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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="tb0005"></elsevierMultimedia></p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0025" class="elsevierStylePara elsevierViewall">In the 19th century&#44; the renowned Canadian physician Sir William Olser described pneumococcal pneumonia as &#8220;The Captain of the Men of Death&#8221;&#46; More than a century later and after extensive research&#44; significant technological advances and investments of enormous amounts of money&#44; the above mentioned phrase remains entirely applicable&#46; In Spain&#44; it is estimated that each year there are 1&#46;6 cases of acute community-acquired pneumonia &#40;CAP&#41; for every 1000 inhabitants&#44; which represents an estimated 53&#44;000 hospitalizations and a cost of 114&#46;8 million euros in treatment alone&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In Uruguay&#44; unfortunately&#44; there is no available information specifically related to CAP&#59; however&#44; the latest available official data correspond to the year 2008 and reveal that respiratory infections were the third leading cause of death in the general population and represent 2890 &#40;9&#46;21&#37;&#41; of the 31&#44;363 registered deaths&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The importance of <span class="elsevierStyleItalic">Streptococcus pneumoniae</span> &#40;<span class="elsevierStyleItalic">S&#46; pneumoniae</span>&#41; as the etiological agent in CAP is based on the fact that &#40;a&#41; it is the most common etiological microorganism&#44;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a> &#40;b&#41; the isolation of antibiotic-resistant strains is increasing in various parts of the world&#44;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a> &#40;c&#41; there are vaccines with proven efficacy and &#40;d&#41; the morbidity and mortality of pneumococcal pneumonia is high&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">From the population standpoint&#44; the prevention of infections is one of the main objectives of virtually all health systems&#46; Among the major successes of immunoprophylaxis are the eradication of smallpox worldwide and poliomyelitis in the Americas and in Europe&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Uruguay&#44; a country with 3&#44;368&#44;595 inhabitants distributed over an area of 176&#44;215<span class="elsevierStyleHsp" style=""></span>km<span class="elsevierStyleSup">2</span>&#44; was the first country in South America to universally incorporate the pneumococcal vaccine for children under 5 years of age&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;9</span></a> In 2008&#44; 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In a recent study&#44;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> Fenoll et al&#46; analyzed the impact of the introduction of the PCV7 vaccine for children in Spain on the prevalence of noninvasive <span class="elsevierStyleItalic">S&#46; pneumoniae</span> serotypes in adults&#46; They compared two groups of samples received in the Spanish reference laboratory for pneumococcus&#59; the first group corresponded to the period 2000&#8211;2001 &#40;prior to PCV7&#41; and the second to the period 2010&#8211;2011 &#40;post PCV7&#41;&#46; They found a significant reduction in the serotypes contained in the vaccine but a 50&#37; increase in the serotypes not contained in the vaccine&#44; especially the 19A &#40;a 294&#37; increase&#41; and 15A &#40;180&#37; increase&#41;&#44; as well as the emergence of two new serotypes &#40;6C and 11A&#41;&#46; They also observed changes in the antibiotic sensitivity profile&#44; with a significant reduction in penicillin- and cefuroxime-resistant strains&#46; 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which was approved by the ethics committee of each participating center&#46;</p><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Design</span><p id="par0050" class="elsevierStylePara elsevierViewall">This was a prospective&#44; observational&#44; cohort study&#46; The patients were recruited during the period from January 1&#44; 2008 to December 31&#44; 2010 at the Police Hospital &#8220;Inspector General Uruguay Genta&#8221;&#44; Clinical Hospital &#8220;Dr&#46; Manuel Quintela&#8221;&#44; Spanish Hospital &#8220;Dr&#46; Juan Jos&#233; Crottogini&#8221;&#44; Armed Forces Central Hospital and in CASMU-IAMPP&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The study included patients admitted to the ward and&#47;or to the intensive care unit &#40;ICU&#41;&#44; who were over 16 years of age and were diagnosed with CAP&#46; CAP due to <span class="elsevierStyleItalic">S&#46; pneumoniae</span> was considered if&#44; at the time of admission to the hospital&#44; 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pneumoniae</span> strains were identified by each participating center&#39;s microbiology laboratory from blood cultures obtained at hospital admission&#46; The isolated strains were transferred to the Department of Laboratories of the MSP&#44; the national reference center&#44; where they performed the confirmation&#44; the sensitivity-to-antibiotics tests and serotyping using the Quellung technique with antisera from the Statens Serum Institut &#40;Copenhagen&#44; Denmark&#41;&#46; The majority of the strains were serotyped until the serotype was defined &#40;example 6B&#41;&#46; In some cases&#44; definition was not possible due to a lack of specific sera &#40;e&#46;g&#46;&#44; <span class="elsevierStyleItalic">pool</span> G&#41;&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">According to the recommendations and protocols of the Clinical Laboratory Standards Institute&#44; the <span class="elsevierStyleItalic">S&#46; pneumoniae</span> was considered penicillin sensitive if the minimum inhibitory concentration &#40;MIC&#41; was &#8804;2<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;ml and erythromycin-sensitive if the MIC was &#8804;0&#46;25<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;ml&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Definitions</span><p id="par0095" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8211;</span><p id="par0100" class="elsevierStylePara elsevierViewall">CAP&#58; medical history and physical examination compatible with the diagnosis of pneumonia associated with the presence of infiltrate&#40;s&#41; in the chest X-rays&#44; without hospitalization in the previous two weeks&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8211;</span><p id="par0105" class="elsevierStylePara elsevierViewall">Mechanical ventilation &#40;MV&#41; was defined as the need for artificial ventilator support &#40;invasive or not&#41; at any time during hospitalization and for at least 12<span class="elsevierStyleHsp" style=""></span>h&#46; The limit of 12<span class="elsevierStyleHsp" style=""></span>h was chosen arbitrarily a priori to exclude those patients in whom ventilator support was temporary and was due to a specific situation&#46; MV was always performed in the ICU and was indicated by intensivists based on international recommendations&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#8211;</span><p id="par0110" class="elsevierStylePara elsevierViewall">Septic shock was defined according to the recommendation of the Consensus Conference of ACCP&#47;SCCM<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> as a condition in which the systolic blood pressure remained below 90<span class="elsevierStyleHsp" style=""></span>mm Hg despite the administration of 20<span class="elsevierStyleHsp" style=""></span>ml&#47;kg of fluids and was accompanied by disorders in peripheral perfusion and&#47;or required vasoactive drugs to maintain systolic blood pressure above 90<span class="elsevierStyleHsp" style=""></span>mm Hg&#46; Septic shock was only considered if diagnosed within the first 72<span class="elsevierStyleHsp" style=""></span>h from admission to the emergency department or the ICU&#44; in cases where the patient was sent directly from the community&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#8211;</span><p id="par0115" class="elsevierStylePara elsevierViewall">The CURB65 scale<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> is a classification of severity applicable to CAP and is composed of the following variables&#58; confusion&#44; urea &#62;7<span class="elsevierStyleHsp" style=""></span>mmol&#47;l&#44; polypnea &#8805;30 breaths per minute&#44; hypotension with systolic blood pressure &#60;90<span class="elsevierStyleHsp" style=""></span>mm Hg or diastolic blood pressure &#60;60<span class="elsevierStyleHsp" style=""></span>mm Hg and age &#8805;65 years&#46; Each variable&#44; when present&#44; was assigned a point&#46; The final score was defined as the sum of all points for each patient&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#8211;</span><p id="par0120" class="elsevierStylePara elsevierViewall">Refractory hypoxemia as a cause of death for the presence of&#44; in the 6<span class="elsevierStyleHsp" style=""></span>h prior to death&#44; a ratio of the partial pressure of oxygen and fraction of inspired oxygen &#40;PaO<span class="elsevierStyleInf">2</span>&#47;FiO<span class="elsevierStyleInf">2</span>&#41; &#8804;100 &#40;with a positive final expiration pressure &#8805;10&#41; and which did not improve with alveolar recruitment maneuvers and prone decubitus positioning&#46; If the patient presented refractory hypoxemia and some other dysfunction&#44; including shock&#44; the cause of death was considered to be multiple organ dysfunction syndrome &#40;MODS&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">&#8211;</span><p id="par0125" class="elsevierStylePara elsevierViewall">The time to the start of antibiotic therapy was considered the period of time&#44; in hours&#44; elapsed between admission to the emergency department or ICU&#44; if the patient was admitted directly from the community&#44; and the administration of the first dose of the antibiotic plan&#46; The combination of ampicillin and sulbactam was considered a single antibiotic&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">&#8211;</span><p id="par0130" class="elsevierStylePara elsevierViewall">In terms of immunoprophylaxis&#44; patients were considered vaccinated if they received the influenza vaccine during the previous year or received the pneumococcal vaccine in the 5 years prior to the current hospitalization&#46;</p></li></ul></p><p id="par0135" class="elsevierStylePara elsevierViewall">Pathological history&#58; &#40;a&#41; alcoholism&#58; daily alcohol consumption greater than 50<span class="elsevierStyleHsp" style=""></span>g&#59; &#40;b&#41; chronic liver disease&#58; presence of portal hypertension and&#47;or pathological or imaging diagnosis &#40;computed tomography or ultrasound&#41; of cirrhosis or hepatic steatosis&#59; &#40;c&#41; immunosuppression&#58; chemotherapy&#44; radiation therapy&#44; treatment with corticosteroids at a dosage greater than 20<span class="elsevierStyleHsp" style=""></span>mg of prednisone per day &#40;or its equivalent&#41; in the month prior to admission&#44; serology positive for human immunodeficiency virus&#44; splenectomy and pregnancy&#59; &#40;d&#41; cancer &#40;considered if the patient&#44; at admission or during the hospitalization&#44; showed the presence of a malignant neoplastic process&#41;&#59; &#40;e&#41; ischemic heart disease&#58; history of acute coronary syndrome and&#47;or myocardial revascularization procedure&#59; &#40;f&#41; chronic renal failure&#58; creatinine levels prior to the current disease &#8805;1&#46;40<span class="elsevierStyleHsp" style=""></span>mg&#47;dl or chronic dialysis&#59; and lastly&#44; &#40;g&#41; the presence of COPD or diabetes was considered if the patient&#44; their physician or their medical history recorded the above mentioned condition&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">There are no national guidelines in Uruguay for the treatment of CAP&#44; and therefore the great majority of physicians adhere to the 2007 recommendations of the American Thoracic Society &#40;ATS&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Statistical analysis</span><p id="par0145" class="elsevierStylePara elsevierViewall">Categorical variables are presented as the number of cases and percentages&#46; Continuous variables as presented as mean and standard deviation&#46; The antibiotic delay times were dichotomized depending on the value associated with the maximum sensitivity and specificity in the ROC curve&#46; The CURB65 was also dichotomized between 0&#8211;1 and 2 or more points&#46; Given that it is part of the CURB65 scale&#44; patient age was not considered independently in the statistical analysis&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Categorical variables were compared using the <span class="elsevierStyleItalic">&#967;</span><span class="elsevierStyleSup">2</span> test or Fisher&#39;s exact test&#44; and the continuous variables were compared using the nonparametric Mann&#8211;Whitney <span class="elsevierStyleItalic">U</span> test&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">The living patient group was compared to the dead patient group at hospital discharge or on day 28 from the admission to the emergency department or the ICU&#44; if the patients were admitted directly from the community&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">We decided a priori to &#40;a&#41; not consider admission to the ICU to be an outcome or episode for analysis&#44; given that the admission criteria to the ICU in Uruguay are heterogeneous depending on the care center and&#44; &#40;b&#41; given that the influence of bacteremia on the prognosis of CAP is unknown<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> and that two different strategies were used in this study for acquiring patients&#44; we considered bacteremia in the entire population for solely descriptive and not prognostic ends&#46; In addition&#44; we decided to perform a specific analysis of the variables associated with mortality in the subgroup of bacteremic patients&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">For each comparison&#44; we performed a univariate analysis that included the first available clinical and laboratory variables&#59; those variables with a <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>0&#46;1 were included in an estimated logistics regression model&#46; We considered the threshold for the two-tailed <span class="elsevierStyleItalic">p</span> value to be less than 0&#46;05&#46; The association between variables and the study episode was estimated using the odds ratio &#40;OR&#41; and 95&#37; confidence interval &#40;CI&#41;&#46;</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Results</span><p id="par0170" class="elsevierStylePara elsevierViewall">We analyzed 192 patients with CAP due to <span class="elsevierStyleItalic">S&#46; pneumoniae</span>&#44; and no patients were excluded&#46; The CASMU-IAMPP was the medical center that provided the study with the most patients &#40;98&#44; 51&#37;&#41;&#44; followed by the Military Hospital &#40;35&#44; 18&#37;&#41;&#44; the Clinical Hospital &#40;31&#44; 16&#37;&#41;&#44; the Spanish Hospital &#40;21&#44; 11&#37;&#41; and the Police Hospital &#40;7&#44; 4&#37;&#41;&#46; The mean age of the entire population was 54&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>19&#46;2 years&#46; One hundred and six &#40;55&#37;&#41; were males&#46; The comorbidities and severity at admission assessed according to the CURB65 scale are shown in <a class="elsevierStyleCrossRefs" href="#tbl0005">Tables 1 and 2</a>&#44; respectively&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0175" class="elsevierStylePara elsevierViewall">In the first 72<span class="elsevierStyleHsp" style=""></span>h after hospital admission&#44; 52 &#40;13&#37;&#41; patients presented septic shock and 80 &#40;42&#37;&#41; required invasive mechanical respiratory assistance&#46;</p><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Microbiology and treatment</span><p id="par0180" class="elsevierStylePara elsevierViewall">At least one blood culture was performed&#44; allowing for the isolation of 147 &#40;76&#46;6&#37;&#41; strains of <span class="elsevierStyleItalic">S&#46; pneumoniae</span>&#46; Blood cultures were taken for 141 patients&#44; along with capsular antigen detection in urine&#46; Of these patients&#44; 45 presented negative blood culture but positive antigen&#44; 75 presented positive blood culture and positive antigen and 21 presented positive blood culture and negative antigen&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">Eighteen strains could not be sent for serotyping and another was defined as belonging to <span class="elsevierStyleItalic">pool</span><span class="elsevierStyleSmallCaps">i</span>&#46; The most common serotypes among the remaining 128 were 7F&#44; 1 and 3 &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46; All strains presented a MIC for penicillin &#8804;2<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;ml &#40;sensitive&#41;&#59; however&#44; 8 &#40;5&#37;&#41; cases presented a MIC for erythromycin &#62;0&#46;25<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;ml &#40;resistant&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0190" class="elsevierStylePara elsevierViewall">The percentage of strains that corresponded to the serotypes included in the 23-valent pneumococcal vaccine was 93&#37; &#40;119&#47;128&#41;&#46; The serotypes not included in the vaccine were 6A&#44; 13&#44; 16F&#44; 18F&#44; 22&#44; 23B&#44; 24F and 34&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">The number of patients who received the influenza vaccine in the year they presented CAP &#40;which led to their inclusion in this study&#41; or who received the pneumococcal vaccine in the 5-year period prior to the acquisition of the infection was 19 &#40;10&#37;&#41; and 7 &#40;4&#37;&#41;&#44; respectively&#46; In 4 patients who were vaccinated with the pneumococcal vaccine&#44; the following serotypes were identified&#58; 7F &#40;62-year-old male and 55-year-old female&#59; both survived&#41;&#44; 8 &#40;73-year-old female&#44; survived&#41; and 23F &#40;82-year-old female&#44; died&#41;&#46; All were sensitive to macrolides&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">The mean time between hospital admission and the administration of the first dose of antibiotics was recorded for 186 patients and was 7&#46;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>7&#46;0<span class="elsevierStyleHsp" style=""></span>h&#46; Using the ROC curve&#44; we identified a value of 6<span class="elsevierStyleHsp" style=""></span>h in the delay to the start of antibiotic therapy as that with the greatest sensitivity and specificity for discriminating the outcome of death at hospital discharge or day 28 of hospitalization&#46; In approximately 6 of every 10 patients who died&#44; antibiotic therapy was initiated after the above-mentioned period &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">Antibiotic treatment included a single antibiotic in 69 &#40;36&#37;&#41; patients and 2 or more antibiotics in 123 &#40;64&#37;&#41; participants&#46; The single antibiotic therapy group was administered ampicillin&#47;sulbactam in 41 &#40;59&#37;&#41; patients&#44; ceftriaxone in 26 &#40;38&#37;&#41; patients&#44; ampicillin in 1 &#40;1&#37;&#41; patient and ciprofloxacin in 1 &#40;1&#37;&#41; patient&#46; In the combined antibiotic therapy group&#44; all patients received at least a beta-lactam antibiotic&#44; which was combined with a macrolide in 115 patients &#40;clarithromycin in 112&#41;&#44; with an aminoglycoside &#40;amikacin&#41; in 2&#44; with a quinolone &#40;ciprofloxacin&#41; in 2&#44; with a lincosamide &#40;clindamycin&#41; in 3 and with a second beta-lactam antibiotic &#40;ceftriaxone&#41; in 1 patient&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Mortality</span><p id="par0210" class="elsevierStylePara elsevierViewall">During the follow-up period&#44; 37 patients died &#40;19&#37;&#41;&#46; The age range for presenting pneumonia was very wide&#59; however&#44; death associated with pneumonia was exceptional before the age of 40 &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0215" class="elsevierStylePara elsevierViewall">Death occurred in the first 72<span class="elsevierStyleHsp" style=""></span>h in 17 patients due to MODS in 12&#44; refractory hypoxemia in 1&#44; arrhythmia in 1&#44; limitation of the therapeutic effort in 1 and was undetermined in 2&#46; The remaining deaths occurred after the previously mentioned period and were due to MODS in 9 cases&#44; refractory hypoxemia in 2&#44; undetermined causes in 7 and limitation of the therapeutic effort in 2 patients&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">The univariate analysis for death is presented in <a class="elsevierStyleCrossRefs" href="#tbl0005">Tables 1 and 2</a>&#46; Septic shock that occurred in the first 72<span class="elsevierStyleHsp" style=""></span>h was more common in patients who died than in those who did not &#40;24&#47;37 compared with 28&#47;155 patients&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>0&#46;01&#41;&#46; Similarly&#44; the number of patients who required invasive mechanical ventilation in the above-mentioned time period was greater in the group that died when compared with the group that survived &#40;27&#47;37 compared with 53&#47;155&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>0&#46;01&#41;&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">The maximum likelihood multivariate logistical model included the following variables&#58; bilateral radiological involvement&#44; delay in the administration of the first antibiotic dose &#8805;6<span class="elsevierStyleHsp" style=""></span>h&#44; CURB65 score &#8805;2&#44; shock in the first 72<span class="elsevierStyleHsp" style=""></span>h after hospital admission&#44; chronic renal failure and COPD&#46; The variables independently associated with mortality were the presence of shock in the first 72<span class="elsevierStyleHsp" style=""></span>h after hospital admission &#40;OR&#58; 7&#46;51&#59; 95&#37; CI&#58; 2&#46;94&#8211;19&#46;17&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>0&#46;01&#41; and a delay in the start of antibiotics equal to or greater than 6<span class="elsevierStyleHsp" style=""></span>h &#40;OR&#58; 2&#46;47&#59; 95&#37; CI&#58; 1&#46;00&#8211;6&#46;17&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Mortality in the bacteremic patient subgroup</span><p id="par0230" class="elsevierStylePara elsevierViewall">We recorded 29 &#40;20&#37;&#41; deaths during the follow-up period in the subgroup of patients with bacteremia&#46; The time between hospital admission and the administration of the first dose of antibiotics was recorded for 143 patients&#46;</p><p id="par0235" class="elsevierStylePara elsevierViewall">The presence of bilateral radiological involvement&#44; combined antibiotic therapy&#44; CURB65 score &#8805;2&#44; shock in the first 72<span class="elsevierStyleHsp" style=""></span>h after hospital admission and chronic renal failure had a <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;1 in the univariate analysis &#40;data not shown&#41;&#44; and were therefore incorporated into the maximum likelihood multivariate logistical model&#46; The variables independently associated with mortality in this subgroup of patients with bacteremia were the presence of shock in the first 72<span class="elsevierStyleHsp" style=""></span>h after hospital admission &#40;OR&#58; 16&#46;72&#59; 95&#37; CI&#58; 4&#46;33&#8211;64&#46;60&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>0&#46;01&#41; and combined antibiotic therapy &#40;OR&#58; 0&#46;15&#59; 95&#37; CI&#58; 0&#46;04&#8211;0&#46;58&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>0&#46;15&#41;&#46;</p></span></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0240" class="elsevierStylePara elsevierViewall">The main findings of the present study are &#40;a&#41; the mortality of pneumococcal CAP in Montevideo-Uruguay is close to 20&#37;&#44; and the 2 variables associated with the disease are the presence of shock during the first 72<span class="elsevierStyleHsp" style=""></span>h after hospital admission and a delay greater than or equal to 6<span class="elsevierStyleHsp" style=""></span>h before starting antibiotic therapy&#59; &#40;b&#41; the main issues in optimizing treatment consist of reducing the time elapsed between hospital admission and the first antibiotic dose and the promotion of the combined use of antimicrobial drugs&#59; &#40;c&#41; the main serotypes of <span class="elsevierStyleItalic">S&#46; pneumoniae</span> were 7F&#44; 1 and 3&#59; and &#40;d&#41; the potential coverage of the 23-valent pneumococcal vaccine is 93&#37;&#46;</p><p id="par0245" class="elsevierStylePara elsevierViewall">Mortality in the present series was high and exceeded the figures published by other groups&#44;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;19&#44;20</span></a> which may be explained at least partially by the greater severity in our population &#40;the presence of septic shock in 13&#37;&#44; a need for mechanical ventilation in 41&#46;7&#37; and CURB65 score &#8805;2 in 47&#46;9&#37;&#41;&#46; Regardless&#44; the most important correctable factor that was identified in the present study&#44; which could also at least partially explain the increased mortality&#44; is the delay in the start of antibiotic therapy&#46; Promptness with antimicrobial therapy and compliance with guidelines are 2 easily implementable&#44; low-cost actions that have shown to be capable of improving the prognosis of CAP&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21&#44;22</span></a> The fact that more than 50&#37; of patients receive the first dose of antibiotic after more than 6<span class="elsevierStyleHsp" style=""></span>h is essentially unacceptable and undoubtedly constitutes one of the most important aspects to improve&#46; A second issue to consider is the benefit of administering combined antibiotic therapy&#44; especially in the subgroup of patients with bacteremia&#44; for whom combined therapy represents an independent protective factor for mortality&#46; The benefits of combined antimicrobial therapy &#40;beta-lactam antibiotics and macrolides or fluoroquinolones&#41; was initially proposed due to the results of a number of retrospective studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">23&#44;24</span></a> Recently&#44; two observational studies found that the combination of macrolides with beta-lactam antibiotics reduced mortality when compared with the isolated administration of beta-lactam antibiotics in CAP that required hospitalization<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> or with the combination of beta-lactam antibiotics and quinolones in severe CAP&#44; which requires endotracheal intubation&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> The exact reason macrolides might improve the prognosis is unknown&#59; however&#44; it is speculated that the improvement may be linked to the high concentration of macrolides in phagocytes and&#47;or to the macrolides&#8217; immunomodulatory effects&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">27&#8211;32</span></a> In this study&#44; we found that virtually all patients received a beta-lactam antibiotic&#59; however&#44; less than 60&#37; received macrolides&#44; which may constitute another factor to be corrected&#46;</p><p id="par0250" class="elsevierStylePara elsevierViewall">In reference to the causes of death in CAP&#44; Garc&#237;a-Vidal et al&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> analyzed the deaths of 181 patients with pneumonia and found that 70&#37; of those who died in the first 48<span class="elsevierStyleHsp" style=""></span>h were older than the others and had a more severe initial clinical presentation&#46; The deceased had a greater number of late comorbidities&#44; especially heart failure and chronic renal failure&#46; The main causes of death&#44; as with our series&#44; were MODS and respiratory dysfunction&#59; however&#44; the relative percentages of each etiology were different&#44; which may be explained by the different definitions used in each study&#46;</p><p id="par0255" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">S&#46; pneumoniae</span> is a Gram-positive&#44; facultative&#44; anaerobic microorganism with a polysaccharide capsule whose antigens allow us to subclassify it into 46 serogroups and into more than 90 distinct serotypes&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> An international group studying <span class="elsevierStyleItalic">S&#46; pneumoniae</span> analyzed 796 strains in adults from 10 different countries &#40;South Africa&#44; US&#44; Sweden&#44; Spain&#44; New Zealand&#44; Taiwan&#44; Argentina&#44; Brazil&#44; Hong Kong and France&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> They reported that the main serotypes were 1&#44; 14&#44; 4 and 3&#59; the overall mortality in the study was 17&#37;&#44; which was not associated with any particular serotype&#46; In Spain&#44; Viciana et al&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> reported 31 different strains in cultures from a heterogeneous group of pneumococcal diseases &#40;93 pneumonias&#44; 60 uncompensated respiratory infections&#44; 6 meningitis&#44; 5 bacteremia without apparent focus and 6 to other less common causes&#41;&#46; The most common serotypes were 19&#44; 3 and 6B&#46; In Uruguay&#44; Hortal et al&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> found that the main circulating serotypes in children over 5 years of age and in adults were 5&#44; 1&#44; 7&#47;7F and 14<span class="elsevierStyleSup">&#46;</span></p><p id="par0260" class="elsevierStylePara elsevierViewall">The above study by Viciana et al&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> found that 43&#46;4&#37; of the <span class="elsevierStyleItalic">S&#46; pneumoniae</span> strains were resistant to penicillin&#46; In Spain&#44; the first strain of penicillin-resistant pneumococcus was isolated from an adult patient from a hospital in Barcelona in 1979&#46; Subsequently&#44; Spain experienced a marked increase&#44; reaching approximately 40&#37; during the 1990s&#46; Currently&#44; this proportion has decreased to 22&#46;3&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a> The absence of identification of penicillin-resistant strains in our community is a relevant issue that provides a considerable advantage given that it reduces the risk of inadequate antibiotic therapy&#44; restricts the required antibiotic arsenal&#44; decreases costs and facilitates the national implementation of protocols&#46; The resistance to macrolides in our study approached 5&#37;&#46; Its influence on the prognosis of pneumonia is also controversial&#59; however&#44; the search for resistance may be important in individuals who are sick enough to require hospitalization&#46;</p><p id="par0265" class="elsevierStylePara elsevierViewall">Currently&#44; the only method proven to be capable of reducing the risk of pneumococcal infection is vaccination&#46; The results of the implementation of a universal campaign of pneumococcal immunoprophylaxis in children from Uruguay have been recently submitted by Dr&#46; Hortal&#39;s group&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a> The administration of PCV7 and subsequently PCV13 determined a reduction of close to 50&#37; in the number of hospitalizations for pneumonia in those under 2 years of age&#44; while simultaneously affecting the circulating serotypes&#44; mainly with an extreme reduction in serotype 14 and disruption of serotype 1 as the most common&#46; In adults&#44; the 23-valent pneumococcal vaccine is recommended&#44; which is composed of 25<span class="elsevierStyleHsp" style=""></span>g of capsular polysaccharide antigens from 23 distinct serotypes &#40;1&#44; 2&#44; 3&#44; 4&#44; 5&#44; 6B&#44; 7F&#44; 8&#44; 9N&#44; 9V&#44; 10A&#44; 11A&#44; 12F&#44; 14&#44; 15B&#44; 17F&#44; 18C&#44; 19A&#44; 19F&#44; 20&#44; 22F&#44; 23F and 33F&#59; the cross-protective reactions against strains not included in the vaccine &#91;such as 6B&#44; 6A&#44; 15B and 15A&#93; have also been demonstrated&#41;&#46; Given that it contains no proteins&#44; the vaccine is capable of inducing the response of B lymphocytes independently of the T lymphocytes&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a> It is estimated that 75&#8211;85&#37; of individuals will present a humoral response to the vaccination&#46; In this study&#44; we found that approximately 90&#37; of the patients presented serotypes included in the 23-valent vaccine&#44; which suggests that a considerable proportion of the analyzed cases could have been avoided if they had been vaccinated&#44; especially since the majority of the analyzed population suffered an invasive disease for which the benefits are greatest&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a> All serotypes identified in patients who had received the 23-valent vaccine in the previous 5 years are included in the vaccine&#39;s potential coverage and could reflect the known loss of efficacy in the elderly population&#44; the presence of some undiagnosed immunocompromised state or the lack of response to a number of specific antigens&#46;</p><p id="par0270" class="elsevierStylePara elsevierViewall">The present study has a number of strengths&#44; including the following&#58; &#40;a&#41; it was conducted prospectively and multicentrically with the participation of the main healthcare centers of Uruguay&#59; &#40;b&#41; the diagnosis of CAP was performed by specialist physicians and supported by microbiological findings&#59; and &#40;c&#41; we comprehensively considered clinical and microbiological factors using variables typically available in clinical practice&#46;</p><p id="par0275" class="elsevierStylePara elsevierViewall">The primary weakness of the present study consists of the use of two different strategies for identifying patients&#44; which resulted in not including patients who were admitted to the ward with an etiological diagnosis of pneumococcal pneumonia by urinary antigen&#46;</p><p id="par0280" class="elsevierStylePara elsevierViewall">In summary&#44; the present study found that CAP is a severe disease with a high mortality&#44; despite not having identified beta-lactam-resistant <span class="elsevierStyleItalic">S&#46; pneumoniae</span> strains&#46; Two therapeutic factors were identified &#40;reduction in the time to administration of the first antibiotics and the combined use of antibiotics&#41;&#44; which are relatively easy to correct and whose impact in the prognosis of the disease may be significant&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Funding</span><p id="par0285" class="elsevierStylePara elsevierViewall">The clinical and genetic research project on CAP was partially funded by a donation from the <span class="elsevierStyleGrantSponsor">ROEMMERS-Uruguay laboratory</span> exclusively directed toward the purchase of laboratory consumables&#46; The money was managed through the Manuel P&#233;rez Foundation of the School of Medicine&#44; University of the Republic&#44; Uruguay&#46; None of the authors received compensation or any other type of benefit for participating in this study&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicts of interest</span><p id="par0290" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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              "titulo" => "Microbiological analysis"
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              "titulo" => "Microbiology and treatment"
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              "titulo" => "Mortality in the bacteremic patient subgroup"
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    "fechaRecibido" => "2012-05-23"
    "fechaAceptado" => "2012-09-25"
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          "palabras" => array:6 [
            0 => "Pneumonia"
            1 => "<span class="elsevierStyleItalic">Streptococcus pneumoniae</span>"
            2 => "Epidemiology"
            3 => "Mortality"
            4 => "Serotypes"
            5 => "Community-acquired pneumonia"
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          "palabras" => array:6 [
            0 => "Neumon&#237;a"
            1 => "<span class="elsevierStyleItalic">Streptococcus pneumoniae</span>"
            2 => "Epidemiolog&#237;a"
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        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The objectives of the present study were&#58; &#40;a&#41; to describe the mortality rate and its associated variables in community-acquired pneumoniae &#40;CAP&#41; due to <span class="elsevierStyleItalic">Streptococcus pneumoniae</span> &#40;<span class="elsevierStyleItalic">S&#46; pneumoniae</span>&#41;&#44; &#40;b&#41; to identify therapeutic issues to improve&#44; &#40;c&#41; to describe the main serotypes of <span class="elsevierStyleItalic">S&#46; pneumoniae</span> and &#40;d&#41; to know the potential coverage of antipneumococcal 23-valent vaccine&#46;</p> <span class="elsevierStyleSectionTitle">Materials and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Inclusion criteria were age &#62;16 years-old hospitalized due to PAC&#46; Pneumococcal PAC etiology was considered if <span class="elsevierStyleItalic">S&#46; pneumoniae</span> was isolated from blood culture and&#47;or positive capsular urinary antigen detected at hospital admission&#46; Exclusion criteria were patients who refused participation and&#47;or pneumococcal infection diagnosis was made within the last month before hospital admission&#46;</p> <span class="elsevierStyleSectionTitle">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A total of 192 patients were included&#44; mean age 54&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>19&#46;2 years&#46; The most frequent comorbidities were diabetes&#44; COPD and immunosupression&#46; There were 147 patients with bacteremia&#46; The most frequent serotypes were 7F&#44; 1 and 3&#46; Beta-lactamic resistant microorganisms were not identified and only 8 &#40;5&#46;4&#37;&#41; strains were erythromycin-resistant&#46; Potential anti-pneumococcal 23-valent vaccine coverage was 93&#37;&#46; Thirty-seven patients died&#46; Variables associated with mortality were shock within the first 72<span class="elsevierStyleHsp" style=""></span>h of hospital admission &#40;OR&#58; 7&#46;51&#59; 95&#37; CI&#58; 2&#46;94&#8211;19&#46;17&#41; and antibiotic delay &#8805;6<span class="elsevierStyleHsp" style=""></span>h &#40;OR&#58; 2&#46;47&#59; 95&#37; CI&#58; 1&#46;00&#8211;6&#46;17&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Pneumococcal pneumonia mortality was 19&#46;3&#37;&#46; Septic shock and antibiotic delay &#8805;6<span class="elsevierStyleHsp" style=""></span>h since hospital admission were associated with hospital mortality&#46; The most frequent serotype was 7F&#46; The potential anti-pneumococcal vaccine coverage is almost 90&#37;&#46;</p>"
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        "titulo" => "Resumen"
        "resumen" => "<span class="elsevierStyleSectionTitle">Introducci&#243;n</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Los objetivos fueron&#58; &#40;a&#41; describir la mortalidad y sus variables asociadas en la neumon&#237;a aguda comunitaria &#40;NAC&#41; a <span class="elsevierStyleItalic">Streptococcus pneumoniae</span> &#40;<span class="elsevierStyleItalic">S&#46; pneumoniae</span>&#41;&#59; &#40;b&#41; identificar aspectos terap&#233;uticos a mejorar&#59; &#40;c&#41; identificar los principales serotipos de <span class="elsevierStyleItalic">S&#46; pneumoniae</span>&#44; y &#40;d&#41; conocer la cobertura potencial de la vacuna antineumoc&#243;cica 23 valente&#46;</p> <span class="elsevierStyleSectionTitle">Material y m&#233;todo</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Criterio de inclusi&#243;n&#58; NAC en pacientes mayores de 16 a&#241;os&#46; Se consider&#243; NAC neumoc&#243;cica si al ingreso hospitalario se aisl&#243; <span class="elsevierStyleItalic">S&#46; pneumoniae</span> desde la sangre y&#47;o se detect&#243; la presencia de ant&#237;geno neumoc&#243;cico capsular en orina&#46; Criterios de exclusi&#243;n&#58; negativa al consentimiento informado o infecci&#243;n neumoc&#243;cica en el mes previo al ingreso&#46;</p> <span class="elsevierStyleSectionTitle">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se identificaron 192 pacientes con edad promedio de 54&#44;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>19&#44;2 a&#241;os&#46; Comorbilidades m&#225;s frecuentes&#58; diabetes&#44; EPOC e inmunodepresi&#243;n&#46; Se detectaron bacteriemias en 147 pacientes&#46; Los serotipos m&#225;s frecuentes fueron&#58; 7F&#44; 1 y 3&#46; Ninguna cepa fue resistente a los betalact&#225;micos y 8 &#40;5&#44;4&#37;&#41; a la eritromicina&#46; Cobertura potencial de la vacuna antineumoc&#243;cica 23 valente&#58; 93&#37;&#46; Fallecieron 37 pacientes&#46; Variables asociadas a la mortalidad&#58; shock en las primeras 72<span class="elsevierStyleHsp" style=""></span>h desde el ingreso al hospital &#40;OR&#58; 7&#44;51&#59; IC 95&#37;&#58; 2&#44;94&#8211;19&#44;17&#41; y demora en el inicio de la antibioticorapia &#8805;6<span class="elsevierStyleHsp" style=""></span>h &#40;OR&#58; 2&#44;47&#59; IC 95&#37;&#58; 1&#44;00&#8211;6&#44;17&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La mortalidad de la NAC neumoc&#243;cica fue del 19&#44;3&#37;&#59; las &#250;nicas 2 variables asociadas a ella fueron el shock s&#233;ptico y la demora &#8805;6<span class="elsevierStyleHsp" style=""></span>h en el inicio de la antibioticoterapia&#46; Adicionalmente el mencionado retraso constituye el principal factor terap&#233;utico a mejorarse en el futuro&#46; El serotipo m&#225;s frecuente fue el 7F&#46; La cobertura potencial de la vacuna 23 valente es cercana al 90&#37;&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara">Please cite this article as&#58; Cardinal-Fern&#225;ndez P&#44; et al&#46; Aspectos cl&#237;nicos y microbiol&#243;gicos de la neumon&#237;a aguda comuni-taria a <span class="elsevierStyleItalic">Streptococcus pneumoniae</span>&#46; Rev Clin Esp&#46; 2013&#58;213&#58;88&#8211;96&#46;</p>"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Number of patient cases distributed by age and outcome at day 28 or at hospital discharge&#46;</p>"
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                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  """
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Bacteremia&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Bilateral radiological involvement&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;03&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Pleural effusion&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">31 &#40;16&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">6 &#40;16&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">25 &#40;16&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;99&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Hemoglobin &#40;g&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0&#46;19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Leukocytosis &#40;mm<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">17&#44;712<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>19&#44;486&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15&#44;109<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>12&#44;419&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14&#44;726<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8133&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;60&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Platelets &#40;&#215;10<span class="elsevierStyleSup">3</span>&#47;mm&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">220<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>101&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">220<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>121&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">214<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>91&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;91&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Excess base&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">&#8722;3&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#46;6&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8722;6&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8722;3&#46;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Combined antibiotic therapy&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">123 &#40;64&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">20 &#40;54&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">103 &#40;66&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0&#46;16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Delay &#8805;6<span class="elsevierStyleHsp" style=""></span>h in the start of antibiotic therapy&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">96 &#40;51&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">22 &#40;64&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">74 &#40;48&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0&#46;09&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>CURB65 &#8722;0&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">34 &#40;17&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3 &#40;8&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">31 &#40;20&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">&#60;0&#46;01&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>CURB65 &#8722;1&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">66 &#40;34&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">8 &#40;21&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">58 &#40;37&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>CURB65 &#8722;2&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">51&#40;26&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">10 &#40;27&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">41 &#40;26&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>CURB65 &#8722;3&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">27 &#40;14&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">8 &#40;21&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">19 &#40;12&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>CURB65 &#8722;4&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">14 &#40;7&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">8 &#40;21&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">6 &#40;3&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>CURB65 &#8805;2&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">92 &#40;47&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">26 &#40;70&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">During the first 72<span class="elsevierStyleHsp" style=""></span>h of hospitalization</span></td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Mechanical ventilation&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Absolute and percentage frequency of each identified serotype&#46;</p>"
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        "tipo" => "MULTIMEDIATEXTO"
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        "texto" => array:1 [
          "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">What we know</span><p id="par0010" class="elsevierStylePara elsevierViewall">Pneumococcal pneumonia represents a high number of hospitalizations and a significant healthcare expenditure in our community&#46; However&#44; there is no available data on what this infection represents in terms of mortality&#44; the most frequently involved serotypes and antibiotic resistance in Latin American countries&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">What this article provides</span><p id="par0015" class="elsevierStylePara elsevierViewall">This study characterizes the mortality&#44; the most frequent serotypes and the antibiotic resistance of pneumococcal pneumonia in Uruguay over a 2-year period&#46; It includes patients admitted to the ICU or who had positive bacteremia or a poorer prognosis&#59; however&#44; the study is one of the few that presents the reality of this common infection in the South American continent&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The Editors</p></span></span>"
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      "titulo" => "References"
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        0 => array:2 [
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The burden of community-acquired pneumonia in Spain"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "V&#46; Monge"
                            1 => "V&#46;M&#46; San-Mart&#237;n"
                            2 => "A&#46; Gonz&#225;lez"
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                    ]
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                    0 => array:1 [
                      "Revista" => array:7 [
                        "tituloSerie" => "European Journal of Public Health"
                        "fecha" => "2001"
                        "volumen" => "11"
                        "paginaInicial" => "362"
                        "paginaFinal" => "364"
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              "identificador" => "bib0010"
              "etiqueta" => "2"
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                0 => array:1 [
                  "referenciaCompleta" => "Ministerio de Salud P&#250;blica&#46; Available from&#58; <a class="elsevierStyleInterRef" href="http://www.msp.gub.uy/">http&#58;&#47;&#47;www&#46;msp&#46;gub&#46;uy</a> &#91;accessed 10&#46;02&#46;12&#93;&#46;"
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                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Aetiology of community acquired pneumonia in Valencia&#44; Spain&#58; a multicentre prospective study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "J&#46; Blanquer"
                            1 => "R&#46; Blanquer"
                            2 => "R&#46; Borras"
                            3 => "D&#46; Nauffal"
                            4 => "P&#46; Morales"
                            5 => "R&#46; Menendez"
                          ]
                        ]
                      ]
                    ]
                  ]
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                        "tituloSerie" => "Thorax"
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                        "paginaInicial" => "508"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The aetiology of severe community-acquired pneumonia and its impact on initial&#44; empiric&#44; antimicrobial chemotherapy"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "C&#46; Feldman"
                            1 => "S&#46; Ross"
                            2 => "A&#46;G&#46; Mahomed"
                            3 => "J&#46; Omar"
                            4 => "C&#46; Smith"
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                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Respiratory Medicine"
                        "fecha" => "1995"
                        "volumen" => "89"
                        "paginaInicial" => "187"
                        "paginaFinal" => "192"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Failure of levofloxacin therapy in two cases of community-acquired pneumonia caused by fluoroquinolone-resistant streptococcus pneumoniae and complicated with empyema"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
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                            1 => "F&#46; L&#243;pez-Medrano"
                            2 => "F&#46; Chaves"
                            3 => "V&#46; Villena"
                            4 => "J&#46; Echave-Sustaeta"
                            5 => "J&#46;M&#46; Aguado"
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                        "tituloSerie" => "Enfermedades Infecciosas y Microbiologia Clinica"
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                      "titulo" => "Antimicrobial susceptibility of bacterial pathogens associated with community-acquired respiratory tract infections in Asia&#58; report from the community-acquired respiratory tract infection pathogen surveillance &#40;cartips&#41; study&#44; 2009&#8211;2010"
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                            0 => "H&#46; Wang"
                            1 => "M&#46; Chen"
                            2 => "Y&#46; Xu"
                            3 => "H&#46; Sun"
                            4 => "Q&#46; Yang"
                            5 => "Y&#46; Hu"
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                    0 => array:2 [
                      "doi" => "10.1016/j.ijantimicag.2011.06.015"
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                        "tituloSerie" => "International Journal of Antimicrobial Agents"
                        "fecha" => "2011"
                        "volumen" => "38"
                        "paginaInicial" => "376"
                        "paginaFinal" => "383"
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                          0 => array:2 [
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              "etiqueta" => "7"
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                      "titulo" => "Mortality from invasive pneumococcal pneumonia in the era of antibiotic resistance&#44; 1995&#8211;1997"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "D&#46;R&#46; Feikin"
                            1 => "A&#46; Schuchat"
                            2 => "M&#46; Kolczak"
                            3 => "N&#46;L&#46; Barrett"
                            4 => "L&#46;H&#46; Harrison"
                            5 => "L&#46; Lefkowitz"
                          ]
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                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "American Journal of Public Health"
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                        "paginaInicial" => "223"
                        "paginaFinal" => "229"
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                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10667183"
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                0 => array:2 [
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                      "titulo" => "Prevention of pneumococcal disease through vaccination"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "A&#46; Gentile"
                            1 => "V&#46; Bazan"
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                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Vaccine"
                        "fecha" => "2011"
                        "volumen" => "29"
                        "numero" => "Suppl&#46; 3"
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              "etiqueta" => "10"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Invasive pneumococcal diseases in Uruguayan children&#58; comparison between serotype distribution and conjugate vaccine formulations"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "T&#46; Camou"
                            1 => "R&#46; Palacio"
                            2 => "J&#46;L&#46; di Fabio"
                            3 => "M&#46; Hortal"
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                      "Revista" => array:6 [
                        "tituloSerie" => "Vaccine"
                        "fecha" => "2003"
                        "volumen" => "21"
                        "paginaInicial" => "2093"
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                          0 => array:2 [
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              "etiqueta" => "11"
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                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Community-acquired pneumonia"
                      "autores" => array:1 [
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        "texto" => "<p id="par0295" class="elsevierStylePara elsevierViewall">First&#44; we would like to express our appreciation to the patients and family members who&#44; under difficult conditions&#44; agreed to participate in this research study&#46; Additionally&#44; we would like to thank the nursing graduates and assistants&#44; the clinical and microbiology laboratory technicians&#44; the physicians&#44; chemists and biologists who participated in the study&#46; Given that the standards of publication of the <span class="elsevierStyleItalic">Revista Cl&#237;nica Espa&#241;ola</span> limit the number of authors to a maximum of 6&#44; we would like to recognize the following colleagues for their enthusiasm and outstanding participation in this research study&#58; Dr&#46; Gabriela Bello&#44; Police hospital &#8220;Inspector General Uruguay-Genta&#8221;&#59; Dr&#46; Claudia Bentancourd&#44; Chair of Pulmonology&#44; School of Medicine&#44; University of the Republic&#59; Dr&#46; Teresa Camou&#44; Department of Laboratories of the MSP&#59; Ex Prof&#46; Dr&#46; Cristina Bazet&#44; Chair of Microbiology&#44; School of Medicine&#44; University of the Republic&#59; Dr&#46; Walter Pedreira&#44; Head of microbiology&#44; Hospital Maciel&#59; Dr&#46; N&#46; Zefferino&#44; Ex Head of the Intensive Care Unit&#44; Armed Forces Central Hospital&#59; Dr&#46; Jorge Gerez&#44; Head of the Intensive Care Unit&#44; Police Hospital &#8220;Inspector General Uruguay Genta&#8221;&#44; and Dr&#46; Alberto Deicas&#44; Head of the Intensive Care Unit&#44; CASMU-IAMPP&#46;</p>"
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Vol. 213. Issue 2.
Pages 88-96 (March 2013)
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Vol. 213. Issue 2.
Pages 88-96 (March 2013)
Original article
Clinical and microbiological aspects of acute community-acquired pneumonia due to Streptococcus pneumoniae
Aspectos clínicos y microbiológicos de la neumonía aguda comunitaria a Streptococcus pneumoniae
P. Cardinal-Fernándeza,
Corresponding author
pablocardinal@hotmail.com

Corresponding author.
, G. García Gabarrotb, P. Echeverriac, G. Zumd, J. Hurtadoe, G. Rieppif
a Departamento de Medicina Intensiva, CASMU-IAMPP, Montevideo, Uruguay
b Departamento de Laboratorios, Ministerio de Salud Pública, Montevideo, Uruguay
c Servicio de Microbiología, HCFFAA, Montevideo, Uruguay
d Servicio de Medicina Intensiva, Hospital Policial, Montevideo, Uruguay
e Servicio de Medicina Intensiva, Hospital Español «Dr. Juan José Crottogini», Montevideo, Uruguay
f Cátedra de Medicina Intensiva, Hospital de Clínicas «Dr. Manuel Quintela», Facultad de Medicina, Universidad de la Republica, Montevideo, Uruguay
Article information
Abstract
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Figures (1)
Tables (3)
Table 1. Pathological history of the general population and univariate analysis according to outcome at discharge or at day 28 from hospital admission.
Table 2. Baseline characteristics and univariate analysis for deaths at hospital discharge or at day 28 from hospital admission.
Table 3. Absolute and percentage frequency of each identified serotype.
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Abstract
Introduction

The objectives of the present study were: (a) to describe the mortality rate and its associated variables in community-acquired pneumoniae (CAP) due to Streptococcus pneumoniae (S. pneumoniae), (b) to identify therapeutic issues to improve, (c) to describe the main serotypes of S. pneumoniae and (d) to know the potential coverage of antipneumococcal 23-valent vaccine.

Materials and methods

Inclusion criteria were age >16 years-old hospitalized due to PAC. Pneumococcal PAC etiology was considered if S. pneumoniae was isolated from blood culture and/or positive capsular urinary antigen detected at hospital admission. Exclusion criteria were patients who refused participation and/or pneumococcal infection diagnosis was made within the last month before hospital admission.

Results

A total of 192 patients were included, mean age 54.6±19.2 years. The most frequent comorbidities were diabetes, COPD and immunosupression. There were 147 patients with bacteremia. The most frequent serotypes were 7F, 1 and 3. Beta-lactamic resistant microorganisms were not identified and only 8 (5.4%) strains were erythromycin-resistant. Potential anti-pneumococcal 23-valent vaccine coverage was 93%. Thirty-seven patients died. Variables associated with mortality were shock within the first 72h of hospital admission (OR: 7.51; 95% CI: 2.94–19.17) and antibiotic delay ≥6h (OR: 2.47; 95% CI: 1.00–6.17).

Conclusions

Pneumococcal pneumonia mortality was 19.3%. Septic shock and antibiotic delay ≥6h since hospital admission were associated with hospital mortality. The most frequent serotype was 7F. The potential anti-pneumococcal vaccine coverage is almost 90%.

Keywords:
Pneumonia
Streptococcus pneumoniae
Epidemiology
Mortality
Serotypes
Community-acquired pneumonia
Resumen
Introducción

Los objetivos fueron: (a) describir la mortalidad y sus variables asociadas en la neumonía aguda comunitaria (NAC) a Streptococcus pneumoniae (S. pneumoniae); (b) identificar aspectos terapéuticos a mejorar; (c) identificar los principales serotipos de S. pneumoniae, y (d) conocer la cobertura potencial de la vacuna antineumocócica 23 valente.

Material y método

Criterio de inclusión: NAC en pacientes mayores de 16 años. Se consideró NAC neumocócica si al ingreso hospitalario se aisló S. pneumoniae desde la sangre y/o se detectó la presencia de antígeno neumocócico capsular en orina. Criterios de exclusión: negativa al consentimiento informado o infección neumocócica en el mes previo al ingreso.

Resultados

Se identificaron 192 pacientes con edad promedio de 54,6±19,2 años. Comorbilidades más frecuentes: diabetes, EPOC e inmunodepresión. Se detectaron bacteriemias en 147 pacientes. Los serotipos más frecuentes fueron: 7F, 1 y 3. Ninguna cepa fue resistente a los betalactámicos y 8 (5,4%) a la eritromicina. Cobertura potencial de la vacuna antineumocócica 23 valente: 93%. Fallecieron 37 pacientes. Variables asociadas a la mortalidad: shock en las primeras 72h desde el ingreso al hospital (OR: 7,51; IC 95%: 2,94–19,17) y demora en el inicio de la antibioticorapia ≥6h (OR: 2,47; IC 95%: 1,00–6,17).

Conclusiones

La mortalidad de la NAC neumocócica fue del 19,3%; las únicas 2 variables asociadas a ella fueron el shock séptico y la demora ≥6h en el inicio de la antibioticoterapia. Adicionalmente el mencionado retraso constituye el principal factor terapéutico a mejorarse en el futuro. El serotipo más frecuente fue el 7F. La cobertura potencial de la vacuna 23 valente es cercana al 90%.

Palabras clave:
Neumonía
Streptococcus pneumoniae
Epidemiología
Mortalidad
Serotipos
Neumonia adquirida en la comunidad

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