Factores asociados al desarrollo de sepsis neonatal en un hospital infantil de tercer nivel en Colombia.

Autores:
Chavarro Tello, Luz Sthefany
Diaz Rengifo, Iván Alejandro
Ospina Acevedo, Aura Lucia
Puello Avila, Antonio Carlos
Pinzón Redondo, Hernando Samuel
Tipo de recurso:
Article of journal
Fecha de publicación:
2020
Institución:
Universidad de Cartagena
Repositorio:
Repositorio Universidad de Cartagena
Idioma:
spa
OAI Identifier:
oai:repositorio.unicartagena.edu.co:11227/13319
Acceso en línea:
https://doi.org/10.32997/rcb-2020-3040
Palabra clave:
C-reactive protein
Neonatal sepsis
Risk factors
Cross-sectional studies
Sepsis neonatal
Factores de riesgo
Estudios de corte transversal
Proteína C-reactiva
Rights
openAccess
License
Revista Ciencias Biomédicas - 2020
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network_acronym_str UCART2
network_name_str Repositorio Universidad de Cartagena
repository_id_str
dc.title.spa.fl_str_mv Factores asociados al desarrollo de sepsis neonatal en un hospital infantil de tercer nivel en Colombia.
dc.title.translated.eng.fl_str_mv Associated factors to neonatal sepsis development in a third-level children's hospital in Colombia.
title Factores asociados al desarrollo de sepsis neonatal en un hospital infantil de tercer nivel en Colombia.
spellingShingle Factores asociados al desarrollo de sepsis neonatal en un hospital infantil de tercer nivel en Colombia.
C-reactive protein
Neonatal sepsis
Risk factors
Cross-sectional studies
Sepsis neonatal
Factores de riesgo
Estudios de corte transversal
Proteína C-reactiva
title_short Factores asociados al desarrollo de sepsis neonatal en un hospital infantil de tercer nivel en Colombia.
title_full Factores asociados al desarrollo de sepsis neonatal en un hospital infantil de tercer nivel en Colombia.
title_fullStr Factores asociados al desarrollo de sepsis neonatal en un hospital infantil de tercer nivel en Colombia.
title_full_unstemmed Factores asociados al desarrollo de sepsis neonatal en un hospital infantil de tercer nivel en Colombia.
title_sort Factores asociados al desarrollo de sepsis neonatal en un hospital infantil de tercer nivel en Colombia.
dc.creator.fl_str_mv Chavarro Tello, Luz Sthefany
Diaz Rengifo, Iván Alejandro
Ospina Acevedo, Aura Lucia
Puello Avila, Antonio Carlos
Pinzón Redondo, Hernando Samuel
dc.contributor.author.spa.fl_str_mv Chavarro Tello, Luz Sthefany
Diaz Rengifo, Iván Alejandro
Ospina Acevedo, Aura Lucia
Puello Avila, Antonio Carlos
Pinzón Redondo, Hernando Samuel
dc.subject.eng.fl_str_mv C-reactive protein
Neonatal sepsis
Risk factors
Cross-sectional studies
topic C-reactive protein
Neonatal sepsis
Risk factors
Cross-sectional studies
Sepsis neonatal
Factores de riesgo
Estudios de corte transversal
Proteína C-reactiva
dc.subject.spa.fl_str_mv Sepsis neonatal
Factores de riesgo
Estudios de corte transversal
Proteína C-reactiva
publishDate 2020
dc.date.accessioned.none.fl_str_mv 2020-01-15 00:00:00
dc.date.available.none.fl_str_mv 2020-01-15 00:00:00
dc.date.issued.none.fl_str_mv 2020-01-15
dc.type.spa.fl_str_mv Artículo de revista
dc.type.coar.fl_str_mv http://purl.org/coar/resource_type/c_2df8fbb1
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dc.identifier.doi.none.fl_str_mv 10.32997/rcb-2020-3040
dc.identifier.eissn.none.fl_str_mv 2389-7252
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dc.relation.ispartofjournal.spa.fl_str_mv Revista Ciencias Biomédicas
dc.relation.bitstream.none.fl_str_mv https://revistas.unicartagena.edu.co/index.php/cbiomedicas/article/download/3040/2572
dc.relation.citationedition.spa.fl_str_mv Núm. 1 , Año 2020
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dc.relation.references.spa.fl_str_mv Khan AM, Morris SK, Bhutta ZA. Neonatal and perinatal infections. Pediatr Clin North Am. 2017;64(4):785-98. https://doi.org/10.1016/j.pcl.2017.03.008
Singer M, Deutschman CS, Seymour CW, Shankar-Hari M, Annane D, Bauer M, et al. The third international consensus definitions for sepsis and septic shock (Sepsis-3). JAMA. 2016; 315(8): 801-10. https://doi.org/10.1001/jama.2016.0287
Lawn J, Shibuya K, Stein C. No cry at birth: global estimates of intrapartum stillbirths and intrapartum-related neonatal deaths. B WORLD HEALTH ORGAN. 2005; 83: 409-17.
Laxminarayan R, Bhutta ZA. Antimicrobial resistance-a threat to neonate survival. Lancet Glob Health. 2016; 4(10): e676-e7. https://doi.org/10.1016/S2214-109X(16)30221-2
Lawn JE, Blencowe H, Oza S, You D, Lee AC, Waiswa P, et al. Every Newborn: progress, priorities, and potential beyond survival. Lancet. 2014;384(9938):189-205. https://doi.org/10.1016/S0140-6736(14)60496-7
Vergnano S, Sharland M, Kazembe P, Mwansambo C, Heath P. Neonatal sepsis: an international perspective. Arch Dis Child Fetal Neonatal. 2005;90(3):F220-FF4. https://doi.org/10.1136/adc.2002.022863
Thaver D, Zaidi AK. Burden of neonatal infections in developing countries: a review of evidence from community-based studies. Pediatr Infect Dis J. 2009;28(1):S3-S9. https://doi.org/10.1097/INF.0b013e3181958755
Wortham JM, Hansen NI, Schrag SJ, Hale E, Van Meurs K, Sánchez PJ, et al. Chorioamnionitis and culture-confirmed, early-onset neonatal infections. Pediatrics. 2016; 137(1): e20152323. https://doi.org/10.1542/peds.2015-2323
Kabwe M, Tembo J, Chilukutu L, Chilufya M, Ngulube F, Lukwesa C, et al. Etiology, antibiotic resistance and risk factors for neonatal sepsis in a large referral center in Zambia. Pediatr Infect Dis J. 2016;35(7):e191-e8. https://doi.org/10.1097/INF.0000000000001154
Kayange N, Kamugisha E, Mwizamholya DL, Jeremiah S, Mshana SE. Predictors of positive blood culture and deaths among neonates with suspected neonatal sepsis in a tertiary hospital, Mwanza-Tanzania. BMC pediatr. 2010;10(1):39. https://doi.org/10.1186/1471-2431-10-39
Fleischmann-Struzek C, Goldfarb DM, Schlattmann P, Schlapbach LJ, Reinhart K, Kissoon N. The global burden of paediatric and neonatal sepsis: a systematic review. Lancet Respir Med. 2018;6(3):223-30. https://doi.org/10.1016/S2213-2600(18)30063-8
Lamba M, Sharma R, Sharma D, Choudhary M, Maheshwari RK. Bacteriological spectrum and antimicrobial susceptibility pattern of neonatal septicaemia in a tertiary care hospital of North India. J Matern Fetal Neonatal Med. 2016; 29(24): 3993-8. https://doi.org/10.3109/14767058.2016.1152251
Hammoud MS, Al-Taiar A, Al-Abdi SY, Bozaid H, Khan A, AlMuhairi LM, et al. Late-onset neonatal sepsis in Arab states in the Gulf region: two-year prospective study. Int J Infect Dis. 2017;55:125-30. https://doi.org/10.1016/j.ijid.2017.01.006
Kurek Eken M, Tüten A, Ozkaya E, Dinçer E, Şenol T, Karatekin G, et al. Evaluation of the maternal and fetal risk factors associated with neonatal care unit hospitalization time. J Matern Fetal Neonatal Med. 2016;29(21):3553-7. https://doi.org/10.3109/14767058.2016.1138466
Pérez RO, Lona JC, Quiles M, Verdugo MÁ, Ascencio EP, Benítez EA. Sepsis neonatal temprana, incidencia y factores de riesgo asociados en un hospital público del occidente de México. Rev chilena Infectol. 2015;32(4):447-52. https://doi.org/10.4067/S0716-10182015000500003
Rios Valdéz CV, Navia Bueno MdP, Díaz Villegas M, Salazar Fuentes HJ. Factores de riesgo asociados a sepsis neonatal. Rev Soc Bol Ped. 2005;44(2):87-92.
Gutiérrez-Muñoz VH, Gutiérrez-Muñoz J, Rosas-Barrientos V. Factores de riesgo en sepsis neonatal en un hospital de tercer nivel en la ciudad de México. Rev Esp Med-Quir. 2005;10(2):21-4.
Kordek A, Torbé A, Tousty J, Łoniewska B, Podraza W, Nikodemski T, et al. The determination of procalcitonin concentration in early-onset neonatal infection: a valuable test regardless of prenatal antibiotic therapy. Clin pediatr. 2017; 56(4): 333-40. https://doi.org/10.1177/0009922816656622
Çelik HT, Portakal O, Yiğit Ş, Hasçelik G, Korkmaz A, Yurdakök M. Efficacy of new leukocyte parameters versus serum C‐reactive protein, procalcitonin, and interleukin‐6 in the diagnosis of neonatal sepsis. Pediatr Int. 2016; 58(2): 119-25. https://doi.org/10.1111/ped.12754
Shane AL, Stoll BJ. Neonatal sepsis: progress towards improved outcomes. J Infect. 2014;68:S24-S32. https://doi.org/10.1016/j.jinf.2013.09.011
Camacho-Gonzalez A, Spearman PW, Stoll BJ. Neonatal infectious diseases: evaluation of neonatal sepsis. Pediatr Clin North Am. 2013;60(2):367. https://doi.org/10.1016/j.pcl.2012.12.003
Hernandez-Bou S, Álvarez CÁ, Fernández MC, Herrero MG, Giralt AG, Pérez MG, et al., editors. Hemocultivos en urgencias pediátricas. Guía práctica de recomendaciones: indicaciones, técnica de extracción, procesamiento e interpretación. An Pediatr; 2016: Elsevier. https://doi.org/10.1016/j.anpedi.2015.06.008
Marchant EA, Boyce GK, Sadarangani M, Lavoie PM. Neonatal sepsis due to coagulase-negative staphylococci. Clin Dev Immunol. 2013;2013. https://doi.org/10.1155/2013/586076
Mendoza L, Osorio M, Fernández M, Henao C, Arias M, Mendoza L, et al. Tiempo de crecimiento bacteriano en hemocultivos en neonatos. Rev chil pediatr. 2015;86(5):337-44. https://doi.org/10.1016/j.rchipe.2015.07.004
Vamsi SR, Bhat RY, Lewis LE, Vandana KE. Time to positivity of blood cultures in neonates. Pediatr Infect Dis J. 2014; 33(2): 212-4. https://doi.org/10.1097/INF.0000000000000018
Guerti K, Devos H, Ieven MM, Mahieu LM. Time to positivity of neonatal blood cultures: fast and furious? J Med Microbiol. 2011;60(4):446-53. https://doi.org/10.1099/jmm.0.020651-0
Abdelhamid SM. Time to positivity and antibiotic sensitivity of neonatal blood cultures. J Infect Dis. 2017; 9(3): 102. https://doi.org/10.4103/jgid.jgid_1_17
Hengst JM. The role of C-reactive protein in the evaluation and management of infants with suspected sepsis. Advances in neonatal care: official journal of the National J Neonatal Nurs. 2003;3(1):3-13. https://doi.org/10.1053/adnc.2003.50010
Chiesa C, Signore F, Assumma M, Buffone E, Tramontozzi P, Osborn JF, et al. Serial measurements of C-reactive protein and interleukin-6 in the immediate postnatal period: reference intervals and analysis of maternal and perinatal confounders. Clin Chem. 2001;47(6):1016-22. https://doi.org/10.1093/clinchem/47.6.1016
Forest J-C, Larivière F, Dolcé P, Masson M, Nadeau L. C-reactive protein as biochemical indicator of bacterial infection in neonates. Clin Biochem. 1986;19(3):192-4. https://doi.org/10.1016/S0009-9120(86)80023-6
Pierrakos C, Vincent J-L. Sepsis biomarkers: a review. Critical care. 2010;14(1):R15. https://doi.org/10.1186/cc8872
Mendoza LA, Arias M, Mendoza LI. Hijo de madre adolescente: riesgos, morbilidad y mortalidad neonatal. Rev Chil Obstet Ginecol. 2012;77(5):375-82. https://doi.org/10.4067/S0717-75262012000500008
Islas L, Cardiel L, Figueroa J. Recién nacidos de madres adolescentes. Problema actual. Rev Mex Pediatr. 2010; 77 (4): 152-5.
Aguilar H, Meléndez J. Perfil epidemiológico del recién nacido con sepsis, atendido en el servicio de neonatología del Hospital Escuela comprendido en el periodo de julio 2004 a septiembre 2006. Revista Médica de los Post Grados de Medicina UNAH. 2007; 10(1): 52.
Licona-Rivera TS, Fajardo-Dubón GE, Ferrera-García RA, Hernández-Orellana AG. Características Epidemiológicas y Clínicas de Neonatos con Sepsis Temprana. Int J Med Surg Sci. 2016; 3(3): 903-8. https://doi.org/10.32457/ijmss.2016.023
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spelling Chavarro Tello, Luz SthefanyDiaz Rengifo, Iván AlejandroOspina Acevedo, Aura LuciaPuello Avila, Antonio CarlosPinzón Redondo, Hernando Samuel2020-01-15 00:00:002020-01-15 00:00:002020-01-152215-784010.32997/rcb-2020-30402389-7252https://doi.org/10.32997/rcb-2020-3040application/pdfspaUniversidad de CartagenaRevista Ciencias Biomédicashttps://revistas.unicartagena.edu.co/index.php/cbiomedicas/article/download/3040/2572Núm. 1 , Año 2020341259Khan AM, Morris SK, Bhutta ZA. Neonatal and perinatal infections. Pediatr Clin North Am. 2017;64(4):785-98. https://doi.org/10.1016/j.pcl.2017.03.008Singer M, Deutschman CS, Seymour CW, Shankar-Hari M, Annane D, Bauer M, et al. The third international consensus definitions for sepsis and septic shock (Sepsis-3). JAMA. 2016; 315(8): 801-10. https://doi.org/10.1001/jama.2016.0287Lawn J, Shibuya K, Stein C. No cry at birth: global estimates of intrapartum stillbirths and intrapartum-related neonatal deaths. B WORLD HEALTH ORGAN. 2005; 83: 409-17.Laxminarayan R, Bhutta ZA. Antimicrobial resistance-a threat to neonate survival. Lancet Glob Health. 2016; 4(10): e676-e7. https://doi.org/10.1016/S2214-109X(16)30221-2Lawn JE, Blencowe H, Oza S, You D, Lee AC, Waiswa P, et al. Every Newborn: progress, priorities, and potential beyond survival. Lancet. 2014;384(9938):189-205. https://doi.org/10.1016/S0140-6736(14)60496-7Vergnano S, Sharland M, Kazembe P, Mwansambo C, Heath P. Neonatal sepsis: an international perspective. Arch Dis Child Fetal Neonatal. 2005;90(3):F220-FF4. https://doi.org/10.1136/adc.2002.022863Thaver D, Zaidi AK. Burden of neonatal infections in developing countries: a review of evidence from community-based studies. Pediatr Infect Dis J. 2009;28(1):S3-S9. https://doi.org/10.1097/INF.0b013e3181958755Wortham JM, Hansen NI, Schrag SJ, Hale E, Van Meurs K, Sánchez PJ, et al. Chorioamnionitis and culture-confirmed, early-onset neonatal infections. Pediatrics. 2016; 137(1): e20152323. https://doi.org/10.1542/peds.2015-2323Kabwe M, Tembo J, Chilukutu L, Chilufya M, Ngulube F, Lukwesa C, et al. Etiology, antibiotic resistance and risk factors for neonatal sepsis in a large referral center in Zambia. Pediatr Infect Dis J. 2016;35(7):e191-e8. https://doi.org/10.1097/INF.0000000000001154Kayange N, Kamugisha E, Mwizamholya DL, Jeremiah S, Mshana SE. Predictors of positive blood culture and deaths among neonates with suspected neonatal sepsis in a tertiary hospital, Mwanza-Tanzania. BMC pediatr. 2010;10(1):39. https://doi.org/10.1186/1471-2431-10-39Fleischmann-Struzek C, Goldfarb DM, Schlattmann P, Schlapbach LJ, Reinhart K, Kissoon N. The global burden of paediatric and neonatal sepsis: a systematic review. Lancet Respir Med. 2018;6(3):223-30. https://doi.org/10.1016/S2213-2600(18)30063-8Lamba M, Sharma R, Sharma D, Choudhary M, Maheshwari RK. Bacteriological spectrum and antimicrobial susceptibility pattern of neonatal septicaemia in a tertiary care hospital of North India. J Matern Fetal Neonatal Med. 2016; 29(24): 3993-8. https://doi.org/10.3109/14767058.2016.1152251Hammoud MS, Al-Taiar A, Al-Abdi SY, Bozaid H, Khan A, AlMuhairi LM, et al. Late-onset neonatal sepsis in Arab states in the Gulf region: two-year prospective study. Int J Infect Dis. 2017;55:125-30. https://doi.org/10.1016/j.ijid.2017.01.006Kurek Eken M, Tüten A, Ozkaya E, Dinçer E, Şenol T, Karatekin G, et al. Evaluation of the maternal and fetal risk factors associated with neonatal care unit hospitalization time. J Matern Fetal Neonatal Med. 2016;29(21):3553-7. https://doi.org/10.3109/14767058.2016.1138466Pérez RO, Lona JC, Quiles M, Verdugo MÁ, Ascencio EP, Benítez EA. Sepsis neonatal temprana, incidencia y factores de riesgo asociados en un hospital público del occidente de México. Rev chilena Infectol. 2015;32(4):447-52. https://doi.org/10.4067/S0716-10182015000500003Rios Valdéz CV, Navia Bueno MdP, Díaz Villegas M, Salazar Fuentes HJ. Factores de riesgo asociados a sepsis neonatal. Rev Soc Bol Ped. 2005;44(2):87-92.Gutiérrez-Muñoz VH, Gutiérrez-Muñoz J, Rosas-Barrientos V. Factores de riesgo en sepsis neonatal en un hospital de tercer nivel en la ciudad de México. Rev Esp Med-Quir. 2005;10(2):21-4.Kordek A, Torbé A, Tousty J, Łoniewska B, Podraza W, Nikodemski T, et al. The determination of procalcitonin concentration in early-onset neonatal infection: a valuable test regardless of prenatal antibiotic therapy. Clin pediatr. 2017; 56(4): 333-40. https://doi.org/10.1177/0009922816656622Çelik HT, Portakal O, Yiğit Ş, Hasçelik G, Korkmaz A, Yurdakök M. Efficacy of new leukocyte parameters versus serum C‐reactive protein, procalcitonin, and interleukin‐6 in the diagnosis of neonatal sepsis. Pediatr Int. 2016; 58(2): 119-25. https://doi.org/10.1111/ped.12754Shane AL, Stoll BJ. Neonatal sepsis: progress towards improved outcomes. J Infect. 2014;68:S24-S32. https://doi.org/10.1016/j.jinf.2013.09.011Camacho-Gonzalez A, Spearman PW, Stoll BJ. Neonatal infectious diseases: evaluation of neonatal sepsis. Pediatr Clin North Am. 2013;60(2):367. https://doi.org/10.1016/j.pcl.2012.12.003Hernandez-Bou S, Álvarez CÁ, Fernández MC, Herrero MG, Giralt AG, Pérez MG, et al., editors. Hemocultivos en urgencias pediátricas. Guía práctica de recomendaciones: indicaciones, técnica de extracción, procesamiento e interpretación. An Pediatr; 2016: Elsevier. https://doi.org/10.1016/j.anpedi.2015.06.008Marchant EA, Boyce GK, Sadarangani M, Lavoie PM. Neonatal sepsis due to coagulase-negative staphylococci. Clin Dev Immunol. 2013;2013. https://doi.org/10.1155/2013/586076Mendoza L, Osorio M, Fernández M, Henao C, Arias M, Mendoza L, et al. Tiempo de crecimiento bacteriano en hemocultivos en neonatos. Rev chil pediatr. 2015;86(5):337-44. https://doi.org/10.1016/j.rchipe.2015.07.004Vamsi SR, Bhat RY, Lewis LE, Vandana KE. Time to positivity of blood cultures in neonates. Pediatr Infect Dis J. 2014; 33(2): 212-4. https://doi.org/10.1097/INF.0000000000000018Guerti K, Devos H, Ieven MM, Mahieu LM. Time to positivity of neonatal blood cultures: fast and furious? J Med Microbiol. 2011;60(4):446-53. https://doi.org/10.1099/jmm.0.020651-0Abdelhamid SM. Time to positivity and antibiotic sensitivity of neonatal blood cultures. J Infect Dis. 2017; 9(3): 102. https://doi.org/10.4103/jgid.jgid_1_17Hengst JM. The role of C-reactive protein in the evaluation and management of infants with suspected sepsis. Advances in neonatal care: official journal of the National J Neonatal Nurs. 2003;3(1):3-13. https://doi.org/10.1053/adnc.2003.50010Chiesa C, Signore F, Assumma M, Buffone E, Tramontozzi P, Osborn JF, et al. Serial measurements of C-reactive protein and interleukin-6 in the immediate postnatal period: reference intervals and analysis of maternal and perinatal confounders. Clin Chem. 2001;47(6):1016-22. https://doi.org/10.1093/clinchem/47.6.1016Forest J-C, Larivière F, Dolcé P, Masson M, Nadeau L. C-reactive protein as biochemical indicator of bacterial infection in neonates. Clin Biochem. 1986;19(3):192-4. https://doi.org/10.1016/S0009-9120(86)80023-6Pierrakos C, Vincent J-L. Sepsis biomarkers: a review. Critical care. 2010;14(1):R15. https://doi.org/10.1186/cc8872Mendoza LA, Arias M, Mendoza LI. Hijo de madre adolescente: riesgos, morbilidad y mortalidad neonatal. Rev Chil Obstet Ginecol. 2012;77(5):375-82. https://doi.org/10.4067/S0717-75262012000500008Islas L, Cardiel L, Figueroa J. Recién nacidos de madres adolescentes. Problema actual. Rev Mex Pediatr. 2010; 77 (4): 152-5.Aguilar H, Meléndez J. Perfil epidemiológico del recién nacido con sepsis, atendido en el servicio de neonatología del Hospital Escuela comprendido en el periodo de julio 2004 a septiembre 2006. Revista Médica de los Post Grados de Medicina UNAH. 2007; 10(1): 52.Licona-Rivera TS, Fajardo-Dubón GE, Ferrera-García RA, Hernández-Orellana AG. Características Epidemiológicas y Clínicas de Neonatos con Sepsis Temprana. Int J Med Surg Sci. 2016; 3(3): 903-8. https://doi.org/10.32457/ijmss.2016.023Revista Ciencias Biomédicas - 2020https://creativecommons.org/licenses/by-nc-sa/4.0/http://purl.org/coar/access_right/c_abf2info:eu-repo/semantics/openAccessEsta obra está bajo una licencia internacional Creative Commons Atribución-NoComercial-CompartirIgual 4.0.https://revistas.unicartagena.edu.co/index.php/cbiomedicas/article/view/3040C-reactive proteinNeonatal sepsisRisk factorsCross-sectional studiesSepsis neonatalFactores de riesgoEstudios de corte transversalProteína C-reactivaFactores asociados al desarrollo de sepsis neonatal en un hospital infantil de tercer nivel en Colombia.Associated factors to neonatal sepsis development in a third-level children's hospital in Colombia.Artículo de revistainfo:eu-repo/semantics/publishedVersionhttp://purl.org/coar/version/c_970fb48d4fbd8a85http://purl.org/coar/resource_type/c_6501http://purl.org/coar/resource_type/c_2df8fbb1Textinfo:eu-repo/semantics/articleJournal articlePublicationOREORE.xmltext/xml2582https://repositorio.unicartagena.edu.co/bitstreams/5113fd4f-60b4-4a4e-960a-0f4b952dd8a7/download495028390bc2ebeac9ef0466677bb18eMD5111227/13319oai:repositorio.unicartagena.edu.co:11227/133192024-09-05 15:30:36.681https://creativecommons.org/licenses/by-nc-sa/4.0/Revista Ciencias Biomédicas - 2020metadata.onlyhttps://repositorio.unicartagena.edu.coBiblioteca Digital Universidad de Cartagenabdigital@metabiblioteca.com