Original Article
Haemophilus Species Isolated in Urethral Exudates as a Possible Causative Agent in Acute Urethritis: A Study of 38 Cases
Aislamiento de Haemophilus spp. en exudados uretrales como posible agente etiológico de uretritis aguda: estudio de 38 casos
J. Magdaleno-Tapial
, C. Valenzuela-Oñate, M.M. Giacaman-von der Weth, B. Ferrer-Guillén, Á. Martínez-Domenech, M. García-Legaz Martínez, J.M. Ortiz-Salvador, D. Subiabre-Ferrer, P. Hernández-Bel
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Servicio de Dermatología, Hospital General Universitario de Valencia, Valencia, España
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Magdaleno-Tapial, C. Valenzuela-Oñate, M.M. Giacaman-von der Weth, B. Ferrer-Guillén, Á. Martínez-Domenech, M. García-Legaz Martínez, J.M. Ortiz-Salvador, D. Subiabre-Ferrer, P. Hernández-Bel" "autores" => array:9 [ 0 => array:2 [ "nombre" => "J." "apellidos" => "Magdaleno-Tapial" ] 1 => array:2 [ "nombre" => "C." "apellidos" => "Valenzuela-Oñate" ] 2 => array:2 [ "nombre" => "M.M." "apellidos" => "Giacaman-von der Weth" ] 3 => array:2 [ "nombre" => "B." "apellidos" => "Ferrer-Guillén" ] 4 => array:2 [ "nombre" => "Á." "apellidos" => "Martínez-Domenech" ] 5 => array:2 [ "nombre" => "M." "apellidos" => "García-Legaz Martínez" ] 6 => array:2 [ "nombre" => "J.M." "apellidos" => "Ortiz-Salvador" ] 7 => array:2 [ "nombre" => "D." "apellidos" => "Subiabre-Ferrer" ] 8 => array:2 [ "nombre" => "P." 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Magdaleno-Tapial, C. Valenzuela-Oñate, M.M. Giacaman-von der Weth, B. Ferrer-Guillén, Á. Martínez-Domenech, M. García-Legaz Martínez, J.M. Ortiz-Salvador, D. Subiabre-Ferrer, P. Hernández-Bel" "autores" => array:9 [ 0 => array:4 [ "nombre" => "J." "apellidos" => "Magdaleno-Tapial" "email" => array:1 [ 0 => "jormagta@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "C." "apellidos" => "Valenzuela-Oñate" ] 2 => array:2 [ "nombre" => "M.M." "apellidos" => "Giacaman-von der Weth" ] 3 => array:2 [ "nombre" => "B." "apellidos" => "Ferrer-Guillén" ] 4 => array:2 [ "nombre" => "Á." "apellidos" => "Martínez-Domenech" ] 5 => array:2 [ "nombre" => "M." "apellidos" => "García-Legaz Martínez" ] 6 => array:2 [ "nombre" => "J.M." "apellidos" => "Ortiz-Salvador" ] 7 => array:2 [ "nombre" => "D." "apellidos" => "Subiabre-Ferrer" ] 8 => array:2 [ "nombre" => "P." "apellidos" => "Hernández-Bel" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Dermatología, Hospital General Universitario de Valencia, Valencia, España" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Aislamiento de <span class="elsevierStyleItalic">Haemophilus</span> spp. en exudados uretrales como posible agente etiológico de uretritis aguda: estudio de 38 casos" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 639 "Ancho" => 750 "Tamanyo" => 39452 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Homosexual patient, aged 23 years, with abundant urethral suppuration caused by <span class="elsevierStyleItalic">Haemophilus parainfluenzae</span>.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Urethritis is the syndrome most frequently associated with sexually transmitted infections (STIs),<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> and is etiologically classified as either gonococcal urethritis (GU), caused by <span class="elsevierStyleItalic">Neisseria gonorrhoeae</span>, or nongonococcal urethritis (NGU), caused by other etiological agents, such as <span class="elsevierStyleItalic">Chlamydia trachomatis</span>, <span class="elsevierStyleItalic">Mycoplasma</span> species, or <span class="elsevierStyleItalic">Ureaplasma</span> species.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> However, the etiology of 30% to 40% of NGU cases is unknown.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> Bacteria of the genus <span class="elsevierStyleItalic">Haemophilus</span> are among several newly proposed etiological agents of NGU, especially among men who have sex with men (MSM).<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Here, we describe the clinical and microbiological characteristics of patients with urethritis caused by <span class="elsevierStyleItalic">Haemophilus</span> species, and discuss the most appropriate treatment strategies in patients with antibiotic resistance.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and Methods</span><p id="par0015" class="elsevierStylePara elsevierViewall">This was a descriptive, observational study, in which data were collected in a structured, prospective interview. The study included all patients with a microbiologically confirmed diagnosis of urethritis who were seen between July 2015 and July 2018 at the Sexually Transmitted Infections Unit of the Hospital General Universitario de Valencia, Valencia, Spain. From this group of patients we selected those in whom <span class="elsevierStyleItalic">Haemophilus</span> species were isolated on chocolate agar. Antibiotic susceptibility of the <span class="elsevierStyleItalic">Haemophilus</span> isolates was evaluated using the disc-plate diffusion method.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Cross-sectional clinical and epidemiological data were collected during the patients’ first visit. All patients were managed in accordance with the clinical guidelines of the Spanish AIDS Study Group (GeSIDA). During the first visit, a urethral exudate sample was taken from all patients with a clinical diagnosis of urethritis for bacterial culture and polymerase chain reaction testing for STIs. This same procedure was performed for all asymptomatic patients who were seen at the STI Unit for unprotected sexual contact with casual partners. Patients with a suspected diagnosis of urethritis were treated empirically with doxycycline (100 mg every 12 h) or a single dose of azithromycin (1 g) at the discretion of their physician. In cases in which GU was suspected owing to the presence of abundant urethral suppuration, a single dose of intramuscular ceftriaxone (250 mg) was also administered.</p><p id="par0025" class="elsevierStylePara elsevierViewall">During a second visit 4 to 6 weeks later, patients were re-evaluated and a second sample collected for microbiological analysis. If the patient's clinical signs and/or the <span class="elsevierStyleItalic">Haemophilus</span> isolate proved resistant to the prescribed treatment, a new antibiotic treatment was selected according to the findings of the antibiogram. In such cases, patients were evaluated once again 4 to 6 weeks after the second visit.</p><p id="par0030" class="elsevierStylePara elsevierViewall">A flow chart illustrating the process of patient inclusion in the study is shown in <a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0035" class="elsevierStylePara elsevierViewall">A total of 113 patients were diagnosed with microbiologically confirmed urethritis, of whom 31 (27.4%) were diagnosed with GU, 66 (58.4%) with NGU, and 16 (14.2%) with mixed urethritis (NG and NGU). <span class="elsevierStyleItalic">Haemophilus</span> species were isolated from 38 patients (33.6%). Clinical and epidemiological data for these patients are summarized in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. Of the 38 patients diagnosed with urethritis due to <span class="elsevierStyleItalic">Haemophilus</span> species, 35 were male and 3 were heterosexual women. The mean age was 30.5 years. Of the 35 male patients, 21 (60%) were MSM. Among the MSM patients, <span class="elsevierStyleItalic">Haemophilus</span> species were isolated from the urethra significantly more often than either <span class="elsevierStyleItalic">N gonorrhoeae</span> (<span class="elsevierStyleItalic">P</span>=.017) or <span class="elsevierStyleItalic">C trachomatis</span> (<span class="elsevierStyleItalic">P</span><.001).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">Thirty-three (86.8%) of the 38 patients had visited the emergency department. The most common presenting complaint was marked urethral suppuration (22 patients [57.9%]). Ten patients (26.3%) were asymptomatic and consulted for unsafe sexual contact; 2 patients reported contact with a person diagnosed with NGU, and the other 8 were seen because they had unsafe sexual contact with a casual partner. The remaining 15.8% were seen for dysuria without evident urethral discharge. In total, 57.1% of patients had a prior STI, the most frequent of which were syphilis, human immunodeficiency virus infection, urethritis, and condylomata acuminata. All patients had received unprotected oral sex within a mean of 22.7 days before the consultation. The most commonly isolated <span class="elsevierStyleItalic">Haemophilus</span> species was <span class="elsevierStyleItalic">H parainfluenzae</span>, which was isolated in 32 patients (84.2%), followed by <span class="elsevierStyleItalic">Haemophilus influenzae</span> (5 patients [13.2%]).</p><p id="par0045" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Haemophilus</span> species were found in isolation in 15 (39.5%) of the 38 patients, 9 of whom (60%) presented with marked urethral suppuration. Urethritis caused by <span class="elsevierStyleItalic">Haemophilus</span> species was associated with GU in 6 patients (15.8%). One or more classical etiological agents of NGU were detected in 17 patients (44.7%): <span class="elsevierStyleItalic">C trachomatis</span> in 7 patients (18.4%); <span class="elsevierStyleItalic">Mycoplasma genitalium</span> in 2 patients (5.2%); <span class="elsevierStyleItalic">Mycoplasma hominis</span> in 4 patients; and <span class="elsevierStyleItalic">Ureaplasma</span> species in 5 patients. Triple coinfection with <span class="elsevierStyleItalic">H parainfluenzae</span>, <span class="elsevierStyleItalic">N gonorroheae</span>, and <span class="elsevierStyleItalic">C trachomatis</span> was detected in 1 patient.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Information on all antibiotic-resistant strains of <span class="elsevierStyleItalic">Haemophilus</span> species isolated from patients is provided in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>. Eight patients were sensitive to all drugs tested, and all cases that were resistant to tetracycline (10 patients) were also resistant to azithromycin. Seventeen patients (44.7%) were treated empirically with a combination of intramuscular ceftriaxone (250 mg) and a single oral dose of azithromycin (1 g), and 12 patients (31.5%) were treated with a combination of intramuscular ceftriaxone (250 mg) and oral doxycycline (100 mg every 12 h) for 7 days. The remaining patients were treated with azithromycin (5 patients) or doxycycline (4 patients) in monotherapy. In total, 21 patients (55.2%) were lost to follow-up. Microbiological eradication of the pathogen was confirmed in the 17 patients (44.8%) who attended follow-up visits, although 6 required treatment with a second, distinct antibiotic, which was selected according to antibiogram results. Of the 21 patients lost to follow-up, 4 (19%) were carriers of <span class="elsevierStyleItalic">Haemophilus</span> species that were resistant to the empirical treatment prescribed at the first visit according to antibiogram results.</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0055" class="elsevierStylePara elsevierViewall">Of the patients diagnosed with microbiologically confirmed urethritis in our STI Unit, we detected <span class="elsevierStyleItalic">Haemophilus</span> species in urethral exudate samples from approximately one third, a greater proportion than that previously reported in Spain.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">H influenzae</span> and <span class="elsevierStyleItalic">H parainfluenzae</span> are microorganisms commonly found in the normal microflora of the human upper respiratory tract.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> Urethritis caused by these microorganisms has been described in patients with STIs<span class="elsevierStyleItalic">.</span> The last decade has seen an increase in the incidence of urethritis caused by <span class="elsevierStyleItalic">Haemophilus</span> species, especially among MSM, owing to an increase in the practice of unprotected oral sex within this group.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> Because this microorganism has been detected in the urethra of 3% to 9.3% of asymptomatic men,<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> its role as a causative agent of urethritis is controversial. We identified <span class="elsevierStyleItalic">Haemophilus</span> species as the sole causative agent of urethritis in 15 of 38 patients (39.5%). A previous study reported detection of <span class="elsevierStyleItalic">Haemophilus</span> species in up to 53% of urethritis patients.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> In our study, 57.9% of patients presented with purulent urethral syndrome that was characterized by spontaneous abundant whitish-green suppuration and was clinically indistinguishable from GU (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). In 36.7% of our patients, a <span class="elsevierStyleItalic">Haemophilus</span> species was the only etiological agent isolated, suggesting that this microorganism was the causative agent of acute urethritis in these patients.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">H parainfluenza</span> was isolated in 84.2% of our patients, and <span class="elsevierStyleItalic">H influenzae</span> in only 13.2%. These proportions, and the distribution of <span class="elsevierStyleItalic">Haemophilus</span> species among MSM described here, are similar to those previously reported,<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> and demonstrate that <span class="elsevierStyleItalic">Haemophilus</span> species are etiologic agents of urethritis mainly among MSM, owing to the low level of condom use during orogenital sexual practices within this group.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Of particular interest was the resistance of the isolated microorganisms to multiple antibiotics. This finding suggests that extra caution is required when selecting empirical adjuvants to intramuscular ceftriaxone when treating urethritis patients. Of the pathogens isolated in our study, 53.6% were resistant to cotrimoxazole and 34.2% were resistant to azithromycin. Furthermore, 26.3% of cases were resistant to both azithromycin and tetracyclines, both of which are recommended first-line drugs for the treatment of NGU.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> While greater proportions of antibiotic-resistant strains have been reported elsewhere, particularly for azithromycin resistance in East Asia,<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> monitoring of these patients is nonetheless necessary owing to the high risk of treatment failure. Another drug combination that may be of interest in clinical practice is amoxicillin and clavulanic acid, against which we detected no resistance. We found only 7 cases of resistance to quinolones, suggesting that drugs of this class may be useful adjuvants for the treatment of urethritis, although higher rates of resistance have been reported among MSM patients with urethritis.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> It should be noted that 5 of the <span class="elsevierStyleItalic">H parainfluenzae</span> isolates showed resistance to 5 or more of the drugs tested, and were therefore considered multidrug-resistant.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> It is thus fundamental to confirm microbiological cure and to remind patients of the importance of follow-up visits.</p><p id="par0075" class="elsevierStylePara elsevierViewall">Limitations of this study include its observational nature and the lack of a control group, which would be required to demonstrate a true pathogenic role of <span class="elsevierStyleItalic">Haemophilus</span> species in urethritis. Furthermore, it is difficult to draw precise conclusions regarding the therapeutic outcomes owing to the small sample size and the large number of cases lost to follow-up. It is also unknown whether antibiotic treatment was effective in patients in whom antibiotic-resistant <span class="elsevierStyleItalic">Haemophilus</span> species were isolated but who were subsequently lost to follow-up.</p><p id="par0080" class="elsevierStylePara elsevierViewall">In summary, our findings underscore the importance of <span class="elsevierStyleItalic">Haemophilus</span> species as an etiological agent of NGU, especially among MSM patients with a history of unprotected oral sex. Patients may present with urethral discharge similar to that caused by <span class="elsevierStyleItalic">N gonorrhoeae</span>, and cure must be confirmed owing to the possibility of <span class="elsevierStyleItalic">Haemophilus</span> species antibiotic resistance. Although in theory this ailment is easily treated, dermatologists must take responsibility for the management of urethritis and other STIs.</p><p id="par0085" class="elsevierStylePara elsevierViewall">In this study we describe the presence of <span class="elsevierStyleItalic">Haemophilus</span> species in the urethral exudate of approximately one third of patients diagnosed with microbiologically confirmed urethritis in our STI Unit, a greater proportion than that reported to date in Spain.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conflicts of Interest</span><p id="par0090" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres1133086" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1065499" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1133087" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1065500" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Material and Methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflicts of Interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-07-28" "fechaAceptado" => "2018-09-03" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1065499" "palabras" => array:4 [ 0 => "Urethritis" 1 => "<span class="elsevierStyleItalic">Haemophilus</span>" 2 => "Antibiotics" 3 => "Sexually transmitted infections" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1065500" "palabras" => array:4 [ 0 => "Uretritis" 1 => "<span class="elsevierStyleItalic">Haemophilus</span>" 2 => "Antibióticos" 3 => "Infecciones de transmisión sexual" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The incidence of urethritis due to <span class="elsevierStyleItalic">Haemophilus</span> species is increasing. The main aim of this study was to describe the clinical and microbiological characteristics of patients with this form of urethritis. A secondary aim was to discuss the adequacy of treatments in patients with different types of antibiotic resistance.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We studied patients with a microbiologically confirmed diagnosis of urethritis seen at the Sexually Transmitted Infections Unit of our hospital between July 2015 and July 2018. We selected all patients in whom <span class="elsevierStyleItalic">Haemophilus</span> species were isolated on chocolate agar. Antibiotic resistance was tested using the disk-diffusion method. Cross-sectional data were collected prospectively during outpatient visits.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Haemophilus</span> species were isolated in 33.6% of cases. The most common clinical manifestation was urethral discharge (57.6%); 60% of the patients were men who have sex with men and in this subgroup <span class="elsevierStyleItalic">Haemophilus</span> species were significantly more common than either <span class="elsevierStyleItalic">Neisseria</span> or <span class="elsevierStyleItalic">Chlamydia</span> species. <span class="elsevierStyleItalic">Haemophilus</span> species were found in isolation in 39.5% of patients and the most common one was <span class="elsevierStyleItalic">Haemophilus parainfluenzae</span> (isolated in 84.2% of cases). In total, 34.2% of patients were resistant to azithromycin and 26.3% were resistant to both azithromycin and tetracycline. Empirical treatment achieved clinical and microbiologic cure in 11 of the patients who were not lost to follow-up (n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>17; 44.7%). The remaining 6 patients required treatment with a new antibiotic.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Haemophilus</span> species are a new cause of nongonococcal urethritis, whose incidence is rising, particularly in men who have sex with men who engage in unprotected oral sex. The clinical manifestations are similar to those seen in gonococcal urethritis. Eradication of infection must be confirmed due to the high rate of antibiotic resistance associated with <span class="elsevierStyleItalic">Haemophilus</span> species.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducción</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La incidencia de uretritis por <span class="elsevierStyleItalic">Haemophilus</span> está aumentando. Nuestro objetivo principal es describir las características clínico-microbiológicas de estos pacientes. Como objetivo secundario discutiremos el tratamiento más adecuado en función de las resistencias antibióticas testadas.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Seleccionamos los pacientes de la Unidad de Infecciones de Transmisión Sexual diagnosticados microbiológicamente de uretritis entre julio de 2015 y julio de 2018. De ellos, seleccionamos aquellos en los que se aisló un <span class="elsevierStyleItalic">Haemophilus</span> mediante cultivo agar chocolate. Las resistencias antibióticas se testaron mediante método de difusión disco-placa. De estos pacientes se recogieron los datos de forma transversal y prospectiva durante las visitas en consultas externas.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se aisló un <span class="elsevierStyleItalic">Haemophilus</span> spp. en 33,6% de los pacientes diagnosticados de uretritis. De estos pacientes, la manifestación clínica más frecuente fue la supuración uretral (57,9%) y el 60% eran hombres que tienen sexo con hombres, siendo el aislamiento de este microorganismo más frecuente de forma estadísticamente significativa entre los hombres que tienen sexo con hombres que el aislamiento de <span class="elsevierStyleItalic">Neisseria</span> o <span class="elsevierStyleItalic">Chlamydia</span>. <span class="elsevierStyleItalic">Haemophilus</span> spp. se encontró de forma aislada en el 39,5% de los pacientes, siendo el más frecuente <span class="elsevierStyleItalic">H. parainfluenzae</span> en el 84,2%. El 34,2% de los casos de <span class="elsevierStyleItalic">Haemophilus</span> aislados fueron resistentes a azitromicina y el 26,3% eran resistentes tanto a azitromicina como a tetraciclinas. En los casos en los que no se perdió el seguimiento del paciente (n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>17; 44,7%), el tratamiento administrado de forma empírica consiguió una remisión clínica y microbiológica en 11 pacientes, mientras que en 6 fue necesario administrar una pauta de un nuevo antibiótico.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Haemophilus</span> es un nuevo agente etiológico de uretritis no gonocócicas cuya incidencia está en aumento, especialmente entre hombres que tienen sexo con hombres que practican sexo oral sin protección. Estos pacientes pueden presentar una clínica similar a una uretritis gonocócica. Es necesario confirmar la erradicación debido al elevado número de resistencias antibióticas testadas en <span class="elsevierStyleItalic">Haemophilus</span> spp.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Magdaleno-Tapial J, Valenzuela-Oñate C, Giacaman-von der Weth MM, Ferrer-Guillén B, Martínez-Domenech Á, García-Legaz Martínez M, et al. <span class="elsevierStyleItalic">Haemophilus</span> Species Isolated in Urethral Exudates as a Possible Causative Agent in Acute Urethritis: A Study of 38 Cases. Actas Dermosifiliogr. 2019;110:38–42.</p>" ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2058 "Ancho" => 2503 "Tamanyo" => 204785 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Flow chart illustrating patient inclusion in the study.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 639 "Ancho" => 750 "Tamanyo" => 39452 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Homosexual patient, aged 23 years, with abundant urethral suppuration caused by <span class="elsevierStyleItalic">Haemophilus parainfluenzae</span>.</p>" ] ] 2 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Abbreviations: HIV, human immunodeficiency virus; SD, standard deviation; STI, sexually transmitted infection.</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="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Data \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Number of Cases (%) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Sex</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">35 (92.1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Female \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 (7.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mean age, y; SD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">30.5; 8.7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Sexual orientation</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Men who have sex with men \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">21 (55.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Heterosexual men \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">13 (34.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Heterosexual women \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 (7.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Unknown \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 (2.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Previous STI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">20 (57.1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Syphilis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8 (21) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Urethritis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 (11.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>HIV infection \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5 (13.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Pediculosis pubis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 (2.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Condyloma acuminatum \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 (11.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Chlamydia trachomatis</span> proctitis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 (2.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Type of consultation</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Emergency department \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">34 (85.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Primary care physician \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5 (14.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Clinical presentation</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Purulent urethral discharge \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">22 (57.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Dysuria \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 (15.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Asymptomatic / unsafe sexual contact \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10 (26.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Haemophilus</span> species</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">H parainfluenzae</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">32 (84.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">H influenzae</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5 (13.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">H haemolyticum</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 (2.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Coinfections</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Haemophilus</span> species sole agent isolated \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">15 (39.5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Haemophilus</span> + <span class="elsevierStyleItalic">Neisseria</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 (15.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Haemophilus</span> + <span class="elsevierStyleItalic">Chlamydia</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7 (18.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Haemophilus</span> + <span class="elsevierStyleItalic">Mycoplasma genitalium</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 (5.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Haemophilus</span> + <span class="elsevierStyleItalic">Mycoplasma hominis</span>/<span class="elsevierStyleItalic">Ureaplasma</span> species \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9 (23.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Treatment outcome</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Clinical signs resolved after antibiotic treatment \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11 (28.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Clinical signs resolved after treatment with more than one antibiotic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 (15.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Lost to follow-up \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">21 (55.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1933238.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Clinical and Microbiological Data for Patients Diagnosed With Urethritis Caused by <span class="elsevierStyleItalic">Haemophilus</span> Species</p>" ] ] 3 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "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="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Antibiotic Tested \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Number of Resistant Cases (%) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cotrimoxazole \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">20 (53.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Azithromycin \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">13 (34.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Tetracyclines \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10 (26.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Amoxicillin \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8 (21) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cefotaxime \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 (2.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ceftriaxone \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 (7.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cefuroxime \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 (7.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ciprofloxacin \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 (15.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Levofloxacin \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 (2.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1933237.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Antibiotic Resistance of Isolated <span class="elsevierStyleItalic">Haemophilus</span> Species</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "[Diagnosis of urethritis in men. 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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 11 | 9 | 20 |
| 2024 Octubre | 126 | 52 | 178 |
| 2024 Septiembre | 168 | 45 | 213 |
| 2024 Agosto | 170 | 76 | 246 |
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| 2024 Junio | 144 | 55 | 199 |
| 2024 Mayo | 168 | 33 | 201 |
| 2024 Abril | 157 | 53 | 210 |
| 2024 Marzo | 120 | 34 | 154 |
| 2024 Febrero | 117 | 44 | 161 |
| 2024 Enero | 129 | 38 | 167 |
| 2023 Diciembre | 123 | 30 | 153 |
| 2023 Noviembre | 108 | 53 | 161 |
| 2023 Octubre | 93 | 43 | 136 |
| 2023 Septiembre | 77 | 36 | 113 |
| 2023 Agosto | 65 | 23 | 88 |
| 2023 Julio | 87 | 46 | 133 |
| 2023 Junio | 85 | 26 | 111 |
| 2023 Mayo | 79 | 29 | 108 |
| 2023 Abril | 56 | 23 | 79 |
| 2023 Marzo | 58 | 30 | 88 |
| 2023 Febrero | 73 | 24 | 97 |
| 2023 Enero | 43 | 36 | 79 |
| 2022 Diciembre | 47 | 41 | 88 |
| 2022 Noviembre | 33 | 29 | 62 |
| 2022 Octubre | 37 | 20 | 57 |
| 2022 Septiembre | 19 | 38 | 57 |
| 2022 Agosto | 23 | 37 | 60 |
| 2022 Julio | 37 | 54 | 91 |
| 2022 Junio | 27 | 29 | 56 |
| 2022 Mayo | 52 | 38 | 90 |
| 2022 Abril | 73 | 39 | 112 |
| 2022 Marzo | 74 | 79 | 153 |
| 2022 Febrero | 84 | 40 | 124 |
| 2022 Enero | 93 | 61 | 154 |
| 2021 Diciembre | 77 | 53 | 130 |
| 2021 Noviembre | 86 | 47 | 133 |
| 2021 Octubre | 70 | 81 | 151 |
| 2021 Septiembre | 69 | 39 | 108 |
| 2021 Agosto | 46 | 45 | 91 |
| 2021 Julio | 61 | 34 | 95 |
| 2021 Junio | 65 | 47 | 112 |
| 2021 Mayo | 97 | 58 | 155 |
| 2021 Abril | 215 | 134 | 349 |
| 2021 Marzo | 115 | 47 | 162 |
| 2021 Febrero | 105 | 44 | 149 |
| 2021 Enero | 88 | 41 | 129 |
| 2020 Diciembre | 85 | 46 | 131 |
| 2020 Noviembre | 79 | 38 | 117 |
| 2020 Octubre | 60 | 16 | 76 |
| 2020 Septiembre | 52 | 23 | 75 |
| 2020 Agosto | 60 | 24 | 84 |
| 2020 Julio | 64 | 26 | 90 |
| 2020 Junio | 197 | 32 | 229 |
| 2020 Mayo | 60 | 12 | 72 |
| 2020 Abril | 48 | 15 | 63 |
| 2020 Marzo | 105 | 11 | 116 |
| 2020 Febrero | 6 | 0 | 6 |
| 2019 Junio | 0 | 1 | 1 |
| 2019 Mayo | 0 | 2 | 2 |
| 2019 Abril | 0 | 1 | 1 |
| 2019 Enero | 1 | 0 | 1 |
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