Uso racional de antimicrobianos en tiempos de COVID-19 en Perú: rol de los programas de optimización del uso de antimicrobianos e intervenciones desde el punto de vista de control de infecciones

Autores/as

DOI:

https://doi.org/10.24265/horizmed.2021.v21n2.12

Palabras clave:

COVID-19, Programas de optimización del uso de los antimicrobianos, Sobreinfección, Coinfección, Control de infecciones

Resumen

La resistencia antimicrobiana (RAM) es una pandemia adicional de lenta evolución que precede a la pandemia de COVID-19 y continuará cuando esta termine. Sin embargo, en países como Perú donde existe un alto consumo y prescripción inadecuada de antimicrobianos puede pasar desapercibida y se puede esperar un escenario futuro más desafiante. Los Programas de Optimización de Uso de Antimicrobianos (PROA) son equipos multidisciplinarios de profesionales que tienen como objetivo retardar la aparición de organismos multirresistentes a través de estrategias como la auditoría de prescripciones o la creación de algoritmos de tratamiento antimicrobiano basados en las tasas locales de RAM.  La dificultad en el diagnóstico oportuno de coinfecciones o superinfecciones en el curso clínico y progresión de COVID-19 predisponen al uso inadecuado de antimicrobianos, obligando a los PROA a adaptar sus estrategias en este panorama cambiante. En Latinoamérica los PROA no sólo tienen que fomentar el cambio de comportamiento en los prescriptores de antimicrobianos sino también luchar contra la epidemia de información falsa (infodemia) y campañas de desinformación sobre COVID-19. Además, la pobre cultura local de prevención y control de infecciones obliga a revisar estrategias para mitigar el impacto posterior en la RAM.

Descargas

Los datos de descargas todavía no están disponibles.

Citas

Ministerio de Salud del Perú. Documento Tecnico: Prevención y Atención de personas afectadas por COVID-19 en el Perú [Internet]. 2020. Disponible en: ttps://cdn.www.gob.pe/uploads/document/file/694719/RM_270-2020-MINSA.PDF

Sociedad Peruana de Medicina Intensiva. Propuesta en base a consideración de manejo de COVID – 19 emitido por la Sociedad Peruana de Enfermedades Infecciosas y Tropicales (SPEIT) revisada y consensuada con la Sociedad Peruana de Medicina Intensiva (SOPEMI), Sociedad Peruana de Medicina [Internet]. 2020. Disponible en: https://www.sopemi.org.pe/sites/default/files/ Propuesta%20Sociedades%20manejo%20clinico%20COVID%20-19%20 SPEIT%20%E2%80%93%20SOPEMI%20-%20SPMI%20-%20SPN%20- %2024-

-2020%20version%20final%201.1%20%281%29.pdf

Acosta G, Escobar G, Bernaola G, Alfaro J, Taype W, Marcos C, et al. Caracterización de pacientes con COVID-19 grave atendidos en un hospital de referencia nacional del Perú. Rev Peru Med Exp Salud Publica. 2020; 37(2): 253-8.

Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet. 2020; 395(10229): 1054-62.

Stevens MP, Patel PK, Nori P. Involving antimicrobial stewardship programs in COVID-19 response efforts: all hands on deck. Infect Control Hosp Epidemiol. 2020; 41(6): 744-5.

Hernández-Gómez C, Hercilla L, Mendo F, Pérez-Lazo G, Contreras E, Ramírez E, et al. Programas de optimización del uso de antimicrobianos en Perú: Un acuerdo sobre lo fundamental. Rev Chil Infectol. 2019; 36(5): 565-75.

Joint commission joins white house effort to reduce antibiotic overuse. Jt Comm Perspect. 2015; 35(7): 4-11.

Metlay JP, Waterer GW, Long AC, Anzueto A, Brozek J, Crothers K, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019; 200(7): e45-67.

Gautret P, Lagier J-C, Parola P, Hoang VT, Meddeb L, Mailhe M, et al. Hydroxychloroquine and azithromycin as a treatment of COVID-19: results of an open-label non-randomized clinical trial. Int J Antimicrob Agents. 2020; 105949.

National Institutes of Health (NIH). Coronavirus Disease 2019 (COVID-19) Treatment Guidelines [Internet]. 2020. Disponible en: https://covid19treatmentguidelines.nih.gov/.

Gérard A, Romani S, Fresse A, Viard D, Parassol N, Granvuillemin A, et al. "Off-label" use of hydroxychloroquine , azithromycin , lopinavir-ritonavir and chloroquine in COVID-19: A survey of cardiacadverse drug reactions by the French Network of Pharmacovigilance Centers. Therapie. 2020; S0040-5957(20): 30091-3.

Bacharier LB, Guilbert TW, Mauger DT, Boehmer S, Beigelman A, Fitzpatrick AM, et al. Early administration of azithromycin and prevention of severe lower respiratory tract illnesses in preschool

children with a history of such illnesses a randomized clinical trial. JAMA. 2015; 314(19): 2034-44.

Million M, Lagier J-C, Gautret P, Colson P, Fournier P-E, Amrane S, et al. Early treatment of COVID-19 patients with hydroxychloroquine and azithromycin: a retrospective analysis of 1061 cases in Marseille,

France. Travel Med Infect Dis. 2020; 101738.

Cramer CL, Patterson A, Alchakaki A, Soubani AO. Immunomodulatory indications of azithromycin in respiratory disease: a concise review for the clinician. Postgrad Med. 2017; 129(5): 493-9.

Kawamura K, Ichikado K, Takaki M, Sakata Y, Yasuda Y, Shingu N, et al. Efficacy of azithromycin in sepsis-associated acute respiratory distress syndrome: a retrospective study and propensity score analysis. Springerplus. 2016; 285(1): 1193.

Castro JD, Siccha SM, Egoavil M, Chaparro E, Hernandez R, Silva W, et al. Antibiotic resistance and distribution of serotypes of invasive pneumococcal strains isolated from hospitalized adults in Lima, Peru. Rev Peru Med Exp Salud Publica. 2017; 34(4): 633-41.

Khaddour K, Sikora A, Tahir N, Nepomuceno D, Huang T. Case report: the importance of novel Coronavirus Disease (COVID-19) and coinfection with other respiratory pathogens in the current pandemic. Am J Trop Med Hyg. 2020; 102(6): 1208-9.

Hong-Rui C, Hao Z, Mei X, Zhen-Bing C, Wan-Xin C. A case of childhood COVID-19 infection with pleural effusion complicated by possible secondary Mycoplasma pneumoniae infection. Pediatr Infect

Dis J. 2020.

Sodhi M, Etminan M. Therapeutic potential for tetracyclines in the treatment of COVID-19. Pharmacotherapy. 2020; 40(5): 487-8.

Phillips JM, Gallagher T, Weiss SR. Neurovirulent murine coronavirus JHM. SD uses cellular zinc metalloproteases for virus entry and cellcell fusion. J Virol. 2017; 91(8): e01564-16.

Rothan HA, Mohamed Z, Paydar M, Rahman NA, Yusof R. Inhibitory effect of doxycycline against dengue virus replication in vitro. Arch Virol. 2014; 159(4): 711-8.

Rothan HA, Bahrani H, Mohamed Z, Teoh TC, Shankar EM, Rahman NA, et al. A combination of doxycycline and ribavirin alleviated chikungunya infection. PLoS One. 2015; 10(5): e0126360.

Rempe S, Hayden J, Robbins R, Hoyt J. Tetracyclines and pulmonary inflammation. Endocrine‚ Metab Immune Disord Targets. 2007; 7: 232.

U.S. National Library of Medicine. Doxycycline: Clinical Trials.gov [Internet]. 2020. Disponible en: https://clinicaltrials.gov/ct2/ results?recrs=&cond=SARS-Cov2&term=doxycycline&cntry=&state=&

city=&dist=

Calvo J, Martínez-Martínez L. Mecanismos de acción de los antimicrobianos. Enferm Infecc Microbiol Clin. 2009; 27(1): 44-52.

Rawson T, Moore L, Zhu N, Ranganathan N, Skolimowska K, Gilchrist M, et al. Bacterial and fungal co-infection in individuals with coronavirus: a rapid review to support COVID-19 antimicrobial prescribing. Clin Infect Dis. 2020; ciaa530.

Torres N, Velásquez R, Mercado EH, Egoavil M, Horna G, Mejía L, et al. Resistencia antibiótica de Streptococcus pneumoniae en portadores nasofaríngeos sanos de siete regiones del Perú. Rev Peru

Med Exp Salud Publica. 2014; 30(4): 575-82.

Valle-Mendoza J, Orellana-Peralta F, Marcelo-Rodríguez A, Verne E, Esquivel-Vizcarra M, Silva-Caso W, et al. High prevalence of mycoplasma pneumoniae and chlamydia pneumoniae in children with acute respiratory infections from Lima, Peru. PLoS One. 2017; 12(1): e0170787.

Caly L, Druce JD, Catton MG, Jans DA, Wagstaff KM. The FDAapproved drug ivermectin inhibits the replication of SARS-CoV-2 in vitro. Antiviral Res. 2020; 178(3): 104787.

Momekov G, Momekova D. Ivermectin as a potential COVID-19 treatment from the pharmacokinetic point of view: antiviral levels are not likely attainable with known dosing regimens. Biotechnol

Biotechnol Equip. 2020; 34(1): 469-74.

U.S.National Library of Medicine. Ivermectin: Clinical Trials.gov [Internet]. 2020. Disponible en: https://clinicaltrials.gov/ct2/results?cond=Covid19&term=ivermectin&cntry=&state=&city=&dist=

Ministerio de Salud del Perú. Dirección General de Medicamentos, insumos y drogas – DIGEMID: Alerta DIGEMID N° 12-2020. Ivermectina: Recomendaciones de uso asociadas a infección por COVID-19 [Internet]. 2020. Disponible en:http://www.digemid.minsa.gob.pe/

Orso D, Federici N, Copetti R, Vetrugno L, Bove T. Infodemic and the spread of fake news in the COVID-19-era. Eur J Emerg Med. 2020; 10.

Diario La República-Perú. Es falso que la doxiciclina sea un tratamiento alternativo para la COVID-19 [Artículo electrónico]. ublicado 12 mayo 2020. Disponible en: https://larepublica.pe/ verificador/2020/05/12/coronavirus-es-falso-que-la-doxiciclinasea-un-tratamiento-alternativo-para-la-covid-19-minsa-oms/

Wirtz VJ, Dreser A, Gonzales R. Trends in antibiotic utilization in eight Latin American countries, 1997-2007. Rev Panam Salud Publica. 2010; 27(3): 219-25.

Ecker L, Ruiz J, Vargas M, Del Valle LJ, Ochoa TJ. Prevalence of purchase of antibiotics without prescription and antibioticrecommendation practices for children under five years of age in private pharmacies in Peri-urban areas of Lima, Peru. Rev Peru Med Exp Salud Publica. 2016; 33(2): 215-23.

Diario Gestión-Perú. Demanda de medicinas para tratar síntomas de COVID-19 aumentó en cinco veces [Artículo electrónico]. Publicado 14 de mayo 2020. Disponible en: https://gestion.pe/economia/

inkafarma-precios-covid-19-demanda-de-medicinas-para-tratarsintomas-de-covid-19-aumento-en-cinco-veces-noticia/?ref=gesr

Hantoushzadeh S, Norooznezhad AH. Inappropriate antibiotic consumption as a possible cause of inflammatory storm and

septic shock in patients diagnosed with Coronavirus Disease 2019 (COVID-19). Arch Med Res. 2020; S0188-4409(20): 30409.

Alkharfy KM, Kellum JA, Frye RF, Matzke GR. Effect of ceftazidime on systemic cytokine concentrations in rats. Antimicrob Agents Chemother. 2000; 44(11): 3217-9.

Bode C, Diedrich B, Muenster S, Hentschel V, Weisheit C, Rommelsheim K, et al. Antibiotics regulate the immune response in both presence and absence of lipopolysaccharide through modulation of Toll-like receptors, cytokine production and phagocytosis in vitro. Int Immunopharmacol. 2014; 18(1): 27-34.

Bengoechea JA, Bamford CGG. SARS-CoV-2, bacterial co-infections, and AMR: the deadly trio in COVID-19?. EMBO Mol Med. 2020.

Clancy CJ, Nguyen MH. COVID-19, superinfections and antimicrobial development: What can we expect?. Clin Infect Dis. 2020; ciaa524.

Bhatraju PK, Ghassemieh BJ, Nichols M, Kim R, Jerome KR, Nalla AK, et al. Covid-19 in critically ill patients in the Seattle region-case series. N Engl J Med. 2020.

Chen N, Zhou M, Dong X, Qu J, Gong F, Han Y, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet. 2020; 395:

-13.

Chen X, Zhao B, Qu Y, Chen Y, Xiong J, Feng Y, et al. Detectable

serum SARS-CoV-2 viral load (RNAaemia) is closely correlated with drastically elevated interleukin 6 (IL-6) level in critically ill COVID-19 patients. Clin Infect Dis. 2020; ciaa449.

Cao J, Tu WJ, Cheng W, Yu L, Liu YK, Hu X, et al. Clinical features and short-term outcomes of 102 patients with Corona Virus Disease 2019 in Wuhan, China. Clin Infect Dis. 2020; ciaa243.

Alanio A, Dellière S, Fodil S, Bretagne S, Mégarbane B. High prevalence of putative invasive pulmonary aspergillosis in critically Ill COVID-19 patients. Lancet Respir Med. 2020; 8(6): e48-9.

Blot SI, Taccone FS, Van den Abeele AM, Bulpa P, Meersseman W, Brusselaers N, et al. A clinical algorithm to diagnose invasive pulmonary aspergillosis in critically ill patients. Am J Respir Crit Care Med. 2012; 186(1): 56-64.

Campochiaro C, Della-torre E, Cavalli G, Luca G De, Ripa M, Boffini N, et al. Efficacy and safety of tocilizumab in severe COVID-19 patients: a single-centre retrospective cohort study. Eur J Intern Med. 2020.

Xiong Y, Sun D, Liu Y, Fan Y, Zhao L, Li X, et al. Clinical and highresolution CT features of the COVID-19 infection: comparison of the initial and follow-up changes. Invest Radiol. 2020; 55(6): 332-9.

Huttner B, Catho G, Pano-Pardo JR, Pulcini C, Schouten J. COVID-19:

don’t neglect antimicrobial stewardship principles!. Clin Microbiol Infect. 2020; S1198-743X(20): 30232-9.

Gilvert DN, editor. Guide Sanford collection 2019: Antimicrobialdrugs; Dosing/Use in special population; pharmacology [Internet]. 2020.

U.S. Food and Drug Administration. FDA drug safety comunication. FDA cautions against use of hydroxychloroquine or chloroquine for COVID-19 outside of the hospital setting or a clinical trial due to risk

of heart rhythm problems [Internet]. 2020. Disponible en: https:// www.fda.gov/drugs/drug-safety-and-availability/fda-cautionsagainst-use-hydroxychloroquine-or-chloroquine-covid-19-outsidehospital-setting-or

Escuela Andaluza de Salud Pública. Fármacos que prolongan el intervalo QT. Bol Ter Andaluz. 2017; 32(2).

El-Tahtawy A, Glue P, Andrews EN, Mardekian J, Amsden GW, Knirsch CA. The effect of azithromycin on ivermectin pharmacokinetics - a population pharmacokinetic model analysis. PLoS Negl Trop Dis.

; 2(5): e236.

Drugbank. Azithromycin [Internet]. 2020. Disponible en: https:// www.drugbank.ca/drugs/DB00207.

Drugbank. Doxycycline [Internet]. 2020. Disponible en: https:// www.drugbank.ca/drugs/DB00254

Drugbank. Ivermectin [Internet]. 2020. Disponible en: https://www. drugbank.ca/drugs/DB00602

BM MICROMEDEX® Drug Monograph: Ivermectin [Internet]. 2020. Disponible en: https://www.micromedexsolutions.com/

Decreto Supremo N°010-2019-SA. Aprobación del Plan Multisectorial para enfrentar la resistencia a los Antimicrobianos 2019-2021 [Internet]. 2020. Disponible en: https://antimicrobianos.ins.gob.

pe/images/contenido/plan-nacional/Decreto_Supremo_010-2019-SA-c.pdf

Cox JA, Vlieghe E, Mendelson M, Wertheim H, Ndegwa L, Villegas MV, et al. Antibiotic stewardship in low- and middle-income countries: the same but different?. Clin Microbiol Infect. 2017; 23(11): 812-8.

Gozzer E, Canchihuamán F, Espinoza R. COVID-19 y la necesidad de actuar para mejorar las capacidades del Perú frente a las pandemias. Rev Peru Med Exp Salud Publica. 2020; 37(2).

Wu Z, McGoogan JM. Characteristics of and important lessons from the Coronavirus Disease 2019 (COVID-19) outbreak in China. JAMA. 2020.

Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX, et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med. 2020; 382: 1708-20.

Langford BJ, Beriault D, Schwartz KL, Seah J, Pasic MD, Cirone R, et al. A real-world assessment of procalcitonin combined with antimicrobial stewardship in a community ICU. J Crit Care. 2020;

: 130-3.

Patel R, Fang FC. Diagnostic stewardship: opportunity for a laboratory-infectious diseases partnership. Clin Infect Dis. 2018; 67(5): 799-801.

Rodriguez-Morales AJ, Cardona-Ospina JA, Gutiérrez-Ocampo E, Villamizar-Peña R, Holguin-Rivera Y, Escalera-Antezana JP, et al. Clinical, laboratory and imaging features of COVID-19: a systematic

review and meta-analysis. Travel Med Infect Dis. 2020; 34: 101623.

Shah NS, Greenberg JA, McNulty MC, Gregg KS, Riddell J, Mangino JE, et al. Bacterial and viral co-infections complicating severe influenza: Incidence and impact among 507 U.S. patients, 2013-14. J

Clin Virol. 2016; 80: 12-9.

Kim D, Quinn J, Pinsky B, Shah NH, Brown I. Rates of co-infection between SARS-CoV-2 and other respiratory pathogens. 2020; 323(20): 2085-6.

Zhang J, Zhou L, Yang Y, Peng W, Wang W, Chen X. Therapeutic and triage strategies for 2019 novel coronavirus disease in fever clinics. Lancet Respir Med. 2020; 8(3): e11-2.

Avila Quispe VA, Muñoz Díaz EJ. Adherencia a la Guía de Práctica Clínica en la Antibióticoterapia en Pacientes con Neumonía del “Hospital II EsSalud”, Cajamarca–2015. Cajamarca: Universidad Privada Antonio Guillermo Urrelo. Facultad de Ciencias de la Salud; 2016.

Lai J, Ma S, Wang Y, Cai Z, Hu J, Wei N, et al. Factors associated with mental health outcomes among health care workers exposed to Coronavirus Disease 2019. JAMA. 2020; 3(3): e203976.

Pérez-Lazo G, Salazar SA, Ramírez BA, Guillermo N, Irigoyen A. Camino a la bacteria pan-resistente: ¿Es posible la implementación de estrategias para disminuir la diseminación interespecies del gen mcr-1 en Perú?. An Fac Med. 2019; 80(1): 131-2.

Rawson TM, Moore LSP, Castro-Sanchez E, Charani E, Davies F, Satta G, et al. COVID-19 and the potential long-term impact on antimicrobial resistance. J Antimicrob Chemother. 2020; dkaa194.

Seaton RA, Scottish Antimicrobial Prescribing Group. Advice to Antimicrobial Management Teams (AMTs) on antimicrobial prescribing in suspected lower respiratory tract infections in the context of the

COVID-19 pandemic [Internet]. 2020. Disponible en: https://www. sapg.scot/about-us/latest-updates/sapg-response-to-covid-19/

The National Institute for Health and Care Excellence. COVID-19 rapid guideline : antibiotics for pneumonia in adults in hospital [Internet]. 2020. Disponible en: https://www.nice.org.uk/guidance/

ng173/resources/prescribing-tables-to-guide-decision-makingabout-antibiotic-choice-pdf-8719038253

British Society for Antimicrobial Chemotherapy. COVID-19 pandemic challenges all aspect of healthcare including both recognition and management of serious acute bacterial infection and effective delivery of antimicrobial stewardship [Internet]. 2020. Disponible

en: http://bsac.org.uk/antibiotic-prescribing-in-the-context-ofcovid-19-pandemic/

The Sinai Health System–University Health Network Antimicrobial Stewardship. Program developed educational materials for patients on COVID-19 medication myths and the status of knowledge and

research on drugs to prevent and manage COVID-19 [Internet]. 2020. Disponible en: https://4d9cc926-c314-41ac-908e-19322efdf1db. filesusr.com/ugd/b5d454_a296769261b54e4983cbeb5040f43ae7.pdf

Spernovasilis NA, Kofteridis DP. COVID-19 and antimicrobial stewardship: what is the interplay?. Infect Control Hosp Epidemiol. 2020: 1-2.

Publique Haut Conseil de la Santé Publique. Relatif à la prévention et à la prise en charge des patients à risque de formes graves de COVID-19 ainsi qu’à la priorisation des tests diagnostiques [Internet].

Disponible en: https://www.hcsp.fr/Explore.cgi/Telecharger? NomFichier=hcspa20200331_corsarcovprienchadesperrisdeforg.pdf

Alhazzani W, Møller MH, Arabi YM, Loeb M, Gong MN, Fan E, et al. Surviving Sepsis Campaign: guidelines on the management of critically ill adults with Coronavirus Disease 2019 (COVID-19). Crit

Care Med. 2020; 48(6): e440-69.

Zhou Q, Gao Y, Wang X, Liu R, Du P, Wang X, et al. Nosocomial infections among patients with COVID-19, SARS and MERS: a rapid review and meta-analysis. Ann Transl Med. 2020; 8(10): 629.

Yagui-Moscoso MJ, Tarqui-Mamani CB, Sanabria-Rojas HA, Encarnación-Gallardo EE. Evaluación de las prácticas de control de infecciones de los trabajadores de la salud en un hospital de Lima

Metropolitana, durante la epidemia de Influenza A H1N1. Rev Salud Pública. 2012; 14(2): 271-81.

World Health Organization. Regional Office for Western Pacific. Routine immunization services during COVID-19 pandemic [Internet]. 2020. Disponible en: https://apps.who.int/iris/bitstream/

handle/10665/331925/Routine-immunization-services-COVID-19-eng.pdf?sequence=1&isAllowed=y

Mendelson M. Could enhanced influenza and pneumococcal vaccination programs help limit the potential damage from SARSCoV-2 to fragile health systems of southern hemisphere countries

this winter?. Int J Infect Dis. 2020; 94: 32-3.

WHO Global Infection Prevention and Control Network. Infection prevention and control during health care when COVID-19 is suspected

[Internet]. 2020. Disponible en: https://www.who.int/publicationsdetail/infection-prevention-and-control-during-health-care-whennovel-coronavirus-(ncov)-infection-is-suspected-20200125

European Centre for Disease Prevention and Control. Infection prevention and control for COVID-19 in healthcare settings-third update [Internet]. 2020. Disponible en: https://www.ecdc.europa.

eu/en/publications-data/infection-prevention-and-control-andpreparedness-covid-19-healthcare-settings

National Center for Immunization and Respiratory Diseases, Division of Viral Diseases. Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings [Internet]. 2020. Disponible en: https://www.cdc.gov/

coronavirus/2019-ncov/hcp/infection-control-recommendations.html

Thompson MG, Pierse N, Sue Huang Q, Prasad N, Duque J, Claire Newbern E, et al. Influenza vaccine effectiveness in preventing influenza-associated intensive care admissions and attenuating

severe disease among adults in New Zealand 2012–2015. Vaccine. 2018; 36(39): 5916-25.

Kuster SP, Shah PS, Coleman BL, Lam PP, Tong A, Wormsbecker A, et al. Incidence of influenza in healthy adults and healthcare workers:

a systematic review and meta-analysis. PLoS ONE. 2011; 6(10): e26239.

Bonten MJM, Huijts SM, Bolkenbaas M, Webber C, Patterson S, Gault S, et al. Polysaccharide conjugate vaccine against pneumococcal pneumonia in adults. N Engl J Med. 2015; 372: 1114-25.

##submission.downloads##

Publicado

2021-05-25

Cómo citar

Pérez-Lazo , G., Soto-Febres, . F., Morales-Moreno, A., Cabrera-Enríquez, . J. A., Díaz-Agudo , J., Rojas , R. ., Arenas-Ramirez, B., & Illescas, . R. (2021). Uso racional de antimicrobianos en tiempos de COVID-19 en Perú: rol de los programas de optimización del uso de antimicrobianos e intervenciones desde el punto de vista de control de infecciones . Horizonte Médico (Lima), 21(2), e1254. https://doi.org/10.24265/horizmed.2021.v21n2.12

Número

Sección

Artículos de revisión