Estudio de la frecuencia y caracterización de las infecciones por Klebsiella pneumoniae carbapenemasa en un hospital de la región de Campos Gerais
DOI:
https://doi.org/10.33448/rsd-v11i16.38275Palabras clave:
Infección Hospitalaria; Bacteria Gramnegativas; Enterobacteriaceae Resistente a los Carbapenémicos; Infecciones por Klebsiella; Farmacorresistencia bacteriana.Resumen
Objetivo: Determinar el perfil y la prevalencia de las infecciones asociadas con la Klebsiella pneumoniae carbapenemase en el ámbito sanitario. Método: Se trata de un estudio descriptivo transversal retrospectivo (Yin, 2015) y se analiza el perfil de estas infecciones en un único hospital público entre 2019 y 2021, a través de la recogida de datos con el Centro de Control de Infecciones Hospitalarias y en las historias clínicas electrónicas. La recopilación incluyo información demográfica, clínica y de laboratorio relacionada con la infección. Resultados: Se analizaron 59 pacientes con infección asociada a KPC (8,3%, 65/780), siendo Klebsiella pneumoniae la especie más aislada (93,4%, 57/61). El mayor número de infecciones se encontró en la unidad de cuidados intensivos (76,7%, 46/60), la mayoría relacionadas con la neumonía asociada al ventilador (29,2%, 19/65), la presencia de 3 comorbilidades o más (55,9%, 33/59) y la atención con al menos un dispositivo invasivo (78%, 46/59). Se encontró terapia antibiótica previa en el 96,7% (58/60) y, tras el cultivo, el 31,7% recibió amikacina y polimixina B. De estos pacientes, 66,1% (39/59) fallecieron y el 33,9% (20/59) fueron dados de alta. Conclusión: los resultados coinciden con la literatura actual, destacando la importancia de la prevención para la diseminación de agentes multirresistentes y el impacto de la pandemia de COVID-19 en el aumento de las IRAS por bacterias Gram negativas.
Citas
Allegranzi, B., Nejad, S. B., Combescure, C., Graafmans, W., Attar, H., Donaldson, L., & Pittet, D. (2011). Burden of endemic health-care-associated infection in developing countries: systematic review and meta-analysis. The Lancet, 377(9761), 228–241. https://doi.org/10.1016/s0140-6736(10)61458-4
Alves, A. P., & Behar, P. R. P. (2013). Infecções hospitalares por enterobactérias produtoras de KPC em um hospital terciário do sul do Brasil. Rev Amrigs, 57(3), 213-8.
Alvim, A. L. S., Couto, B. R. G. M., & Gazzinelli, A. (2019). Epidemiological profile of healthcare-associated infections caused by Carbapenemase-producing Enterobacteriaceae. Revista Da Escola de Enfermagem Da USP, 53. https://doi.org/10.1590/s1980-220x2018001903474
Amgain, K., Rana, T., Shrestha, R., & Shrestha, S. (2019). Healthcare Associated Infections: Epidemiology, Contributing Factors and Control Measure in Developing Country. Journal of Karnali Academy of Health Sciences, 2(3), 161–165. https://doi.org/10.3126/jkahs.v2i3.26642
Anvisa. (2021a). Prevenção de infecções por microrganismos multirresistente em serviços de saúde. Agência Nacional de Vigilância Sanitária (Anvisa), https://www.gov.br/anvisa/pt-br/centraisdeconteudo/publicacoes/servicosdesaude/publicacoes/manual-prevencao-de-multirresistentes7.pdf
Anvisa. (2021b). Programa Nacional de Prevenção e Controle de Infecções Relacionadas à Assistência à Saúde (PNPCIRAS) 2021 a 2025. Agência Nacional de Vigilância Sanitária (Anvisa), https://www.gov.br/anvisa/pt-br/centraisdeconteudo/publicacoes/servicosdesaude/publicacoes/pnpciras_2021_2025.pdf
Arcari, G., Raponi, G., Sacco, F., Bibbolino, G., Di Lella, F. M., Alessandri, F., Coletti, M., Trancassini, M., Deales, A., Pugliese, F., Antonelli, G., & Carattoli, A. (2021). Klebsiella pneumoniae infections in COVID-19 patients: a 2-month retrospective analysis in an Italian hospital. International Journal of Antimicrobial Agents, 57(1), 106245. https://doi.org/10.1016/j.ijantimicag.2020.106245
Aurilio, C., Sansone, P., Barbarisi, M., Pota, V., Giaccari, L. G., Coppolino, F., Barbarisi, A., Passavanti, M. B., & Pace, M. C. (2022). Mechanisms of Action of Carbapenem Resistance. Antibiotics, 11(3), 421. https://doi.org/10.3390/antibiotics11030421
Balsalobre, L., Blanco, A., & Alarcón, T. (2019). Beta‐Lactams. Antibiotic Drug Resistance, 57–72. https://doi.org/10.1002/9781119282549.ch3
Bassetti, M., Giacobbe, D. R., Giamarellou, H., Viscoli, C., Daikos, G. L., Dimopoulos, G., De Rosa, F. G., Giamarellos-Bourboulis, E. J., Rossolini, G. M., Righi, E., Karaiskos, I., Tumbarello, M., Nicolau, D. P., Viale, P. L., & Poulakou, G. (2018). Management of KPC-producing Klebsiella pneumoniae infections. Clinical Microbiology and Infection, 24(2), 133–144. https://doi.org/10.1016/j.cmi.2017.08.030
Bassetti, M., & Peghin, M. (2020). How to manage KPC infections. Therapeutic Advances in Infectious Disease, 7, 204993612091204. https://doi.org/10.1177/2049936120912049
Bonomo, R. A., Burd, E. M., Conly, J., Limbago, B. M., Poirel, L., Segre, J. A., & Westblade, L. F. (2018). Carbapenemase-Producing Organisms: A Global Scourge. Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America, 66(8), 1290–1297. https://doi.org/10.1093/cid/cix893
Braga, I. A., Campos, P. A., Gontijo-Filho, P. P., & Ribas, R. M. (2018). Multi-hospital point prevalence study of healthcare-associated infections in 28 adult intensive care units in Brazil. Journal of Hospital Infection, 99(3), 318–324. https://doi.org/10.1016/j.jhin.2018.03.003
Codjoe, F., & Donkor, E. (2017). Carbapenem Resistance: A Review. Medical Sciences, 6(1), 1. https://doi.org/10.3390/medsci6010001
Cronin, K. M., Poy Lorenzo, Y. S., Olenski, M. E., Bloch, A. E., Visvanathan, K., Waters, M. J., & Buising, K. L. (2017). Risk factors for KPC-producing Enterobacteriaceae acquisition and infection in a healthcare setting with possible local transmission: a case–control study. Journal of Hospital Infection, 96(2), 111–115. https://doi.org/10.1016/j.jhin.2017.02.010
Silva, K. E. da, Maciel, W. G., Sacchi, F. P. C., Carvalhaes, C. G., Rodrigues-Costa, F., Silva, A. C. R. da, Croda, M. G., Negrão, F. J., Croda, J., Gales, A. C., & Simionatto, S. (2016). Risk factors for KPC-producing Klebsiella pneumoniae: watch out for surgery. Journal of Medical Microbiology, 65(6), 547–553. https://doi.org/10.1099/jmm.0.000254
David, L. E. de, Carraro, E., Zimmer, D., Razera, A., Peternelli, M. P., Kosinski, B., & Santos, J. R. (2022). ANÁLISE DESCRITIVA DE IRAS EM UTI NO ANO DE 2020. The Brazilian Journal of Infectious Diseases, 26, 102230. https://doi.org/10.1016/j.bjid.2021.102230
Despotovic, A., Milosevic, B., Milosevic, I., Mitrovic, N., Cirkovic, A., Jovanovic, S., & Stevanovic, G. (2020). Hospital-acquired infections in the adult intensive care unit—Epidemiology, antimicrobial resistance patterns, and risk factors for acquisition and mortality. American Journal of Infection Control, 48(10), 1211–1215. https://doi.org/10.1016/j.ajic.2020.01.009
Doi, Y.; & Paterson, D. L. (2015). Carbapenemase-Producing Enterobacteriaceae. Seminars in Respiratory and Critical Care Medicine, 36(01), 074–084. https://doi.org/10.1055/s-0035-1544208
Dumitru, I., Dumitrascu, M., Vlad, N., Cernat, R., Ilie-Serban, C., Hangan, A., Slujitoru, R., Gherghina, A., Mitroi-Maxim, C., Curtali, L., Carp, D., Dumitrescu, A., Mitan, R., Lesanu, R., & Rugina, S. (2021). Carbapenem-Resistant Klebsiella pneumoniae Associated with COVID-19. Antibiotics, 10(5), 561. https://doi.org/10.3390/antibiotics10050561
Elshamy, A. A., & Aboshanab, K. M. (2020). A review on bacterial resistance to carbapenems: epidemiology, detection and treatment options. Future Science OA, 6(3), FSO438. https://doi.org/10.2144/fsoa-2019-0098
Glied, S., Cohen, B., Liu, J., Neidell, M., & Larson, E. (2016). Trends in mortality, length of stay, and hospital charges associated with health care–associated infections, 2006-2012. American Journal of Infection Control, 44(9), 983–989. https://doi.org/10.1016/j.ajic.2016.03.010
Gomez-Simmonds, A., Annavajhala, M. K., McConville, T. H., Dietz, D. E., Shoucri, S. M., Laracy, J. C., ... & Uhlemann, A. C. (2021). Carbapenemase-producing Enterobacterales causing secondary infections during the COVID-19 crisis at a New York City hospital. Journal of Antimicrobial Chemotherapy, 76(2), 380-384.
Grasselli, G., Scaravilli, V., Mangioni, D., Scudeller, L., Alagna, L., Bartoletti, M., Bellani, G., Biagioni, E., Bonfanti, P., Bottino, N., Coloretti, I., Cutuli, S. L., Pascale, G. D., Ferlicca, D., Fior, G., Forastieri, A., Franzetti, M., Greco, M., Guzzardella, A., & Linguadoca, S. (2021). Hospital-Acquired Infections in Critically Ill Patients With COVID-19. CHEST, 0(0). https://doi.org/10.1016/j.chest.2021.04.002
Greissl, C., Saleh, A., & Hamprecht, A. (2018). Rapid detection of OXA-48-like, KPC, NDM, and VIM carbapenemases in Enterobacterales by a new multiplex immunochromatographic test. European Journal of Clinical Microbiology & Infectious Diseases, 38(2), 331–335. https://doi.org/10.1007/s10096-018-3432-2
Gupta, N., Limbago, B. M., Patel, J. B., & Kallen, A. J. (2011). Carbapenem-Resistant Enterobacteriaceae: Epidemiology and Prevention. Clinical Infectious Diseases, 53(1), 60–67. https://doi.org/10.1093/cid/cir202
Hall, B. G., & Barlow, M. (2005). Revised Ambler classification of β-lactamases. Journal of Antimicrobial Chemotherapy, 55(6), 1050–1051.
https://doi.org/10.1093/jac/dki130
Haque, M., Sartelli, M., McKimm, J., & Abu Bakar, M. (2018). Health care-associated infections - an overview. Infection and drug resistance, 11, 2321–2333. https://doi.org/10.2147/IDR.S177247
Hirsch, E. B., & Tam, V. H. (2010). Detection and treatment options for Klebsiella pneumoniae carbapenemases (KPCs): an emerging cause of multidrug-resistant infection. Journal of Antimicrobial Chemotherapy, 65(6), 1119–1125. https://doi.org/10.1093/jac/dkq108
Leal, H. F., Azevedo, J., Silva, G. E. O., Amorim, A. M. L., de Roma, L. R. C., Arraes, A. C. P., Gouveia, E. L., Reis, M. G., Mendes, A. V., Oliveira Silva, M. de, Barberino, M. G., Martins, I. S., & Reis, J. N. (2019). Bloodstream infections caused by multidrug-resistant gram-negative bacteria: epidemiological, clinical and microbiological features. BMC Infectious Diseases, 19(1), 609. https://doi.org/10.1186/s12879-019-4265-z
Lee, X. J., Stewardson, A. J., Worth, L. J., Graves, N., & Wozniak, T. M. (2020). Attributable Length of Stay, Mortality Risk, and Costs of Bacterial Health Care–Associated Infections in Australia: A Retrospective Case-cohort Study. Clinical Infectious Diseases. https://doi.org/10.1093/cid/ciaa1228
Logan, L. K., & Weinstein, R. A. (2017). The Epidemiology of Carbapenem-Resistant Enterobacteriaceae: The Impact and Evolution of a Global Menace. The Journal of Infectious Diseases, 215(suppl_1), S28–S36. https://doi.org/10.1093/infdis/jiw282
Machado, L. G., Resende, D. S., Campos, P. A. de, Ferreira, M. L., Braga, I. A., Aires, C. A. M., Boschiroli, A. M., Tenório, M. T. F., Francisco, M. M. F., Lima, R. R. de, Filho, P. P. G., & Ribas, R. M. (2022). INFECÇÕES RELACIONADAS À ASSISTÊNCIA À SAÚDE NO BRASIL: PREVALÊNCIA MULTICÊNTRICA E ESTUDO CASO-CONTROLE PAREADO. The Brazilian Journal of Infectious Diseases, 26, 102252. https://doi.org/10.1016/j.bjid.2021.102252
Magill, S. S., O’Leary, E., Janelle, S. J., Thompson, D. L., Dumyati, G., Nadle, J., Wilson, L. E., Kainer, M. A., Lynfield, R., Greissman, S., Ray, S. M., Beldavs, Z., Gross, C., Bamberg, W., Sievers, M., Concannon, C., Buhr, N., Warnke, L., Maloney, M., & Ocampo, V. (2018). Changes in Prevalence of Health Care–Associated Infections in U.S. Hospitals. New England Journal of Medicine, 379(18), 1732–1744. https://doi.org/10.1056/nejmoa1801550
Marçal, T. V. G., da Costa, L. F., Nicoletti, D. R., Fernandes, M. T. C., Amorin, B., & Hermes, D. (2021). Incidência de KPC (Klebsiella Pneumoniae Carbapenemase) em adultos internados em hospitais nas regiões do Brasil de 2006 a 2016: revisão bibliográfica. Saúde Coletiva (Barueri), 11(62), 5174–5191. https://doi.org/10.36489/saudecoletiva.2021v11i62p5174-5191
McCreary, E. K., Heil, E. L., & Tamma, P. D. (2021). New Perspectives on Antimicrobial Agents: Cefiderocol. Antimicrobial Agents and Chemotherapy, 65(8). https://doi.org/10.1128/aac.02171-20
Monteiro, J., Santos, A. F., Asensi, M. D., Peirano, G., & Gales, A. C. (2009). First Report of KPC-2-Producing Klebsiella pneumoniae Strains in Brazil. Antimicrobial Agents and Chemotherapy, 53(1), 333–334. https://doi.org/10.1128/aac.00736-08
Murray, C. J., Ikuta, K. S., Sharara, F., Swetschinski, L., Aguilar, G. R., Gray, A., Han, C., Bisignano, C., Rao, P., Wool, E., Johnson, S. C., Browne, A. J., Chipeta, M. G., Fell, F., Hackett, S., Haines-Woodhouse, G., Hamadani, B. H. K., Kumaran, E. A. P., McManigal, B., & Agarwal, R. (2022). Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis. The Lancet, 399(10325), 629–655. https://doi.org/10.1016/S0140-6736(21)02724-0
Nabi, J., Akhter, Y., & Tabassum, N. (2020). Epidemiology and Transmission of Infectious Diseases [ISBN: 978-93-5407-406-6] Health Care Associated Infections: A Global Threat.
Nordmann, P., Naas, T., & Poirel, L. (2011). Global Spread of Carbapenemase-producingEnterobacteriaceae. Emerging Infectious Diseases, 17(10), 1791–1798. https://doi.org/10.3201/eid1710.110655
Nordmann, P., & Poirel, L. (2019). Epidemiology and Diagnostics of Carbapenem Resistance in Gram-negative Bacteria. Clinical Infectious Diseases, 69(Supplement_7), S521–S528. https://doi.org/10.1093/cid/ciz824
O’Neill, J. (2016, May 18). Tackling drug-resistant infections globally: final report and recommendations. Analysis & Policy Observatory (APO). https://apo.org.au/node/63983
OMS. (2014). Antimicrobial resistance: global report on surveillance. World Health Organization (WHO), https://apps.who.int/iris/handle/10665/112642
OMS. (2017). Prioritization of pathogens to guide discovery, research and development of new antibiotics for drug-resistant bacterial infections, including tuberculosis. World Health Organization (WHO), https://apps.who.int/iris/handle/10665/311820
Osme, S. F., de Souza, J. M., Osme, I. T., Almeida, A. P. S., Arantes, A., Mendes-Rodrigues, C., Filho, P. P. G., & Ribas, R. M. (2022). ESTIMATIVA DO IMPACTO FINANCEIRO DAS INFECÇÕES RELACIONADAS À ASSISTÊNCIA À SAÚDE EM UNIDADES DE TERAPIA INTENSIVA DE HOSPITAIS UNIVERSITÁRIOS BRASILEIROS FILIADOS AO SISTEMA ÚNICO DE SAÚDE. The Brazilian Journal of Infectious Diseases, 26, 102240. https://doi.org/10.1016/j.bjid.2021.102240
Papadimitriou-Olivgeris, M., Christofidou, M., Fligou, F., Bartzavali, C., Vrettos, T., Filos, K. S., Marangos, M., & Anastassiou, E. D. (2014). The role of colonization pressure in the dissemination of colistin or tigecycline resistant KPC-producing Klebsiella pneumoniae in critically ill patients. Infection, 42(5), 883–890. https://doi.org/10.1007/s15010-014-0653-x
Peleg, A. Y., & Hooper, D. C. (2010). Hospital-Acquired Infections Due to Gram-Negative Bacteria. New England Journal of Medicine, 362(19), 1804–1813. https://doi.org/10.1056/NEJMra0904124
Prňová, J., Prnová, J., Reizigová, L., Havriško, M., Pazderka, L., Lovecká, D., Šmidovičová, L., & Škvarková, Z. (2021). Outbreak of KPC Klebsiella pneumoniae during second wave of COVID-19 pandemic in University hospital Trnava. Lekarsky Obzor, 481–484. https://pesquisa.bvsalud.org/global-literature-on-novel-coronavirus-2019-ncov/resource/pt/covidwho-1589898
Poirel, L., Sadek, M., Kusaksizoglu, A., & Nordmann, P. (2022). Co-resistance to ceftazidime-avibactam and cefiderocol in clinical isolates producing KPC variants. European Journal of Clinical Microbiology & Infectious Diseases. https://doi.org/10.1007/s10096-021-04397-x
Porreca, A. M., Sullivan, K. V., & Gallagher, J. C. (2018). The Epidemiology, Evolution, and Treatment of KPC-Producing Organisms. Current Infectious Disease Reports, 20(6). https://doi.org/10.1007/s11908-018-0617-x
Pournaras, S., Poulou, A., & Tsakris, A. (2010). Inhibitor-based methods for the detection of KPC carbapenemase-producing Enterobacteriaceae in clinical practice by using boronic acid compounds. Journal of Antimicrobial Chemotherapy, 65(7), 1319–1321. https://doi.org/10.1093/jac/dkq124
Rodríguez-Acelas, A. L., de Abreu Almeida, M., Engelman, B., & Cañon-Montañez, W. (2017). Risk factors for health care–associated infection in hospitalized adults: Systematic review and meta-analysis. American Journal of Infection Control, 45(12), e149–e156. https://doi.org/10.1016/j.ajic.2017.08.016
Schörner, M. A. (2016). Estudo caso-controle dos aspectos clínicos, fatores de risco e mortalidade associados a infecções nosocomiais por Klebsiella pneumoniae produtoras de carbapenemases do tipo KPC. https://repositorio.ufsc.br/handle/123456789/168130
Seibert, G., Hörner, R., Meneghetti, B., Alves, R., Frasson, N., Forno, D., & Salla, A. (2014). Infecções hospitalares por enterobactérias produtoras de Klebsiella pneumoniae carbapenemase em um hospital escola. Einstein, 12(3), 282–288. https://doi.org/10.1590/S1679-45082014AO3131
Sikora, A., & Zahra, F. (2020). Nosocomial Infections. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK559312/
Silva, K. E. da, Maciel, W. G., Sacchi, F. P. C., Carvalhaes, C. G., Rodrigues-Costa, F., Silva, A. C. R. da, ... & Simionatto, S. (2016). Risk factors for KPC-producing Klebsiella pneumoniae: watch out for surgery. Journal of medical microbiology, 65(6), 547-553.
Souza, E. S., Belei, R. A., Carrilho, C. M. D. de M., Matsuo, T., Yamada-Ogatta, S. F., Andrade, G., Perugini, M. R. E., Pieri, F. M., Dessunti, E. M., & Kerbauy, G. (2015). Mortality and risks related to healthcare-associated infection. Texto & Contexto - Enfermagem, 24(1), 220–228. https://doi.org/10.1590/0104-07072015002940013
Soares, V., & Viegas, D. (2022). Emergência de Enterobacterales produtoras de metalo-beta- lactamases em um Hospital de Referência para Covid-19 Emergency of Enterobacterales producing metallo-beta-lactamases in a referral hospital for Covid-19. Revista Brasileira de Análises Clínicas (RBAC). 54(2), 188–192. https://doi.org/10.21877/2448-3877.202200025
Spaziante, M., Oliva, A., Ceccarelli, G., & Venditti, M. (2020). What are the treatment options for resistant Klebsiella pneumoniae carbapenemase (KPC)-producing bacteria? Expert Opinion on Pharmacotherapy, 21(15), 1781–1787. https://doi.org/10.1080/14656566.2020.1779221
Sydnor, E. R. M., & Perl, T. M. (2011). Hospital Epidemiology and Infection Control in Acute-Care Settings. Clinical Microbiology Reviews, 24(1), 141–173. https://doi.org/10.1128/cmr.00027-10
Tuon, F. F., Rocha, J. L., Toledo, P., Arend, L. N., Dias, C. H., Leite, T. M., Penteado-Filho, S. R., Pilonetto, M., & Zavascki, A. P. (2012). Risk factors for KPC-producing Klebsiella pneumoniae bacteremia. The Brazilian Journal of Infectious Diseases, 16(5), 416–419. https://doi.org/10.1016/j.bjid.2012.08.006
Tumbarello, M., Trecarichi, E. M., De Rosa, F. G., Giannella, M., Giacobbe, D. R., Bassetti, M., Losito, A. R., Bartoletti, M., Del Bono, V., Corcione, S., Maiuro, G., Tedeschi, S., Celani, L., Cardellino, C. S., Spanu, T., Marchese, A., Ambretti, S., Cauda, R., Viscoli, C., & Viale, P. (2015). Infections caused by KPC-producing Klebsiella pneumoniae: differences in therapy and mortality in a multicentre study. Journal of Antimicrobial Chemotherapy, 70(7), 2133–2143. https://doi.org/10.1093/jac/dkv086
Tumbarello, M., Trecarichi, E. M., Tumietto, F., Del Bono, V., De Rosa, F. G., Bassetti, M., Losito, A. R., Tedeschi, S., Saffioti, C., Corcione, S., Giannella, M., Raffaelli, F., Pagani, N., Bartoletti, M., Spanu, T., Marchese, A., Cauda, R., Viscoli, C., & Viale, P. (2014). Predictive Models for Identification of Hospitalized Patients Harboring KPC-Producing Klebsiella pneumoniae. Antimicrobial Agents and Chemotherapy, 58(6), 3514–3520. https://doi.org/10.1128/aac.02373-13
Van Duin, D., & Doi, Y. (2016). The global epidemiology of carbapenemase-producing Enterobacteriaceae. Virulence, 8(4), 460–469. https://doi.org/10.1080/21505594.2016.1222343
Yigit, H., Queenan, A. M., Anderson, G. J., Domenech-Sanchez, A., Biddle, J. W., Steward, C. D., Alberti, S., Bush, K., & Tenover, F. C. (2001). Novel Carbapenem-Hydrolyzing -Lactamase, KPC-1, from a Carbapenem-Resistant Strain of Klebsiella pneumoniae. Antimicrobial Agents and Chemotherapy, 45(4), 1151–1161. https://doi.org/10.1128/aac.45.4.1151-1161.2001
Yin, R.K. (2015). O estudo de caso. Porto Alegre: Bookman.
Zimlichman, E., Henderson, D., Tamir, O., Franz, C., Song, P., Yamin, C. K., Keohane, C., Denham, C. R., & Bates, D. W. (2013). Health Care–Associated Infections. JAMA Internal Medicine, 173(22), 2039. https://doi.org/10.1001/jamainternmed.2013.9763
Descargas
Publicado
Cómo citar
Número
Sección
Licencia
Derechos de autor 2022 Fábio Marcelo Dudkiewicz; Larissa Bail; Carmen Antônia Sanches Ito; Maria Dagmar da Rocha Gaspar; João Pedro Wardani de Castro; Elisangela Gueiber Montes
Esta obra está bajo una licencia internacional Creative Commons Atribución 4.0.
Los autores que publican en esta revista concuerdan con los siguientes términos:
1) Los autores mantienen los derechos de autor y conceden a la revista el derecho de primera publicación, con el trabajo simultáneamente licenciado bajo la Licencia Creative Commons Attribution que permite el compartir el trabajo con reconocimiento de la autoría y publicación inicial en esta revista.
2) Los autores tienen autorización para asumir contratos adicionales por separado, para distribución no exclusiva de la versión del trabajo publicada en esta revista (por ejemplo, publicar en repositorio institucional o como capítulo de libro), con reconocimiento de autoría y publicación inicial en esta revista.
3) Los autores tienen permiso y son estimulados a publicar y distribuir su trabajo en línea (por ejemplo, en repositorios institucionales o en su página personal) a cualquier punto antes o durante el proceso editorial, ya que esto puede generar cambios productivos, así como aumentar el impacto y la cita del trabajo publicado.
