aureus en Pediatría en dos Instituciones de Salud de Santander - Colombia del 2018 al 2021 |
spellingShingle |
Características Epidemiológicas, Clínicas y Microbiológicas de las Infecciones por Staphylococcus aureus en Pediatría en dos Instituciones de Salud de Santander - Colombia del 2018 al 2021 Staphylococcus aureus Infecciones Staphylococcus aureus Meticilino Resistente Infección Adquirida en Comunidad Infections, Methicillin-Resistant Staphylococcus aureus Community-Acquired Infection |
title_short |
Características Epidemiológicas, Clínicas y Microbiológicas de las Infecciones por Staphylococcus aureus en Pediatría en dos Instituciones de Salud de Santander - Colombia del 2018 al 2021 |
title_full |
Características Epidemiológicas, Clínicas y Microbiológicas de las Infecciones por Staphylococcus aureus en Pediatría en dos Instituciones de Salud de Santander - Colombia del 2018 al 2021 |
title_fullStr |
Características Epidemiológicas, Clínicas y Microbiológicas de las Infecciones por Staphylococcus aureus en Pediatría en dos Instituciones de Salud de Santander - Colombia del 2018 al 2021 |
title_full_unstemmed |
Características Epidemiológicas, Clínicas y Microbiológicas de las Infecciones por Staphylococcus aureus en Pediatría en dos Instituciones de Salud de Santander - Colombia del 2018 al 2021 |
title_sort |
Características Epidemiológicas, Clínicas y Microbiológicas de las Infecciones por Staphylococcus aureus en Pediatría en dos Instituciones de Salud de Santander - Colombia del 2018 al 2021 |
dc.creator.fl_str_mv |
Becerra-Riaño, Karen Linceyth |
dc.contributor.advisor.none.fl_str_mv |
Vargas-Soler, José Antonio Aguilar-Jiménez, Jhancy Rocío |
dc.contributor.author.none.fl_str_mv |
Becerra-Riaño, Karen Linceyth |
dc.contributor.jury.none.fl_str_mv |
Cáceres-Torres, Gonzalo Erasmo Barrera-Arguello, Carlos Fernando |
dc.subject.proposal.other.fl_str_mv |
Staphylococcus aureus |
topic |
Staphylococcus aureus Infecciones Staphylococcus aureus Meticilino Resistente Infección Adquirida en Comunidad Infections, Methicillin-Resistant Staphylococcus aureus Community-Acquired Infection |
dc.subject.proposal.spa.fl_str_mv |
Infecciones Staphylococcus aureus Meticilino Resistente Infección Adquirida en Comunidad |
dc.subject.proposal.eng.fl_str_mv |
Infections, Methicillin-Resistant Staphylococcus aureus Community-Acquired Infection |
description |
Digital |
publishDate |
2024 |
dc.date.accessioned.none.fl_str_mv |
2024-04-11T19:57:51Z |
dc.date.available.none.fl_str_mv |
2024-04-11T19:57:51Z |
dc.date.issued.none.fl_str_mv |
2024-02-26 |
dc.type.none.fl_str_mv |
Trabajo de grado - Especialización |
dc.type.coarversion.none.fl_str_mv |
http://purl.org/coar/version/c_71e4c1898caa6e32 |
dc.type.content.none.fl_str_mv |
Text |
dc.type.driver.none.fl_str_mv |
info:eu-repo/semantics/masterThesis |
dc.type.redcol.none.fl_str_mv |
http://purl.org/redcol/resource_type/TM |
dc.type.version.none.fl_str_mv |
info:eu-repo/semantics/submittedVersion |
status_str |
submittedVersion |
dc.identifier.instname.none.fl_str_mv |
Universidad de Santander |
dc.identifier.local.none.fl_str_mv |
T 78.24 B212c |
dc.identifier.reponame.none.fl_str_mv |
Repositorio Digital Universidad de Santander |
dc.identifier.repourl.none.fl_str_mv |
https://repositorio.udes.edu.co |
dc.identifier.uri.none.fl_str_mv |
https://repositorio.udes.edu.co/handle/001/10183 |
identifier_str_mv |
Universidad de Santander T 78.24 B212c Repositorio Digital Universidad de Santander |
url |
https://repositorio.udes.edu.co https://repositorio.udes.edu.co/handle/001/10183 |
dc.language.iso.none.fl_str_mv |
spa |
language |
spa |
dc.relation.references.none.fl_str_mv |
C. E. Bocchini, E. O. Mason, K. G. Hulten, W. A. Hammerman, and S. L. Kaplan, “Recurrent community-associated staphylococcus aureus infections in children presenting to texas children’s hospital in Houston, Texas,” Pediatric Infectious Disease Journal, vol. 32, no. 11, pp. 1189–1193, Nov. 2013, doi: 10.1097/INF.0b013e3182a5c30d. A. H. Hasanpour et al., “The global prevalence of methicillin-resistant Staphylococcus aureus colonization in residents of elderly care centers: a systematic review and meta-analysis,” Antimicrobial Resistance and Infection Control, vol. 12, no. 1. BioMed Central Ltd, Dec. 01, 2023. doi: 10.1186/s13756-023-01210-6. L. Srinivasan, “Healthcare-Associated Infections.” H. Humphreys, F. Fitzpatick, and B. J. Harvey, “Gender differences in rates of carriage and bloodstream infection caused by methicillin-resistant staphylococcus aureus: Are they real, do they matter and why?,” Clinical Infectious Diseases, vol. 61, no. 11, pp. 1708–1714, Dec. 2015, doi: 10.1093/cid/civ576. S. Monecke et al., “A field guide to pandemic, epidemic and sporadic clones of methicillin-resistant Staphylococcus aureus,” PLoS One, vol. 6, no. 4, 2011, doi: 10.1371/journal.pone.0017936. N. A. Turner et al., “Methicillin-resistant Staphylococcus aureus: an overview of basic and clinical research,” Nature Reviews Microbiology, vol. 17, no. 4. Nature Publishing Group, pp. 203–218, Apr. 01, 2019. doi: 10.1038/s41579-018-0147-4. N. A. Pathare et al., “Prevalence of methicillin resistant Staphylococcus aureus [MRSA] colonization or carriage among health-care workers,” J Infect Public Health, vol. 9, no. 5, pp. 571–576, Sep. 2016, doi: 10.1016/j.jiph.2015.12.004. C. J. Ghia, S. Waghela, and G. Rambhad, “ A Systemic Literature Review and Meta-Analysis Reporting the Prevalence and Impact of Methicillin-Resistant Staphylococcus aureus Infection in India ,” Infectious Diseases: Research and Treatment, vol. 13, p. 117863372097056, Jan. 2020, doi: 10.1177/1178633720970569 Z. W. Jaradat, M. Khwaileh, W. Al Mousa, Q. O. Ababneh, and A. Al Nabulsi, “Occurrence, distribution and pattern analysis of methicillin resistant (MRSA) and methicillin sensitive (MSSA) Staphylococcus aureus on fomites in public facilities,” Pathog Glob Health, vol. 115, no. 6, pp. 377–391, 2021, doi: 10.1080/20477724.2021.1906563. H. W. Boucher and G. R. Corey, “Epidemiology of methicillin-resistant Staphylococcus aureus,” Clinical Infectious Diseases, vol. 46, no. SUPPL. 5, Jun. 2008, doi: 10.1086/533590. J. E. Coia et al., “Guidelines for the control and prevention of meticillin-resistant Staphylococcus aureus (MRSA) in healthcare facilities,” Journal of Hospital Infection, vol. 63, pp. S1–S44, May 2006, doi: 10.1016/j.jhin.2006.01.001. A. M. Milstone, B. W. Goldner, T. Ross, J. W. Shepard, K. C. Carroll, and T. M. Perl, “Methicillin-resistant staphylococcus aureus colonization and risk of subsequent infection in critically ill children: Importance of preventing nosocomial methicillin-resistant staphylococcus aureus transmission,” Clinical Infectious Diseases, vol. 53, no. 9, pp. 853–859, Nov. 2011, doi: 10.1093/cid/cir547. C. Sun et al., “Predictive models for sepsis in children with Staphylococcus aureus bloodstream infections: a retrospective cohort study,” BMC Pediatr, vol. 23, no. 1, Dec. 2023, doi: 10.1186/s12887-023-04317-2. S. Lakhundi and K. Zhang, “Methicillin-Resistant Staphylococcus aureus: Molecular Characterization, Evolution, and Epidemiology,” Clinical microbiology reviews, vol. 31, no. 4. NLM (Medline), Oct. 01, 2018. doi: 10.1128/CMR.00020-18. F. Götz, T. Bannerman, and K.-H. Schleifer, “The Genera Staphylococcus and Macrococcus,” in The Prokaryotes, Springer US, 2006, pp. 5–75. doi: 10.1007/0-387-30744-3_1. D. A. Fassbind, R. Q. Rezende, C. A. G. Dias, and F. Motta, “Community-acquired and healthcare-associated Staphylococcus aureus infections in a pediatric hospital in southern Brazil over 8 years: how common is MRSA?,” Front Pediatr, vol. 11, 2023, doi: 10.3389/fped.2023.1212239. A. S. Lee et al., “Methicillin-resistant Staphylococcus aureus,” Nat Rev Dis Primers, vol. 4, May 2018, doi: 10.1038/nrdp.2018.33. E. Cervantes-García, R. García-González, and P. María Salazar-Schettino, “Características generales del Staphylococcus aureus,” 2014. [Online]. Available: www.medigraphic.com/patologiaclinicawww.medigraphic.org.mx P. R. Murray, K. S. Rosenthal, and M. A. Pfaller, Review of Medical Microbiology & Immunology: A Guide to Clinical Infectious Diseases, 17th ed. 2022. J. M. Miller et al., “A Guide to Utilization of the Microbiology Laboratory for Diagnosis of Infectious Diseases: 2018 Update by the Infectious Diseases Society of America and the American Society for Microbiology,” Clinical Infectious Diseases, vol. 67, no. 6, pp. e1–e94, Aug. 2018, doi: 10.1093/cid/ciy381. S. L. Kaplan, “Staphylococcus aureus infections in children: The implications of changing trends,” Pediatrics, vol. 137, no. 4. American Academy of Pediatrics, Apr. 01, 2016. doi: 10.1542/peds.2016-0101. S. L. Kaplan, K. G. Hulten, and E. O. Mason, “794 SECTION 16 Bacterial Infections Staphylococcus aureus Infections (Coagulase-Positive Staphylococci).” B. Löffler and L. Tuchscherr, “Staphylococcus aureus toxins: Promoter or handicap during infection?,” Toxins, vol. 13, no. 4. MDPI AG, 2021. doi: 10.3390/TOXINS13040287. G. Almada, A. M. Paula, D. Victoria, M. Mugavero, and M. G. Marquez, “Síndrome de Shock Tóxico. A propósito de un caso en un paciente pediátrico,” South Florida Journal of Development, vol. 4, no. 9, pp. 3483–3486, Nov. 2023, doi: 10.46932/sfjdv4n9-011. Y. Zhou et al., “Molecular Characteristics of Methicillin-Resistant and Susceptible Staphylococcus aureus from Pediatric Patients in Eastern China,” Pathogens, vol. 12, no. 4, Apr. 2023, doi: 10.3390/pathogens12040549. B. A. Diep, “Use of whole-genome sequencing for outbreak investigations,” The Lancet Infectious Diseases, vol. 13, no. 2. pp. 99–101, Feb. 2013. doi: 10.1016/S1473-3099(12)70276-1. T. Ito et al., “Classification of staphylococcal cassette chromosome mec (SCCmec): Guidelines for reporting novel SCCmec elements,” Antimicrobial Agents and Chemotherapy, vol. 53, no. 12. pp. 4961–4967, Dec. 2009. doi: 10.1128/AAC.00579-09. C. Liu et al., “Clinical practice guidelines by the Infectious Diseases Society of America for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children,” Clinical Infectious Diseases, vol. 52, no. 3, Feb. 2011, doi: 10.1093/cid/ciq146. P. See et al., “Factors linked to Staphylococcus aureus healthcare-associated infections among pediatric intensive care unit colonized patients,” Archives de Pediatrie, vol. 30, no. 3, pp. 153–157, Apr. 2023, doi: 10.1016/j.arcped.2023.01.002. G. İ. Bayhan et al., “Community-acquired S. aureus infection in childhood: a multi-center study,” Turkish Journal of Pediatrics, vol. 65, no. 3, pp. 469–478, 2023, doi: 10.24953/turkjped.2021.4583. S. L. Weiss and J. C. Fitzgerald, “Pediatric Sepsis Diagnosis, Management, and Sub-phenotypes,” Pediatrics, Jan. 2023, doi: 10.1542/peds.2023-062967. M. S. Linz, A. Mattappallil, D. Finkel, and D. Parker, “Clinical Impact of Staphylococcus aureus Skin and Soft Tissue Infections,” Antibiotics, vol. 12, no. 3. MDPI, Mar. 01, 2023. doi: 10.3390/antibiotics12030557. I. C. Kalu, C. M. Kao, and S. A. Fritz, “Management and Prevention of Staphylococcus aureus Infections in Children,” Infectious Disease Clinics of North America, vol. 36, no. 1. W.B. Saunders, pp. 73–100, Mar. 01, 2022. doi: 10.1016/j.idc.2021.11.006. R. F. Hamdy, D. Dona, M. B. Jacobs, and J. S. Gerber, “Risk Factors for Complications in Children with Staphylococcus aureus Bacteremia,” Journal of Pediatrics, vol. 208, pp. 214-220.e2, May 2019, doi: 10.1016/j.jpeds.2018.12.002. M. Lorrot et al., “Antibiotic therapy for osteoarticular infections in 2023: Proposals from the Pediatric Infectious Pathology Group (GPIP),” Infectious Diseases Now, vol. 53, no. 8. Elsevier Masson s.r.l., Nov. 01, 2023. doi: 10.1016/j.idnow.2023.104789. S. Y. C. Tong, J. S. Davis, E. Eichenberger, T. L. Holland, and V. G. Fowler, “Staphylococcus aureus infections: Epidemiology, pathophysiology, clinical manifestations, and management,” Clin Microbiol Rev, vol. 28, no. 3, pp. 603–661, 2015, doi: 10.1128/CMR.00134-14. M. K. Dishop, “Developmental and Pediatric Lung Disease Processing of Pediatric Lung Biopsy Specimens 113 Processing of Pediatric Cystic Lung Lesion Specimens 114.” N. Shilo and C. Quach, “Pulmonary Infections and Community Associated Methicillin Resistant Staphylococcus Aureus: A Dangerous Mix?,” Paediatric Respiratory Reviews, vol. 12, no. 3. pp. 182–189, Sep. 2011. doi: 10.1016/j.prrv.2010.10.007. D. Chen, L. Cao, and W. Li, “Etiological and clinical characteristics of severe pneumonia in pediatric intensive care unit (PICU),” BMC Pediatr, vol. 23, no. 1, Dec. 2023, doi: 10.1186/s12887-023-04175-y. M. Dardari, E. Cinteza, C. M. Vasile, P. Padovani, and R. Vatasescu, “Infective Endocarditis among Pediatric Patients with Prosthetic Valves and Cardiac Devices: A Review and Update of Recent Emerging Diagnostic and Management Strategies,” Journal of Clinical Medicine, vol. 12, no. 15. Multidisciplinary Digital Publishing Institute (MDPI), Aug. 01, 2023. doi: 10.3390/jcm12154941. S. M. Mandal, A. K. Ghosh, and B. R. Pati, “Dissemination of antibiotic resistance in methicillin-resistant Staphylococcus aureus and vancomycin-resistant S aureus strains isolated from hospital effluents,” Am J Infect Control, vol. 43, no. 12, pp. e87–e88, 2015, doi: 10.1016/j.ajic.2015.08.015. D. Buonsenso et al., “Retrospective Study on Staphylococcus aureus Resistance Profile and Antibiotic Use in a Pediatric Population,” Antibiotics, vol. 12, no. 9, Sep. 2023, doi: 10.3390/antibiotics12091378. W. Su et al., “Antibiotic susceptibility and clonal distribution of Staphylococcus aureus from pediatric skin and soft tissue infections: 10-year trends in multicenter investigation in China,” Front Cell Infect Microbiol, vol. 13, 2023, doi: 10.3389/fcimb.2023.1179509. D. J. Elliott, T. E. Zaoutis, A. B. Troxel, A. Loh, and R. Keren, “Empiric antimicrobial therapy for pediatric skin and soft-tissue infections in the era of methicillin-resistant Staphylococcus aureus,” Pediatrics, vol. 123, no. 6, Jun. 2009, doi: 10.1542/peds.2008-2428. K. J. Popovich et al., “SHEA/IDSA/APIC Practice Recommendation: Strategies to prevent methicillin-resistant Staphylococcus aureus transmission and infection in acute-care hospitals: 2022 Update,” Infect Control Hosp Epidemiol, vol. 44, no. 7, pp. 1039–1067, Jul. 2023, doi: 10.1017/ice.2023.102. P. Nandhini, P. Kumar, S. Mickymaray, A. S. Alothaim, J. Somasundaram, and M. Rajan, “Recent Developments in Methicillin-Resistant Staphylococcus aureus (MRSA) Treatment: A Review,” Antibiotics, vol. 11, no. 5. MDPI, May 01, 2022. doi: 10.3390/antibiotics11050606. M. De Salud, Resolución 08430 del 4 de octubre de 1993 R. Castro-Orozco, L. M. Villafañe-Ferrer, E. Álvarez-Rivera, M. M. De Arco, C. L. Rambaut-Donado, and G. V Vitola-Heins, “Methicillin-resistant Staphylococcus aureus in children attending school in Cartagena, Colombia,” 2010. M. A. Machuca, C. I. González, and L. M. Sosa, “Methicillin-resistant Staphylococcus aureus causes both community-associated and health care-associated infections in children at the Hospital Universitario de Santander,” Biomedica, vol. 34, no. SUPPL.1, pp. 163–169, 2014, doi: 10.7705/biomedica.v34i0.1648. J. Camacho-Cruz et al., “Differences between Methicillin-susceptible Versus Methicillin-resistant Staphylococcus aureus Infections in Pediatrics: Multicenter Cohort Study Conducted in Bogotá, Colombia, 2014-2018,” Pediatric Infectious Disease Journal, vol. 41, no. 1, pp. 12–19, Jan. 2022, doi: 10.1097/INF.0000000000003349. C. Pozzi et al., “Methicillin resistance alters the biofilm phenotype and attenuates virulence in staphylococcus aureus device-associated infections,” PLoS Pathog, vol. 8, no. 4, Apr. 2012, doi: 10.1371/journal.ppat.1002626. E. Y. Klein et al., “National costs associated with methicillin-susceptible and methicillin-resistant staphylococcus aureus hospitalizations in the United States, 2010-2014,” Clinical Infectious Diseases, vol. 68, no. 1. Oxford University Press, pp. 22–28, Jan. 01, 2019. doi: 10.1093/cid/ciy399. I. D. Khan, A. Basu, S. Kiran, S. Trivedi, P. Pandit, and A. Chattoraj, “Device-Associated Healthcare-Associated Infections (DA-HAI) and the caveat of multiresistance in a multidisciplinary intensive care unit,” Med J Armed Forces India, vol. 73, no. 3, pp. 222–231, Jul. 2017, doi: 10.1016/j.mjafi.2016.10.008. Z. A. Elnasser, H. M. Obeidat, M. E. Bani-Salem, Z. O. Amarin, A. F. Banni-Issa, and N. M. Kaplan, “Is methicillin-resistant Staphylococcus aureus a common pathogen in ventilation-associated pneumonia?: The experience of a tertiary teaching hospital in Jordan,” Medicine (United States), vol. 100, no. 20, p. E26069, May 2021, doi: 10.1097/MD.0000000000026069. A. P. Kourtis et al., “Morbidity and Mortality Weekly Report Vital Signs: Epidemiology and Recent Trends in Methicillin-Resistant and in Methicillin-Susceptible Staphylococcus aureus Bloodstream Infections-United States,” 2017. [Online]. Available: https://www.cdc.gov/mmwr M. F. Q. Kluytmans-Vandenbergh and J. A. J. W. Kluytmans, “REVIEW Community-acquired methicillin-resistant Staphylococcus aureus: current perspectives.” T. S. Naimi et al., “Comparison of Community-and Health Care-Associated Methicillin-Resistant Staphylococcus aureus Infection.” [Online]. Available: http://jama.jamanetwork.com/ L. Weiss, A. Lansell, J. Figueroa, P. S. Suchdev, and A. Kirpalani, “Declining prevalence of methicillin-resistant Staphylococcus aureus septic arthritis and osteomyelitis in children: Implications for treatment,” Antibiotics, vol. 9, no. 3, 2020, doi: 10.3390/antibiotics9030101. M. Gijón et al., “Factors associated with severity in invasive community-acquired Staphylococcus aureus infections in children: a prospective European multicentre study,” Clinical Microbiology and Infection, vol. 22, no. 7, pp. 643.e1-643.e6, Jul. 2016, doi: 10.1016/j.cmi.2016.04.004. P. Fu et al., “Clinical and molecular characteristics of methicillin-resistant Staphylococcus aureus in bone and joint infection among children,” Ann Clin Microbiol Antimicrob, vol. 22, no. 1, Dec. 2023, doi: 10.1186/s12941-023-00654-3. S. L. Wang et al., “Clinical Characteristics and Microbial Profiles of Paediatric Patients with Methicillin-Resistant Staphylococcus aureus Pneumonia in China,” Jundishapur J Microbiol, vol. 15, no. 11, Nov. 2022, doi: 10.5812/jjm-132894. C. B. Creech, B. G. Johnson, R. E. Bartilson, E. Yang, and F. E. Barr, “Increasing use of extracorporeal life support in methicillin-resistant Staphylococcus aureus sepsis in children,” Pediatric Critical Care Medicine, vol. 8, no. 3, 2007, doi: 10.1097/01.PCC.0000262801.81331.C7. K. J. Whittington et al., “Staphylococcus aureus Bacteremia in Pediatric Patients: Uncovering a Rural Health Challenge,” Open Forum Infect Dis, vol. 10, no. 7, pp. S16–S20, Jul. 2023, doi: 10.1093/ofid/ofad296. M. J. Groome, W. C. Albrich, J. Wadula, M. Khoosal, and S. A. Madhi, “Community-onset Staphylococcus aureus bacteraemia in hospitalised African children: High incidence in HIV-infected children and high prevalence of multidrug resistance,” Paediatrics and International Child Health, vol. 32, no. 3. pp. 140–146, Aug. 2012. doi: 10.1179/1465328111Y.0000000044. B. J. McMullan et al., “Clinical management of staphylococcus aureus bacteremia in neonates, children, and adolescents,” Pediatrics, vol. 146, no. 3, Sep. 2020, doi: 10.1542/PEDS.2020-0134. B. J. McMullan et al., “Epidemiology and mortality of staphylococcus aureus Bacteremia in Australian and New Zealand children,” JAMA Pediatr, vol. 170, no. 10, pp. 979–986, Oct. 2016, doi: 10.1001/jamapediatrics.2016.1477. H. Hakim, J. M. Mylotte, and H. Faden, “Morbidity and mortality of Staphylococcal bacteremia in children,” Am J Infect Control, vol. 35, no. 2, pp. 102–105, Mar. 2007, doi: 10.1016/j.ajic.2006.09.016. A. I. Hidron et al., “Risk Factors for Nasal MRSA Carriage • CID,” 2005. [Online]. Available: https://academic.oup.com/cid/article/41/2/159/529398 D. E. Sutter, E. Milburn, U. Chukwuma, N. Dzialowy, A. M. Maranich, and D. R. Hospenthal, “Changing Susceptibility of Staphylococcus aureus in a US Pediatric Population,” 2016. [Online]. Available: http://publications.aap.org/pediatrics/article-pdf/137/4/e20153099/1093401/peds_20153099.pdf |
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Vargas-Soler, José Antoniod68c1369-889a-4d7a-8542-82ec23071872-1Aguilar-Jiménez, Jhancy Rocío8d191136-6cf5-46f4-9c46-d02c2a408890600Becerra-Riaño, Karen Linceyth71ca8aa2-15e0-4018-82db-6d73fe06b1ec-1Cáceres-Torres, Gonzalo Erasmo420b800b-a641-49af-a41b-82505e11f659-1Barrera-Arguello, Carlos Fernandodd7d4afe-4da2-460a-b8ed-dbef5dd766eb-12024-04-11T19:57:51Z2024-04-11T19:57:51Z2024-02-26DigitalIntroducción. Las infecciones por Staphylococcus aureus (S. aureus) son frecuentes en pediatría, tanto hospitalarias como de la comunidad. Este estudio se llevó a cabo con el propósito de evaluar el comportamiento epidemiológico, clínico y microbiológico de las infecciones por S. aureus en dos instituciones de salud, consideradas centro de referencia pediátrico en Santander (Colombia). Materiales y métodos. Estudio observacional de corte trasversal analítico. Se examinó a menores de 18 años, con aislamientos de S. aureus, tratados en dos hospitales de Santander entre el 2018 y 2021. El análisis estadístico incluyó proporciones, rangos intercuartílicos y medianas. El análisis bivariado se hizo por medio de pruebas chi2, prueba exacta de Fisher y pruebas como U de Mann Whitney o T de Student. El análisis multivariable se llevó a cabo mediante modelos de regresión logística y binomial. Resultados. Se obtuvieron 154 registros clínicos. SAMS fue detectado en el (51,3%), predominó el género masculino (66,9%). Del total de infecciones por SAMR, el 55,7% estuvieron asociadas con la comunidad. Se encontró significancia estadística en infecciones por SAMR logrando mayor prevalencia de requerimiento de soporte inotrópico/vasopresor que en el grupo de SAMS (RP 2,22; IC95% 1,07-4,6; p=0,02) de igual forma las infecciones por SAMR presentaron un valor de neutrófilos al inicio de la infección mayor (mediana 9,4 103/ml; RIQ 5460-15100; p=0,03) que los casos SAMS. Conclusiones. Las infecciones por S. aureus mostraron una distribución similar en cuanto a resistencia, siendo más común el origen hematológico, seguido de la piel y los tejidos blandos. La tasa de infecciones resistentes a la meticilina fue del 48,7%. Los factores de riesgo para complicaciones graves incluyeron bacteriemia persistente, y el uso de soporte ECMO se identificó como un riesgo significativo para la mortalidad. Estos hallazgos ofrecen información para mejorar las estrategias de tratamiento y manejo de estas infecciones.Staphylococcus aureus (S. aureus) infections pose a significant challenge in pediatrics, impacting both hospital and community settings. This study addressed the prevalence and characteristics of these infections in two healthcare institutions in Santander, Colombia, aiming to evaluate their epidemiological, clinical, and microbiological behavior. An analytical cross-sectional observational study was conducted, selecting individuals under 18 years old treated between January 2018 and December 2021, with S. aureus isolates processed using the VITEK system and WHONET software for antimicrobial susceptibility testing. From the 154 clinical records obtained, a total of 288 isolates were identified, with a distribution of 51.3% SAMS and 48.7% SAMR. Males predominated (66.9%). A higher prevalence of SAMR infections associated with the community (55.7%) was observed. SAMR infections showed a higher prevalence of inotropic/vasopressor support requirement and higher neutrophil values than SAMS. In patients with SAMR, a higher frequency of appropriate treatment was observed in cases with bacteremia. Additionally, a higher frequency of appropriate treatment was found in SAMR patients with bacteremia. Staphylococcus aureus infections primarily affected males with comorbidities, with cardiovascular diseases being the most common, frequently originating from hematology, skin, and soft tissues. Methicillin resistance was 48.7%, predominantly associated with the community. Risk factors for severe complications, such as persistent bacteremia and prolonged hospitalization in specific age groups, were identified. The requirement for ECMO support stood out as a significant risk factor for mortality. These findings provide crucial information for improving the management and treatment strategies for S. aureus infections in the pediatric population.EspecializaciónEspecialista en Cuidado Intensivo PediátricoIntroducción 19 Planteamiento del Problema 20 Pregunta de Investigación 22 Justificación 23 Objetivos 24 Objetivo General 24 Objetivos Específicos 24 Marco Referencial 25 Staphylococcus aureus - Origen y Clasificación Taxonómica 25 Morfología 26 Estructura 27 Cápsula 27 Pared Celular 28 Proteínas de Superficie 29 Proteínas Secretadas 30 Membrana Citoplasmática 31 Genoma 31 Metabolismo 32 Definiciones Para las Infecciones por S. aureus 32 Patogenia 33 Manifestaciones Clínicas y Enfermedades 35 Diagnóstico de Laboratorio 39 Pruebas Bioquímicas Para S. aureus 40 Pruebas Inmunoenzimáticas (ELISA) 40 Identificación Molecular 41 Tratamiento 41 Manejo del Staphylococcus aureus Resistente a la Meticilina 42 Metodología 44 Tipo de Estudio 44 Población de Estudio y Muestra 44 Criterios de Inclusión y Exclusión 44 Criterios de inclusión 44 Criterios de Exclusión 45 Procedimientos 45 Instrumentos de Recolección de Datos 45 Recolección de Datos 45 Variables 46 Análisis Estadístico 46 Consideraciones Éticas, Bioéticas y de Integridad Científica 48 Resultados 49 Descripción de las Características de la Población a Estudio 50 Descripción de Factores Clínicos de la Población Estudiada 53 Descripción del Foco Infeccioso Primario por S. aureus 54 Episodio Actual de Infección por S. aureus 55 Manifestaciones Clínicas 55 Hallazgos de Laboratorio 56 Hallazgos Radiológicos 57 Infecciones Relacionadas con la Atención en Salud 58 Tratamiento 58 Fenotipos de Resistencia y su Variación Durante el Tiempo 59 Análisis Bivariado. Comparación de Factores Asociados a SAMR 61 Análisis Bivariado. Comparación de Complicaciones Asociadas a SAMR 64 Factores Asociados a las Complicaciones de las Infecciones por S. aureus. Análisis Multivariable 66 Discusión 69 Limitaciones del Estudio 73 Conclusiones 74 Referencias Bibliográficas 76 Apéndices 8694 papplication/pdfapplication/mswordUniversidad de SantanderT 78.24 B212cRepositorio Digital Universidad de Santanderhttps://repositorio.udes.edu.cohttps://repositorio.udes.edu.co/handle/001/10183spaUniversidad de SantanderBucaramangaFacultad de Ciencias Médicas y de la SaludBucaramanga, ColombiaEspecialización en Cuidado Intensivo PediátricoC. E. Bocchini, E. O. Mason, K. G. Hulten, W. A. Hammerman, and S. L. Kaplan, “Recurrent community-associated staphylococcus aureus infections in children presenting to texas children’s hospital in Houston, Texas,” Pediatric Infectious Disease Journal, vol. 32, no. 11, pp. 1189–1193, Nov. 2013, doi: 10.1097/INF.0b013e3182a5c30d.A. H. 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Hidron et al., “Risk Factors for Nasal MRSA Carriage • CID,” 2005. [Online]. Available: https://academic.oup.com/cid/article/41/2/159/529398D. E. Sutter, E. Milburn, U. Chukwuma, N. Dzialowy, A. M. Maranich, and D. R. Hospenthal, “Changing Susceptibility of Staphylococcus aureus in a US Pediatric Population,” 2016. [Online]. Available: http://publications.aap.org/pediatrics/article-pdf/137/4/e20153099/1093401/peds_20153099.pdfDerechos Reservados - Universidad de Santander, 2024. 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GF1dG9yKSBwYXJhIGVqZXJjZXIgZXN0b3MgZGVyZWNob3Mgc29icmUgbGEgT2JyYSB0YWwgeSBjb21vIHNlIGluZGljYSBhIGNvbnRpbnVhY2nDs246PC9wPgogICAgPG9sIHR5cGU9ImEiPgogICAgICA8bGk+UmVwcm9kdWNpciBsYSBPYnJhLCBpbmNvcnBvcmFyIGxhIE9icmEgZW4gdW5hIG8gbcOhcyBPYnJhcyBDb2xlY3RpdmFzLCB5IHJlcHJvZHVjaXIgbGEgT2JyYSBpbmNvcnBvcmFkYSBlbiBsYXMgT2JyYXMgQ29sZWN0aXZhcy48L2xpPgogICAgICA8bGk+RGlzdHJpYnVpciBjb3BpYXMgbyBmb25vZ3JhbWFzIGRlIGxhcyBPYnJhcywgZXhoaWJpcmxhcyBww7pibGljYW1lbnRlLCBlamVjdXRhcmxhcyBww7pibGljYW1lbnRlIHkvbyBwb25lcmxhcyBhIGRpc3Bvc2ljacOzbiBww7pibGljYSwgaW5jbHV5w6luZG9sYXMgY29tbyBpbmNvcnBvcmFkYXMgZW4gT2JyYXMgQ29sZWN0aXZhcywgc2Vnw7puIGNvcnJlc3BvbmRhLjwvbGk+CiAgICAgIDxsaT5EaXN0cmlidWlyIGNvcGlhcyBkZSBsYXMgT2JyYXMgRGVyaXZhZGFzIHF1ZSBzZSBnZW5lcmVuLCBleGhpYmlybGFzIHDDumJsaWNhbWVudGUsIGVqZWN1dGFybGFzIHDDumJsaWNhbWVudGUgeS9vIHBvbmVybGFzIGEgZGlzcG9zaWNpw7NuIHDDumJsaWNhLjwvbGk+CiAgICA8L29sPgogICAgPHA+TG9zIGRlcmVjaG9zIG1lbmNpb25hZG9zIGFudGVyaW9ybWVudGUgcHVlZGVuIHNlciBlamVyY2lkb3MgZW4gdG9kb3MgbG9zIG1lZGlvcyB5IGZvcm1hdG9zLCBhY3R1YWxtZW50ZSBjb25vY2lkb3MgbyBxdWUgc2UgaW52ZW50ZW4gZW4gZWwgZnV0dXJvLiBMb3MgZGVyZWNob3MgYW50ZXMgbWVuY2lvbmFkb3MgaW5jbHV5ZW4gZWwgZGVyZWNobyBhIHJlYWxpemFyIGRpY2hhcyBtb2RpZmljYWNpb25lcyBlbiBsYSBtZWRpZGEgcXVlIHNlYW4gdMOpY25pY2FtZW50ZSBuZWNlc2FyaWFzIHBhcmEgZWplcmNlciBsb3MgZGVyZWNob3MgZW4gb3RybyBtZWRpbyBvIGZvcm1hdG9zLCBwZXJvIGRlIG90cmEgbWFuZXJhIHVzdGVkIG5vIGVzdMOhIGF1dG9yaXphZG8gcGFyYSByZWFsaXphciBvYnJhcyBkZXJpdmFkYXMuIFRvZG9zIGxvcyBkZXJlY2hvcyBubyBvdG9yZ2Fkb3MgZXhwcmVzYW1lbnRlIHBvciBlbCBMaWNlbmNpYW50ZSBxdWVkYW4gcG9yIGVzdGUgbWVkaW8gcmVzZXJ2YWRvcywgaW5jbHV5ZW5kbyBwZXJvIHNpbiBsaW1pdGFyc2UgYSBhcXVlbGxvcyBxdWUgc2UgbWVuY2lvbmFuIGVuIGxhcyBzZWNjaW9uZXMgNChkKSB5IDQoZSkuPC9wPgogIDwvbGk+CiAgPGJyLz4KICA8bGk+CiAgICBSZXN0cmljY2lvbmVzLgogICAgPHA+TGEgbGljZW5jaWEgb3RvcmdhZGEgZW4gbGEgYW50ZXJpb3IgU2VjY2nDs24gMyBlc3TDoSBleHByZXNhbWVudGUgc3VqZXRhIHkgbGltaXRhZGEgcG9yIGxhcyBzaWd1aWVudGVzIHJlc3RyaWNjaW9uZXM6PC9wPgogICAgPG9sIHR5cGU9ImEiPgogICAgICA8bGk+VXN0ZWQgcHVlZGUgZGlzdHJpYnVpciwgZXhoaWJpciBww7pibGljYW1lbnRlLCBlamVjdXRhciBww7pibGljYW1lbnRlLCBvIHBvbmVyIGEgZGlzcG9zaWNpw7NuIHDDumJsaWNhIGxhIE9icmEgc8OzbG8gYmFqbyBsYXMgY29uZGljaW9uZXMgZGUgZXN0YSBMaWNlbmNpYSwgeSBVc3RlZCBkZWJlIGluY2x1aXIgdW5hIGNvcGlhIGRlIGVzdGEgbGljZW5jaWEgbyBkZWwgSWRlbnRpZmljYWRvciBVbml2ZXJzYWwgZGUgUmVjdXJzb3MgZGUgbGEgbWlzbWEgY29uIGNhZGEgY29waWEgZGUgbGEgT2JyYSBxdWUgZGlzdHJpYnV5YSwgZXhoaWJhIHDDumJsaWNhbWVudGUsIGVqZWN1dGUgcMO6YmxpY2FtZW50ZSBvIHBvbmdhIGEgZGlzcG9zaWNpw7NuIHDDumJsaWNhLiBObyBlcyBwb3NpYmxlIG9mcmVjZXIgbyBpbXBvbmVyIG5pbmd1bmEgY29uZGljacOzbiBzb2JyZSBsYSBPYnJhIHF1ZSBhbHRlcmUgbyBsaW1pdGUgbGFzIGNvbmRpY2lvbmVzIGRlIGVzdGEgTGljZW5jaWEgbyBlbCBlamVyY2ljaW8gZGUgbG9zIGRlcmVjaG9zIGRlIGxvcyBkZXN0aW5hdGFyaW9zIG90b3JnYWRvcyBlbiBlc3RlIGRvY3VtZW50by4gTm8gZXMgcG9zaWJsZSBzdWJsaWNlbmNpYXIgbGEgT2JyYS4gVXN0ZWQgZGViZSBtYW50ZW5lciBpbnRhY3RvcyB0b2RvcyBsb3MgYXZpc29zIHF1ZSBoYWdhbiByZWZlcmVuY2lhIGEgZXN0YSBMaWNlbmNpYSB5IGEgbGEgY2zDoXVzdWxhIGRlIGxpbWl0YWNpw7NuIGRlIGdhcmFudMOtYXMuIFVzdGVkIG5vIHB1ZWRlIGRpc3RyaWJ1aXIsIGV4aGliaXIgcMO6YmxpY2FtZW50ZSwgZWplY3V0YXIgcMO6YmxpY2FtZW50ZSwgbyBwb25lciBhIGRpc3Bvc2ljacOzbiBww7pibGljYSBsYSBPYnJhIGNvbiBhbGd1bmEgbWVkaWRhIHRlY25vbMOzZ2ljYSBxdWUgY29udHJvbGUgZWwgYWNjZXNvIG8gbGEgdXRpbGl6YWNpw7NuIGRlIGVsbGEgZGUgdW5hIGZvcm1hIHF1ZSBzZWEgaW5jb25zaXN0ZW50ZSBjb24gbGFzIGNvbmRpY2lvbmVzIGRlIGVzdGEgTGljZW5jaWEuIExvIGFudGVyaW9yIHNlIGFwbGljYSBhIGxhIE9icmEgaW5jb3Jwb3JhZGEgYSB1bmEgT2JyYSBDb2xlY3RpdmEsIHBlcm8gZXN0byBubyBleGlnZSBxdWUgbGEgT2JyYSBDb2xlY3RpdmEgYXBhcnRlIGRlIGxhIG9icmEgbWlzbWEgcXVlZGUgc3VqZXRhIGEgbGFzIGNvbmRpY2lvbmVzIGRlIGVzdGEgTGljZW5jaWEuIFNpIFVzdGVkIGNyZWEgdW5hIE9icmEgQ29sZWN0aXZhLCBwcmV2aW8gYXZpc28gZGUgY3VhbHF1aWVyIExpY2VuY2lhbnRlIGRlYmUsIGVuIGxhIG1lZGlkYSBkZSBsbyBwb3NpYmxlLCBlbGltaW5hciBkZSBsYSBPYnJhIENvbGVjdGl2YSBjdWFscXVpZXIgcmVmZXJlbmNpYSBhIGRpY2hvIExpY2VuY2lhbnRlIG8gYWwgQXV0b3IgT3JpZ2luYWwsIHNlZ8O6biBsbyBzb2xpY2l0YWRvIHBvciBlbCBMaWNlbmNpYW50ZSB5IGNvbmZvcm1lIGxvIGV4aWdlIGxhIGNsw6F1c3VsYSA0KGMpLjwvbGk+CiAgICAgIDxsaT5Vc3RlZCBubyBwdWVkZSBlamVyY2VyIG5pbmd1bm8gZGUgbG9zIGRlcmVjaG9zIHF1ZSBsZSBoYW4gc2lkbyBvdG9yZ2Fkb3MgZW4gbGEgU2VjY2nDs24gMyBwcmVjZWRlbnRlIGRlIG1vZG8gcXVlIGVzdMOpbiBwcmluY2lwYWxtZW50ZSBkZXN0aW5hZG9zIG8gZGlyZWN0YW1lbnRlIGRpcmlnaWRvcyBhIGNvbnNlZ3VpciB1biBwcm92ZWNobyBjb21lcmNpYWwgbyB1bmEgY29tcGVuc2FjacOzbiBtb25ldGFyaWEgcHJpdmFkYS4gRWwgaW50ZXJjYW1iaW8gZGUgbGEgT2JyYSBwb3Igb3RyYXMgb2JyYXMgcHJvdGVnaWRhcyBwb3IgZGVyZWNob3MgZGUgYXV0b3IsIHlhIHNlYSBhIHRyYXbDqXMgZGUgdW4gc2lzdGVtYSBwYXJhIGNvbXBhcnRpciBhcmNoaXZvcyBkaWdpdGFsZXMgKGRpZ2l0YWwgZmlsZS1zaGFyaW5nKSBvIGRlIGN1YWxxdWllciBvdHJhIG1hbmVyYSBubyBzZXLDoSBjb25zaWRlcmFkbyBjb21vIGVzdGFyIGRlc3RpbmFkbyBwcmluY2lwYWxtZW50ZSBvIGRpcmlnaWRvIGRpcmVjdGFtZW50ZSBhIGNvbnNlZ3VpciB1biBwcm92ZWNobyBjb21lcmNpYWwgbyB1bmEgY29tcGVuc2FjacOzbiBtb25ldGFyaWEgcHJpdmFkYSwgc2llbXByZSBxdWUgbm8gc2UgcmVhbGljZSB1biBwYWdvIG1lZGlhbnRlIHVuYSBjb21wZW5zYWNpw7NuIG1vbmV0YXJpYSBlbiByZWxhY2nDs24gY29uIGVsIGludGVyY2FtYmlvIGRlIG9icmFzIHByb3RlZ2lkYXMgcG9yIGVsIGRlcmVjaG8gZGUgYXV0b3IuPC9saT4KICAgICAgPGxpPlNpIHVzdGVkIGRpc3RyaWJ1eWUsIGV4aGliZSBww7pibGljYW1lbnRlLCBlamVjdXRhIHDDumJsaWNhbWVudGUgbyBlamVjdXRhIHDDumJsaWNhbWVudGUgZW4gZm9ybWEgZGlnaXRhbCBsYSBPYnJhIG8gY3VhbHF1aWVyIE9icmEgRGVyaXZhZGEgdSBPYnJhIENvbGVjdGl2YSwgVXN0ZWQgZGViZSBtYW50ZW5lciBpbnRhY3RhIHRvZGEgbGEgaW5mb3JtYWNpw7NuIGRlIGRlcmVjaG8gZGUgYXV0b3IgZGUgbGEgT2JyYSB5IHByb3BvcmNpb25hciwgZGUgZm9ybWEgcmF6b25hYmxlIHNlZ8O6biBlbCBtZWRpbyBvIG1hbmVyYSBxdWUgVXN0ZWQgZXN0w6kgdXRpbGl6YW5kbzogKGkpIGVsIG5vbWJyZSBkZWwgQXV0b3IgT3JpZ2luYWwgc2kgZXN0w6EgcHJvdmlzdG8gKG8gc2V1ZMOzbmltbywgc2kgZnVlcmUgYXBsaWNhYmxlKSwgeS9vIChpaSkgZWwgbm9tYnJlIGRlIGxhIHBhcnRlIG8gbGFzIHBhcnRlcyBxdWUgZWwgQXV0b3IgT3JpZ2luYWwgeS9vIGVsIExpY2VuY2lhbnRlIGh1YmllcmVuIGRlc2lnbmFkbyBwYXJhIGxhIGF0cmlidWNpw7NuICh2LmcuLCB1biBpbnN0aXR1dG8gcGF0cm9jaW5hZG9yLCBlZGl0b3JpYWwsIHB1YmxpY2FjacOzbikgZW4gbGEgaW5mb3JtYWNpw7NuIGRlIGxvcyBkZXJlY2hvcyBkZSBhdXRvciBkZWwgTGljZW5jaWFudGUsIHTDqXJtaW5vcyBkZSBzZXJ2aWNpb3MgbyBkZSBvdHJhcyBmb3JtYXMgcmF6b25hYmxlczsgZWwgdMOtdHVsbyBkZSBsYSBPYnJhIHNpIGVzdMOhIHByb3Zpc3RvOyBlbiBsYSBtZWRpZGEgZGUgbG8gcmF6b25hYmxlbWVudGUgZmFjdGlibGUgeSwgc2kgZXN0w6EgcHJvdmlzdG8sIGVsIElkZW50aWZpY2Fkb3IgVW5pZm9ybWUgZGUgUmVjdXJzb3MgKFVuaWZvcm0gUmVzb3VyY2UgSWRlbnRpZmllcikgcXVlIGVsIExpY2VuY2lhbnRlIGVzcGVjaWZpY2EgcGFyYSBzZXIgYXNvY2lhZG8gY29uIGxhIE9icmEsIHNhbHZvIHF1ZSB0YWwgVVJJIG5vIHNlIHJlZmllcmEgYSBsYSBub3RhIHNvYnJlIGxvcyBkZXJlY2hvcyBkZSBhdXRvciBvIGEgbGEgaW5mb3JtYWNpw7NuIHNvYnJlIGVsIGxpY2VuY2lhbWllbnRvIGRlIGxhIE9icmE7IHkgZW4gZWwgY2FzbyBkZSB1bmEgT2JyYSBEZXJpdmFkYSwgYXRyaWJ1aXIgZWwgY3LDqWRpdG8gaWRlbnRpZmljYW5kbyBlbCB1c28gZGUgbGEgT2JyYSBlbiBsYSBPYnJhIERlcml2YWRhICh2LmcuLCAiVHJhZHVjY2nDs24gRnJhbmNlc2EgZGUgbGEgT2JyYSBkZWwgQXV0b3IgT3JpZ2luYWwsIiBvICJHdWnDs24gQ2luZW1hdG9ncsOhZmljbyBiYXNhZG8gZW4gbGEgT2JyYSBvcmlnaW5hbCBkZWwgQXV0b3IgT3JpZ2luYWwiKS4gVGFsIGNyw6lkaXRvIHB1ZWRlIHNlciBpbXBsZW1lbnRhZG8gZGUgY3VhbHF1aWVyIGZvcm1hIHJhem9uYWJsZTsgZW4gZWwgY2Fzbywgc2luIGVtYmFyZ28sIGRlIE9icmFzIERlcml2YWRhcyB1IE9icmFzIENvbGVjdGl2YXMsIHRhbCBjcsOpZGl0byBhcGFyZWNlcsOhLCBjb21vIG3DrW5pbW8sIGRvbmRlIGFwYXJlY2UgZWwgY3LDqWRpdG8gZGUgY3VhbHF1aWVyIG90cm8gYXV0b3IgY29tcGFyYWJsZSB5IGRlIHVuYSBtYW5lcmEsIGFsIG1lbm9zLCB0YW4gZGVzdGFjYWRhIGNvbW8gZWwgY3LDqWRpdG8gZGUgb3RybyBhdXRvciBjb21wYXJhYmxlLjwvbGk+CiAgICAgIDxsaT4KICAgICAgICBQYXJhIGV2aXRhciB0b2RhIGNvbmZ1c2nDs24sIGVsIExpY2VuY2lhbnRlIGFjbGFyYSBxdWUsIGN1YW5kbyBsYSBvYnJhIGVzIHVuYSBjb21wb3NpY2nDs24gbXVzaWNhbDoKICAgICAgICA8b2wgdHlwZT0iaSI+CiAgICAgICAgICA8bGk+UmVnYWzDrWFzIHBvciBpbnRlcnByZXRhY2nDs24geSBlamVjdWNpw7NuIGJham8gbGljZW5jaWFzIGdlbmVyYWxlcy4gRWwgTGljZW5jaWFudGUgc2UgcmVzZXJ2YSBlbCBkZXJlY2hvIGV4Y2x1c2l2byBkZSBhdXRvcml6YXIgbGEgZWplY3VjacOzbiBww7pibGljYSBvIGxhIGVqZWN1Y2nDs24gcMO6YmxpY2EgZGlnaXRhbCBkZSBsYSBvYnJhIHkgZGUgcmVjb2xlY3Rhciwgc2VhIGluZGl2aWR1YWxtZW50ZSBvIGEgdHJhdsOpcyBkZSB1bmEgc29jaWVkYWQgZGUgZ2VzdGnDs24gY29sZWN0aXZhIGRlIGRlcmVjaG9zIGRlIGF1dG9yIHkgZGVyZWNob3MgY29uZXhvcyAocG9yIGVqZW1wbG8sIFNBWUNPKSwgbGFzIHJlZ2Fsw61hcyBwb3IgbGEgZWplY3VjacOzbiBww7pibGljYSBvIHBvciBsYSBlamVjdWNpw7NuIHDDumJsaWNhIGRpZ2l0YWwgZGUgbGEgb2JyYSAocG9yIGVqZW1wbG8gV2ViY2FzdCkgbGljZW5jaWFkYSBiYWpvIGxpY2VuY2lhcyBnZW5lcmFsZXMsIHNpIGxhIGludGVycHJldGFjacOzbiBvIGVqZWN1Y2nDs24gZGUgbGEgb2JyYSBlc3TDoSBwcmltb3JkaWFsbWVudGUgb3JpZW50YWRhIHBvciBvIGRpcmlnaWRhIGEgbGEgb2J0ZW5jacOzbiBkZSB1bmEgdmVudGFqYSBjb21lcmNpYWwgbyB1bmEgY29tcGVuc2FjacOzbiBtb25ldGFyaWEgcHJpdmFkYS48L2xpPgogICAgICAgICAgPGxpPlJlZ2Fsw61hcyBwb3IgRm9ub2dyYW1hcy4gRWwgTGljZW5jaWFudGUgc2UgcmVzZXJ2YSBlbCBkZXJlY2hvIGV4Y2x1c2l2byBkZSByZWNvbGVjdGFyLCBpbmRpdmlkdWFsbWVudGUgbyBhIHRyYXbDqXMgZGUgdW5hIHNvY2llZGFkIGRlIGdlc3Rpw7NuIGNvbGVjdGl2YSBkZSBkZXJlY2hvcyBkZSBhdXRvciB5IGRlcmVjaG9zIGNvbmV4b3MgKHBvciBlamVtcGxvLCBsb3MgY29uc2FncmFkb3MgcG9yIGxhIFNBWUNPKSwgdW5hIGFnZW5jaWEgZGUgZGVyZWNob3MgbXVzaWNhbGVzIG8gYWxnw7puIGFnZW50ZSBkZXNpZ25hZG8sIGxhcyByZWdhbMOtYXMgcG9yIGN1YWxxdWllciBmb25vZ3JhbWEgcXVlIFVzdGVkIGNyZWUgYSBwYXJ0aXIgZGUgbGEgb2JyYSAo4oCcdmVyc2nDs24gY292ZXLigJ0pIHkgZGlzdHJpYnV5YSwgZW4gbG9zIHTDqXJtaW5vcyBkZWwgcsOpZ2ltZW4gZGUgZGVyZWNob3MgZGUgYXV0b3IsIHNpIGxhIGNyZWFjacOzbiBvIGRpc3RyaWJ1Y2nDs24gZGUgZXNhIHZlcnNpw7NuIGNvdmVyIGVzdMOhIHByaW1vcmRpYWxtZW50ZSBkZXN0aW5hZGEgbyBkaXJpZ2lkYSBhIG9idGVuZXIgdW5hIHZlbnRhamEgY29tZXJjaWFsIG8gdW5hIGNvbXBlbnNhY2nDs24gbW9uZXRhcmlhIHByaXZhZGEuPC9saT4KICAgICAgICA8L29sPgogICAgICA8L2xpPgogICAgICA8bGk+R2VzdGnDs24gZGUgRGVyZWNob3MgZGUgQXV0b3Igc29icmUgSW50ZXJwcmV0YWNpb25lcyB5IEVqZWN1Y2lvbmVzIERpZ2l0YWxlcyAoV2ViQ2FzdGluZykuIFBhcmEgZXZpdGFyIHRvZGEgY29uZnVzacOzbiwgZWwgTGljZW5jaWFudGUgYWNsYXJhIHF1ZSwgY3VhbmRvIGxhIG9icmEgc2VhIHVuIGZvbm9ncmFtYSwgZWwgTGljZW5jaWFudGUgc2UgcmVzZXJ2YSBlbCBkZXJlY2hvIGV4Y2x1c2l2byBkZSBhdXRvcml6YXIgbGEgZWplY3VjacOzbiBww7pibGljYSBkaWdpdGFsIGRlIGxhIG9icmEgKHBvciBlamVtcGxvLCB3ZWJjYXN0KSB5IGRlIHJlY29sZWN0YXIsIGluZGl2aWR1YWxtZW50ZSBvIGEgdHJhdsOpcyBkZSB1bmEgc29jaWVkYWQgZGUgZ2VzdGnDs24gY29sZWN0aXZhIGRlIGRlcmVjaG9zIGRlIGF1dG9yIHkgZGVyZWNob3MgY29uZXhvcyAocG9yIGVqZW1wbG8sIEFDSU5QUk8pLCBsYXMgcmVnYWzDrWFzIHBvciBsYSBlamVjdWNpw7NuIHDDumJsaWNhIGRpZ2l0YWwgZGUgbGEgb2JyYSAocG9yIGVqZW1wbG8sIHdlYmNhc3QpLCBzdWpldGEgYSBsYXMgZGlzcG9zaWNpb25lcyBhcGxpY2FibGVzIGRlbCByw6lnaW1lbiBkZSBEZXJlY2hvIGRlIEF1dG9yLCBzaSBlc3RhIGVqZWN1Y2nDs24gcMO6YmxpY2EgZGlnaXRhbCBlc3TDoSBwcmltb3JkaWFsbWVudGUgZGlyaWdpZGEgYSBvYnRlbmVyIHVuYSB2ZW50YWphIGNvbWVyY2lhbCBvIHVuYSBjb21wZW5zYWNpw7NuIG1vbmV0YXJpYSBwcml2YWRhLjwvbGk+CiAgICA8L29sPgogIDwvbGk+CiAgPGJyLz4KICA8bGk+CiAgICBSZXByZXNlbnRhY2lvbmVzLCBHYXJhbnTDrWFzIHkgTGltaXRhY2lvbmVzIGRlIFJlc3BvbnNhYmlsaWRhZC4KICAgIDxwPkEgTUVOT1MgUVVFIExBUyBQQVJURVMgTE8gQUNPUkRBUkFOIERFIE9UUkEgRk9STUEgUE9SIEVTQ1JJVE8sIEVMIExJQ0VOQ0lBTlRFIE9GUkVDRSBMQSBPQlJBIChFTiBFTCBFU1RBRE8gRU4gRUwgUVVFIFNFIEVOQ1VFTlRSQSkg4oCcVEFMIENVQUzigJ0sIFNJTiBCUklOREFSIEdBUkFOVMONQVMgREUgQ0xBU0UgQUxHVU5BIFJFU1BFQ1RPIERFIExBIE9CUkEsIFlBIFNFQSBFWFBSRVNBLCBJTVBMw41DSVRBLCBMRUdBTCBPIENVQUxRVUlFUkEgT1RSQSwgSU5DTFVZRU5ETywgU0lOIExJTUlUQVJTRSBBIEVMTEFTLCBHQVJBTlTDjUFTIERFIFRJVFVMQVJJREFELCBDT01FUkNJQUJJTElEQUQsIEFEQVBUQUJJTElEQUQgTyBBREVDVUFDScOTTiBBIFBST1DDk1NJVE8gREVURVJNSU5BRE8sIEFVU0VOQ0lBIERFIElORlJBQ0NJw5NOLCBERSBBVVNFTkNJQSBERSBERUZFQ1RPUyBMQVRFTlRFUyBPIERFIE9UUk8gVElQTywgTyBMQSBQUkVTRU5DSUEgTyBBVVNFTkNJQSBERSBFUlJPUkVTLCBTRUFOIE8gTk8gREVTQ1VCUklCTEVTIChQVUVEQU4gTyBOTyBTRVIgRVNUT1MgREVTQ1VCSUVSVE9TKS4gQUxHVU5BUyBKVVJJU0RJQ0NJT05FUyBOTyBQRVJNSVRFTiBMQSBFWENMVVNJw5NOIERFIEdBUkFOVMONQVMgSU1QTMONQ0lUQVMsIEVOIENVWU8gQ0FTTyBFU1RBIEVYQ0xVU0nDk04gUFVFREUgTk8gQVBMSUNBUlNFIEEgVVNURUQuPC9wPgogIDwvbGk+CiAgPGJyLz4KICA8bGk+CiAgICBMaW1pdGFjacOzbiBkZSByZXNwb25zYWJpbGlkYWQuCiAgICA8cD5BIE1FTk9TIFFVRSBMTyBFWElKQSBFWFBSRVNBTUVOVEUgTEEgTEVZIEFQTElDQUJMRSwgRUwgTElDRU5DSUFOVEUgTk8gU0VSw4EgUkVTUE9OU0FCTEUgQU5URSBVU1RFRCBQT1IgREHDkU8gQUxHVU5PLCBTRUEgUE9SIFJFU1BPTlNBQklMSURBRCBFWFRSQUNPTlRSQUNUVUFMLCBQUkVDT05UUkFDVFVBTCBPIENPTlRSQUNUVUFMLCBPQkpFVElWQSBPIFNVQkpFVElWQSwgU0UgVFJBVEUgREUgREHDkU9TIE1PUkFMRVMgTyBQQVRSSU1PTklBTEVTLCBESVJFQ1RPUyBPIElORElSRUNUT1MsIFBSRVZJU1RPUyBPIElNUFJFVklTVE9TIFBST0RVQ0lET1MgUE9SIEVMIFVTTyBERSBFU1RBIExJQ0VOQ0lBIE8gREUgTEEgT0JSQSwgQVVOIENVQU5ETyBFTCBMSUNFTkNJQU5URSBIQVlBIFNJRE8gQURWRVJUSURPIERFIExBIFBPU0lCSUxJREFEIERFIERJQ0hPUyBEQcORT1MuIEFMR1VOQVMgTEVZRVMgTk8gUEVSTUlURU4gTEEgRVhDTFVTScOTTiBERSBDSUVSVEEgUkVTUE9OU0FCSUxJREFELCBFTiBDVVlPIENBU08gRVNUQSBFWENMVVNJw5NOIFBVRURFIE5PIEFQTElDQVJTRSBBIFVTVEVELjwvcD4KICA8L2xpPgogIDxici8+CiAgPGxpPgogICAgVMOpcm1pbm8uCiAgICA8b2wgdHlwZT0iYSI+CiAgICAgIDxsaT5Fc3RhIExpY2VuY2lhIHkgbG9zIGRlcmVjaG9zIG90b3JnYWRvcyBlbiB2aXJ0dWQgZGUgZWxsYSB0ZXJtaW5hcsOhbiBhdXRvbcOhdGljYW1lbnRlIHNpIFVzdGVkIGluZnJpbmdlIGFsZ3VuYSBjb25kaWNpw7NuIGVzdGFibGVjaWRhIGVuIGVsbGEuIFNpbiBlbWJhcmdvLCBsb3MgaW5kaXZpZHVvcyBvIGVudGlkYWRlcyBxdWUgaGFuIHJlY2liaWRvIE9icmFzIERlcml2YWRhcyBvIENvbGVjdGl2YXMgZGUgVXN0ZWQgZGUgY29uZm9ybWlkYWQgY29uIGVzdGEgTGljZW5jaWEsIG5vIHZlcsOhbiB0ZXJtaW5hZGFzIHN1cyBsaWNlbmNpYXMsIHNpZW1wcmUgcXVlIGVzdG9zIGluZGl2aWR1b3MgbyBlbnRpZGFkZXMgc2lnYW4gY3VtcGxpZW5kbyDDrW50ZWdyYW1lbnRlIGxhcyBjb25kaWNpb25lcyBkZSBlc3RhcyBsaWNlbmNpYXMuIExhcyBTZWNjaW9uZXMgMSwgMiwgNSwgNiwgNywgeSA4IHN1YnNpc3RpcsOhbiBhIGN1YWxxdWllciB0ZXJtaW5hY2nDs24gZGUgZXN0YSBMaWNlbmNpYS48L2xpPgogICAgICA8bGk+U3VqZXRhIGEgbGFzIGNvbmRpY2lvbmVzIHkgdMOpcm1pbm9zIGFudGVyaW9yZXMsIGxhIGxpY2VuY2lhIG90b3JnYWRhIGFxdcOtIGVzIHBlcnBldHVhIChkdXJhbnRlIGVsIHBlcsOtb2RvIGRlIHZpZ2VuY2lhIGRlIGxvcyBkZXJlY2hvcyBkZSBhdXRvciBkZSBsYSBvYnJhKS4gTm8gb2JzdGFudGUgbG8gYW50ZXJpb3IsIGVsIExpY2VuY2lhbnRlIHNlIHJlc2VydmEgZWwgZGVyZWNobyBhIHB1YmxpY2FyIHkvbyBlc3RyZW5hciBsYSBPYnJhIGJham8gY29uZGljaW9uZXMgZGUgbGljZW5jaWEgZGlmZXJlbnRlcyBvIGEgZGVqYXIgZGUgZGlzdHJpYnVpcmxhIGVuIGxvcyB0w6lybWlub3MgZGUgZXN0YSBMaWNlbmNpYSBlbiBjdWFscXVpZXIgbW9tZW50bzsgZW4gZWwgZW50ZW5kaWRvLCBzaW4gZW1iYXJnbywgcXVlIGVzYSBlbGVjY2nDs24gbm8gc2Vydmlyw6EgcGFyYSByZXZvY2FyIGVzdGEgbGljZW5jaWEgbyBxdWUgZGViYSBzZXIgb3RvcmdhZGEgLCBiYWpvIGxvcyB0w6lybWlub3MgZGUgZXN0YSBsaWNlbmNpYSksIHkgZXN0YSBsaWNlbmNpYSBjb250aW51YXLDoSBlbiBwbGVubyB2aWdvciB5IGVmZWN0byBhIG1lbm9zIHF1ZSBzZWEgdGVybWluYWRhIGNvbW8gc2UgZXhwcmVzYSBhdHLDoXMuIExhIExpY2VuY2lhIHJldm9jYWRhIGNvbnRpbnVhcsOhIHNpZW5kbyBwbGVuYW1lbnRlIHZpZ2VudGUgeSBlZmVjdGl2YSBzaSBubyBzZSBsZSBkYSB0w6lybWlubyBlbiBsYXMgY29uZGljaW9uZXMgaW5kaWNhZGFzIGFudGVyaW9ybWVudGUuPC9saT4KICAgIDwvb2w+CiAgPC9saT4KICA8YnIvPgogIDxsaT4KICAgIFZhcmlvcy4KICAgIDxvbCB0eXBlPSJhIj4KICAgICAgPGxpPkNhZGEgdmV6IHF1ZSBVc3RlZCBkaXN0cmlidXlhIG8gcG9uZ2EgYSBkaXNwb3NpY2nDs24gcMO6YmxpY2EgbGEgT2JyYSBvIHVuYSBPYnJhIENvbGVjdGl2YSwgZWwgTGljZW5jaWFudGUgb2ZyZWNlcsOhIGFsIGRlc3RpbmF0YXJpbyB1bmEgbGljZW5jaWEgZW4gbG9zIG1pc21vcyB0w6lybWlub3MgeSBjb25kaWNpb25lcyBxdWUgbGEgbGljZW5jaWEgb3RvcmdhZGEgYSBVc3RlZCBiYWpvIGVzdGEgTGljZW5jaWEuPC9saT4KICAgICAgPGxpPlNpIGFsZ3VuYSBkaXNwb3NpY2nDs24gZGUgZXN0YSBMaWNlbmNpYSByZXN1bHRhIGludmFsaWRhZGEgbyBubyBleGlnaWJsZSwgc2Vnw7puIGxhIGxlZ2lzbGFjacOzbiB2aWdlbnRlLCBlc3RvIG5vIGFmZWN0YXLDoSBuaSBsYSB2YWxpZGV6IG5pIGxhIGFwbGljYWJpbGlkYWQgZGVsIHJlc3RvIGRlIGNvbmRpY2lvbmVzIGRlIGVzdGEgTGljZW5jaWEgeSwgc2luIGFjY2nDs24gYWRpY2lvbmFsIHBvciBwYXJ0ZSBkZSBsb3Mgc3VqZXRvcyBkZSBlc3RlIGFjdWVyZG8sIGFxdcOpbGxhIHNlIGVudGVuZGVyw6EgcmVmb3JtYWRhIGxvIG3DrW5pbW8gbmVjZXNhcmlvIHBhcmEgaGFjZXIgcXVlIGRpY2hhIGRpc3Bvc2ljacOzbiBzZWEgdsOhbGlkYSB5IGV4aWdpYmxlLjwvbGk+CiAgICAgIDxsaT5OaW5nw7puIHTDqXJtaW5vIG8gZGlzcG9zaWNpw7NuIGRlIGVzdGEgTGljZW5jaWEgc2UgZXN0aW1hcsOhIHJlbnVuY2lhZGEgeSBuaW5ndW5hIHZpb2xhY2nDs24gZGUgZWxsYSBzZXLDoSBjb25zZW50aWRhIGEgbWVub3MgcXVlIGVzYSByZW51bmNpYSBvIGNvbnNlbnRpbWllbnRvIHNlYSBvdG9yZ2FkbyBwb3IgZXNjcml0byB5IGZpcm1hZG8gcG9yIGxhIHBhcnRlIHF1ZSByZW51bmNpZSBvIGNvbnNpZW50YS48L2xpPgogICAgICA8bGk+RXN0YSBMaWNlbmNpYSByZWZsZWphIGVsIGFjdWVyZG8gcGxlbm8gZW50cmUgbGFzIHBhcnRlcyByZXNwZWN0byBhIGxhIE9icmEgYXF1w60gbGljZW5jaWFkYS4gTm8gaGF5IGFycmVnbG9zLCBhY3VlcmRvcyBvIGRlY2xhcmFjaW9uZXMgcmVzcGVjdG8gYSBsYSBPYnJhIHF1ZSBubyBlc3TDqW4gZXNwZWNpZmljYWRvcyBlbiBlc3RlIGRvY3VtZW50by4gRWwgTGljZW5jaWFudGUgbm8gc2UgdmVyw6EgbGltaXRhZG8gcG9yIG5pbmd1bmEgZGlzcG9zaWNpw7NuIGFkaWNpb25hbCBxdWUgcHVlZGEgc3VyZ2lyIGVuIGFsZ3VuYSBjb211bmljYWNpw7NuIGVtYW5hZGEgZGUgVXN0ZWQuIEVzdGEgTGljZW5jaWEgbm8gcHVlZGUgc2VyIG1vZGlmaWNhZGEgc2luIGVsIGNvbnNlbnRpbWllbnRvIG11dHVvIHBvciBlc2NyaXRvIGRlbCBMaWNlbmNpYW50ZSB5IFVzdGVkLjwvbGk+CiAgICA8L29sPgogIDwvbGk+CiAgPGJyLz4KPC9vbD4K 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