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y la necesidad de implantar material de instrumentaci&#243;n<a class="elsevierStyleCrossRefs" href="#bib0345"><span class="elsevierStyleSup">4&#8211;6</span></a>&#46; En Estados Unidos&#44; la IHQ supone el 22&#37; de todas las infecciones relacionadas con la asistencia m&#233;dica y a&#241;ade entre 1&#46;000 y 10&#46;000 millones de d&#243;lares de sobrecoste cada a&#241;o<a class="elsevierStyleCrossRefs" href="#bib0360"><span class="elsevierStyleSup">7&#8211;9</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">En la pr&#225;ctica habitual se emplea la antibioterapia profil&#225;ctica para intentar reducir la incidencia de IHQ&#46; En general se prescriben cefalosporinas de primera generaci&#243;n por v&#237;a intravenosa &#40;por ejemplo&#44; cefazolina&#41; o vancomicina&#44; administradas 1<span class="elsevierStyleHsp" style=""></span>h antes del inicio de la intervenci&#243;n o durante la inducci&#243;n anest&#233;sica&#44; que pueden mantenerse cada 8<span class="elsevierStyleHsp" style=""></span>h durante 24<span class="elsevierStyleHsp" style=""></span>h o 48<span class="elsevierStyleHsp" style=""></span>h de forma discrecional<a class="elsevierStyleCrossRefs" href="#bib0375"><span class="elsevierStyleSup">10&#44;11</span></a>&#46; Este protocolo se ha demostrado muy eficaz en la prevenci&#243;n de IHQ provocada por <span class="elsevierStyleItalic">Staphylococcus aureus &#40;S&#46; aureus&#41;</span>&#44; que es el microorganismo m&#225;s frecuentemente involucrado<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">12</span></a>&#46; Sin embargo&#44; y dado que un n&#250;mero creciente de cepas de este germen han desarrollado resistencias a m&#250;ltiples antibi&#243;ticos<a class="elsevierStyleCrossRefs" href="#bib0390"><span class="elsevierStyleSup">13&#44;14</span></a>&#44; se ha propuesto una alternativa en adyuvancia a la profilaxis intravenosa&#58; polvo liofilizado de vancomicina espolvoreado directamente sobre el campo quir&#250;rgico previo al cierre de la herida<a class="elsevierStyleCrossRefs" href="#bib0400"><span class="elsevierStyleSup">15&#8211;19</span></a>&#46; De esta forma&#44; se alcanzan concentraciones locales del medicamento tan altas que incluso aquellos microorganismos moderadamente resistentes que puedan permanecer en el lecho quir&#250;rgico son erradicados<a class="elsevierStyleCrossRefs" href="#bib0405"><span class="elsevierStyleSup">16&#44;20</span></a>&#46; La aplicaci&#243;n local de vancomicina se ha demostrado segura en t&#233;rminos de absorci&#243;n y toxicidad sist&#233;micas<a class="elsevierStyleCrossRefs" href="#bib0415"><span class="elsevierStyleSup">18&#44;21</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Dado que el enorme gradiente entre la concentraci&#243;n de vancomicina en el lecho quir&#250;rgico y la circulaci&#243;n sangu&#237;nea destruye pr&#225;cticamente todos los microorganismos&#44; se piensa que este sistema de administraci&#243;n no induce resistencias contra el antibi&#243;tico<a class="elsevierStyleCrossRefs" href="#bib0405"><span class="elsevierStyleSup">16&#44;22</span></a>&#46; Sin embargo&#44; la aplicaci&#243;n t&#243;pica de vancomicina s&#237; parece aumentar el riesgo de IHQ provocada por bacterias gramnegativas<a class="elsevierStyleCrossRefs" href="#bib0440"><span class="elsevierStyleSup">23&#44;24</span></a>&#46; Hasta la fecha no se han comunicado efectos adversos graves asociados a la administraci&#243;n local de vancomicina&#46; An&#225;logamente&#44; la vancomicina t&#243;pica espolvoreada en el espacio subgaleal tambi&#233;n puede emplearse como prevenci&#243;n de la IHQ en craneotom&#237;as<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">25</span></a>&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">En el momento actual no existe una recomendaci&#243;n formal o protocolo estandarizado para el uso de vancomicina t&#243;pica como profilaxis de IHQ en cirug&#237;a de columna y se emplea como indicaci&#243;n <span class="elsevierStyleItalic">off-label</span> &#40;fuera de indicaci&#243;n del prospecto&#41; y de forma discrecional por el cirujano responsable de cada caso&#46; A pesar de las evidencias a favor de su uso&#44; esta forma de administraci&#243;n no ha recibido a&#250;n aprobaci&#243;n por la <span class="elsevierStyleItalic">Food and Drug Administration</span> &#40;FDA&#41; norteamericana ni por la Agencia Europea del Medicamento<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">16</span></a>&#46; El objetivo de este estudio unic&#233;ntrico es valorar de forma prospectiva la efectividad de la vancomicina t&#243;pica como prevenci&#243;n de IHQ en una cohorte homog&#233;nea de pacientes intervenidos de columna&#44; de forma electiva&#44; por abordaje posterior&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material y m&#233;todos</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Dise&#241;o del estudio</span><p id="par0025" class="elsevierStylePara elsevierViewall">Se trata de un estudio unic&#233;ntrico observacional de cohortes de tipo ambispectivo&#44; cuasiexperimental de comparaci&#243;n pre- y postintervenci&#243;n con controles hist&#243;ricos&#44; realizado entre mayo de 2017 y octubre de 2018&#46; El estudio obtuvo la aprobaci&#243;n del Comit&#233; de &#201;tica e Investigaci&#243;n Cl&#237;nica del centro &#40;Ref&#46;&#58; CEIC 1891&#41; incluyendo la aprobaci&#243;n del documento de consentimiento informado empleado&#46; Asimismo&#44; recibi&#243; la aprobaci&#243;n de la Comisi&#243;n de Farmacia y de la Comisi&#243;n de Infecciones y Profilaxis Quir&#250;rgica del centro&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Se incluyeron pacientes consecutivos mayores de 18 a&#241;os que fueron sometidos a cirug&#237;a de columna cervical&#44; dorsal o lumbosacra por abordaje posterior&#44; de forma electiva&#44; por cualquier causa &#40;degenerativa&#44; tumoral&#44; traum&#225;tica&#44; etc&#46;&#41; independientemente del n&#250;mero de niveles afectados&#46; Todos los abordajes quir&#250;rgicos fueron bilaterales&#46; Se excluyeron los abordajes unilaterales o percut&#225;neos y todos los pacientes diagnosticados de cualquier tipo de inmunodepresi&#243;n&#44; en tratamiento inmunosupresor&#44; intervenidos por espondilodiscitis o en tratamiento por infecci&#243;n en cualquier otra localizaci&#243;n&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Se recogieron datos demogr&#225;ficos y de factores de riesgo de infecci&#243;n de cada paciente&#46; Asimismo&#44; se especific&#243; el tratamiento antibi&#243;tico empleado y utilizaci&#243;n de drenaje en herida quir&#250;rgica&#46; En todos los pacientes&#44; el &#225;rea a intervenir se prepar&#243; con soluci&#243;n de povidona yodada&#44; sin rasurado&#44; seg&#250;n t&#233;cnica est&#225;ndar&#46; La profilaxis antibi&#243;tica preoperatoria empleada fue cefazolina en dosis de 1 o 2<span class="elsevierStyleHsp" style=""></span>g por v&#237;a intravenosa &#40;o vancomicina 1<span class="elsevierStyleHsp" style=""></span>g por v&#237;a intravenosa en al&#233;rgicos a betalact&#225;micos&#41; al inicio de la intervenci&#243;n y repitiendo dosis cuando la intervenci&#243;n se prolong&#243; m&#225;s de 4<span class="elsevierStyleHsp" style=""></span>h&#46; Esta pauta se mantuvo 24<span class="elsevierStyleHsp" style=""></span>h tras la intervenci&#243;n&#44; repitiendo dosis cada 8<span class="elsevierStyleHsp" style=""></span>h en caso de cefazolina y cada 12<span class="elsevierStyleHsp" style=""></span>h con vancomicina&#46; En todas las intervenciones participaron 2 neurocirujanos de plantilla &#40;de un grupo de 5&#41; con amplia experiencia en cirug&#237;a de columna&#44; sin participaci&#243;n de residentes&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Los pacientes fueron divididos en 2 grupos&#58; un grupo de tratamiento <span class="elsevierStyleItalic">&#40;grupo postintervenci&#243;n&#41;</span> al que adem&#225;s de la profilaxis antibi&#243;tica intravenosa descrita se le administr&#243; polvo liofilizado de vancomicina t&#243;pica en la herida quir&#250;rgica&#44; y un grupo de comparaci&#243;n <span class="elsevierStyleItalic">&#40;grupo preintervenci&#243;n&#41;</span> que &#250;nicamente recibi&#243; la profilaxis intravenosa&#46; Los pacientes intervenidos de cirug&#237;a electiva en el servicio inmediatamente antes del per&#237;odo de estudio&#44; es decir&#44; entre enero de 2016 y abril de 2017&#44; sirvieron como grupo de comparaci&#243;n&#44; con los mismos criterios de inclusi&#243;n y exclusi&#243;n descritos para el grupo de vancomicina&#46; En el grupo de postintervenci&#243;n se identificaron de forma prospectiva todos los casos de IHQ tanto superficial como profunda&#44; mientras que en el grupo preintervenci&#243;n dicha informaci&#243;n se obtuvo de forma retrospectiva de los historiales m&#233;dicos&#46; Se analizaron los microorganismos involucrados en cada infecci&#243;n y su susceptibilidad antibi&#243;tica&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Protocolo de tratamiento y seguimiento</span><p id="par0045" class="elsevierStylePara elsevierViewall">El protocolo de tratamiento consisti&#243; en esparcir de forma lo m&#225;s uniformemente posible 1<span class="elsevierStyleHsp" style=""></span>g de polvo liofilizado y no reconstituido de vancomicina directamente en la herida quir&#250;rgica antes del cierre&#44; tanto en el plano subfascial &#40;profundo&#41; como suprafascial &#40;superficial&#41; como se muestra en la <a class="elsevierStyleCrossRef" href="#fig0005">figura 1</a>&#46; Previamente se hab&#237;a realizado un adecuado control de la hemostasia y lavado profuso del campo quir&#250;rgico con suero fisiol&#243;gico&#46; Se dej&#243; drenaje en el lecho quir&#250;rgico&#44; a juicio del cirujano responsable del paciente&#44; que se conect&#243; a aspiraci&#243;n suave una vez que la herida estuvo completamente suturada&#46; El drenaje se retir&#243; tras un m&#225;ximo de 3 d&#237;as&#44; aunque generalmente se hace a las 24<span class="elsevierStyleHsp" style=""></span>h&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">La IHQ puede manifestarse como infecci&#243;n superficial o profunda&#46; El diagn&#243;stico de IHQ se realiz&#243; en base a los hallazgos cl&#237;nicos&#44; de laboratorio y microbiol&#243;gicos&#58; supuraci&#243;n de la herida&#44; dehiscencia de los bordes&#44; fiebre&#44; dolor local&#44; aumento de par&#225;metros sangu&#237;neos de inflamaci&#243;n&#47;infecci&#243;n&#44; cultivos microbiol&#243;gicos positivos&#44; o combinaciones de los anteriores&#44; de acuerdo a las recomendaciones de los <span class="elsevierStyleItalic">Centers for Disease Control and Prevention</span> &#40;CDC&#41; norteamericanos<a class="elsevierStyleCrossRefs" href="#bib0455"><span class="elsevierStyleSup">26&#44;27</span></a>&#46; Se define <span class="elsevierStyleItalic">IHQ superficial</span> aquella que afecta a piel y tejidos subcut&#225;neos y que puede resolverse con curas locales de la herida y antibioterapia oral en el plazo de unos d&#237;as&#46; Una <span class="elsevierStyleItalic">IHQ profunda</span> afecta adem&#225;s al compartimento subfascial y requiere para su curaci&#243;n desbridamiento quir&#250;rgico&#44; irrigaci&#243;n de la herida y antibioterapia oral o intravenosa&#46; Es necesario precisar que no es imprescindible una confirmaci&#243;n microbiol&#243;gica para diagnosticar una IHQ&#46; Contrariamente&#44; una colecci&#243;n autolimitada y no purulenta que provoca m&#237;nima inflamaci&#243;n se considera simplemente un <span class="elsevierStyleItalic">seroma</span> postoperatorio&#44; siempre que el cultivo microbiol&#243;gico resulte negativo&#46; Una leve y transitoria inflamaci&#243;n y&#47;o supuraci&#243;n en relaci&#243;n con alguno de los puntos de sutura tampoco se considera IHQ&#46; El seguimiento de los pacientes se realiz&#243; en la consulta externa de Neurocirug&#237;a por el neurocirujano responsable de cada caso&#46; Se registr&#243; el final del seguimiento de cada paciente como la fecha de la &#250;ltima consulta realizada&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Las medias y proporciones de las variables cl&#237;nicas se compararon mediante el estad&#237;stico Z o el estad&#237;stico t de Student &#40;o el test de Wilcoxon&#41;&#44; la prueba de chi-cuadrado y el test exacto de Fisher&#44; asumiendo significaci&#243;n estad&#237;stica con valores de p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#46; Todo el an&#225;lisis estad&#237;stico se realiz&#243; mediante el paquete de software libre <span class="elsevierStyleItalic">Epidat versi&#243;n 3&#46;1</span> &#40;SERGAS&#44; Servicio Gallego de Salud&#41;&#46;</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Resultados</span><p id="par0060" class="elsevierStylePara elsevierViewall">Se reclutaron 150 pacientes en cada grupo &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>300&#41;&#46; En la <a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a> se comparan las caracter&#237;sticas demogr&#225;ficas y cl&#237;nicas de ambos grupos&#46; Ambas cohortes resultaron ser homog&#233;neas y comparables en pr&#225;cticamente todas las variables de estudio&#46; &#218;nicamente destaca una mayor proporci&#243;n de pacientes fumadores &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;0372&#41; en el grupo postintervenci&#243;n y una mayor proporci&#243;n de obesos &#40;&#237;ndice de masa corporal<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>30&#41; en el grupo preintervenci&#243;n &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;0098&#41;&#46; En el grupo postintervenci&#243;n se realizaron menos laminectom&#237;as simples &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;0361&#41; con una tendencia no significativa a realizar m&#225;s fijaciones con o sin laminectom&#237;a&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Efecto global de la vancomicina en la incidencia de infecci&#243;n de herida quir&#250;rgica</span><p id="par0065" class="elsevierStylePara elsevierViewall">Globalmente&#44; ocurrieron 12 infecciones en el grupo postintervenci&#243;n&#44; 7 IHQ superficiales y 5 profundas&#46; En el grupo preintervenci&#243;n ocurrieron 16 infecciones&#44; 7 superficiales y 9 profundas&#46; La incidencia global de IHQ fue del 8&#37; en el grupo de postintervenci&#243;n y del 10&#44;66&#37; en el grupo preintervenci&#243;n&#46; La incidencia de IHQ profunda que precis&#243; re-intervenci&#243;n y desbridamiento fue del 3&#44;33&#37; en el grupo postintervenci&#243;n y del 6&#37; en el grupo preintervenci&#243;n&#44; con una reducci&#243;n relativa del riesgo del 2&#44;66&#37;&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">En la cohorte estudiada&#44; el riesgo de infecci&#243;n profunda en los pacientes tratados con vancomicina fue casi la mitad respecto al grupo control&#44; aunque esta tendencia no alcanz&#243; la significaci&#243;n estad&#237;stica&#58; <span class="elsevierStyleItalic">OR 0&#44;54 &#40;IC 95&#37; 0&#44;17-1&#44;65&#41;&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;4115</span>&#46; El n&#250;mero de pacientes a tratar para prevenir una IHQ profunda fue de 37&#46; Las diferencias de riesgo en la tasa global de infecci&#243;n &#40;OR 0&#44;72&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;55&#41; y en la tasa de infecci&#243;n superficial &#40;OR 0&#44;34&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#41; entre los 2 grupos tampoco resultaron significativas &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">El intervalo de tiempo medio hasta la aparici&#243;n de una infecci&#243;n profunda fue de 18&#44;6 d&#237;as en el grupo postintervenci&#243;n &#40;mediana 18 d&#237;as&#44; rango 10-27 d&#237;as&#41; y de 21&#44;7 d&#237;as en el grupo preintervenci&#243;n &#40;mediana de 26 d&#237;as&#44; rango 10-38 d&#237;as&#41;&#44; diferencias no significativas &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;5397&#41;&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">An&#225;lisis global de la cohorte</span><p id="par0080" class="elsevierStylePara elsevierViewall">En la cohorte completa &#40;N<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>300&#41;&#44; incluyendo los tratados y no tratados con vancomicina&#44; se constat&#243; una tendencia significativa a la infecci&#243;n profunda cuando la intervenci&#243;n se realiz&#243; sobre 4 o m&#225;s niveles espinales &#40;OR 4&#44;71&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;0025&#41;&#46; De igual forma&#44; el motivo de indicaci&#243;n quir&#250;rgica tambi&#233;n fue un factor diferenciador en la cohorte completa&#46; As&#237;&#44; cuando los pacientes se intervinieron por causa degenerativa existi&#243; una menor probabilidad de infecci&#243;n profunda &#40;OR 0&#44;18&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;0011&#41; y cuando lo hicieron por causa tumoral&#44; esta probabilidad fue significativamente mayor &#40;OR 10&#44;53&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;0003&#41;&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">La duraci&#243;n de la intervenci&#243;n por encima de 200<span class="elsevierStyleHsp" style=""></span>min &#40;aproximadamente el promedio de ambos grupos&#41; predispuso a la infecci&#243;n profunda&#44; aunque de forma no significativa &#40;OR 2&#44;04&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;2023&#41;&#46; Estos resultados se muestran en la <a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a>&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Evoluci&#243;n y complicaciones</span><p id="par0090" class="elsevierStylePara elsevierViewall">Todas las IHQ superficiales se resolvieron con antibioterapia oral&#46; Asimismo&#44; todas las IHQ profundas se resolvieron con la reintervenci&#243;n y el desbridamiento junto a antibioterapia sist&#233;mica&#44; inicialmente emp&#237;rica y posteriormente dirigida por antibiograma&#46; Los microorganismos implicados en las IHQ se detallan en las <a class="elsevierStyleCrossRefs" href="#tbl0020">tablas 4 y 5</a>&#46; El porcentaje de IHQ profunda causadas por grampositivos y gramnegativos fue del 20&#37; y del 80&#37; respectivamente en los tratados con vancomicina&#44; y del 67&#37; y del 33&#37;&#44; respectivamente en los no tratados&#44; diferencias evidentes&#44; aunque no significativas &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;2646&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">No se constataron efectos adversos locales ni sist&#233;micos achacables al tratamiento local con vancomicina&#46; Aunque los pacientes con comorbilidades &#40;diabetes&#44; etc&#46;&#41; fueron m&#225;s proclives a la infecci&#243;n profunda&#44; esta tendencia no result&#243; significativa&#46; Todas las IHQ y los seromas eventualmente se resolvieron con el tratamiento administrado y las curas de las heridas&#46; El seguimiento mediano result&#243; similar en ambos grupos&#44; siendo en el grupo postintervenci&#243;n de 94 d&#237;as &#40;rango&#44; 4-562 d&#237;as&#41; y de 131 d&#237;as &#40;rango&#44; 15-1&#46;018&#41; en el grupo preintervenci&#243;n &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;1399&#41;&#46; No se constataron reactivaciones de infecciones tratadas y curadas ni se produjeron reingresos por esta causa&#46; En el grupo postintervenci&#243;n se reintervinieron 2 pacientes&#44; uno por hematoma de lecho quir&#250;rgico y otro por f&#237;stula de LCR&#46; En el grupo preintervenci&#243;n se reintervinieron 3 pacientes&#44; todos por f&#237;stula de LCR&#46; Todos los casos de f&#237;stula se resolvieron y los cultivos de LCR y de la herida quir&#250;rgica fueron negativos&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">A lo largo del per&#237;odo de estudio&#44; se constataron 17 fallecimientos en total &#40;5&#44;7&#37; de la cohorte completa&#41;&#44; 10 en el grupo postintervenci&#243;n y 7 en el grupo preintervenci&#243;n &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;6175&#41;&#44; ninguno relacionado directamente con la IHQ&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Discusi&#243;n</span><p id="par0105" class="elsevierStylePara elsevierViewall">Los resultados de este estudio muestran una tendencia a la reducci&#243;n de las IHQ profundas que precisan desbridamiento quir&#250;rgico cuando se emplea de forma sistem&#225;tica la vancomicina en polvo en el lecho quir&#250;rgico&#44; en pacientes intervenidos de columna por abordaje posterior bilateral por cualquier etiolog&#237;a&#46; Por otra parte&#44; no se constataron efectos adversos locales o sist&#233;micos relacionados con la administraci&#243;n t&#243;pica de vancomicina&#44; ni hubo mayor incidencia de seromas&#46; S&#237; se constat&#243; una tendencia no significativa al aumento de las IHQ profundas por microorganismos gramnegativos en el grupo tratado con vancomicina&#44; aunque no se seleccionaron microorganismos resistentes&#44; en la l&#237;nea de lo publicado recientemente<a class="elsevierStyleCrossRef" href="#bib0445"><span class="elsevierStyleSup">24</span></a>&#46;</p><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">La vancomicina t&#243;pica en cirug&#237;a de columna</span><p id="par0110" class="elsevierStylePara elsevierViewall">La vancomicina es un antibi&#243;tico glucop&#233;ptido producido por el microorganismo <span class="elsevierStyleItalic">Amycolatopsis orientalis</span>&#44; aislado por primera vez en 1953 por Edmund Kornfeld<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">16</span></a>&#46; Su mecanismo bactericida consiste en la inhibici&#243;n de la bios&#237;ntesis de la pared bacteriana pr&#225;cticamente solo de las bacterias grampositivas&#46; Dada su mala absorci&#243;n intestinal&#44; en 1958 la FDA aprob&#243; su uso por v&#237;a intravenosa para el tratamiento de infecciones graves por estafilococos resistentes a meticilina<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">28</span></a>&#46; Los CDC recomendaron su empleo como profilaxis quir&#250;rgica en cirug&#237;a mayor que precise implantar pr&#243;tesis en centros con tasas altas de infecci&#243;n por estafilococo resistente a meticilina<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">16</span></a>&#46; En 1986 la FDA aprob&#243; la administraci&#243;n oral de vancomicina para el tratamiento de la colitis seudomembranosa por <span class="elsevierStyleItalic">Clostridium difficile</span><a class="elsevierStyleCrossRef" href="#bib0470"><span class="elsevierStyleSup">29</span></a>&#46; Sin embargo&#44; la administraci&#243;n t&#243;pica de vancomicina no consta por el momento entre las formas de administraci&#243;n descritas en el prospecto del f&#225;rmaco&#44; no tiene la aprobaci&#243;n formal de la FDA ni de la Agencia Europea del Medicamento&#44; por lo que su uso est&#225; supeditado a la aprobaci&#243;n institucional de cada centro en el contexto de estudios sobre su eficacia y seguridad&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">El <span class="elsevierStyleItalic">S&#46; aureus</span> supone el 30&#37; de todas las IHQ globalmente y al menos el 50&#37; de las infecciones en procedimientos ortop&#233;dicos y neuroquir&#250;rgicos<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">30</span></a>&#46; Dado que el porcentaje de cepas estafiloc&#243;cicas resistentes a meticilina supera el 50&#37;<a class="elsevierStyleCrossRefs" href="#bib0390"><span class="elsevierStyleSup">13&#44;31</span></a>&#44; la profilaxis intravenosa habitual puede no ser eficaz&#46; La administraci&#243;n t&#243;pica del polvo de vancomicina en la herida quir&#250;rgica se ha demostrado efectiva contra bacterias grampositivas&#44; incluso contra aquellas moderadamente resistentes&#44; debido a la elevada concentraci&#243;n local del f&#225;rmaco que se alcanza<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">16</span></a>&#46; Esta forma de administraci&#243;n impide la absorci&#243;n r&#225;pida del medicamento con lo que se minimizan los efectos sist&#233;micos del mismo<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">18</span></a>&#46; Asimismo&#44; el enorme gradiente de concentraci&#243;n que se crea entre la superficie de la herida y la circulaci&#243;n sangu&#237;nea adyacente erradica pr&#225;cticamente el 100&#37; de los estafilococos presentes en la herida&#44; y parece proteger frente a la creaci&#243;n de resistencias al f&#225;rmaco<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">22</span></a>&#44; por lo que te&#243;ricamente no se seleccionan cepas resistentes&#46; Esta hip&#243;tesis&#44; sin embargo&#44; no se ha evaluado de forma espec&#237;fica en estudios cl&#237;nicos&#46; La absorci&#243;n sist&#233;mica de vancomicina tras la aplicaci&#243;n t&#243;pica parece m&#237;nima<a class="elsevierStyleCrossRefs" href="#bib0415"><span class="elsevierStyleSup">18&#44;22</span></a> o nula<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">32</span></a> seg&#250;n varios estudios que evaluaron las concentraciones plasm&#225;ticas de vancomicina tras su administraci&#243;n t&#243;pica&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Efectividad de la vancomicina en la infecci&#243;n de herida quir&#250;rgica</span><p id="par0120" class="elsevierStylePara elsevierViewall">El polvo de vancomicina en las heridas quir&#250;rgicas se empez&#243; a utilizar en los a&#241;os 80 en cirug&#237;a card&#237;aca para disminuir la tasa de infecci&#243;n en las esternotom&#237;as<a class="elsevierStyleCrossRefs" href="#bib0435"><span class="elsevierStyleSup">22&#44;33</span></a>&#46; En las &#250;ltimas 2 d&#233;cadas&#44; numerosos estudios han testeado el efecto de la vancomicina en polvo sobre la incidencia de IHQ en procedimientos espinales&#46; La gran mayor&#237;a de los estudios son series retrospectivas<a class="elsevierStyleCrossRefs" href="#bib0385"><span class="elsevierStyleSup">12&#44;17&#44;19&#44;34</span></a> y &#250;nicamente consta un ensayo cl&#237;nico aleatorizado<a class="elsevierStyleCrossRef" href="#bib0500"><span class="elsevierStyleSup">35</span></a>&#46; La <a class="elsevierStyleCrossRef" href="#tbl0030">tabla 6</a> muestra las conclusiones de los estudios de revisi&#243;n sistem&#225;tica de la literatura<a class="elsevierStyleCrossRefs" href="#bib0405"><span class="elsevierStyleSup">16&#44;36&#8211;38</span></a> y metaan&#225;lisis<a class="elsevierStyleCrossRefs" href="#bib0445"><span class="elsevierStyleSup">24&#44;25&#44;39&#8211;41</span></a> publicados en los &#250;ltimos a&#241;os respecto al efecto del polvo de vancomicina en la incidencia de IHQ tras cirug&#237;a espinal&#46;</p><elsevierMultimedia ident="tbl0030"></elsevierMultimedia><p id="par0125" class="elsevierStylePara elsevierViewall">Los trabajos de revisi&#243;n publicados a partir de 2015&#44; que ya incluyen decenas de miles de casos&#44; muestran una evidencia cada vez m&#225;s s&#243;lida de que el polvo de vancomicina protege de la IHQ&#44; especialmente de la infecci&#243;n profunda&#44; sin que se establezca una clara relaci&#243;n dosis-respuesta&#46; El metaan&#225;lisis de Dodson et al&#46;<a class="elsevierStyleCrossRef" href="#bib0445"><span class="elsevierStyleSup">24</span></a>&#44; publicado en enero de 2019&#44; confirma la eficacia de este tratamiento y comunica un riesgo de IHQ combinado de 0&#44;55 &#40;0&#44;45-0&#44;67&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;0001&#41;&#44; muy similar al encontrado en el presente estudio&#46; Asimismo&#44; se constat&#243; una tendencia no significativa al aumento de infecciones por g&#233;rmenes gramnegativos &#40;OR 1&#44;11&#59; IC 95&#37; 0&#44;66-1&#44;86&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;701&#41;&#46; En todos los trabajos se hace hincapi&#233; en la necesidad de contar con estudios prospectivos y en la correcta definici&#243;n de IHQ&#46; En las diversas revisiones sistem&#225;ticas se muestra la efectividad del tratamiento&#44; se constata la ausencia de complicaciones graves sist&#233;micas o locales&#44; y se discuten aspectos controvertidos como la incidencia de seudoartrosis&#44; seromas o complicaciones sist&#233;micas derivadas del uso de vancomicina t&#243;pica&#46; En el a&#241;o 2017&#44; sin embargo&#44; el <span class="elsevierStyleItalic">American College of Surgeons</span><a class="elsevierStyleCrossRef" href="#bib0535"><span class="elsevierStyleSup">42</span></a> y los CDC<a class="elsevierStyleCrossRef" href="#bib0540"><span class="elsevierStyleSup">43</span></a> publicaron unas gu&#237;as para la prevenci&#243;n de la IHQ en las que no se recomienda de manera expl&#237;cita el uso de polvo de vancomicina como profilaxis quir&#250;rgica y se resalta la necesidad de futuros estudios sobre el tema&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Varios estudios de coste-efectividad<a class="elsevierStyleCrossRefs" href="#bib0545"><span class="elsevierStyleSup">44&#8211;46</span></a> han constatado ahorros por encima de 200&#46;000 a 400&#46;000 d&#243;lares por cada 100 procedimientos quir&#250;rgicos de fusi&#243;n espinal por traumatismos o deformidades toracolumbares&#44; cuando se emplea el polvo de vancomicina&#44; asumiendo un coste por vial de entre 30 y 40 d&#243;lares&#44; precio bastante superior al que se obtiene en Espa&#241;a&#44; que se encuentra en torno a 1-6 euros por vial de 1<span class="elsevierStyleHsp" style=""></span>g &#40;el coste en nuestro centro es de 1&#44;76&#8364; por vial de 1<span class="elsevierStyleHsp" style=""></span>g&#41;&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">En los diversos trabajos se han empleado dosis t&#243;picas de vancomicina de entre 0&#44;5<span class="elsevierStyleHsp" style=""></span>g y 6<span class="elsevierStyleHsp" style=""></span>g<a class="elsevierStyleCrossRefs" href="#bib0440"><span class="elsevierStyleSup">23&#44;32</span></a>&#44; aunque la mayor&#237;a de los estudios se han realizado con 1<span class="elsevierStyleHsp" style=""></span>g de polvo liofilizado&#46; No existe un protocolo estandarizado sobre c&#243;mo se debe repartir la dosis del f&#225;rmaco en el campo quir&#250;rgico&#46; La recomendaci&#243;n general es espolvorearlo sobre toda la herida&#44; incluyendo los compartimentos infra- y suprafasciales&#44; sobre el injerto &#243;seo cuando este se emplea y sobre la superficie de la duramadre&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Posibles efectos adversos de la aplicaci&#243;n t&#243;pica de vancomicina</span><p id="par0140" class="elsevierStylePara elsevierViewall">Diversos trabajos y el &#250;ltimo metaan&#225;lisis publicado sugieren la posibilidad de que el polvo de vancomicina favorezca la aparici&#243;n de IHQ por microorganismos<span class="elsevierStyleItalic">gramnegativos</span><a class="elsevierStyleCrossRefs" href="#bib0445"><span class="elsevierStyleSup">24&#44;32</span></a>&#46; En nuestra serie as&#237; lo hemos constatado tambi&#233;n&#44; de forma que en el grupo postintervenci&#243;n el 80&#37; de IHQ fueron causadas por gramnegativos&#44; mientras que solo el 33&#37; lo fue en el grupo preintervenci&#243;n&#44; diferencias importantes&#44; aunque no estad&#237;sticamente significativas&#44; probablemente debido a la baja prevalencia basal y al tama&#241;o muestral&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Desde un punto de vista te&#243;rico&#44; surge la duda sobre el posible efecto que el polvo de vancomicina pudiera tener como inhibidor de la formaci&#243;n &#243;sea &#40;en intervenciones que impliquen artrodesis&#41; y en el posible aumento en la incidencia de <span class="elsevierStyleItalic">seudoartrosis</span>&#46; Seg&#250;n algunos estudios&#44; la concentraci&#243;n de vancomicina que resulta citot&#243;xica para los osteoblastos debe ser mayor de 10&#46;000<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;ml<a class="elsevierStyleCrossRef" href="#bib0560"><span class="elsevierStyleSup">47</span></a>&#44; concentraci&#243;n que no parece alcanzarse mediante administraci&#243;n t&#243;pica<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">16</span></a>&#46; La vancomicina es&#44; adem&#225;s&#44; menos t&#243;xica sobre la regeneraci&#243;n &#243;sea que las quinolonas<a class="elsevierStyleCrossRef" href="#bib0565"><span class="elsevierStyleSup">48</span></a> o la gentamicina<a class="elsevierStyleCrossRef" href="#bib0570"><span class="elsevierStyleSup">49</span></a>&#46; La revisi&#243;n de Alcal&#225;-Cerra et al&#46;<a class="elsevierStyleCrossRef" href="#bib0575"><span class="elsevierStyleSup">50</span></a> indica que el uso de polvo de vancomicina no favorece la aparici&#243;n de seudoartrosis aunque&#44; por el momento&#44; no existen estudios prospectivos cl&#237;nicos que eval&#250;en espec&#237;ficamente este punto&#46; El per&#237;odo de seguimiento de nuestra serie no permite obtener conclusiones al respecto&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Otra posible complicaci&#243;n achacada al polvo de vancomicina es la formaci&#243;n de <span class="elsevierStyleItalic">seromas</span> en las heridas&#46; El estudio de Ghobrial et al&#46;<a class="elsevierStyleCrossRef" href="#bib0440"><span class="elsevierStyleSup">23</span></a> mostr&#243; un aumento en la incidencia de seromas postoperatorios en una cohorte de pacientes tratados con polvo de vancomicina&#44; aunque no se compar&#243; con un grupo control&#46; En nuestra serie no se evidenci&#243; una diferencia significativa&#58; aparecieron 3 seromas en el grupo postintervenci&#243;n y 4 en el grupo preintervenci&#243;n&#44; todos ellos se solucionaron con curas locales de la herida&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Finalmente&#44; se han descrito <span class="elsevierStyleItalic">efectos generales</span> como absorci&#243;n sist&#233;mica con niveles sangu&#237;neos supraterap&#233;uticos&#44; nefro- u ototoxicidad&#44; todos ellos de forma muy espor&#225;dica y casi excepcional<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">16</span></a>&#46; Globalmente&#44; la incidencia de efectos adversos&#44; incluyendo los seromas no llega al 0&#44;3&#37;<a class="elsevierStyleCrossRef" href="#bib0510"><span class="elsevierStyleSup">37</span></a>&#46; DeFrancesco et al&#46;<a class="elsevierStyleCrossRef" href="#bib0580"><span class="elsevierStyleSup">51</span></a> solo evidenciaron una reacci&#243;n cut&#225;nea adversa transitoria sobre 1&#46;398 casos de utilizaci&#243;n de polvo de vancomicina en cirug&#237;a de escoliosis en un estudio multic&#233;ntrico en 10 centros de Europa y Estados Unidos&#46; El &#250;nico caso grave documentado en la literatura es un paciente que sufri&#243; un colapso circulatorio que precis&#243; aminas en el postoperatorio&#44; en principio achacado a una posible reacci&#243;n anafilactoide a la vancomicina en polvo&#44; pero que ocurri&#243; en el contexto de una vertebrectom&#237;a para una met&#225;stasis espinal de mama en la que se perdieron 2<span class="elsevierStyleHsp" style=""></span>l de sangre y se precisaron m&#250;ltiples transfusiones de sangre&#44; plasma y otros derivados<a class="elsevierStyleCrossRef" href="#bib0585"><span class="elsevierStyleSup">52</span></a>&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">La aplicaci&#243;n del polvo de vancomicina directamente encima de la superficie dural es una maniobra factible<a class="elsevierStyleCrossRef" href="#bib0590"><span class="elsevierStyleSup">53</span></a> y segura que&#44; en nuestra experiencia&#44; no ha producido complicaciones neurol&#243;gicas&#46; Sin embargo&#44; el estudio de Goldschmidt et al&#46;<a class="elsevierStyleCrossRef" href="#bib0595"><span class="elsevierStyleSup">54</span></a> comprob&#243;&#44; en un modelo in vitro&#44; que la duramadre expuesta a altas concentraciones de vancomicina experimenta procesos de muerte celular&#44; inhibici&#243;n del crecimiento y alteraciones de la morfolog&#237;a celular&#44; de intensidad dosis-dependiente&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Controversias</span><p id="par0165" class="elsevierStylePara elsevierViewall">La farmacocin&#233;tica de la vancomicina administrada en polvo no es bien conocida y se requieren estudios b&#225;sicos y cl&#237;nicos que definan espec&#237;ficamente su perfil de absorci&#243;n&#44; distribuci&#243;n y metabolismo&#46; La decisi&#243;n sobre la dosis a emplear &#40;en general 1 o 2<span class="elsevierStyleHsp" style=""></span>g de polvo&#41; contin&#250;a siendo discrecional y no existen estudios cl&#237;nicos que avalen una dosificaci&#243;n en concreto&#46; El reciente estudio de Haimoto et al&#46;<a class="elsevierStyleCrossRef" href="#bib0600"><span class="elsevierStyleSup">55</span></a> sugiere la posibilidad de espolvorear la vancomicina &#250;nicamente en el compartimento suprafascial&#44; al parecer obteniendo los mismos efectos beneficiosos&#44; pero evitando la posibilidad de absorci&#243;n sist&#233;mica&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">A tenor de los estudios publicados&#44; es muy posible que su empleo cambie el patr&#243;n etiol&#243;gico hacia una mayor incidencia de infecciones por gramnegativos y polimicrobianos<a class="elsevierStyleCrossRefs" href="#bib0605"><span class="elsevierStyleSup">56&#8211;58</span></a>&#46; Esta tendencia&#44; sin embargo&#44; a priori no parece relevante desde el punto de vista de la curaci&#243;n de la infecci&#243;n&#44; estancia hospitalaria ni del desarrollo de cepas resistentes a los antibi&#243;ticos usados<a class="elsevierStyleCrossRef" href="#bib0605"><span class="elsevierStyleSup">56</span></a>&#44; ni tampoco a la vancomicina<a class="elsevierStyleCrossRef" href="#bib0620"><span class="elsevierStyleSup">59</span></a>&#46; Un reciente ensayo aleatorizado ha comparado el uso local de 1<span class="elsevierStyleHsp" style=""></span>g polvo de vancomicina con 1<span class="elsevierStyleHsp" style=""></span>g de polvo de ampicilina&#44; en pacientes sometidos a cirug&#237;as de fusi&#243;n tor&#225;cica o lumbar&#44; sin encontrar diferencias significativas en la tasa de IHQ<a class="elsevierStyleCrossRef" href="#bib0625"><span class="elsevierStyleSup">60</span></a>&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Otra cuesti&#243;n interesante es si se debe esperar un a&#241;o de evoluci&#243;n como recomienda el CDC<a class="elsevierStyleCrossRefs" href="#bib0460"><span class="elsevierStyleSup">27&#44;43</span></a>&#44; para poder descartar la presencia de IHQ&#44; dado que las infecciones&#44; tanto superficiales como profundas&#44; aparecen mucho m&#225;s precozmente como hemos constatado en nuestra serie&#46; El hecho de que no se haya producido ninguna reactivaci&#243;n de una IHQ previa ni reingresos tard&#237;os por infecci&#243;n&#44; tras casi 2 a&#241;os de evoluci&#243;n del grupo control&#44; avala esta afirmaci&#243;n&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">La cuesti&#243;n m&#225;s controvertida respecto al uso de polvo de vancomicina en profilaxis de IHQ es si esta debe administrarse de forma seleccionada&#44; como sugieren algunos estudios recientes<a class="elsevierStyleCrossRefs" href="#bib0630"><span class="elsevierStyleSup">61&#44;62</span></a>&#44; o de forma sistematizada a todos los pacientes<a class="elsevierStyleCrossRef" href="#bib0520"><span class="elsevierStyleSup">39</span></a>&#46; A favor de la primera opci&#243;n&#44; y seg&#250;n los resultados de este estudio&#44; podemos afirmar que los pacientes con factores de riesgo &#40;diab&#233;ticos&#44; obesos&#44; fumadores&#41;&#44; aquellos intervenidos por causa tumoral y en los que se realizan fijaciones dorsales de m&#250;ltiples niveles parecen beneficiarse m&#225;s del tratamiento&#46; En apoyo al uso sistem&#225;tico&#44; podr&#237;a argumentarse que se trata de un tratamiento muy sencillo de aplicar&#44; no consume tiempo quir&#250;rgico apenas&#44; no produce toxicidad local ni sist&#233;mica relevante&#44; es muy barato y reduce costes&#44; pues evita una infecci&#243;n grave por cada 37 pacientes a los que se les administra&#46; En procedimientos espinales en la infancia&#44; el n&#250;mero de pacientes a tratar para evitar una infecci&#243;n se estima en solo 9 por lo que algunos recomiendan su uso de forma rutinaria<a class="elsevierStyleCrossRef" href="#bib0640"><span class="elsevierStyleSup">63</span></a>&#46; A nuestro juicio el caso ideal ser&#237;a el de un paciente obeso o diab&#233;tico que precisa una cirug&#237;a instrumentada dorsal de m&#225;s de 4 niveles&#44; especialmente por causa tumoral<a class="elsevierStyleCrossRef" href="#bib0645"><span class="elsevierStyleSup">64</span></a>&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">Este tratamiento se emplea actualmente como uso compasivo y fuera de indicaci&#243;n formal del prospecto del medicamento&#46; Su aprobaci&#243;n institucional queda pendiente a pesar de la creciente evidencia a favor de su uso y su perfil de seguridad&#46; Esta evidencia parece que empieza a extenderse tambi&#233;n al &#225;mbito de la cirug&#237;a craneal<a class="elsevierStyleCrossRefs" href="#bib0450"><span class="elsevierStyleSup">25&#44;65</span></a>&#44; lo que de confirmarse probablemente tendr&#225; implicaciones relevantes en la pr&#225;ctica neuroquir&#250;rgica habitual&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Limitaciones del estudio</span><p id="par0190" class="elsevierStylePara elsevierViewall">Este estudio tiene una serie de limitaciones&#46; Se trata de un estudio no aleatorizado de cohortes prospectivo en el grupo de tratamiento&#44; aunque retrospectivo en el grupo que sirve de comparaci&#243;n&#44; por lo que los resultados en este grupo pueden estar sujetos a sesgos de recuerdo o de registro en el historial&#46; El escaso n&#250;mero de eventos infecciosos ocurridos &#40;14 en total&#44; 9 en preintervenci&#243;n y 5 en postintervenci&#243;n&#41; hace dif&#237;cil hallar diferencias estad&#237;sticamente significativas e impiden la realizaci&#243;n de an&#225;lisis estratificados&#46; La ausencia de c&#225;lculo del tama&#241;o muestral a priori&#44; teniendo en cuenta la baja incidencia esperable de IHQ&#44; es una limitaci&#243;n del estudio&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">A pesar de que las t&#233;cnicas quir&#250;rgicas realizadas est&#225;n bastante estandarizadas y el criterio t&#233;cnico y de indicaci&#243;n es homog&#233;neo entre los 5 neurocirujanos participantes&#44; existe un te&#243;rico sesgo relacionado con la variabilidad individual en la realizaci&#243;n de la t&#233;cnica quir&#250;rgica&#46; Asimismo&#44; la colocaci&#243;n de un drenaje en la herida quir&#250;rgica es una decisi&#243;n discrecional de cada cirujano que introduce otro elemento de variabilidad&#46; Aunque comparables&#44; ambos grupos difirieron levemente en lo relativo a ciertos factores de riesgo pretratamiento como la obesidad y tabaquismo&#46; Finalmente se trata de un estudio unic&#233;ntrico&#44; cuyas conclusiones deben ser idealmente corroboradas por otros grupos en condiciones de reproducibilidad similares&#46;</p></span></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Conclusiones</span><p id="par0200" class="elsevierStylePara elsevierViewall">La profilaxis de IHQ con polvo de vancomicina t&#243;pico en cirug&#237;a electiva de columna por abordaje posterior bilateral&#44; por patolog&#237;a de cualquier causa o nivel&#44; no redujo de forma estad&#237;sticamente significativa la incidencia de IHQ superficial o profunda&#46; Los resultados de este estudio de cohortes indican una tendencia a favor del tratamiento&#44; aunque no permiten recomendar su empleo de forma rutinaria en todos los pacientes intervenidos&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">El tratamiento con polvo de vancomicina indujo un aumento no estad&#237;sticamente significativo de la incidencia de IHQ profunda por microorganismos gramnegativos&#46; Todas las infecciones curaron con el desbridamiento quir&#250;rgico y&#47;o antibioterapia sist&#233;mica&#46; La profilaxis con polvo de vancomicina no provoc&#243; reacciones adversas locales ni sist&#233;micas ni produjo mayor incidencia de seromas postoperatorios&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Financiaci&#243;n</span><p id="par0210" class="elsevierStylePara elsevierViewall">Este trabajo no ha recibido financiaci&#243;n alguna de agencias p&#250;blicas&#44; entidades sin &#225;nimo de lucro o empresas privadas&#46;</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Conflicto de intereses</span><p id="par0215" class="elsevierStylePara elsevierViewall">Ninguno&#46;</p></span></span>"
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              "titulo" => "Evoluci&#243;n y complicaciones"
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          "titulo" => "Discusi&#243;n"
          "secciones" => array:5 [
            0 => array:2 [
              "identificador" => "sec0050"
              "titulo" => "La vancomicina t&#243;pica en cirug&#237;a de columna"
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            1 => array:2 [
              "identificador" => "sec0055"
              "titulo" => "Efectividad de la vancomicina en la infecci&#243;n de herida quir&#250;rgica"
            ]
            2 => array:2 [
              "identificador" => "sec0060"
              "titulo" => "Posibles efectos adversos de la aplicaci&#243;n t&#243;pica de vancomicina"
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              "identificador" => "sec0065"
              "titulo" => "Controversias"
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              "titulo" => "Limitaciones del estudio"
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          "titulo" => "Conclusiones"
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          "identificador" => "sec0080"
          "titulo" => "Financiaci&#243;n"
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        10 => array:2 [
          "identificador" => "sec0085"
          "titulo" => "Conflicto de intereses"
        ]
        11 => array:1 [
          "titulo" => "Bibliograf&#237;a"
        ]
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    "pdfFichero" => "main.pdf"
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    "fechaRecibido" => "2019-05-20"
    "fechaAceptado" => "2019-07-25"
    "PalabrasClave" => array:2 [
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec1213222"
          "palabras" => array:5 [
            0 => "Polvo de vancomicina"
            1 => "Infecci&#243;n de herida quir&#250;rgica"
            2 => "Profilaxis"
            3 => "Laminectom&#237;a"
            4 => "Artrodesis"
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec1213223"
          "palabras" => array:5 [
            0 => "Vancomycin powder"
            1 => "Surgical site infection"
            2 => "Prophylaxis"
            3 => "Laminectomy"
            4 => "Arthrodesis"
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    "resumen" => array:2 [
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objetivo</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Evaluar la efectividad y seguridad del polvo de vancomicina t&#243;pico como profilaxis de infecci&#243;n de herida quir&#250;rgica &#40;IHQ&#41; en cirug&#237;a de columna electiva por abordaje posterior&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material y m&#233;todos</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Estudio unic&#233;ntrico cuasiexperimental de comparaci&#243;n pre- y postintervenci&#243;n&#46; El grupo postintervenci&#243;n recibi&#243; profilaxis antibi&#243;tica est&#225;ndar preoperatoria junto a 1<span class="elsevierStyleHsp" style=""></span>g de polvo de vancomicina en el lecho quir&#250;rgico antes del cierre de la herida&#46; El grupo preintervenci&#243;n solo recibi&#243; la profilaxis intravenosa&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Participaron 150 pacientes en cada grupo&#46; Ocurrieron 12 infecciones &#40;7 superficiales&#44; 5 profundas&#41; en el grupo postintervenci&#243;n y 16 infecciones &#40;7 superficiales&#44; 9 profundas&#41; en el grupo preintervenci&#243;n&#46; El riesgo de IHQ profunda se redujo del 6&#37; al 3&#44;3&#37; &#40;OR 0&#44;54&#59; IC 95&#37; 0&#44;17-1&#44;65&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;411&#41; con el tratamiento&#46; El porcentaje de IHQ profunda por gramnegativos-positivos fue del 80-20&#37; en el grupo tratado con vancomicina y del 33-67&#37; en los no tratados &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;265&#41;&#46; No se produjeron efectos adversos locales ni sist&#233;micos por el tratamiento&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusi&#243;n</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">La profilaxis con polvo de vancomicina en cirug&#237;a electiva de columna por abordaje posterior no redujo de forma significativa la incidencia de IHQ superficial o profunda&#46; Se constat&#243; una tendencia al aumento de IHQ profunda por microorganismos gramnegativos en los tratados con vancomicina&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Objetivo"
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          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Material y m&#233;todos"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusi&#243;n"
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      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objective</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">To assess the effectiveness and safety of vancomycin powder as surgical site infection &#40;SSI&#41; prophylaxis in posterior bilateral elective spinal surgery&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Materials and methods</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Single-center quasi-experimental pre and postintervention comparative cohort study&#46; The post-intervention group received standard intravenous antibiotic prophylaxis plus 1<span class="elsevierStyleHsp" style=""></span>g of vancomycin powder into the surgical field before wound closure&#44; and the pre-intervention group only the intravenous prophylaxis&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">150 patients were included in each group&#46; Twelve SSI &#40;7 superficial and 5 deep&#41; occurred in the post-intervention group and 16 SSI &#40;7 superficial and 9 deep&#41; in the pre-intervention group&#46; The risk of deep SSI decreased from 6&#46;0&#37; to 3&#46;3&#37; &#40;OR 0&#44;54&#44; 95&#37;CI 0&#46;17-1&#46;65&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;411&#41; with vancomycin powder&#46; The percentage of deep SSI due to gram negative-positive germs were 80&#37;-20&#37; and 33&#37;-67&#37; for the post- and pre-intervention groups&#44; respectively &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;265&#41;&#46; No local or systemic adverse effects occurred attributable to vancomycin powder&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusion</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">In posterior elective spinal surgery&#44; prophylaxis with vancomycin powder did not result in a significantly reduced incidence of superficial and deep SSI&#46; There was a trend towards a higher incidence of deep SSI caused by gram negative microorganisms among those treated with vancomycin&#46;</p></span>"
        "secciones" => array:4 [
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            "identificador" => "abst0025"
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            "identificador" => "abst0030"
            "titulo" => "Materials and methods"
          ]
          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Results"
          ]
          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusion"
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Este trabajo se present&#243; para optar al premio Sixto Obrador 2019 de la Sociedad Espa&#241;ola de Neurocirug&#237;a&#46;</p>"
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        "etiqueta" => "Figura 1"
        "tipo" => "MULTIMEDIAFIGURA"
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        "descripcion" => array:1 [
          "es" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Fotograf&#237;a operatoria de la herida quir&#250;rgica justo antes del cierre de la misma en la que se ha administrado el polvo de vancomicina&#46;</p>"
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          "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">El asterisco &#40;&#42;&#41; indica diferencia estad&#237;sticamente significativa &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41;&#46;</p>"
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Grupo postintervenci&#243;n&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">N</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">150&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#40;57&#41; 38&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#40;62&#41; 41&#44;3&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;6369&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">63&#44;5 &#40;15-86&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">62 &#40;17-90&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;4153&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Etiolog&#237;a &#40;N&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Degenerativo&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">104&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">116&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;1510&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Traumatismo&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;2259&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Tumor&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">11&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;6761&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;4780&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " colspan="4" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Nivel intervenido &#40;N&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Intervenci&#243;n previa en mismo nivel &#40;N&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Riesgo anest&#233;sico &#40;N&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>ASA I&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">30&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;2188&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>ASA II&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>ASA III&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;3406&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Comorbilidad &#40;N&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Diab&#233;tico&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;8704&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Fumador&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;0372&#42;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Obesidad&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">21&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">40&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;0098&#42;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Estancia total media &#40;desviaci&#243;n est&#225;ndar&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">7 &#40;19&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">6 &#40;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;5606&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Estancia postoperatoria mediana &#40;rango&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3 &#40;1-112&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3 &#40;1-63&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#44;0000&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " colspan="4" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">T&#233;cnica quir&#250;rgica &#40;N&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Laminectom&#237;a&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">75&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">94&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;0361&#42;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Laminectom&#237;a<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>fijaci&#243;n&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">52&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">42&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;2626&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Fijaci&#243;n solo&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">21&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">14&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Otra&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;4780&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Drenaje en herida &#40;N&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">135&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">119&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;0162&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Duraci&#243;n media operaci&#243;n en minutos &#40;desviaci&#243;n est&#225;ndar&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">210 &#40;55&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">188 &#40;57&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;0008&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Tiempo medio seguimiento en d&#237;as &#40;desviaci&#243;n est&#225;ndar&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">94 &#40;140&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">131 &#40;272&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;1399&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Exitus &#40;N&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">10&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;6175&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Seroma &#40;N&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;0000&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Infecci&#243;n superficial &#40;N&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;0000&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Infecci&#243;n profunda &#40;N&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;4127&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab2253398.png"
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          "es" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Descripci&#243;n de los hallazgos cl&#237;nicos y demogr&#225;ficos de la cohorte&#46; Comparativa de ambos grupos de estudio</p>"
        ]
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                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="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Vancomicina&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Control&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">OR &#40;IC 95&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Tasa de infecci&#243;n global &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&#44;66&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;72&#40;0&#44;33-1&#44;59&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;5516&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Tasa de infecci&#243;n superficial &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#44;66&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#44;66&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#40;0&#44;34-2&#44;92&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;0000&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Tasa de infecci&#243;n profunda &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#44;33&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#44;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;54&#40;0&#44;17-1&#44;65&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;4115&nbsp;\t\t\t\t\t\t\n
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          "es" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Resultados del estudio prospectivo&#46; Proporci&#243;n y riesgo de infecci&#243;n de herida quir&#250;rgica global&#44; superficial y profunda en ambos grupos</p>"
        ]
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          "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">El asterisco &#40;&#42;&#41; indica diferencia estad&#237;sticamente significativa &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41;&#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="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Cohorte completa&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Intervenci&#243;n sobre 4 niveles o m&#225;s&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">OR 4&#44;71&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;0025&#42;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">DegenerativaTraum&#225;ticatumoral&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">OR 0&#44;18&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;0003&#42;OR 1&#44;28&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;7054OR 10&#44;53&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;0003&#42;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Duraci&#243;n de 200<span class="elsevierStyleHsp" style=""></span>min o m&#225;s&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">OR 2&#44;04&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;2023&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "es" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Factores de riesgo para infecci&#243;n de herida quir&#250;rgica profunda en la cohorte entera&#46; Se muestran el riesgo mediante OR y el valor de significaci&#243;n estad&#237;stica</p>"
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        "tabla" => array:1 [
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            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="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Casos&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Caracter&#237;sticas&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Tiempo hasta la infecci&#243;n&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Microorganismo cultivado&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Tratamiento&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Resultado&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Var&#243;n&#44; 55&#46; Fractura lumbar&#46; Fijaci&#243;n posterior 5 nivelesASA III&#44; DM-2&#44; cirug&#237;a 255<span class="elsevierStyleHsp" style=""></span>min&#44; 41 d&#237;as estancia UCI preoperatoria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10 d&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Escherichia coli</span> sensible&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Desbridamiento quir&#250;rgico<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>antibioterapia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Curaci&#243;nParaplej&#237;a establecida por traumatismo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Var&#243;n&#44; 82&#46; Mieloma L2&#46; Laminectom&#237;a 5 niveles&#46; ASA II&#44; 270<span class="elsevierStyleHsp" style=""></span>min&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">25 d&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Klebsiella pneumoniae</span> sensible&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Desbridamiento quir&#250;rgico<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>antibioterapia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Curaci&#243;nExitus tras 415 d&#237;as por progresi&#243;n de enfermedad&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Var&#243;n&#44; 75&#46; Fractura dorsolumbar&#46; Laminectom&#237;a y fijaci&#243;n 4 niveles&#44; 255<span class="elsevierStyleHsp" style=""></span>min&#46; ASA III&#46; Fumador&#44; obeso&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18 d&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Klebsiella</span><span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Pseudomonas</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Desbridamiento quir&#250;rgico<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span> antibioterapia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Curaci&#243;nExitus por ictus tras 140 d&#237;as&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Var&#243;n&#44; 68&#46; Tumor dorsal&#44; laminectom&#237;a 4 niveles&#44; 465<span class="elsevierStyleHsp" style=""></span>min&#46; ASA III&#44; fumador&#44; obeso&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13 d&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Polimicrobiano&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Desbridamiento quir&#250;rgico<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>antibioterapia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Curaci&#243;n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mujer&#44; 83&#46; Tumor cervicodorsal&#44; laminectom&#237;a 3 niveles&#44; 190<span class="elsevierStyleHsp" style=""></span>min&#46; ASA II&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">27 d&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Staphylococcus epidermidis</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Desbridamiento quir&#250;rgico<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>antibioterapia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Curaci&#243;nRedesbridamiento tras 41 d&#237;as&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "es" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Descripci&#243;n de los casos de infecci&#243;n de herida quir&#250;rgica profunda en el grupo de vancomicina</p>"
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        "etiqueta" => "Tabla 5"
        "tipo" => "MULTIMEDIATABLA"
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">SARM&#58; <span class="elsevierStyleItalic">Staphylococcus aureus</span> resistente a meticilina&#46;</p>"
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            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="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Casos&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Antecedentes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Tiempo hasta la infecci&#243;n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Microorganismo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Tratamiento&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Resultado&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Var&#243;n&#44; 57&#46; Mielopat&#237;a cervical&#44; laminectom&#237;a 5 niveles&#46; ASA II&#44; diab&#233;tico y obeso&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14 d&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">SARM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Desbridamiento quir&#250;rgico<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>antibioterapia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Curaci&#243;n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Var&#243;n&#44; 72&#46; Met&#225;stasis cervical&#44; fijaci&#243;n 4 niveles&#44; 390<span class="elsevierStyleHsp" style=""></span>min&#46; ASA II&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">26 d&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Streptococcus mitis</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Desbridamiento quir&#250;rgico<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>antibioterapia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Curaci&#243;nExitus a los 88 d&#237;as por progresi&#243;n tumor&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Var&#243;n&#44; 74&#46; Met&#225;stasis cervical&#44; fijaci&#243;n 4 niveles&#44; 250<span class="elsevierStyleHsp" style=""></span>min&#46; ASA II&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">26 d&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Streptococcus mitis</span><span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>Enterococo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Desbridamiento quir&#250;rgico<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>antibioterapia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Curaci&#243;n&#46;Exitus tras 11 meses por progresi&#243;n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Var&#243;n&#44; 66&#46; Listesis lumbar&#44; laminectom&#237;a y fijaci&#243;n 2 niveles&#44; 210<span class="elsevierStyleHsp" style=""></span>min&#46; ASA II&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11 d&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Enterococo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Desbridamiento quir&#250;rgico<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>antibioterapia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Curaci&#243;n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mujer&#44; 58&#46; Estenosis lumbar&#44; laminectom&#237;a&#44; 120<span class="elsevierStyleHsp" style=""></span>min&#46; ASA I&#44; diab&#233;tica&#44; obesa&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16 d&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Staphylococcus aureus</span> sensible&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Desbridamiento quir&#250;rgico<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>antibioterapia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Curaci&#243;n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mujer&#44; 79&#46; Linfoma lumbar&#44; laminectom&#237;a&#44; 150<span class="elsevierStyleHsp" style=""></span>min&#46; ASA III&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">38 d&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">SARM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Desbridamiento quir&#250;rgico<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>antibioterapia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Curaci&#243;nExitus 10 meses despu&#233;s por progresi&#243;n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mujer&#44; 35&#46; Hernia L5S1&#44; laminectom&#237;a&#44; 120<span class="elsevierStyleHsp" style=""></span>min&#46; ASA I&#44; obesa&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">27 d&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Escherichia coli</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Desbridamiento quir&#250;rgico<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>antibioterapia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Curaci&#243;n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Var&#243;n&#44; 81&#46; Listesis L4L5&#44; laminectom&#237;a y fijaci&#243;n&#44; 210<span class="elsevierStyleHsp" style=""></span>min&#46; ASA II&#44; obeso&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">28 d&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Staphylococcus epidermidis</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Desbridamiento quir&#250;rgico<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>antibioterapia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Curaci&#243;n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Var&#243;n&#44; 55&#46; Fractura dorsolumbar&#44; laminectom&#237;a y fijaci&#243;n 5 niveles&#44; 250<span class="elsevierStyleHsp" style=""></span>min&#46; ASA II&#44; diab&#233;tico&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10 d&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Escherichia coli</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Desbridamiento quir&#250;rgico<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>antibioterapia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Curaci&#243;n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "es" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Descripci&#243;n de los casos de infecci&#243;n de herida quir&#250;rgica profunda en el grupo de controles</p>"
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                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="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Estudio&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Tipo de estudio&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Hallazgos&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Comentario&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dodson et al&#46;<a class="elsevierStyleCrossRef" href="#bib0445"><span class="elsevierStyleSup">24</span></a>&#44; 2019&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Revisi&#243;n sistem&#225;tica y metaan&#225;lisis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Incluye 25 estudios con grupo control&#46; La vancomicina en polvo disminuye el riesgo de infecci&#243;n &#40;RR 0&#44;55&#59; IC 95&#37; 0&#44;45-0&#44;67&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;0001&#41;&#46; No demostr&#243; aumento de infecciones por gramnegativos &#40;RR 1&#44;11&#59; IC 95&#37; 0&#44;66-1&#44;86&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;701&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">El polvo de vancomicina protege frente a la infecci&#243;n de herida quir&#250;rgica aunque no parece claro el efecto sobre el aumento de incidencia de infecciones por gramnegativos&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Texakalidis et al&#46;<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">25</span></a>&#44; 2019&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Revisi&#243;n sistem&#225;tica y metaan&#225;lisis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">En cirug&#237;a de columna incluye 25 estudios con 16&#46;369 pacientes&#46; La vancomicina en polvo disminuye el riesgo de infecci&#243;n global &#40;OR 0&#44;41&#59; IC 95&#37; 0&#44;30-0&#44;57&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; y en infecci&#243;n profunda &#40;OR 0&#44;31&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; pero no en superficial&#46; No diferencias entre emplear 1<span class="elsevierStyleHsp" style=""></span>g o 2<span class="elsevierStyleHsp" style=""></span>g de polvo de vancomicina&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">El polvo de vancomicina parece proteger de las infecciones de herida quir&#250;rgica&#44; especialmente de las profundas&#46; No parece existir un efecto dosis dependiente entre 1<span class="elsevierStyleHsp" style=""></span>g o 2<span class="elsevierStyleHsp" style=""></span>g&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Tailaiti et al&#46;<a class="elsevierStyleCrossRef" href="#bib0520"><span class="elsevierStyleSup">39</span></a>&#44; 2018&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Revisi&#243;n sistem&#225;tica y metaan&#225;lisis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Incluye 27 estudios y 17&#46;321 pacientes&#46; OR global 0&#44;39 &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;01&#41;&#46; En pacientes instrumentados&#44; OR 0&#44;31 &#40;0&#44;19-050&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;01&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">EL polvo de vancomicina fue eficaz solo si se puso instrumentaci&#243;n&#44; no en el resto&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Xie et al&#46;<a class="elsevierStyleCrossRef" href="#bib0505"><span class="elsevierStyleSup">36</span></a>&#44; 2018&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Revisi&#243;n sistem&#225;tica de la literatura&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Incluye un estudio prospectivo y 9 retrospectivos &#40;2&#46;394 pacientes&#41;&#46; Cuando se emple&#243; 1<span class="elsevierStyleHsp" style=""></span>g de polvo de vancomicina predominaron los gramnegativos&#44; y con 2<span class="elsevierStyleHsp" style=""></span>g los grampositivos&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Parece existir una tendencia a aumentar la incidencia de infecci&#243;n por gramnegativos&#44; que se influye de la dosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Xie et al&#46;<a class="elsevierStyleCrossRef" href="#bib0525"><span class="elsevierStyleSup">40</span></a>&#44; 2017&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Revisi&#243;n sistem&#225;tica y metaan&#225;lisis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Incluye un estudio prospectivo y 19 estudios retrospectivos&#46; Evidencian un riesgo 2&#44;83 veces mayor de infecci&#243;n si no se usa polvo de vancomicina &#40;IC 95&#37; 2&#44;03-3&#44;95&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;083&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">La dosis de polvo y si se espolvorea en toda la herida o no parece influir en la incidencia de infecci&#243;n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ghobrial et al&#46;<a class="elsevierStyleCrossRef" href="#bib0510"><span class="elsevierStyleSup">37</span></a>&#44; 2015&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Revisi&#243;n sistem&#225;tica de la literatura&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Incluy&#243; 16 estudios relativos a complicaciones &#40;6&#46;701 pacientes&#41;&#46; Tasa de infecci&#243;n del 1&#44;36&#37; y del 7&#44;47&#37; en vancomicina y control&#44; respectivamente&#46; Un 0&#44;3&#37; efectos adversos&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Veintitr&#233;s efectos adversos&#58; una nefropat&#237;a&#44; 2 ototoxicidad&#44; una absorci&#243;n sist&#233;mica&#44; 19 seromas con cultivo negativo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">L&#243;pez et al&#46;<a class="elsevierStyleCrossRef" href="#bib0515"><span class="elsevierStyleSup">38</span></a>&#44; 2015&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Revisi&#243;n sistem&#225;tica de la literatura&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Incluye 16 estudios &#40;un ensayo aleatorizado y controlado&#41;&#46; Metodolog&#237;a metaanal&#237;tica GRADE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Vancomicina probablemente no reduce las infecciones en cirug&#237;a de bajo riesgo y dudoso en alto riesgo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Kang et al&#46;<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">16</span></a>&#44; 2015&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Revisi&#243;n sistem&#225;tica de la literatura&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Incluye estudios en PubMed y Ovid solo en ingl&#233;s&#46; Evidencia moderada a favor de la vancomicina en polvo en la incidencia de infecci&#243;n de herida quir&#250;rgica&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No protocolos establecidos respecto a uso y dosis&#46; No efectos secundarios relevantes&#46; Uso discrecional&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Bakhsheshian et al&#46;<a class="elsevierStyleCrossRef" href="#bib0530"><span class="elsevierStyleSup">41</span></a>&#44; 2015&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Revisi&#243;n sistem&#225;tica y metaan&#225;lisis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Incluye un ensayo aleatorizado&#44; 13 estudios comparativos y 4 series de casos&#46; La vancomicina protege de infecci&#243;n profunda &#40;OR 0&#44;23&#59; IC 95&#37; 0&#44;22-0&#44;82&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; y global &#40;OR 0&#44;43&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;01&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Apoya el uso de vancomicina t&#243;pica en el adulto&#46; Es segura&#46; La recomendaci&#243;n se basa casi toda en evidencia clase <span class="elsevierStyleSmallCaps">iii</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "es" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Resumen de estudios tipo revisi&#243;n sistem&#225;tica y metaan&#225;lisis que eval&#250;an el efecto del polvo de vancomicina en la incidencia de infecci&#243;n de herida quir&#250;rgica en cirug&#237;a de columna</p>"
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                            0 => "I&#46; Collins"
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                      "doi" => "10.1007/s00586-007-0559-8"
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                            1 => "P&#46;P&#46; Horsting"
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                      "doi" => "10.1007/s00586-010-1421-y"
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                        "volumen" => "21 Suppl 4"
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                        0 => array:2 [
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Polvo de vancomicina tópico para la prevención de infección de herida quirúrgica en cirugía electiva de columna por vía posterior
Vancomycin powder for the prevention of surgical site infection in posterior elective spinal surgery
Pedro David Delgado-Lópeza,
Autor para correspondencia
pedrodl@yahoo.com

Autor para correspondencia.
, Javier Martín-Alonsoa, Vicente Martín-Velascoa, José Manuel Castilla-Díeza, Ana Galacho-Harrieroa, Sara Ortega-Cuberoa, Ana Isabel Herrero-Gutiérrezb, Antonio Rodríguez-Salazara
a Servicio de Neurocirugía, Hospital Universitario de Burgos, Burgos, España
b Departamento de Enfermería de Neurocirugía, Hospital Universitario de Burgos, Burgos, España
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y la necesidad de implantar material de instrumentaci&#243;n<a class="elsevierStyleCrossRefs" href="#bib0345"><span class="elsevierStyleSup">4&#8211;6</span></a>&#46; En Estados Unidos&#44; la IHQ supone el 22&#37; de todas las infecciones relacionadas con la asistencia m&#233;dica y a&#241;ade entre 1&#46;000 y 10&#46;000 millones de d&#243;lares de sobrecoste cada a&#241;o<a class="elsevierStyleCrossRefs" href="#bib0360"><span class="elsevierStyleSup">7&#8211;9</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">En la pr&#225;ctica habitual se emplea la antibioterapia profil&#225;ctica para intentar reducir la incidencia de IHQ&#46; En general se prescriben cefalosporinas de primera generaci&#243;n por v&#237;a intravenosa &#40;por ejemplo&#44; cefazolina&#41; o vancomicina&#44; administradas 1<span class="elsevierStyleHsp" style=""></span>h antes del inicio de la intervenci&#243;n o durante la inducci&#243;n anest&#233;sica&#44; que pueden mantenerse cada 8<span class="elsevierStyleHsp" style=""></span>h durante 24<span class="elsevierStyleHsp" style=""></span>h o 48<span class="elsevierStyleHsp" style=""></span>h de forma discrecional<a class="elsevierStyleCrossRefs" href="#bib0375"><span class="elsevierStyleSup">10&#44;11</span></a>&#46; Este protocolo se ha demostrado muy eficaz en la prevenci&#243;n de IHQ provocada por <span class="elsevierStyleItalic">Staphylococcus aureus &#40;S&#46; aureus&#41;</span>&#44; que es el microorganismo m&#225;s frecuentemente involucrado<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">12</span></a>&#46; Sin embargo&#44; y dado que un n&#250;mero creciente de cepas de este germen han desarrollado resistencias a m&#250;ltiples antibi&#243;ticos<a class="elsevierStyleCrossRefs" href="#bib0390"><span class="elsevierStyleSup">13&#44;14</span></a>&#44; se ha propuesto una alternativa en adyuvancia a la profilaxis intravenosa&#58; polvo liofilizado de vancomicina espolvoreado directamente sobre el campo quir&#250;rgico previo al cierre de la herida<a class="elsevierStyleCrossRefs" href="#bib0400"><span class="elsevierStyleSup">15&#8211;19</span></a>&#46; De esta forma&#44; se alcanzan concentraciones locales del medicamento tan altas que incluso aquellos microorganismos moderadamente resistentes que puedan permanecer en el lecho quir&#250;rgico son erradicados<a class="elsevierStyleCrossRefs" href="#bib0405"><span class="elsevierStyleSup">16&#44;20</span></a>&#46; La aplicaci&#243;n local de vancomicina se ha demostrado segura en t&#233;rminos de absorci&#243;n y toxicidad sist&#233;micas<a class="elsevierStyleCrossRefs" href="#bib0415"><span class="elsevierStyleSup">18&#44;21</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Dado que el enorme gradiente entre la concentraci&#243;n de vancomicina en el lecho quir&#250;rgico y la circulaci&#243;n sangu&#237;nea destruye pr&#225;cticamente todos los microorganismos&#44; se piensa que este sistema de administraci&#243;n no induce resistencias contra el antibi&#243;tico<a class="elsevierStyleCrossRefs" href="#bib0405"><span class="elsevierStyleSup">16&#44;22</span></a>&#46; Sin embargo&#44; la aplicaci&#243;n t&#243;pica de vancomicina s&#237; parece aumentar el riesgo de IHQ provocada por bacterias gramnegativas<a class="elsevierStyleCrossRefs" href="#bib0440"><span class="elsevierStyleSup">23&#44;24</span></a>&#46; Hasta la fecha no se han comunicado efectos adversos graves asociados a la administraci&#243;n local de vancomicina&#46; An&#225;logamente&#44; la vancomicina t&#243;pica espolvoreada en el espacio subgaleal tambi&#233;n puede emplearse como prevenci&#243;n de la IHQ en craneotom&#237;as<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">25</span></a>&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">En el momento actual no existe una recomendaci&#243;n formal o protocolo estandarizado para el uso de vancomicina t&#243;pica como profilaxis de IHQ en cirug&#237;a de columna y se emplea como indicaci&#243;n <span class="elsevierStyleItalic">off-label</span> &#40;fuera de indicaci&#243;n del prospecto&#41; y de forma discrecional por el cirujano responsable de cada caso&#46; A pesar de las evidencias a favor de su uso&#44; esta forma de administraci&#243;n no ha recibido a&#250;n aprobaci&#243;n por la <span class="elsevierStyleItalic">Food and Drug Administration</span> &#40;FDA&#41; norteamericana ni por la Agencia Europea del Medicamento<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">16</span></a>&#46; El objetivo de este estudio unic&#233;ntrico es valorar de forma prospectiva la efectividad de la vancomicina t&#243;pica como prevenci&#243;n de IHQ en una cohorte homog&#233;nea de pacientes intervenidos de columna&#44; de forma electiva&#44; por abordaje posterior&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material y m&#233;todos</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Dise&#241;o del estudio</span><p id="par0025" class="elsevierStylePara elsevierViewall">Se trata de un estudio unic&#233;ntrico observacional de cohortes de tipo ambispectivo&#44; cuasiexperimental de comparaci&#243;n pre- y postintervenci&#243;n con controles hist&#243;ricos&#44; realizado entre mayo de 2017 y octubre de 2018&#46; El estudio obtuvo la aprobaci&#243;n del Comit&#233; de &#201;tica e Investigaci&#243;n Cl&#237;nica del centro &#40;Ref&#46;&#58; CEIC 1891&#41; incluyendo la aprobaci&#243;n del documento de consentimiento informado empleado&#46; Asimismo&#44; recibi&#243; la aprobaci&#243;n de la Comisi&#243;n de Farmacia y de la Comisi&#243;n de Infecciones y Profilaxis Quir&#250;rgica del centro&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Se incluyeron pacientes consecutivos mayores de 18 a&#241;os que fueron sometidos a cirug&#237;a de columna cervical&#44; dorsal o lumbosacra por abordaje posterior&#44; de forma electiva&#44; por cualquier causa &#40;degenerativa&#44; tumoral&#44; traum&#225;tica&#44; etc&#46;&#41; independientemente del n&#250;mero de niveles afectados&#46; Todos los abordajes quir&#250;rgicos fueron bilaterales&#46; Se excluyeron los abordajes unilaterales o percut&#225;neos y todos los pacientes diagnosticados de cualquier tipo de inmunodepresi&#243;n&#44; en tratamiento inmunosupresor&#44; intervenidos por espondilodiscitis o en tratamiento por infecci&#243;n en cualquier otra localizaci&#243;n&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Se recogieron datos demogr&#225;ficos y de factores de riesgo de infecci&#243;n de cada paciente&#46; Asimismo&#44; se especific&#243; el tratamiento antibi&#243;tico empleado y utilizaci&#243;n de drenaje en herida quir&#250;rgica&#46; En todos los pacientes&#44; el &#225;rea a intervenir se prepar&#243; con soluci&#243;n de povidona yodada&#44; sin rasurado&#44; seg&#250;n t&#233;cnica est&#225;ndar&#46; La profilaxis antibi&#243;tica preoperatoria empleada fue cefazolina en dosis de 1 o 2<span class="elsevierStyleHsp" style=""></span>g por v&#237;a intravenosa &#40;o vancomicina 1<span class="elsevierStyleHsp" style=""></span>g por v&#237;a intravenosa en al&#233;rgicos a betalact&#225;micos&#41; al inicio de la intervenci&#243;n y repitiendo dosis cuando la intervenci&#243;n se prolong&#243; m&#225;s de 4<span class="elsevierStyleHsp" style=""></span>h&#46; Esta pauta se mantuvo 24<span class="elsevierStyleHsp" style=""></span>h tras la intervenci&#243;n&#44; repitiendo dosis cada 8<span class="elsevierStyleHsp" style=""></span>h en caso de cefazolina y cada 12<span class="elsevierStyleHsp" style=""></span>h con vancomicina&#46; En todas las intervenciones participaron 2 neurocirujanos de plantilla &#40;de un grupo de 5&#41; con amplia experiencia en cirug&#237;a de columna&#44; sin participaci&#243;n de residentes&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Los pacientes fueron divididos en 2 grupos&#58; un grupo de tratamiento <span class="elsevierStyleItalic">&#40;grupo postintervenci&#243;n&#41;</span> al que adem&#225;s de la profilaxis antibi&#243;tica intravenosa descrita se le administr&#243; polvo liofilizado de vancomicina t&#243;pica en la herida quir&#250;rgica&#44; y un grupo de comparaci&#243;n <span class="elsevierStyleItalic">&#40;grupo preintervenci&#243;n&#41;</span> que &#250;nicamente recibi&#243; la profilaxis intravenosa&#46; Los pacientes intervenidos de cirug&#237;a electiva en el servicio inmediatamente antes del per&#237;odo de estudio&#44; es decir&#44; entre enero de 2016 y abril de 2017&#44; sirvieron como grupo de comparaci&#243;n&#44; con los mismos criterios de inclusi&#243;n y exclusi&#243;n descritos para el grupo de vancomicina&#46; En el grupo de postintervenci&#243;n se identificaron de forma prospectiva todos los casos de IHQ tanto superficial como profunda&#44; mientras que en el grupo preintervenci&#243;n dicha informaci&#243;n se obtuvo de forma retrospectiva de los historiales m&#233;dicos&#46; Se analizaron los microorganismos involucrados en cada infecci&#243;n y su susceptibilidad antibi&#243;tica&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Protocolo de tratamiento y seguimiento</span><p id="par0045" class="elsevierStylePara elsevierViewall">El protocolo de tratamiento consisti&#243; en esparcir de forma lo m&#225;s uniformemente posible 1<span class="elsevierStyleHsp" style=""></span>g de polvo liofilizado y no reconstituido de vancomicina directamente en la herida quir&#250;rgica antes del cierre&#44; tanto en el plano subfascial &#40;profundo&#41; como suprafascial &#40;superficial&#41; como se muestra en la <a class="elsevierStyleCrossRef" href="#fig0005">figura 1</a>&#46; Previamente se hab&#237;a realizado un adecuado control de la hemostasia y lavado profuso del campo quir&#250;rgico con suero fisiol&#243;gico&#46; Se dej&#243; drenaje en el lecho quir&#250;rgico&#44; a juicio del cirujano responsable del paciente&#44; que se conect&#243; a aspiraci&#243;n suave una vez que la herida estuvo completamente suturada&#46; El drenaje se retir&#243; tras un m&#225;ximo de 3 d&#237;as&#44; aunque generalmente se hace a las 24<span class="elsevierStyleHsp" style=""></span>h&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">La IHQ puede manifestarse como infecci&#243;n superficial o profunda&#46; El diagn&#243;stico de IHQ se realiz&#243; en base a los hallazgos cl&#237;nicos&#44; de laboratorio y microbiol&#243;gicos&#58; supuraci&#243;n de la herida&#44; dehiscencia de los bordes&#44; fiebre&#44; dolor local&#44; aumento de par&#225;metros sangu&#237;neos de inflamaci&#243;n&#47;infecci&#243;n&#44; cultivos microbiol&#243;gicos positivos&#44; o combinaciones de los anteriores&#44; de acuerdo a las recomendaciones de los <span class="elsevierStyleItalic">Centers for Disease Control and Prevention</span> &#40;CDC&#41; norteamericanos<a class="elsevierStyleCrossRefs" href="#bib0455"><span class="elsevierStyleSup">26&#44;27</span></a>&#46; Se define <span class="elsevierStyleItalic">IHQ superficial</span> aquella que afecta a piel y tejidos subcut&#225;neos y que puede resolverse con curas locales de la herida y antibioterapia oral en el plazo de unos d&#237;as&#46; Una <span class="elsevierStyleItalic">IHQ profunda</span> afecta adem&#225;s al compartimento subfascial y requiere para su curaci&#243;n desbridamiento quir&#250;rgico&#44; irrigaci&#243;n de la herida y antibioterapia oral o intravenosa&#46; Es necesario precisar que no es imprescindible una confirmaci&#243;n microbiol&#243;gica para diagnosticar una IHQ&#46; Contrariamente&#44; una colecci&#243;n autolimitada y no purulenta que provoca m&#237;nima inflamaci&#243;n se considera simplemente un <span class="elsevierStyleItalic">seroma</span> postoperatorio&#44; siempre que el cultivo microbiol&#243;gico resulte negativo&#46; Una leve y transitoria inflamaci&#243;n y&#47;o supuraci&#243;n en relaci&#243;n con alguno de los puntos de sutura tampoco se considera IHQ&#46; El seguimiento de los pacientes se realiz&#243; en la consulta externa de Neurocirug&#237;a por el neurocirujano responsable de cada caso&#46; Se registr&#243; el final del seguimiento de cada paciente como la fecha de la &#250;ltima consulta realizada&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Las medias y proporciones de las variables cl&#237;nicas se compararon mediante el estad&#237;stico Z o el estad&#237;stico t de Student &#40;o el test de Wilcoxon&#41;&#44; la prueba de chi-cuadrado y el test exacto de Fisher&#44; asumiendo significaci&#243;n estad&#237;stica con valores de p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#46; Todo el an&#225;lisis estad&#237;stico se realiz&#243; mediante el paquete de software libre <span class="elsevierStyleItalic">Epidat versi&#243;n 3&#46;1</span> &#40;SERGAS&#44; Servicio Gallego de Salud&#41;&#46;</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Resultados</span><p id="par0060" class="elsevierStylePara elsevierViewall">Se reclutaron 150 pacientes en cada grupo &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>300&#41;&#46; En la <a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a> se comparan las caracter&#237;sticas demogr&#225;ficas y cl&#237;nicas de ambos grupos&#46; Ambas cohortes resultaron ser homog&#233;neas y comparables en pr&#225;cticamente todas las variables de estudio&#46; &#218;nicamente destaca una mayor proporci&#243;n de pacientes fumadores &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;0372&#41; en el grupo postintervenci&#243;n y una mayor proporci&#243;n de obesos &#40;&#237;ndice de masa corporal<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>30&#41; en el grupo preintervenci&#243;n &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;0098&#41;&#46; En el grupo postintervenci&#243;n se realizaron menos laminectom&#237;as simples &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;0361&#41; con una tendencia no significativa a realizar m&#225;s fijaciones con o sin laminectom&#237;a&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Efecto global de la vancomicina en la incidencia de infecci&#243;n de herida quir&#250;rgica</span><p id="par0065" class="elsevierStylePara elsevierViewall">Globalmente&#44; ocurrieron 12 infecciones en el grupo postintervenci&#243;n&#44; 7 IHQ superficiales y 5 profundas&#46; En el grupo preintervenci&#243;n ocurrieron 16 infecciones&#44; 7 superficiales y 9 profundas&#46; La incidencia global de IHQ fue del 8&#37; en el grupo de postintervenci&#243;n y del 10&#44;66&#37; en el grupo preintervenci&#243;n&#46; La incidencia de IHQ profunda que precis&#243; re-intervenci&#243;n y desbridamiento fue del 3&#44;33&#37; en el grupo postintervenci&#243;n y del 6&#37; en el grupo preintervenci&#243;n&#44; con una reducci&#243;n relativa del riesgo del 2&#44;66&#37;&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">En la cohorte estudiada&#44; el riesgo de infecci&#243;n profunda en los pacientes tratados con vancomicina fue casi la mitad respecto al grupo control&#44; aunque esta tendencia no alcanz&#243; la significaci&#243;n estad&#237;stica&#58; <span class="elsevierStyleItalic">OR 0&#44;54 &#40;IC 95&#37; 0&#44;17-1&#44;65&#41;&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;4115</span>&#46; El n&#250;mero de pacientes a tratar para prevenir una IHQ profunda fue de 37&#46; Las diferencias de riesgo en la tasa global de infecci&#243;n &#40;OR 0&#44;72&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;55&#41; y en la tasa de infecci&#243;n superficial &#40;OR 0&#44;34&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#41; entre los 2 grupos tampoco resultaron significativas &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">El intervalo de tiempo medio hasta la aparici&#243;n de una infecci&#243;n profunda fue de 18&#44;6 d&#237;as en el grupo postintervenci&#243;n &#40;mediana 18 d&#237;as&#44; rango 10-27 d&#237;as&#41; y de 21&#44;7 d&#237;as en el grupo preintervenci&#243;n &#40;mediana de 26 d&#237;as&#44; rango 10-38 d&#237;as&#41;&#44; diferencias no significativas &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;5397&#41;&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">An&#225;lisis global de la cohorte</span><p id="par0080" class="elsevierStylePara elsevierViewall">En la cohorte completa &#40;N<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>300&#41;&#44; incluyendo los tratados y no tratados con vancomicina&#44; se constat&#243; una tendencia significativa a la infecci&#243;n profunda cuando la intervenci&#243;n se realiz&#243; sobre 4 o m&#225;s niveles espinales &#40;OR 4&#44;71&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;0025&#41;&#46; De igual forma&#44; el motivo de indicaci&#243;n quir&#250;rgica tambi&#233;n fue un factor diferenciador en la cohorte completa&#46; As&#237;&#44; cuando los pacientes se intervinieron por causa degenerativa existi&#243; una menor probabilidad de infecci&#243;n profunda &#40;OR 0&#44;18&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;0011&#41; y cuando lo hicieron por causa tumoral&#44; esta probabilidad fue significativamente mayor &#40;OR 10&#44;53&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;0003&#41;&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">La duraci&#243;n de la intervenci&#243;n por encima de 200<span class="elsevierStyleHsp" style=""></span>min &#40;aproximadamente el promedio de ambos grupos&#41; predispuso a la infecci&#243;n profunda&#44; aunque de forma no significativa &#40;OR 2&#44;04&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;2023&#41;&#46; Estos resultados se muestran en la <a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a>&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Evoluci&#243;n y complicaciones</span><p id="par0090" class="elsevierStylePara elsevierViewall">Todas las IHQ superficiales se resolvieron con antibioterapia oral&#46; Asimismo&#44; todas las IHQ profundas se resolvieron con la reintervenci&#243;n y el desbridamiento junto a antibioterapia sist&#233;mica&#44; inicialmente emp&#237;rica y posteriormente dirigida por antibiograma&#46; Los microorganismos implicados en las IHQ se detallan en las <a class="elsevierStyleCrossRefs" href="#tbl0020">tablas 4 y 5</a>&#46; El porcentaje de IHQ profunda causadas por grampositivos y gramnegativos fue del 20&#37; y del 80&#37; respectivamente en los tratados con vancomicina&#44; y del 67&#37; y del 33&#37;&#44; respectivamente en los no tratados&#44; diferencias evidentes&#44; aunque no significativas &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;2646&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">No se constataron efectos adversos locales ni sist&#233;micos achacables al tratamiento local con vancomicina&#46; Aunque los pacientes con comorbilidades &#40;diabetes&#44; etc&#46;&#41; fueron m&#225;s proclives a la infecci&#243;n profunda&#44; esta tendencia no result&#243; significativa&#46; Todas las IHQ y los seromas eventualmente se resolvieron con el tratamiento administrado y las curas de las heridas&#46; El seguimiento mediano result&#243; similar en ambos grupos&#44; siendo en el grupo postintervenci&#243;n de 94 d&#237;as &#40;rango&#44; 4-562 d&#237;as&#41; y de 131 d&#237;as &#40;rango&#44; 15-1&#46;018&#41; en el grupo preintervenci&#243;n &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;1399&#41;&#46; No se constataron reactivaciones de infecciones tratadas y curadas ni se produjeron reingresos por esta causa&#46; En el grupo postintervenci&#243;n se reintervinieron 2 pacientes&#44; uno por hematoma de lecho quir&#250;rgico y otro por f&#237;stula de LCR&#46; En el grupo preintervenci&#243;n se reintervinieron 3 pacientes&#44; todos por f&#237;stula de LCR&#46; Todos los casos de f&#237;stula se resolvieron y los cultivos de LCR y de la herida quir&#250;rgica fueron negativos&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">A lo largo del per&#237;odo de estudio&#44; se constataron 17 fallecimientos en total &#40;5&#44;7&#37; de la cohorte completa&#41;&#44; 10 en el grupo postintervenci&#243;n y 7 en el grupo preintervenci&#243;n &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;6175&#41;&#44; ninguno relacionado directamente con la IHQ&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Discusi&#243;n</span><p id="par0105" class="elsevierStylePara elsevierViewall">Los resultados de este estudio muestran una tendencia a la reducci&#243;n de las IHQ profundas que precisan desbridamiento quir&#250;rgico cuando se emplea de forma sistem&#225;tica la vancomicina en polvo en el lecho quir&#250;rgico&#44; en pacientes intervenidos de columna por abordaje posterior bilateral por cualquier etiolog&#237;a&#46; Por otra parte&#44; no se constataron efectos adversos locales o sist&#233;micos relacionados con la administraci&#243;n t&#243;pica de vancomicina&#44; ni hubo mayor incidencia de seromas&#46; S&#237; se constat&#243; una tendencia no significativa al aumento de las IHQ profundas por microorganismos gramnegativos en el grupo tratado con vancomicina&#44; aunque no se seleccionaron microorganismos resistentes&#44; en la l&#237;nea de lo publicado recientemente<a class="elsevierStyleCrossRef" href="#bib0445"><span class="elsevierStyleSup">24</span></a>&#46;</p><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">La vancomicina t&#243;pica en cirug&#237;a de columna</span><p id="par0110" class="elsevierStylePara elsevierViewall">La vancomicina es un antibi&#243;tico glucop&#233;ptido producido por el microorganismo <span class="elsevierStyleItalic">Amycolatopsis orientalis</span>&#44; aislado por primera vez en 1953 por Edmund Kornfeld<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">16</span></a>&#46; Su mecanismo bactericida consiste en la inhibici&#243;n de la bios&#237;ntesis de la pared bacteriana pr&#225;cticamente solo de las bacterias grampositivas&#46; Dada su mala absorci&#243;n intestinal&#44; en 1958 la FDA aprob&#243; su uso por v&#237;a intravenosa para el tratamiento de infecciones graves por estafilococos resistentes a meticilina<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">28</span></a>&#46; Los CDC recomendaron su empleo como profilaxis quir&#250;rgica en cirug&#237;a mayor que precise implantar pr&#243;tesis en centros con tasas altas de infecci&#243;n por estafilococo resistente a meticilina<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">16</span></a>&#46; En 1986 la FDA aprob&#243; la administraci&#243;n oral de vancomicina para el tratamiento de la colitis seudomembranosa por <span class="elsevierStyleItalic">Clostridium difficile</span><a class="elsevierStyleCrossRef" href="#bib0470"><span class="elsevierStyleSup">29</span></a>&#46; Sin embargo&#44; la administraci&#243;n t&#243;pica de vancomicina no consta por el momento entre las formas de administraci&#243;n descritas en el prospecto del f&#225;rmaco&#44; no tiene la aprobaci&#243;n formal de la FDA ni de la Agencia Europea del Medicamento&#44; por lo que su uso est&#225; supeditado a la aprobaci&#243;n institucional de cada centro en el contexto de estudios sobre su eficacia y seguridad&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">El <span class="elsevierStyleItalic">S&#46; aureus</span> supone el 30&#37; de todas las IHQ globalmente y al menos el 50&#37; de las infecciones en procedimientos ortop&#233;dicos y neuroquir&#250;rgicos<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">30</span></a>&#46; Dado que el porcentaje de cepas estafiloc&#243;cicas resistentes a meticilina supera el 50&#37;<a class="elsevierStyleCrossRefs" href="#bib0390"><span class="elsevierStyleSup">13&#44;31</span></a>&#44; la profilaxis intravenosa habitual puede no ser eficaz&#46; La administraci&#243;n t&#243;pica del polvo de vancomicina en la herida quir&#250;rgica se ha demostrado efectiva contra bacterias grampositivas&#44; incluso contra aquellas moderadamente resistentes&#44; debido a la elevada concentraci&#243;n local del f&#225;rmaco que se alcanza<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">16</span></a>&#46; Esta forma de administraci&#243;n impide la absorci&#243;n r&#225;pida del medicamento con lo que se minimizan los efectos sist&#233;micos del mismo<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">18</span></a>&#46; Asimismo&#44; el enorme gradiente de concentraci&#243;n que se crea entre la superficie de la herida y la circulaci&#243;n sangu&#237;nea adyacente erradica pr&#225;cticamente el 100&#37; de los estafilococos presentes en la herida&#44; y parece proteger frente a la creaci&#243;n de resistencias al f&#225;rmaco<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">22</span></a>&#44; por lo que te&#243;ricamente no se seleccionan cepas resistentes&#46; Esta hip&#243;tesis&#44; sin embargo&#44; no se ha evaluado de forma espec&#237;fica en estudios cl&#237;nicos&#46; La absorci&#243;n sist&#233;mica de vancomicina tras la aplicaci&#243;n t&#243;pica parece m&#237;nima<a class="elsevierStyleCrossRefs" href="#bib0415"><span class="elsevierStyleSup">18&#44;22</span></a> o nula<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">32</span></a> seg&#250;n varios estudios que evaluaron las concentraciones plasm&#225;ticas de vancomicina tras su administraci&#243;n t&#243;pica&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Efectividad de la vancomicina en la infecci&#243;n de herida quir&#250;rgica</span><p id="par0120" class="elsevierStylePara elsevierViewall">El polvo de vancomicina en las heridas quir&#250;rgicas se empez&#243; a utilizar en los a&#241;os 80 en cirug&#237;a card&#237;aca para disminuir la tasa de infecci&#243;n en las esternotom&#237;as<a class="elsevierStyleCrossRefs" href="#bib0435"><span class="elsevierStyleSup">22&#44;33</span></a>&#46; En las &#250;ltimas 2 d&#233;cadas&#44; numerosos estudios han testeado el efecto de la vancomicina en polvo sobre la incidencia de IHQ en procedimientos espinales&#46; La gran mayor&#237;a de los estudios son series retrospectivas<a class="elsevierStyleCrossRefs" href="#bib0385"><span class="elsevierStyleSup">12&#44;17&#44;19&#44;34</span></a> y &#250;nicamente consta un ensayo cl&#237;nico aleatorizado<a class="elsevierStyleCrossRef" href="#bib0500"><span class="elsevierStyleSup">35</span></a>&#46; La <a class="elsevierStyleCrossRef" href="#tbl0030">tabla 6</a> muestra las conclusiones de los estudios de revisi&#243;n sistem&#225;tica de la literatura<a class="elsevierStyleCrossRefs" href="#bib0405"><span class="elsevierStyleSup">16&#44;36&#8211;38</span></a> y metaan&#225;lisis<a class="elsevierStyleCrossRefs" href="#bib0445"><span class="elsevierStyleSup">24&#44;25&#44;39&#8211;41</span></a> publicados en los &#250;ltimos a&#241;os respecto al efecto del polvo de vancomicina en la incidencia de IHQ tras cirug&#237;a espinal&#46;</p><elsevierMultimedia ident="tbl0030"></elsevierMultimedia><p id="par0125" class="elsevierStylePara elsevierViewall">Los trabajos de revisi&#243;n publicados a partir de 2015&#44; que ya incluyen decenas de miles de casos&#44; muestran una evidencia cada vez m&#225;s s&#243;lida de que el polvo de vancomicina protege de la IHQ&#44; especialmente de la infecci&#243;n profunda&#44; sin que se establezca una clara relaci&#243;n dosis-respuesta&#46; El metaan&#225;lisis de Dodson et al&#46;<a class="elsevierStyleCrossRef" href="#bib0445"><span class="elsevierStyleSup">24</span></a>&#44; publicado en enero de 2019&#44; confirma la eficacia de este tratamiento y comunica un riesgo de IHQ combinado de 0&#44;55 &#40;0&#44;45-0&#44;67&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;0001&#41;&#44; muy similar al encontrado en el presente estudio&#46; Asimismo&#44; se constat&#243; una tendencia no significativa al aumento de infecciones por g&#233;rmenes gramnegativos &#40;OR 1&#44;11&#59; IC 95&#37; 0&#44;66-1&#44;86&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;701&#41;&#46; En todos los trabajos se hace hincapi&#233; en la necesidad de contar con estudios prospectivos y en la correcta definici&#243;n de IHQ&#46; En las diversas revisiones sistem&#225;ticas se muestra la efectividad del tratamiento&#44; se constata la ausencia de complicaciones graves sist&#233;micas o locales&#44; y se discuten aspectos controvertidos como la incidencia de seudoartrosis&#44; seromas o complicaciones sist&#233;micas derivadas del uso de vancomicina t&#243;pica&#46; En el a&#241;o 2017&#44; sin embargo&#44; el <span class="elsevierStyleItalic">American College of Surgeons</span><a class="elsevierStyleCrossRef" href="#bib0535"><span class="elsevierStyleSup">42</span></a> y los CDC<a class="elsevierStyleCrossRef" href="#bib0540"><span class="elsevierStyleSup">43</span></a> publicaron unas gu&#237;as para la prevenci&#243;n de la IHQ en las que no se recomienda de manera expl&#237;cita el uso de polvo de vancomicina como profilaxis quir&#250;rgica y se resalta la necesidad de futuros estudios sobre el tema&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Varios estudios de coste-efectividad<a class="elsevierStyleCrossRefs" href="#bib0545"><span class="elsevierStyleSup">44&#8211;46</span></a> han constatado ahorros por encima de 200&#46;000 a 400&#46;000 d&#243;lares por cada 100 procedimientos quir&#250;rgicos de fusi&#243;n espinal por traumatismos o deformidades toracolumbares&#44; cuando se emplea el polvo de vancomicina&#44; asumiendo un coste por vial de entre 30 y 40 d&#243;lares&#44; precio bastante superior al que se obtiene en Espa&#241;a&#44; que se encuentra en torno a 1-6 euros por vial de 1<span class="elsevierStyleHsp" style=""></span>g &#40;el coste en nuestro centro es de 1&#44;76&#8364; por vial de 1<span class="elsevierStyleHsp" style=""></span>g&#41;&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">En los diversos trabajos se han empleado dosis t&#243;picas de vancomicina de entre 0&#44;5<span class="elsevierStyleHsp" style=""></span>g y 6<span class="elsevierStyleHsp" style=""></span>g<a class="elsevierStyleCrossRefs" href="#bib0440"><span class="elsevierStyleSup">23&#44;32</span></a>&#44; aunque la mayor&#237;a de los estudios se han realizado con 1<span class="elsevierStyleHsp" style=""></span>g de polvo liofilizado&#46; No existe un protocolo estandarizado sobre c&#243;mo se debe repartir la dosis del f&#225;rmaco en el campo quir&#250;rgico&#46; La recomendaci&#243;n general es espolvorearlo sobre toda la herida&#44; incluyendo los compartimentos infra- y suprafasciales&#44; sobre el injerto &#243;seo cuando este se emplea y sobre la superficie de la duramadre&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Posibles efectos adversos de la aplicaci&#243;n t&#243;pica de vancomicina</span><p id="par0140" class="elsevierStylePara elsevierViewall">Diversos trabajos y el &#250;ltimo metaan&#225;lisis publicado sugieren la posibilidad de que el polvo de vancomicina favorezca la aparici&#243;n de IHQ por microorganismos<span class="elsevierStyleItalic">gramnegativos</span><a class="elsevierStyleCrossRefs" href="#bib0445"><span class="elsevierStyleSup">24&#44;32</span></a>&#46; En nuestra serie as&#237; lo hemos constatado tambi&#233;n&#44; de forma que en el grupo postintervenci&#243;n el 80&#37; de IHQ fueron causadas por gramnegativos&#44; mientras que solo el 33&#37; lo fue en el grupo preintervenci&#243;n&#44; diferencias importantes&#44; aunque no estad&#237;sticamente significativas&#44; probablemente debido a la baja prevalencia basal y al tama&#241;o muestral&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Desde un punto de vista te&#243;rico&#44; surge la duda sobre el posible efecto que el polvo de vancomicina pudiera tener como inhibidor de la formaci&#243;n &#243;sea &#40;en intervenciones que impliquen artrodesis&#41; y en el posible aumento en la incidencia de <span class="elsevierStyleItalic">seudoartrosis</span>&#46; Seg&#250;n algunos estudios&#44; la concentraci&#243;n de vancomicina que resulta citot&#243;xica para los osteoblastos debe ser mayor de 10&#46;000<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;ml<a class="elsevierStyleCrossRef" href="#bib0560"><span class="elsevierStyleSup">47</span></a>&#44; concentraci&#243;n que no parece alcanzarse mediante administraci&#243;n t&#243;pica<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">16</span></a>&#46; La vancomicina es&#44; adem&#225;s&#44; menos t&#243;xica sobre la regeneraci&#243;n &#243;sea que las quinolonas<a class="elsevierStyleCrossRef" href="#bib0565"><span class="elsevierStyleSup">48</span></a> o la gentamicina<a class="elsevierStyleCrossRef" href="#bib0570"><span class="elsevierStyleSup">49</span></a>&#46; La revisi&#243;n de Alcal&#225;-Cerra et al&#46;<a class="elsevierStyleCrossRef" href="#bib0575"><span class="elsevierStyleSup">50</span></a> indica que el uso de polvo de vancomicina no favorece la aparici&#243;n de seudoartrosis aunque&#44; por el momento&#44; no existen estudios prospectivos cl&#237;nicos que eval&#250;en espec&#237;ficamente este punto&#46; El per&#237;odo de seguimiento de nuestra serie no permite obtener conclusiones al respecto&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Otra posible complicaci&#243;n achacada al polvo de vancomicina es la formaci&#243;n de <span class="elsevierStyleItalic">seromas</span> en las heridas&#46; El estudio de Ghobrial et al&#46;<a class="elsevierStyleCrossRef" href="#bib0440"><span class="elsevierStyleSup">23</span></a> mostr&#243; un aumento en la incidencia de seromas postoperatorios en una cohorte de pacientes tratados con polvo de vancomicina&#44; aunque no se compar&#243; con un grupo control&#46; En nuestra serie no se evidenci&#243; una diferencia significativa&#58; aparecieron 3 seromas en el grupo postintervenci&#243;n y 4 en el grupo preintervenci&#243;n&#44; todos ellos se solucionaron con curas locales de la herida&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Finalmente&#44; se han descrito <span class="elsevierStyleItalic">efectos generales</span> como absorci&#243;n sist&#233;mica con niveles sangu&#237;neos supraterap&#233;uticos&#44; nefro- u ototoxicidad&#44; todos ellos de forma muy espor&#225;dica y casi excepcional<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">16</span></a>&#46; Globalmente&#44; la incidencia de efectos adversos&#44; incluyendo los seromas no llega al 0&#44;3&#37;<a class="elsevierStyleCrossRef" href="#bib0510"><span class="elsevierStyleSup">37</span></a>&#46; DeFrancesco et al&#46;<a class="elsevierStyleCrossRef" href="#bib0580"><span class="elsevierStyleSup">51</span></a> solo evidenciaron una reacci&#243;n cut&#225;nea adversa transitoria sobre 1&#46;398 casos de utilizaci&#243;n de polvo de vancomicina en cirug&#237;a de escoliosis en un estudio multic&#233;ntrico en 10 centros de Europa y Estados Unidos&#46; El &#250;nico caso grave documentado en la literatura es un paciente que sufri&#243; un colapso circulatorio que precis&#243; aminas en el postoperatorio&#44; en principio achacado a una posible reacci&#243;n anafilactoide a la vancomicina en polvo&#44; pero que ocurri&#243; en el contexto de una vertebrectom&#237;a para una met&#225;stasis espinal de mama en la que se perdieron 2<span class="elsevierStyleHsp" style=""></span>l de sangre y se precisaron m&#250;ltiples transfusiones de sangre&#44; plasma y otros derivados<a class="elsevierStyleCrossRef" href="#bib0585"><span class="elsevierStyleSup">52</span></a>&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">La aplicaci&#243;n del polvo de vancomicina directamente encima de la superficie dural es una maniobra factible<a class="elsevierStyleCrossRef" href="#bib0590"><span class="elsevierStyleSup">53</span></a> y segura que&#44; en nuestra experiencia&#44; no ha producido complicaciones neurol&#243;gicas&#46; Sin embargo&#44; el estudio de Goldschmidt et al&#46;<a class="elsevierStyleCrossRef" href="#bib0595"><span class="elsevierStyleSup">54</span></a> comprob&#243;&#44; en un modelo in vitro&#44; que la duramadre expuesta a altas concentraciones de vancomicina experimenta procesos de muerte celular&#44; inhibici&#243;n del crecimiento y alteraciones de la morfolog&#237;a celular&#44; de intensidad dosis-dependiente&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Controversias</span><p id="par0165" class="elsevierStylePara elsevierViewall">La farmacocin&#233;tica de la vancomicina administrada en polvo no es bien conocida y se requieren estudios b&#225;sicos y cl&#237;nicos que definan espec&#237;ficamente su perfil de absorci&#243;n&#44; distribuci&#243;n y metabolismo&#46; La decisi&#243;n sobre la dosis a emplear &#40;en general 1 o 2<span class="elsevierStyleHsp" style=""></span>g de polvo&#41; contin&#250;a siendo discrecional y no existen estudios cl&#237;nicos que avalen una dosificaci&#243;n en concreto&#46; El reciente estudio de Haimoto et al&#46;<a class="elsevierStyleCrossRef" href="#bib0600"><span class="elsevierStyleSup">55</span></a> sugiere la posibilidad de espolvorear la vancomicina &#250;nicamente en el compartimento suprafascial&#44; al parecer obteniendo los mismos efectos beneficiosos&#44; pero evitando la posibilidad de absorci&#243;n sist&#233;mica&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">A tenor de los estudios publicados&#44; es muy posible que su empleo cambie el patr&#243;n etiol&#243;gico hacia una mayor incidencia de infecciones por gramnegativos y polimicrobianos<a class="elsevierStyleCrossRefs" href="#bib0605"><span class="elsevierStyleSup">56&#8211;58</span></a>&#46; Esta tendencia&#44; sin embargo&#44; a priori no parece relevante desde el punto de vista de la curaci&#243;n de la infecci&#243;n&#44; estancia hospitalaria ni del desarrollo de cepas resistentes a los antibi&#243;ticos usados<a class="elsevierStyleCrossRef" href="#bib0605"><span class="elsevierStyleSup">56</span></a>&#44; ni tampoco a la vancomicina<a class="elsevierStyleCrossRef" href="#bib0620"><span class="elsevierStyleSup">59</span></a>&#46; Un reciente ensayo aleatorizado ha comparado el uso local de 1<span class="elsevierStyleHsp" style=""></span>g polvo de vancomicina con 1<span class="elsevierStyleHsp" style=""></span>g de polvo de ampicilina&#44; en pacientes sometidos a cirug&#237;as de fusi&#243;n tor&#225;cica o lumbar&#44; sin encontrar diferencias significativas en la tasa de IHQ<a class="elsevierStyleCrossRef" href="#bib0625"><span class="elsevierStyleSup">60</span></a>&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Otra cuesti&#243;n interesante es si se debe esperar un a&#241;o de evoluci&#243;n como recomienda el CDC<a class="elsevierStyleCrossRefs" href="#bib0460"><span class="elsevierStyleSup">27&#44;43</span></a>&#44; para poder descartar la presencia de IHQ&#44; dado que las infecciones&#44; tanto superficiales como profundas&#44; aparecen mucho m&#225;s precozmente como hemos constatado en nuestra serie&#46; El hecho de que no se haya producido ninguna reactivaci&#243;n de una IHQ previa ni reingresos tard&#237;os por infecci&#243;n&#44; tras casi 2 a&#241;os de evoluci&#243;n del grupo control&#44; avala esta afirmaci&#243;n&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">La cuesti&#243;n m&#225;s controvertida respecto al uso de polvo de vancomicina en profilaxis de IHQ es si esta debe administrarse de forma seleccionada&#44; como sugieren algunos estudios recientes<a class="elsevierStyleCrossRefs" href="#bib0630"><span class="elsevierStyleSup">61&#44;62</span></a>&#44; o de forma sistematizada a todos los pacientes<a class="elsevierStyleCrossRef" href="#bib0520"><span class="elsevierStyleSup">39</span></a>&#46; A favor de la primera opci&#243;n&#44; y seg&#250;n los resultados de este estudio&#44; podemos afirmar que los pacientes con factores de riesgo &#40;diab&#233;ticos&#44; obesos&#44; fumadores&#41;&#44; aquellos intervenidos por causa tumoral y en los que se realizan fijaciones dorsales de m&#250;ltiples niveles parecen beneficiarse m&#225;s del tratamiento&#46; En apoyo al uso sistem&#225;tico&#44; podr&#237;a argumentarse que se trata de un tratamiento muy sencillo de aplicar&#44; no consume tiempo quir&#250;rgico apenas&#44; no produce toxicidad local ni sist&#233;mica relevante&#44; es muy barato y reduce costes&#44; pues evita una infecci&#243;n grave por cada 37 pacientes a los que se les administra&#46; En procedimientos espinales en la infancia&#44; el n&#250;mero de pacientes a tratar para evitar una infecci&#243;n se estima en solo 9 por lo que algunos recomiendan su uso de forma rutinaria<a class="elsevierStyleCrossRef" href="#bib0640"><span class="elsevierStyleSup">63</span></a>&#46; A nuestro juicio el caso ideal ser&#237;a el de un paciente obeso o diab&#233;tico que precisa una cirug&#237;a instrumentada dorsal de m&#225;s de 4 niveles&#44; especialmente por causa tumoral<a class="elsevierStyleCrossRef" href="#bib0645"><span class="elsevierStyleSup">64</span></a>&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">Este tratamiento se emplea actualmente como uso compasivo y fuera de indicaci&#243;n formal del prospecto del medicamento&#46; Su aprobaci&#243;n institucional queda pendiente a pesar de la creciente evidencia a favor de su uso y su perfil de seguridad&#46; Esta evidencia parece que empieza a extenderse tambi&#233;n al &#225;mbito de la cirug&#237;a craneal<a class="elsevierStyleCrossRefs" href="#bib0450"><span class="elsevierStyleSup">25&#44;65</span></a>&#44; lo que de confirmarse probablemente tendr&#225; implicaciones relevantes en la pr&#225;ctica neuroquir&#250;rgica habitual&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Limitaciones del estudio</span><p id="par0190" class="elsevierStylePara elsevierViewall">Este estudio tiene una serie de limitaciones&#46; Se trata de un estudio no aleatorizado de cohortes prospectivo en el grupo de tratamiento&#44; aunque retrospectivo en el grupo que sirve de comparaci&#243;n&#44; por lo que los resultados en este grupo pueden estar sujetos a sesgos de recuerdo o de registro en el historial&#46; El escaso n&#250;mero de eventos infecciosos ocurridos &#40;14 en total&#44; 9 en preintervenci&#243;n y 5 en postintervenci&#243;n&#41; hace dif&#237;cil hallar diferencias estad&#237;sticamente significativas e impiden la realizaci&#243;n de an&#225;lisis estratificados&#46; La ausencia de c&#225;lculo del tama&#241;o muestral a priori&#44; teniendo en cuenta la baja incidencia esperable de IHQ&#44; es una limitaci&#243;n del estudio&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">A pesar de que las t&#233;cnicas quir&#250;rgicas realizadas est&#225;n bastante estandarizadas y el criterio t&#233;cnico y de indicaci&#243;n es homog&#233;neo entre los 5 neurocirujanos participantes&#44; existe un te&#243;rico sesgo relacionado con la variabilidad individual en la realizaci&#243;n de la t&#233;cnica quir&#250;rgica&#46; Asimismo&#44; la colocaci&#243;n de un drenaje en la herida quir&#250;rgica es una decisi&#243;n discrecional de cada cirujano que introduce otro elemento de variabilidad&#46; Aunque comparables&#44; ambos grupos difirieron levemente en lo relativo a ciertos factores de riesgo pretratamiento como la obesidad y tabaquismo&#46; Finalmente se trata de un estudio unic&#233;ntrico&#44; cuyas conclusiones deben ser idealmente corroboradas por otros grupos en condiciones de reproducibilidad similares&#46;</p></span></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Conclusiones</span><p id="par0200" class="elsevierStylePara elsevierViewall">La profilaxis de IHQ con polvo de vancomicina t&#243;pico en cirug&#237;a electiva de columna por abordaje posterior bilateral&#44; por patolog&#237;a de cualquier causa o nivel&#44; no redujo de forma estad&#237;sticamente significativa la incidencia de IHQ superficial o profunda&#46; Los resultados de este estudio de cohortes indican una tendencia a favor del tratamiento&#44; aunque no permiten recomendar su empleo de forma rutinaria en todos los pacientes intervenidos&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">El tratamiento con polvo de vancomicina indujo un aumento no estad&#237;sticamente significativo de la incidencia de IHQ profunda por microorganismos gramnegativos&#46; Todas las infecciones curaron con el desbridamiento quir&#250;rgico y&#47;o antibioterapia sist&#233;mica&#46; La profilaxis con polvo de vancomicina no provoc&#243; reacciones adversas locales ni sist&#233;micas ni produjo mayor incidencia de seromas postoperatorios&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Financiaci&#243;n</span><p id="par0210" class="elsevierStylePara elsevierViewall">Este trabajo no ha recibido financiaci&#243;n alguna de agencias p&#250;blicas&#44; entidades sin &#225;nimo de lucro o empresas privadas&#46;</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Conflicto de intereses</span><p id="par0215" class="elsevierStylePara elsevierViewall">Ninguno&#46;</p></span></span>"
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              "titulo" => "Evoluci&#243;n y complicaciones"
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          "titulo" => "Discusi&#243;n"
          "secciones" => array:5 [
            0 => array:2 [
              "identificador" => "sec0050"
              "titulo" => "La vancomicina t&#243;pica en cirug&#237;a de columna"
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            1 => array:2 [
              "identificador" => "sec0055"
              "titulo" => "Efectividad de la vancomicina en la infecci&#243;n de herida quir&#250;rgica"
            ]
            2 => array:2 [
              "identificador" => "sec0060"
              "titulo" => "Posibles efectos adversos de la aplicaci&#243;n t&#243;pica de vancomicina"
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              "identificador" => "sec0065"
              "titulo" => "Controversias"
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              "titulo" => "Limitaciones del estudio"
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          "titulo" => "Conclusiones"
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          "identificador" => "sec0080"
          "titulo" => "Financiaci&#243;n"
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        10 => array:2 [
          "identificador" => "sec0085"
          "titulo" => "Conflicto de intereses"
        ]
        11 => array:1 [
          "titulo" => "Bibliograf&#237;a"
        ]
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    "pdfFichero" => "main.pdf"
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    "fechaRecibido" => "2019-05-20"
    "fechaAceptado" => "2019-07-25"
    "PalabrasClave" => array:2 [
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec1213222"
          "palabras" => array:5 [
            0 => "Polvo de vancomicina"
            1 => "Infecci&#243;n de herida quir&#250;rgica"
            2 => "Profilaxis"
            3 => "Laminectom&#237;a"
            4 => "Artrodesis"
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec1213223"
          "palabras" => array:5 [
            0 => "Vancomycin powder"
            1 => "Surgical site infection"
            2 => "Prophylaxis"
            3 => "Laminectomy"
            4 => "Arthrodesis"
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    "resumen" => array:2 [
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objetivo</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Evaluar la efectividad y seguridad del polvo de vancomicina t&#243;pico como profilaxis de infecci&#243;n de herida quir&#250;rgica &#40;IHQ&#41; en cirug&#237;a de columna electiva por abordaje posterior&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material y m&#233;todos</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Estudio unic&#233;ntrico cuasiexperimental de comparaci&#243;n pre- y postintervenci&#243;n&#46; El grupo postintervenci&#243;n recibi&#243; profilaxis antibi&#243;tica est&#225;ndar preoperatoria junto a 1<span class="elsevierStyleHsp" style=""></span>g de polvo de vancomicina en el lecho quir&#250;rgico antes del cierre de la herida&#46; El grupo preintervenci&#243;n solo recibi&#243; la profilaxis intravenosa&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Participaron 150 pacientes en cada grupo&#46; Ocurrieron 12 infecciones &#40;7 superficiales&#44; 5 profundas&#41; en el grupo postintervenci&#243;n y 16 infecciones &#40;7 superficiales&#44; 9 profundas&#41; en el grupo preintervenci&#243;n&#46; El riesgo de IHQ profunda se redujo del 6&#37; al 3&#44;3&#37; &#40;OR 0&#44;54&#59; IC 95&#37; 0&#44;17-1&#44;65&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;411&#41; con el tratamiento&#46; El porcentaje de IHQ profunda por gramnegativos-positivos fue del 80-20&#37; en el grupo tratado con vancomicina y del 33-67&#37; en los no tratados &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;265&#41;&#46; No se produjeron efectos adversos locales ni sist&#233;micos por el tratamiento&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusi&#243;n</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">La profilaxis con polvo de vancomicina en cirug&#237;a electiva de columna por abordaje posterior no redujo de forma significativa la incidencia de IHQ superficial o profunda&#46; Se constat&#243; una tendencia al aumento de IHQ profunda por microorganismos gramnegativos en los tratados con vancomicina&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Objetivo"
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          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Material y m&#233;todos"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusi&#243;n"
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      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objective</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">To assess the effectiveness and safety of vancomycin powder as surgical site infection &#40;SSI&#41; prophylaxis in posterior bilateral elective spinal surgery&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Materials and methods</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Single-center quasi-experimental pre and postintervention comparative cohort study&#46; The post-intervention group received standard intravenous antibiotic prophylaxis plus 1<span class="elsevierStyleHsp" style=""></span>g of vancomycin powder into the surgical field before wound closure&#44; and the pre-intervention group only the intravenous prophylaxis&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">150 patients were included in each group&#46; Twelve SSI &#40;7 superficial and 5 deep&#41; occurred in the post-intervention group and 16 SSI &#40;7 superficial and 9 deep&#41; in the pre-intervention group&#46; The risk of deep SSI decreased from 6&#46;0&#37; to 3&#46;3&#37; &#40;OR 0&#44;54&#44; 95&#37;CI 0&#46;17-1&#46;65&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;411&#41; with vancomycin powder&#46; The percentage of deep SSI due to gram negative-positive germs were 80&#37;-20&#37; and 33&#37;-67&#37; for the post- and pre-intervention groups&#44; respectively &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;265&#41;&#46; No local or systemic adverse effects occurred attributable to vancomycin powder&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusion</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">In posterior elective spinal surgery&#44; prophylaxis with vancomycin powder did not result in a significantly reduced incidence of superficial and deep SSI&#46; There was a trend towards a higher incidence of deep SSI caused by gram negative microorganisms among those treated with vancomycin&#46;</p></span>"
        "secciones" => array:4 [
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            "identificador" => "abst0025"
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            "identificador" => "abst0030"
            "titulo" => "Materials and methods"
          ]
          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Results"
          ]
          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusion"
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Este trabajo se present&#243; para optar al premio Sixto Obrador 2019 de la Sociedad Espa&#241;ola de Neurocirug&#237;a&#46;</p>"
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        "etiqueta" => "Figura 1"
        "tipo" => "MULTIMEDIAFIGURA"
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        "descripcion" => array:1 [
          "es" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Fotograf&#237;a operatoria de la herida quir&#250;rgica justo antes del cierre de la misma en la que se ha administrado el polvo de vancomicina&#46;</p>"
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          "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">El asterisco &#40;&#42;&#41; indica diferencia estad&#237;sticamente significativa &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41;&#46;</p>"
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Grupo postintervenci&#243;n&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">N</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">150&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#40;57&#41; 38&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#40;62&#41; 41&#44;3&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;6369&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">63&#44;5 &#40;15-86&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">62 &#40;17-90&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;4153&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Etiolog&#237;a &#40;N&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Degenerativo&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">104&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">116&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;1510&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Traumatismo&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;2259&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Tumor&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">11&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;6761&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;4780&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " colspan="4" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Nivel intervenido &#40;N&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Intervenci&#243;n previa en mismo nivel &#40;N&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Riesgo anest&#233;sico &#40;N&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>ASA I&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">30&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;2188&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>ASA II&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>ASA III&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;3406&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Comorbilidad &#40;N&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Diab&#233;tico&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;8704&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Fumador&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;0372&#42;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Obesidad&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">21&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">40&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;0098&#42;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Estancia total media &#40;desviaci&#243;n est&#225;ndar&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">7 &#40;19&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">6 &#40;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;5606&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Estancia postoperatoria mediana &#40;rango&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3 &#40;1-112&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3 &#40;1-63&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#44;0000&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " colspan="4" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">T&#233;cnica quir&#250;rgica &#40;N&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Laminectom&#237;a&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">75&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">94&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;0361&#42;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Laminectom&#237;a<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>fijaci&#243;n&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">52&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">42&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;2626&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Fijaci&#243;n solo&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">21&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">14&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Otra&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;4780&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Drenaje en herida &#40;N&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">135&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">119&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;0162&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Duraci&#243;n media operaci&#243;n en minutos &#40;desviaci&#243;n est&#225;ndar&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">210 &#40;55&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">188 &#40;57&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;0008&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Tiempo medio seguimiento en d&#237;as &#40;desviaci&#243;n est&#225;ndar&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">94 &#40;140&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">131 &#40;272&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;1399&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Exitus &#40;N&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">10&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;6175&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Seroma &#40;N&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;0000&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Infecci&#243;n superficial &#40;N&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;0000&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Infecci&#243;n profunda &#40;N&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;4127&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab2253398.png"
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          "es" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Descripci&#243;n de los hallazgos cl&#237;nicos y demogr&#225;ficos de la cohorte&#46; Comparativa de ambos grupos de estudio</p>"
        ]
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                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="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Vancomicina&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Control&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">OR &#40;IC 95&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Tasa de infecci&#243;n global &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&#44;66&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;72&#40;0&#44;33-1&#44;59&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;5516&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Tasa de infecci&#243;n superficial &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#44;66&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#44;66&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#40;0&#44;34-2&#44;92&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;0000&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Tasa de infecci&#243;n profunda &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#44;33&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#44;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;54&#40;0&#44;17-1&#44;65&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;4115&nbsp;\t\t\t\t\t\t\n
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          "es" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Resultados del estudio prospectivo&#46; Proporci&#243;n y riesgo de infecci&#243;n de herida quir&#250;rgica global&#44; superficial y profunda en ambos grupos</p>"
        ]
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          "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">El asterisco &#40;&#42;&#41; indica diferencia estad&#237;sticamente significativa &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41;&#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="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Cohorte completa&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Intervenci&#243;n sobre 4 niveles o m&#225;s&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">OR 4&#44;71&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;0025&#42;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">DegenerativaTraum&#225;ticatumoral&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">OR 0&#44;18&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;0003&#42;OR 1&#44;28&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;7054OR 10&#44;53&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;0003&#42;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Duraci&#243;n de 200<span class="elsevierStyleHsp" style=""></span>min o m&#225;s&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">OR 2&#44;04&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;2023&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "es" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Factores de riesgo para infecci&#243;n de herida quir&#250;rgica profunda en la cohorte entera&#46; Se muestran el riesgo mediante OR y el valor de significaci&#243;n estad&#237;stica</p>"
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        "tabla" => array:1 [
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            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="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Casos&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Caracter&#237;sticas&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Tiempo hasta la infecci&#243;n&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Microorganismo cultivado&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Tratamiento&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Resultado&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Var&#243;n&#44; 55&#46; Fractura lumbar&#46; Fijaci&#243;n posterior 5 nivelesASA III&#44; DM-2&#44; cirug&#237;a 255<span class="elsevierStyleHsp" style=""></span>min&#44; 41 d&#237;as estancia UCI preoperatoria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10 d&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Escherichia coli</span> sensible&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Desbridamiento quir&#250;rgico<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>antibioterapia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Curaci&#243;nParaplej&#237;a establecida por traumatismo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Var&#243;n&#44; 82&#46; Mieloma L2&#46; Laminectom&#237;a 5 niveles&#46; ASA II&#44; 270<span class="elsevierStyleHsp" style=""></span>min&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">25 d&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Klebsiella pneumoniae</span> sensible&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Desbridamiento quir&#250;rgico<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>antibioterapia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Curaci&#243;nExitus tras 415 d&#237;as por progresi&#243;n de enfermedad&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Var&#243;n&#44; 75&#46; Fractura dorsolumbar&#46; Laminectom&#237;a y fijaci&#243;n 4 niveles&#44; 255<span class="elsevierStyleHsp" style=""></span>min&#46; ASA III&#46; Fumador&#44; obeso&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18 d&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Klebsiella</span><span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Pseudomonas</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Desbridamiento quir&#250;rgico<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span> antibioterapia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Curaci&#243;nExitus por ictus tras 140 d&#237;as&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Var&#243;n&#44; 68&#46; Tumor dorsal&#44; laminectom&#237;a 4 niveles&#44; 465<span class="elsevierStyleHsp" style=""></span>min&#46; ASA III&#44; fumador&#44; obeso&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13 d&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Polimicrobiano&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Desbridamiento quir&#250;rgico<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>antibioterapia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Curaci&#243;n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mujer&#44; 83&#46; Tumor cervicodorsal&#44; laminectom&#237;a 3 niveles&#44; 190<span class="elsevierStyleHsp" style=""></span>min&#46; ASA II&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">27 d&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Staphylococcus epidermidis</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Desbridamiento quir&#250;rgico<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>antibioterapia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Curaci&#243;nRedesbridamiento tras 41 d&#237;as&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "es" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Descripci&#243;n de los casos de infecci&#243;n de herida quir&#250;rgica profunda en el grupo de vancomicina</p>"
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        "etiqueta" => "Tabla 5"
        "tipo" => "MULTIMEDIATABLA"
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">SARM&#58; <span class="elsevierStyleItalic">Staphylococcus aureus</span> resistente a meticilina&#46;</p>"
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            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="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Casos&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Antecedentes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Tiempo hasta la infecci&#243;n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Microorganismo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Tratamiento&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Resultado&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Var&#243;n&#44; 57&#46; Mielopat&#237;a cervical&#44; laminectom&#237;a 5 niveles&#46; ASA II&#44; diab&#233;tico y obeso&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14 d&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">SARM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Desbridamiento quir&#250;rgico<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>antibioterapia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Curaci&#243;n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Var&#243;n&#44; 72&#46; Met&#225;stasis cervical&#44; fijaci&#243;n 4 niveles&#44; 390<span class="elsevierStyleHsp" style=""></span>min&#46; ASA II&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">26 d&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Streptococcus mitis</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Desbridamiento quir&#250;rgico<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>antibioterapia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Curaci&#243;nExitus a los 88 d&#237;as por progresi&#243;n tumor&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Var&#243;n&#44; 74&#46; Met&#225;stasis cervical&#44; fijaci&#243;n 4 niveles&#44; 250<span class="elsevierStyleHsp" style=""></span>min&#46; ASA II&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">26 d&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Streptococcus mitis</span><span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>Enterococo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Desbridamiento quir&#250;rgico<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>antibioterapia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Curaci&#243;n&#46;Exitus tras 11 meses por progresi&#243;n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Var&#243;n&#44; 66&#46; Listesis lumbar&#44; laminectom&#237;a y fijaci&#243;n 2 niveles&#44; 210<span class="elsevierStyleHsp" style=""></span>min&#46; ASA II&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11 d&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Enterococo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Desbridamiento quir&#250;rgico<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>antibioterapia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Curaci&#243;n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mujer&#44; 58&#46; Estenosis lumbar&#44; laminectom&#237;a&#44; 120<span class="elsevierStyleHsp" style=""></span>min&#46; ASA I&#44; diab&#233;tica&#44; obesa&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16 d&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Staphylococcus aureus</span> sensible&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Desbridamiento quir&#250;rgico<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>antibioterapia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Curaci&#243;n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mujer&#44; 79&#46; Linfoma lumbar&#44; laminectom&#237;a&#44; 150<span class="elsevierStyleHsp" style=""></span>min&#46; ASA III&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">38 d&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">SARM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Desbridamiento quir&#250;rgico<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>antibioterapia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Curaci&#243;nExitus 10 meses despu&#233;s por progresi&#243;n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mujer&#44; 35&#46; Hernia L5S1&#44; laminectom&#237;a&#44; 120<span class="elsevierStyleHsp" style=""></span>min&#46; ASA I&#44; obesa&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">27 d&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Escherichia coli</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Desbridamiento quir&#250;rgico<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>antibioterapia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Curaci&#243;n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Var&#243;n&#44; 81&#46; Listesis L4L5&#44; laminectom&#237;a y fijaci&#243;n&#44; 210<span class="elsevierStyleHsp" style=""></span>min&#46; ASA II&#44; obeso&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">28 d&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Staphylococcus epidermidis</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Desbridamiento quir&#250;rgico<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>antibioterapia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Curaci&#243;n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Var&#243;n&#44; 55&#46; Fractura dorsolumbar&#44; laminectom&#237;a y fijaci&#243;n 5 niveles&#44; 250<span class="elsevierStyleHsp" style=""></span>min&#46; ASA II&#44; diab&#233;tico&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10 d&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Escherichia coli</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Desbridamiento quir&#250;rgico<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>antibioterapia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Curaci&#243;n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "es" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Descripci&#243;n de los casos de infecci&#243;n de herida quir&#250;rgica profunda en el grupo de controles</p>"
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                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="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Estudio&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Tipo de estudio&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Hallazgos&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Comentario&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dodson et al&#46;<a class="elsevierStyleCrossRef" href="#bib0445"><span class="elsevierStyleSup">24</span></a>&#44; 2019&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Revisi&#243;n sistem&#225;tica y metaan&#225;lisis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Incluye 25 estudios con grupo control&#46; La vancomicina en polvo disminuye el riesgo de infecci&#243;n &#40;RR 0&#44;55&#59; IC 95&#37; 0&#44;45-0&#44;67&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;0001&#41;&#46; No demostr&#243; aumento de infecciones por gramnegativos &#40;RR 1&#44;11&#59; IC 95&#37; 0&#44;66-1&#44;86&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;701&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">El polvo de vancomicina protege frente a la infecci&#243;n de herida quir&#250;rgica aunque no parece claro el efecto sobre el aumento de incidencia de infecciones por gramnegativos&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Texakalidis et al&#46;<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">25</span></a>&#44; 2019&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Revisi&#243;n sistem&#225;tica y metaan&#225;lisis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">En cirug&#237;a de columna incluye 25 estudios con 16&#46;369 pacientes&#46; La vancomicina en polvo disminuye el riesgo de infecci&#243;n global &#40;OR 0&#44;41&#59; IC 95&#37; 0&#44;30-0&#44;57&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; y en infecci&#243;n profunda &#40;OR 0&#44;31&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; pero no en superficial&#46; No diferencias entre emplear 1<span class="elsevierStyleHsp" style=""></span>g o 2<span class="elsevierStyleHsp" style=""></span>g de polvo de vancomicina&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">El polvo de vancomicina parece proteger de las infecciones de herida quir&#250;rgica&#44; especialmente de las profundas&#46; No parece existir un efecto dosis dependiente entre 1<span class="elsevierStyleHsp" style=""></span>g o 2<span class="elsevierStyleHsp" style=""></span>g&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Tailaiti et al&#46;<a class="elsevierStyleCrossRef" href="#bib0520"><span class="elsevierStyleSup">39</span></a>&#44; 2018&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Revisi&#243;n sistem&#225;tica y metaan&#225;lisis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Incluye 27 estudios y 17&#46;321 pacientes&#46; OR global 0&#44;39 &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;01&#41;&#46; En pacientes instrumentados&#44; OR 0&#44;31 &#40;0&#44;19-050&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;01&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">EL polvo de vancomicina fue eficaz solo si se puso instrumentaci&#243;n&#44; no en el resto&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Xie et al&#46;<a class="elsevierStyleCrossRef" href="#bib0505"><span class="elsevierStyleSup">36</span></a>&#44; 2018&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Revisi&#243;n sistem&#225;tica de la literatura&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Incluye un estudio prospectivo y 9 retrospectivos &#40;2&#46;394 pacientes&#41;&#46; Cuando se emple&#243; 1<span class="elsevierStyleHsp" style=""></span>g de polvo de vancomicina predominaron los gramnegativos&#44; y con 2<span class="elsevierStyleHsp" style=""></span>g los grampositivos&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Parece existir una tendencia a aumentar la incidencia de infecci&#243;n por gramnegativos&#44; que se influye de la dosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Xie et al&#46;<a class="elsevierStyleCrossRef" href="#bib0525"><span class="elsevierStyleSup">40</span></a>&#44; 2017&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Revisi&#243;n sistem&#225;tica y metaan&#225;lisis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Incluye un estudio prospectivo y 19 estudios retrospectivos&#46; Evidencian un riesgo 2&#44;83 veces mayor de infecci&#243;n si no se usa polvo de vancomicina &#40;IC 95&#37; 2&#44;03-3&#44;95&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;083&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">La dosis de polvo y si se espolvorea en toda la herida o no parece influir en la incidencia de infecci&#243;n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ghobrial et al&#46;<a class="elsevierStyleCrossRef" href="#bib0510"><span class="elsevierStyleSup">37</span></a>&#44; 2015&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Revisi&#243;n sistem&#225;tica de la literatura&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Incluy&#243; 16 estudios relativos a complicaciones &#40;6&#46;701 pacientes&#41;&#46; Tasa de infecci&#243;n del 1&#44;36&#37; y del 7&#44;47&#37; en vancomicina y control&#44; respectivamente&#46; Un 0&#44;3&#37; efectos adversos&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Veintitr&#233;s efectos adversos&#58; una nefropat&#237;a&#44; 2 ototoxicidad&#44; una absorci&#243;n sist&#233;mica&#44; 19 seromas con cultivo negativo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">L&#243;pez et al&#46;<a class="elsevierStyleCrossRef" href="#bib0515"><span class="elsevierStyleSup">38</span></a>&#44; 2015&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Revisi&#243;n sistem&#225;tica de la literatura&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Incluye 16 estudios &#40;un ensayo aleatorizado y controlado&#41;&#46; Metodolog&#237;a metaanal&#237;tica GRADE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Vancomicina probablemente no reduce las infecciones en cirug&#237;a de bajo riesgo y dudoso en alto riesgo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Kang et al&#46;<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">16</span></a>&#44; 2015&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Revisi&#243;n sistem&#225;tica de la literatura&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Incluye estudios en PubMed y Ovid solo en ingl&#233;s&#46; Evidencia moderada a favor de la vancomicina en polvo en la incidencia de infecci&#243;n de herida quir&#250;rgica&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No protocolos establecidos respecto a uso y dosis&#46; No efectos secundarios relevantes&#46; Uso discrecional&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Bakhsheshian et al&#46;<a class="elsevierStyleCrossRef" href="#bib0530"><span class="elsevierStyleSup">41</span></a>&#44; 2015&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Revisi&#243;n sistem&#225;tica y metaan&#225;lisis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Incluye un ensayo aleatorizado&#44; 13 estudios comparativos y 4 series de casos&#46; La vancomicina protege de infecci&#243;n profunda &#40;OR 0&#44;23&#59; IC 95&#37; 0&#44;22-0&#44;82&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; y global &#40;OR 0&#44;43&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;01&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Apoya el uso de vancomicina t&#243;pica en el adulto&#46; Es segura&#46; La recomendaci&#243;n se basa casi toda en evidencia clase <span class="elsevierStyleSmallCaps">iii</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "es" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Resumen de estudios tipo revisi&#243;n sistem&#225;tica y metaan&#225;lisis que eval&#250;an el efecto del polvo de vancomicina en la incidencia de infecci&#243;n de herida quir&#250;rgica en cirug&#237;a de columna</p>"
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                            0 => "I&#46; Collins"
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                      "doi" => "10.1007/s00586-007-0559-8"
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                            1 => "P&#46;P&#46; Horsting"
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                      "doi" => "10.1007/s00586-010-1421-y"
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                        "volumen" => "21 Suppl 4"
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                        0 => array:2 [
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Información del artículo
ISSN: 11301473
Idioma original: Español
DOI:10.1016/j.neucir.2019.07.004
Datos actualizados diariamente
año/Mes Html Pdf Total
2024 Junio 24 4 28
2024 Abril 1 2 3
2024 Enero 1 2 3
2023 Diciembre 1 2 3
2023 Julio 1 0 1
2023 Marzo 9 2 11
2023 Febrero 1 0 1
2022 Mayo 1 2 3
2022 Enero 4 4 8
2021 Diciembre 2 4 6
2021 Noviembre 3 0 3
2021 Octubre 0 2 2
2021 Abril 1 2 3
2020 Diciembre 1 2 3
2020 Septiembre 1 0 1
2020 Julio 4 0 4
2020 Mayo 1 0 1
2020 Abril 15 2 17
2020 Marzo 2 0 2
2020 Febrero 1 2 3
2019 Noviembre 1 2 3
2019 Octubre 11 2 13
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Cervical spine spondylodiscitis due to neglected esophageal...
Neurocirugia. 2024;35:334-9
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