Original Article
The use of polymerase chain reaction in the diagnosis of invasive meningococcal disease
La reacción en cadena de la polimerasa en el diagnóstico de la enfermedad meningocócica invasiva
C. Fernández-San Joséa, F.A. Moraga-Llopa,
, G. Codinab, P. Soler-Palacína, M. Espiaua, C. Figuerasa
Corresponding author
a Unidad de Patología Infecciosa e Inmunodeficiencias de Pediatría, Hospital Universitario Vall d’Hebron, Universidad Autónoma de Barcelona, Institut de Recerca Vall d’Hebron, Barcelona, Spain
b Servicio de Microbiología, Hospital Universitario Vall d’Hebron, Universidad Autónoma de Barcelona, Institut de Recerca Vall d’Hebron, Barcelona, Spain
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Soler-Palacín, M. Espiau, C. Figueras" "autores" => array:6 [ 0 => array:3 [ "nombre" => "C." "apellidos" => "Fernández-San José" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 1 => array:4 [ "nombre" => "F.A." "apellidos" => "Moraga-Llop" "email" => array:1 [ 0 => "fmoraga@acmcb.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 2 => array:3 [ "nombre" => "G." "apellidos" => "Codina" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "P." 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"apellidos" => "Figueras" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Unidad de Patología Infecciosa e Inmunodeficiencias de Pediatría, Hospital Universitario Vall d’Hebron, Universidad Autónoma de Barcelona, Institut de Recerca Vall d’Hebron, Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Microbiología, Hospital Universitario Vall d’Hebron, Universidad Autónoma de Barcelona, Institut de Recerca Vall d’Hebron, Barcelona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "La reacción en cadena de la polimerasa en el diagnóstico de la enfermedad meningocócica invasiva" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 441 "Ancho" => 962 "Tamanyo" => 62569 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Distribution of the 75 patients with invasive meningococcal disease by year and serogroup.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Invasive meningococcal disease (IMD) constitutes a serious public health problem worldwide, with a high impact on society and a high rate of morbidity and mortality in all age groups. Despite advances in our knowledge of the disease and its diagnosis and treatment, and the implementation of new preventive strategies, IMD is endemic in many countries, even developed ones, with attack rates of between 1 and 5 cases per 100,000 inhabitants.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In Spain, according to data from the national system of epidemiological surveillance (Sistema Nacional de Vigilancia Epidemiológica [SNVE]) from 2004 to 2011, the overall incidence rate for IMD was of 0.92–1.67 cases per 100,000 inhabitants.<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">2–4</span></a> The highest incidence in children occurs in those younger than 1 year, with a rate of 13 cases per 100,000 in the 2009–2010 season.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">3</span></a> Serogroups B and C caused over 90% of the IMD cases in Spain.<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">2,3,5</span></a> The introduction of the conjugate meningococcal C vaccine in 2001 has reduced the incidence of IMD caused by this serotype by up to 88%,<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">6</span></a> but it is still a serious disease due to its sequelae (11–19%)<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">2,3</span></a> and mortality rate (5–14%).<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">1–3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The diagnosis of IMD is confirmed by ascertaining the presence of <span class="elsevierStyleItalic">Neisseria meningitidis</span> (<span class="elsevierStyleItalic">N. meningitidis</span>) in the blood or in the cerebrospinal fluid (CSF), or in both, either by culture or by detection of bacterial deoxyribonucleic acid (DNA),<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">5,7</span></a> or the two methods. Culture continues to be the gold standard for microbiological diagnosis, and it also allows for antimicrobial sensitivity and strain identification testing of the isolate. Still, it does have limitations, chief among which is its low diagnostic yield when the samples are taken from patients who have received previous antibiotic treatment.<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">5,8–11</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Even if the culture is performed, there is a sizable percentage of reported IMD cases without a microbiological diagnosis, and this limits the analysis of its epidemiological evolution and the impact of vaccination.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The introduction of DNA detection techniques that use polymerase chain reaction (PCR) represents an advance in confirmatory diagnosis, and various studies and clinical practise guidelines recommend routine PCR testing.<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">5,8,12–14</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The aim of this study was to make an epidemiological analysis of IMD in our country, assess the usefulness of PCR in the diagnosis of IMD, and study the correlation of negative cultures in confirmed cases with previous antibiotic therapy.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Patients and methods</span><p id="par0035" class="elsevierStylePara elsevierViewall">We performed a retrospective study of the medical records of patients younger than 16 years with a clinical diagnosis of IMD confirmed by culture, PCR, or both, admitted to the Hospital Universitari Vall d’Hebron between January 2004 and December 2012. All the cases were selected based on culture and PCR results from the microbiology department.</p><p id="par0040" class="elsevierStylePara elsevierViewall">We collected data on demographic, clinical, and laboratory variables, and also documented whether the patient had received antibiotic therapy prior to sample collection.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Samples of blood, CSF or both were collected for culture and PCR (both techniques were performed on a single sample), and were processed and analysed in the molecular diagnosis, blood culture, and general culture laboratories of the microbiology department. PCR testing was done on samples larger than 100<span class="elsevierStyleHsp" style=""></span>μL. Nucleic acids were extracted from the samples with the <span class="elsevierStyleItalic">EasyMag</span><span class="elsevierStyleSup">®</span> automated platform (bioMèrieux, Marcy-l’Étoile, France) and later amplified by multiplex PCR for <span class="elsevierStyleItalic">N. meningitidis</span> (ctrA region, capsular transport gene), <span class="elsevierStyleItalic">Haemophilus influenzae</span> type b (bexA, capsulation gene) and <span class="elsevierStyleItalic">Streptococcus pneumoniae</span> (ply, pneumolysin gene) with <span class="elsevierStyleItalic">TaqMan</span><span class="elsevierStyleSup">®</span> fluorescent probes in a <span class="elsevierStyleItalic">Smartcycler</span><span class="elsevierStyleSup">®</span> thermal cycler (Cepheid, Sunnyvale, USA).<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">15</span></a><span class="elsevierStyleItalic">N. meningitidis</span> was serotyped by agglutination with specific antisera in cases for which the strain was available; and otherwise by PCR following the method described by Mölling et al.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">16</span></a> Blood cultures were done in paediatric FAN bottles using the <span class="elsevierStyleItalic">BacT/ALERT</span><span class="elsevierStyleSup">®</span><span class="elsevierStyleItalic">3D</span> system (Biomèrieux, Marcy l’Etoile, France). Samples for CSF cultures were centrifuged at 1500<span class="elsevierStyleHsp" style=""></span>rpm for 15<span class="elsevierStyleHsp" style=""></span>min and the sediment was inoculated in blood agar plates and LAN enriched medium.</p><p id="par0050" class="elsevierStylePara elsevierViewall">We performed a descriptive analysis of the sample to identify extreme or erroneous values, and then expressed discrete variables as frequencies and proportions, and continuous variables as means (or medians) and their corresponding standard deviations (or interquartile ranges). We used the chi-square test to assess the statistical significance of the association between the administration of antibiotics prior to sample collection and negative culture results. The level of statistical significance was set at <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.05. The statistical analysis was done with the software <span class="elsevierStyleItalic">SPSS</span><span class="elsevierStyleSup">®</span> version 20.0 (SPSS, Chicago, USA).</p><p id="par0055" class="elsevierStylePara elsevierViewall">The study was approved by the ethics committee of the hospital.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0060" class="elsevierStylePara elsevierViewall">Between January 2004 and December 2012, our hospital admitted 75 patients with a clinical diagnosis of IMD confirmed by culture, PCR or both. The case distribution remained homogeneous during the 9 years of the study, save for an increased incidence in 2009 and 2010 (29/75, 38.7%) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> summarises the most pertinent demographic and clinical data of the patients.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">The microbiological data are presented in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>. In 8 of the 36 patients with a clinical diagnosis of IMD (23 had meningitis and 13 septicaemia with meningitis), the diagnosis was confirmed by culture alone, as molecular testing was not performed. In the remaining 28 it was possible to do CSF cultures and PCR. The PCR assay was positive in 100% of the cases, and the culture in 50%, that is, half of the cases (14 patients) were diagnosed by means of PCR.</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">In 5 of the 52 patients diagnosed with septicaemia (39 with septicaemia and 13 with septicaemia with meningitis), the diagnosis was confirmed by culture alone, as molecular testing was not performed. In the remaining 47 patients it was possible to perform both culture and PCR assays. The PCR results were positive in 100% of the cases and the culture was positive in 51.1% of cases, that is, 48.9% of the cases (23 patients) were diagnosed by PCR.</p><p id="par0075" class="elsevierStylePara elsevierViewall">The meningococcal serogroup could be determined in 88.6% of the samples (78/88). PCR successfully serotyped 81.6% (31/38) of the samples: 95.8% of peripheral blood samples (22 serogroup B and 1 serogroup C) and 57.1% of CSF samples (8 serogroup B) (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>).</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">One or more doses of antibiotics had been given to 53.3% of the patients (40/75) before sample collection, and 40% (16) of these patients could only be diagnosed by PCR. In our study, the association between the administration of antibiotics prior to sample collection and negative culture results did not reach statistical significance (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.53).</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0085" class="elsevierStylePara elsevierViewall">Invasive meningococcal disease has clinical forms of varying severity, such as septicaemia and meningitis. It can progress quickly, and patients with a fulminant course may develop purpura, disseminated intravascular coagulation, shock and coma, often in spite of early and appropriate diagnosis and management.<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">1,5</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">The clinical and microbiological results obtained in our series are consistent with the literature, with the IMD incidence peaking in infants younger than 1 year, the highest prevalence corresponding to serogroup B, and considerable associated sequelae and mortality rates.<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">2–4</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">The development of molecular techniques has advanced the microbiological diagnosis of IMD. These methods are increasingly used in reference hospitals and offer several advantages compared to culture: they are more sensitive, specific and quick, and its detection ability is not affected by the previous administration of antibiotics<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">5,8,10–12</span></a>; yet they also have drawbacks, such as their high cost and the need for qualified personnel to perform them.<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">5,8,13</span></a> The latest data published in the European Invasive Bacterial Diseases Surveillance Network<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">17</span></a> report for season 2008–2009 show that while culture continues to be the gold standard for diagnosing IMD (47.9% in 2008 and 44.7% in 2009), the percentage of cases confirmed only by PCR is 25%, and even higher in countries such as Greece (42.7%), United Kingdom (51.6%) and Ireland (58.3%). Also, the Spanish Ministry of Health recently published a clinical practise guideline for the management of IMD that recommends routine PCR testing for diagnosis, even if culture continues to be the gold standard.<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">5,13</span></a> After reviewing the literature, the authors of the guideline reported that the increase of IMD cases with a diagnosis confirmed by PCR ranges between 30% and 40%.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">5</span></a> The introduction of multiplex PCR in our setting has allowed the diagnosis of 38.7% of the cases of IMD that could not have been confirmed otherwise, a percentage similar to those found in other studies.<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">5,13</span></a> Furthermore, PCR has allowed the identification of the serogroup of 81.6% of samples for which the strain of <span class="elsevierStyleItalic">N. meningitidis</span> was not available, an important fact when it comes to epidemiologic surveillance and research on vaccine effectiveness.</p><p id="par0100" class="elsevierStylePara elsevierViewall">Several studies have assessed the sensitivity of PCR compared to culture.<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">5,9,10,12,13</span></a> The guidelines of the National Institute for Health and Care Excellence of the United Kingdom<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">13</span></a> include 4 studies on PCR that support its routine performance. Their results show that PCR has a sensitivity of 87–88%, while the sensitivity of culture ranges between 17% and 58%. Another study included in the clinical practise guideline of the Spanish Ministry of Health<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">5</span></a> assessed the use of PCR in CSF samples for the confirmatory diagnosis of IMD, and found a sensitivity of 92% for PCR and of 64% for culture.</p><p id="par0105" class="elsevierStylePara elsevierViewall">In our study, in patients for whom we could compare the results of both diagnostic tests, PCR was positive in 100% of the analysed samples, while the culture had a much lower positive rate (50.7%), which confirms the greater sensitivity of PCR compared to the gold standard. We ought to note that our study was not designed to calculate the sensitivity or predictive value of these two microbiological methods, and that this study could not analyse the results of some samples due to the reduced amount collected.</p><p id="par0110" class="elsevierStylePara elsevierViewall">Another important limitation of our study is that the sample selection was based on IMD cases with a confirmed microbiological diagnosis, and did not include suspected cases.</p><p id="par0115" class="elsevierStylePara elsevierViewall">The association between negative culture results and the administration of antibiotics prior to sample collection is well known.<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">5,8,10–13</span></a> Although it did not reach statistical significance in our study, this was probably due to the small sample size.</p><p id="par0120" class="elsevierStylePara elsevierViewall">The introduction of microbiological molecular techniques has advanced the diagnosis of IMD, leading to a considerable increase in the number of confirmed cases. Despite its high sensitivity and other advantages mentioned above, PCR cannot replace culture as the gold standard. It is recommended that both tests be performed simultaneously because both offer considerable benefits, such as serogroup determination and a greater sensitivity due to a reduction in false negatives; furthermore, serotyping and the assessment of antibiotic resistance can only be undertaken in strains isolated in the culture.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conflicts of interest</span><p id="par0125" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres476158" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction, objectives and aims" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Patients and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec498190" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres476159" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Pacientes y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec498191" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Patients 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" => "2013-10-28" "fechaAceptado" => "2014-03-04" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec498190" "palabras" => array:4 [ 0 => "Meningococcal infections" 1 => "Meningococcal meningitis" 2 => "Meningococcal disease" 3 => "Polymerase chain reaction" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec498191" "palabras" => array:4 [ 0 => "Infección por meningococo" 1 => "Meningitis por meningococo" 2 => "Enfermedad meningocócica" 3 => "Reacción en cadena de la polimerasa" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction, objectives and aims</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Invasive meningococcal disease (IMD) remains a serious public health problem. Although culture is the gold standard, previous antibiotic therapy reduces its sensibility. The aim of this study is the epidemiological analysis of IMD in our area, to assess the usefulness of polymerase chain reaction (PCR) to increase its diagnostic accuracy, and to show the association of antibiotic administration with the negative result of the culture.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Patients and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A retrospective study was conducted on all children younger than 16 years with microbiologically (positive culture and/or PCR) confirmed IMD, admitted to our hospital between 2004 and 2012.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Seventy-five patients were included, of whom 52% had sepsis, 30.7% meningitis, and 17.3% with both. PCR showed positive results in all samples, whereas a positive result was seen in 50.7% of the cultures. Previously administered antibiotic was documented in 40 patients (53.3%), and 40% of them were confirmed by PCR only.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">PCR was the only test providing evidence for IMD diagnosis and serogroup determination in almost 39% of cases.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction, objectives and aims" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Patients 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 objetivos</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La enfermedad meningocócica invasiva (EMI) constituye un grave problema de salud pública. A pesar de que el cultivo es la técnica de referencia para su diagnóstico, la administración previa de antibiótico altera su sensibilidad. Los objetivos de este estudio son el análisis epidemiológico de la EMI en nuestro medio, evaluar la utilidad de la reacción en cadena de la polimerasa (PCR) para incrementar el diagnóstico de confirmación de la EMI y valorar la asociación de la administración de antibiótico con el resultado negativo del cultivo.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Pacientes y métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio retrospectivo de los pacientes menores de 16 años diagnosticados de EMI mediante cultivo, PCR o ambos, que ingresaron en nuestro centro en el periodo 2004–2012.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se incluyó a 75 pacientes, de los cuales el 52% presentó sepsis, el 30,7% meningitis y el 17,3% sepsis con meningitis. La PCR fue positiva en todas las muestras de sangre y líquido cefalorraquídeo analizadas, mientras que el cultivo tuvo una positividad muy inferior (50,7%). Recibieron antibiótico antes de la extracción de las muestras 40 pacientes (53,3%) y el 40% de ellos fueron confirmados por la PCR.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Gracias a la PCR se obtuvo un diagnóstico de confirmación de EMI en el 38,7% de los casos y del serogrupo, hecho relevante para la vigilancia epidemiológica y el estudio de la efectividad vacunal.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Pacientes 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="npar0020">Please cite this article as: Fernández-San José C, Moraga-Llop FA, Codina G, Soler-Palacín P, Espiau M, Figueras C. La reacción en cadena de la polimerasa en el diagnóstico de la enfermedad meningocócica invasiva. An Pediatr (Barc). 2015;82:139–143.</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" => 441 "Ancho" => 962 "Tamanyo" => 62569 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Distribution of the 75 patients with invasive meningococcal disease by year and serogroup.</p>" ] ] 1 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">C5, complement component 5; ICU, intensive care unit.</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=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">Mean age</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.1 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Clinical presentation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">Age less than 1 year</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">21 (28%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Septicaemia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">39 (52%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">Sex</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Meningitis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">23 (30.7%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " 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="char" valign="top">46 (61.3%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Septicaemia with meningitis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13 (17.3%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " 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="char" valign="top">29 (38.7%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Mean length of stay \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10.9 days \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">Serogroups</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Admission to ICU \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">56 (74.7%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>B \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">66 (88%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Mortality \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (5.3%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>C \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (4%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Sequelae \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Y \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (1.3%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Deafness \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (8%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Nontypeable \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (6.7%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Other \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (2.7%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">Incomplete vaccination</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Complement deficiency (C5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (1.3%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">against serogroup C</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (4%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab752230.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Demographic and clinical characteristics of the 75 patients with invasive meningococcal disease.</p>" ] ] 2 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:3 [ "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">CSF, cerebrospinal fluid; N, number of samples; PCR, polymerase chain reaction.</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"><span class="elsevierStyleItalic">N</span> total<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>88 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Included samples<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a></th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Excluded samples</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \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">CSF (<span class="elsevierStyleItalic">N</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>28) \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">Blood (<span class="elsevierStyleItalic">N</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>47) \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">CSF (<span class="elsevierStyleItalic">N</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>8) \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">Blood (<span class="elsevierStyleItalic">N</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>5) \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 " align="left" valign="top">Diagnosis confirmed by PCR \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14/28 (50%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">23/47 (48.9%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Diagnosis confirmed by culture and PCR \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14/28 (50%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">24/47 (51.1%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Diagnosis confirmed by culture<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8/36 (22.2%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5/52 (9.6%) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab752231.png" ] ] ] "notaPie" => array:2 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Samples for culture and PCR collected simultaneously.</p>" ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "b" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">PCR was not done and sample insufficient for PCR.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Microbiological characteristics of the 75 patients with invasive meningococcal disease.</p>" ] ] 3 => array:7 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:3 [ "leyenda" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">CSF: cerebrospinal fluid.</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">Total samples (88) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Available strain</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Unavailable strain<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">a</span></a></th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \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">CSF (<span class="elsevierStyleItalic">N</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>22) \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">Blood (<span class="elsevierStyleItalic">N</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>28) \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">CSF (<span class="elsevierStyleItalic">N</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>14) \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">Blood (<span class="elsevierStyleItalic">N</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>24) \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="5" align="left" valign="top"><span class="elsevierStyleItalic">Serogroup</span></td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>B \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">24 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">22 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>C \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Y \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Nontypeable \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab752229.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0015" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0015">The serogroup of unavailable strains was established by polymerase chain reaction.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Serogroup distribution of CSF and peripheral blood samples.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:17 [ 0 => array:3 [ "identificador" => "bib0090" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Meningococcal infection" "autores" => array:1 [ 0 => array:2 [ "colaboracion" => "American Academy of Pediatrics" "etal" => false ] ] ] ] "host" => array:1 [ 0 => array:1 [ "LibroEditado" => array:4 [ "titulo" => "Red book: 2012 report of the Committee on Infectious Diseases" "paginaInicial" => "500" "paginaFinal" => "509" "serieFecha" => "2012" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0095" "etiqueta" => "2" "referencia" => array:1 [ 0 => 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 8 | 8 | 16 |
| 2024 October | 36 | 34 | 70 |
| 2024 September | 40 | 43 | 83 |
| 2024 August | 55 | 51 | 106 |
| 2024 July | 43 | 22 | 65 |
| 2024 June | 44 | 26 | 70 |
| 2024 May | 49 | 25 | 74 |
| 2024 April | 49 | 34 | 83 |
| 2024 March | 47 | 26 | 73 |
| 2024 February | 39 | 25 | 64 |
| 2024 January | 31 | 19 | 50 |
| 2023 December | 25 | 23 | 48 |
| 2023 November | 39 | 27 | 66 |
| 2023 October | 36 | 17 | 53 |
| 2023 September | 24 | 21 | 45 |
| 2023 August | 33 | 22 | 55 |
| 2023 July | 47 | 29 | 76 |
| 2023 June | 42 | 31 | 73 |
| 2023 May | 41 | 21 | 62 |
| 2023 April | 33 | 25 | 58 |
| 2023 March | 41 | 23 | 64 |
| 2023 February | 30 | 27 | 57 |
| 2023 January | 27 | 33 | 60 |
| 2022 December | 50 | 22 | 72 |
| 2022 November | 43 | 43 | 86 |
| 2022 October | 33 | 35 | 68 |
| 2022 September | 42 | 31 | 73 |
| 2022 August | 36 | 46 | 82 |
| 2022 July | 32 | 45 | 77 |
| 2022 June | 33 | 20 | 53 |
| 2022 May | 41 | 47 | 88 |
| 2022 April | 24 | 39 | 63 |
| 2022 March | 55 | 41 | 96 |
| 2022 February | 45 | 34 | 79 |
| 2022 January | 47 | 36 | 83 |
| 2021 December | 34 | 46 | 80 |
| 2021 November | 36 | 53 | 89 |
| 2021 October | 48 | 59 | 107 |
| 2021 September | 30 | 40 | 70 |
| 2021 August | 27 | 39 | 66 |
| 2021 July | 40 | 32 | 72 |
| 2021 June | 65 | 28 | 93 |
| 2021 May | 65 | 37 | 102 |
| 2021 April | 123 | 35 | 158 |
| 2021 March | 51 | 27 | 78 |
| 2021 February | 22 | 12 | 34 |
| 2021 January | 32 | 10 | 42 |
| 2020 December | 38 | 16 | 54 |
| 2020 November | 26 | 16 | 42 |
| 2020 October | 25 | 19 | 44 |
| 2020 September | 32 | 16 | 48 |
| 2020 August | 15 | 12 | 27 |
| 2020 July | 30 | 19 | 49 |
| 2020 June | 26 | 14 | 40 |
| 2020 May | 39 | 17 | 56 |
| 2020 April | 29 | 14 | 43 |
| 2020 March | 45 | 9 | 54 |
| 2020 February | 41 | 12 | 53 |
| 2020 January | 41 | 11 | 52 |
| 2019 December | 47 | 19 | 66 |
| 2019 November | 18 | 11 | 29 |
| 2019 October | 43 | 13 | 56 |
| 2019 September | 28 | 17 | 45 |
| 2019 August | 29 | 22 | 51 |
| 2019 July | 32 | 24 | 56 |
| 2019 June | 27 | 42 | 69 |
| 2019 May | 39 | 15 | 54 |
| 2019 April | 76 | 29 | 105 |
| 2019 March | 38 | 18 | 56 |
| 2019 February | 32 | 21 | 53 |
| 2019 January | 19 | 24 | 43 |
| 2018 December | 52 | 31 | 83 |
| 2018 November | 63 | 42 | 105 |
| 2018 October | 42 | 22 | 64 |
| 2018 September | 28 | 16 | 44 |
| 2018 August | 2 | 0 | 2 |
| 2018 July | 1 | 0 | 1 |
| 2018 June | 2 | 0 | 2 |
| 2018 May | 3 | 0 | 3 |
| 2018 April | 15 | 0 | 15 |
| 2018 March | 26 | 0 | 26 |
| 2018 February | 8 | 0 | 8 |
| 2018 January | 15 | 0 | 15 |
| 2017 December | 10 | 0 | 10 |
| 2017 November | 19 | 0 | 19 |
| 2017 October | 15 | 0 | 15 |
| 2017 September | 9 | 0 | 9 |
| 2017 August | 9 | 0 | 9 |
| 2017 July | 25 | 1 | 26 |
| 2017 June | 28 | 7 | 35 |
| 2017 May | 20 | 9 | 29 |
| 2017 April | 18 | 3 | 21 |
| 2017 March | 7 | 0 | 7 |
| 2017 February | 5 | 6 | 11 |
| 2017 January | 7 | 2 | 9 |
| 2016 December | 19 | 5 | 24 |
| 2016 November | 28 | 5 | 33 |
| 2016 October | 33 | 6 | 39 |
| 2016 September | 41 | 9 | 50 |
| 2016 August | 31 | 2 | 33 |
| 2016 July | 8 | 3 | 11 |
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