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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Background</span><p id="par0005" class="elsevierStylePara elsevierViewall">According to recent studies&#44; the incidence of community-acquired pneumonia &#40;CAP&#41; in adults is 3&#8211;20 cases per 1000 inhabitants&#47;year&#44; with an upward trend&#46;<a class="elsevierStyleCrossRefs" href="#bib0405"><span class="elsevierStyleSup">1&#44;2</span></a> There is an indisputable relationship between the incidence of CAP and advanced age&#44; tobacco or alcohol consumption&#44; low weight &#40;body mass index &#60;16&#41; and&#44; probably&#44; morbid obesity and close contact with children&#46;<a class="elsevierStyleCrossRefs" href="#bib0405"><span class="elsevierStyleSup">1&#8211;4</span></a> Chronic obstructive pulmonary disease &#40;COPD&#41;&#44; cerebrovascular disorders&#44; advanced human immunodeficiency virus &#40;HIV&#41; infection and&#44; probably&#44; cardiovascular diseases increase the risk 2 to 4-fold&#46;<a class="elsevierStyleCrossRefs" href="#bib0405"><span class="elsevierStyleSup">1&#44;5</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We can cautiously include the fact that a number of authors have found relationships between CAP and a work environment subject to dust and abrupt temperature changes and between CAP and poor dental hygiene&#44; relationships that seem reasonable&#46;<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">6</span></a> The seasonal relationship between Legionnaires&#8217; disease and warm periods is perfectly documented&#59; however&#44; a recent study also established a relationship with rainy climate conditions&#44; while winter causes an increase in the incidence of pneumococcal pneumonia&#46;<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">7</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">An intense debate has arisen regarding certain drugs and the increased or decreased incidence of CAP&#46; The controversy is not resolved&#44; but perhaps if we put aside the possible pernicious role of inhaled corticosteroids and the consumption of benzodiazepines&#44; the evidence does not side with the increased risk that proton pump inhibitors can play or with the reduction in risk attributable to angiotensin <span class="elsevierStyleSmallCaps">II</span> inhibitors and statins&#46;<a class="elsevierStyleCrossRefs" href="#bib0425"><span class="elsevierStyleSup">5&#44;8&#8211;13</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Aspiration pneumonia deserves a separate chapter&#46; As its name suggests&#44; this condition requires the presence of a number of predisposing factors that have been well established for decades&#44; including alcoholism&#44; neurological disease&#44; gastrointestinal disease that impedes upper intestinal transit and conditions that cause a reduced level of consciousness&#46;<a class="elsevierStyleCrossRef" href="#bib0470"><span class="elsevierStyleSup">14</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The hopes placed in the pneumococcal polysaccharide vaccination&#44; which has been available for decades&#44; have been largely frustrated by numerous studies that&#44; at best&#44; attribute to it a slight benefit in terms of severity indicator parameters but not in terms of incidence and mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">15</span></a> The excellent results published after the massive vaccination of the pediatric population with the conjugate vaccination have renewed hopes for the adult population&#46; Preliminary studies have suggested that the pneumococcal vaccine achieves a significant reduction in pneumococcal infections caused by the vaccine serotypes but has less impact on the overall incidence of CAP&#46;<a class="elsevierStyleCrossRef" href="#bib0480"><span class="elsevierStyleSup">16</span></a> Similarly&#44; the benefits of the influenza vaccination are undebatable&#44; although they appear to be limited&#46;<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">17</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Approximately 30&#8211;40&#37; of patients with CAP require hospitalization&#44; and 2&#8211;10&#37; require hospitalization in an intensive care unit &#40;ICU&#41;&#46; The overall mortality rate during hospitalization is 2&#46;7&#37;&#44; a figure that increases significantly if we include the immediate aftermath &#40;8&#37; at 90 days&#44; 21&#37; at 12 months and 36&#37; at 5 years&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0405"><span class="elsevierStyleSup">1&#44;2&#44;18</span></a> All of this results in very high overall healthcare expenditures&#44; particularly in terms of hospitalization expenses&#44; which represent more than 90&#37; of the total cost&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Clinical diagnosis</span><p id="par0035" class="elsevierStylePara elsevierViewall">The medical history is the key element in the diagnosis of the disease&#46; The presence of 2 or more symptoms or clinical signs &#40;fever&#44; cough&#44; expectoration&#44; dyspnea&#44; pleuritic pain and characteristic physical signs&#41; is considered essential in any study that assesses patients with CAP&#46; Any clinician with certain experience knows that a simple reduction in the level of consciousness in an elderly individual could be due to pneumonia&#46; The same is true when faced with a patient with fever with no respiratory manifestations&#46;<a class="elsevierStyleCrossRef" href="#bib0495"><span class="elsevierStyleSup">19</span></a> However&#44; the lack of specific clinical data forces us to rule out other diagnostic options&#46; The presence of pleuritic pain or very obvious symptomatology can be of considerable use&#46;<a class="elsevierStyleCrossRefs" href="#bib0405"><span class="elsevierStyleSup">1&#44;19&#44;20</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Chest radiography confirms the clinical diagnosis&#44; with findings that are easy to recognize in young patients with no previous respiratory diseases and when the X-rays are performed in good conditions&#46;<a class="elsevierStyleCrossRef" href="#bib0495"><span class="elsevierStyleSup">19</span></a> Nevertheless&#44; we are not always faced with such circumstances&#46; Small condensations&#44; which are difficult to observe in a plain X-ray&#44; are obvious if we conduct chest computed tomography&#46; Chest ultrasonography is an alternative diagnostic technique in the hands of experts and it enables us to detect the presence of pleural effusion with increased accuracy&#46;<a class="elsevierStyleCrossRef" href="#bib0505"><span class="elsevierStyleSup">21</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The differentiation between patients with typical or atypical clinical conditions &#40;based on the presence or absence&#44; respectively&#44; of 3 or more of the following manifestations&#58; sudden onset&#44; chills&#44; pleuritic pain&#44; purulent expectoration&#44; marked symptomatology and leukocytosis&#41; has no absolute predictive usefulness&#46; However&#44; the differentiation correlates with a greater or lesser probability of conventional or atypical bacterial agents and is still of practical usefulness&#44; particularly for patients with nonsevere CAP&#46;<a class="elsevierStyleCrossRefs" href="#bib0510"><span class="elsevierStyleSup">22&#44;23</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Apart from these general clinical variables&#44; various pathogens have been correlated with specific clinical and epidemiological findings &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; Recent studies have shown that <span class="elsevierStyleItalic">Streptococcus pneumoniae</span> &#40;<span class="elsevierStyleItalic">S</span>&#46; <span class="elsevierStyleItalic">pneumoniae</span>&#41; is still the most common etiological agent&#44; followed by conventional bacteria and&#44; particularly among individuals with underlying diseases&#44; <span class="elsevierStyleItalic">Haemophilus influenzae</span> &#40;<span class="elsevierStyleItalic">H&#46; influenzae</span>&#41;&#44; <span class="elsevierStyleItalic">Staphylococcus aureus</span> &#40;<span class="elsevierStyleItalic">S&#46; aureus</span>&#41;&#44; <span class="elsevierStyleItalic">Moraxella catarrhalis</span>&#44; <span class="elsevierStyleItalic">Pseudomonas aeruginosa</span> &#40;<span class="elsevierStyleItalic">P&#46; aeruginosa</span>&#41; and other Gram-negative bacilli&#46;<a class="elsevierStyleCrossRefs" href="#bib0405"><span class="elsevierStyleSup">1&#44;19</span></a><span class="elsevierStyleItalic">P&#46; aeruginosa</span> and Gram-negative enteric bacilli frequently appear in patients with severe CAP&#44; immunosuppression&#44; advanced COPD and bronchiectasis and in those treated systemically with corticosteroids&#44; although cases of pneumonia by <span class="elsevierStyleItalic">P&#46; aeruginosa</span> and <span class="elsevierStyleItalic">Acinetobacter spp</span>&#46; have been documented in previously healthy individuals&#46;<a class="elsevierStyleCrossRefs" href="#bib0520"><span class="elsevierStyleSup">24&#44;25</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">Among the atypical agents&#44; <span class="elsevierStyleItalic">Mycoplasma pneumoniae</span> &#40;<span class="elsevierStyleItalic">M</span>&#46; <span class="elsevierStyleItalic">pneumoniae</span>&#41; constitutes the prototype microorganism responsible for clinical conditions with few symptoms&#44; affecting young individuals and causing a subacute clinical condition with low severity&#46; However&#44; severe or fulminant episodes have been reported&#46;<a class="elsevierStyleCrossRefs" href="#bib0405"><span class="elsevierStyleSup">1&#44;26</span></a> Its epidemic character&#44; at times within the same family group&#44; is well known but is often not taken into account&#46;<a class="elsevierStyleCrossRef" href="#bib0535"><span class="elsevierStyleSup">27</span></a><span class="elsevierStyleItalic">Chlamydophila pneumoniae</span>&#44; <span class="elsevierStyleItalic">Chlamydophila psittaci</span> and <span class="elsevierStyleItalic">Coxiella burnetii</span> complete the spectrum of these agents&#44; with greater of lesser relative importance according to epidemiological studies based on the diagnostic tests performed&#44; the presence of disease outbreaks and the geographical regions considered&#46;<a class="elsevierStyleCrossRefs" href="#bib0495"><span class="elsevierStyleSup">19&#44;28</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Legionella pneumophila</span> deserves special mention&#46; This agent is associated with severe clinical conditions that frequently require hospitalization in ICUs and can be associated with particular clinical manifestations&#46; A number of centers have fairly accurate predictive scales for this etiology&#46;<a class="elsevierStyleCrossRef" href="#bib0545"><span class="elsevierStyleSup">29</span></a> Neurological or gastrointestinal abnormalities or hyponatremia constitute factors that have been typically related to this pathogen&#44; along with the previously mentioned epidemiological characteristics &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0405"><span class="elsevierStyleSup">1&#44;30</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">The importance of the virus as a direct cause of CAP is undebatable after the recent pandemic caused by the influenza virus H1N1&#44; which was responsible for very severe multilobar processes&#46; Even in these cases&#44; however&#44; the association with other pathogenic bacteria &#40;mainly <span class="elsevierStyleItalic">S&#46; pneumoniae</span> and <span class="elsevierStyleItalic">S&#46; aureus</span>&#41; was common&#46;<a class="elsevierStyleCrossRef" href="#bib0555"><span class="elsevierStyleSup">31</span></a> Studies based on molecular diagnostic techniques dramatically raise the frequency with which the virus is isolated in patients with CAP&#44; but the actual relationship between the virus and pulmonary involvement is more questionable&#46; The presence of extrapulmonary manifestations&#44; such as headache and rhinorrhea&#44; or a bilateral patchy image suggest a viral etiology&#46;<a class="elsevierStyleCrossRef" href="#bib0560"><span class="elsevierStyleSup">32</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">In individuals infected by HIV&#44; <span class="elsevierStyleItalic">S&#46; pneumoniae</span> is the most common etiology when immunity is acceptable and <span class="elsevierStyleItalic">Pneumocystis jiroveci</span> when immunodeficiency is intense &#40;CD4&#43; lymphocyte count below 200&#47;mm<span class="elsevierStyleSup">3</span>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0565"><span class="elsevierStyleSup">33</span></a> The relative importance of anaerobes and oropharyngeal flora is debatable&#44; and their role might be greater than previously thought&#44; even apart from patients with aspiration pneumonia&#46;<a class="elsevierStyleCrossRef" href="#bib0570"><span class="elsevierStyleSup">34</span></a><span class="elsevierStyleItalic">S&#46; aureus</span> is characterized by the severe clinical conditions it causes&#44; with bilateral infiltrates&#44; often cavitated and associated with pleural effusion and previous influenza virus infection&#46; Its potential methicillin resistance increases the relevance of this microorganism&#46;<a class="elsevierStyleCrossRef" href="#bib0575"><span class="elsevierStyleSup">35</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Finally&#44; there have been various studies in recent years that compared CAP with pulmonary tuberculosis&#46; The latter disease is characterized by a more overlapping clinical condition whose evolution is long and at times afebrile&#46; The disease is associated with anorexia and weight loss and with a clear predilection for affecting the upper lobes&#46;<a class="elsevierStyleCrossRef" href="#bib0580"><span class="elsevierStyleSup">36</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Additional tests</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Biomarkers</span><p id="par0080" class="elsevierStylePara elsevierViewall">Over the last decade&#44; numerous studies have assessed the diagnostic and prognostic usefulness of biomarkers in CAP&#46; C-reactive protein &#40;CRP&#41; has been used to differentiate pneumonia from other respiratory infections such as tuberculosis&#44; which express lower values&#46; CRP has also been used to differentiate CAP of bacterial etiology from CAP of viral etiology or CAP caused by atypical microorganisms&#44; which are also characterized by lower values&#46;<a class="elsevierStyleCrossRefs" href="#bib0405"><span class="elsevierStyleSup">1&#44;23&#44;37</span></a> Applied to pleural fluid samples&#44; CRP is useful for differentiating patients with simple pleural effusion from those with complicated pleural effusion&#46;<a class="elsevierStyleCrossRef" href="#bib0590"><span class="elsevierStyleSup">38</span></a> Procalcitonin appears to fulfill similar functions and even shows more favorable results&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Both CRP and procalcitonin have been incorporated into prognostic scales&#44; thereby increasing their predictive value&#46;<a class="elsevierStyleCrossRef" href="#bib0595"><span class="elsevierStyleSup">39</span></a> Higher levels are associated with increased severity&#44; more aggressive etiologies and a risk of bacteremia or empyema&#46; Their greatest practical usefulness probably lies in monitoring patient progress&#46; The lack of a significant reduction during the patient&#39;s evolution warns of the possibility of complications and is associated with a poorer prognosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0600"><span class="elsevierStyleSup">40&#44;41</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">It is difficult to list all the remaining parameters that have been associated in some way with the diagnosis and prognosis of CAP &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; Among the most investigated are proadrenomedullin&#44; various interleukins&#44; dimer-D&#44; copeptin and natriuretic peptides&#46; The more routine substances and values that have also shown predictive ability include pH values&#44; pCO<span class="elsevierStyleInf">2</span> and vitamin D&#46; Although they have actual prognostic ability&#44; it is very unlikely that most of these markers will end up being used in actual clinical applications&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Microbiological studies</span><p id="par0095" class="elsevierStylePara elsevierViewall">Ultimately&#44; we have no truly useful technique for establishing the etiological diagnosis of CAP&#44; although we still should use these techniques in certain circumstances&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Blood cultures are recommended for all patients who require hospitalization&#59; however&#44; only approximately 10&#37; will present bacteremia&#46;<a class="elsevierStyleCrossRefs" href="#bib0405"><span class="elsevierStyleSup">1&#44;42</span></a> According to certain studies&#44; it seems reasonable to limit its use to patients with more severe CAP&#44; particularly if they have septic shock&#44; are immunosuppressed or have a clinical condition suggestive of bacterial infection&#46; If this is not the case&#44; the recent use of antibiotics will reduce its benefits&#46;<a class="elsevierStyleCrossRefs" href="#bib0405"><span class="elsevierStyleSup">1&#44;43</span></a> We should consider that samples aimed at isolating the microorganism through cultures should be extracted before starting antibiotic treatment&#46; Thus&#44; the laboratory results predictive of bacteremia&#44; the case for some biomarkers&#44; will have little importance in practice&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">The controversy over the use of sputum examination has dogged CAP for several decades and no short-term outcome is in sight&#46; In certain centers experienced in obtaining good quality samples and that have microbiologists on call 24<span class="elsevierStyleHsp" style=""></span>h a day&#44; good results have been achieved with Gram staining and subsequent culture&#59; however&#44; saliva samples or late processed samples are not cost-effective&#46; Obtaining samples using invasive methods&#44; particularly from patients in ICU&#44; improves the results&#46;<a class="elsevierStyleCrossRef" href="#bib0620"><span class="elsevierStyleSup">44</span></a> It has been reported that the absence of <span class="elsevierStyleItalic">S&#46; aureus</span> in nasal smears rules out this microorganism as a potential pathogen&#46;<a class="elsevierStyleCrossRef" href="#bib0625"><span class="elsevierStyleSup">45</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">The presence of pleural fluid in sufficient quantities&#44; which occurs in approximately 20&#37; of patients&#44; requires a sample to detect patients with empyema or complicated pleural effusion&#46; The microbiological study of the fluid provides valuable information in approximately 20&#37; of cases&#46;<a class="elsevierStyleCrossRef" href="#bib0630"><span class="elsevierStyleSup">46</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">Antigen detection in urine is another regularly used technique&#46; This test undoubtedly provides a greater number of diagnoses among patients with pneumococcal pneumonia&#44; increasing by 11&#37; the number of cases detected by the other techniques&#46; According to a recent study&#44; this test enables the identification of the pneumococcal serotype involved&#46;<a class="elsevierStyleCrossRefs" href="#bib0635"><span class="elsevierStyleSup">47&#44;48</span></a> Taking warfarin &#40;but not antibiotics&#41; could reduce the sensitivity of the technique&#44; which has high specificity&#46;<a class="elsevierStyleCrossRef" href="#bib0645"><span class="elsevierStyleSup">49</span></a> However&#44; this test has 2 fundamental disadvantages&#58; &#40;1&#41; it does not provide information on antibacterial sensitivity and &#40;2&#41; it only enables the detection of the presence of this microorganism&#44; whose coverage is always considered in any empirical regimen&#46; Consequently&#44; at best we can only expect benefits related to a reduction in the antibacterial spectrum of the treatment and in the adverse effects associated with the treatment&#44; but no benefits in terms of survival&#46; Additionally&#44; the price of the test is higher than that of the antibiotic regimens employed&#44; and a calculation of the cost-benefit balance turns out negative&#44; especially if used indiscriminately&#44; as happens in many centers&#46;<a class="elsevierStyleCrossRefs" href="#bib0405"><span class="elsevierStyleSup">1&#44;50</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">For its part&#44; detecting the <span class="elsevierStyleItalic">Legionella</span> antigen in urine has become virtually the technique of choice for diagnosing this etiology&#44; given that the remaining tests are cumbersome and lack of good sensitivity&#46; Nevertheless&#44; the test shares the same drawbacks we mentioned for the pneumococcus antigen&#44; and the cost-benefit balance is also unfavorable&#46;<a class="elsevierStyleCrossRef" href="#bib0655"><span class="elsevierStyleSup">51</span></a> Therefore&#44; a number of centers reserve this test for patients with criteria suggestive of <span class="elsevierStyleItalic">Legionella</span> infection&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">The polymerase chain reaction &#40;PCR&#41; technique represents the eternal promise that it can resolve&#44; once and for all&#44; the etiological diagnosis of CAP&#46; There is no doubt that its sensitivity is superior to that of the other diagnostic methods&#46; However&#44; PCR requires a specific study of each pathogen&#44; which represents its principal disadvantage&#44; moreover if we consider that what is most useful clinically is the isolation of certain unusual microorganisms that require specific treatments&#44; such as <span class="elsevierStyleItalic">P&#46; aeruginosa</span> and <span class="elsevierStyleItalic">S&#46; aureus</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0495"><span class="elsevierStyleSup">19</span></a> At present&#44; PCR has not achieved a defined role within the routinely employed diagnostic techniques&#44; if we exclude the influenza virus infection&#46; It has also been suggested that PCR could be of clinical importance in detecting the resistance of <span class="elsevierStyleItalic">M&#46; pneumoniae</span> to macrolides&#46;<a class="elsevierStyleCrossRef" href="#bib0660"><span class="elsevierStyleSup">52</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">We will end by stating that serologies represent the past&#44; when compared with PCR&#46; There are those who still support the usefulness of IgM in diagnosing <span class="elsevierStyleItalic">M&#46; pneumoniae</span> infection&#44; although it does not appear that it will become a reference technique&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Prognosis</span><p id="par0135" class="elsevierStylePara elsevierViewall">We should emphasize the extraordinary success that Fine et al&#46; had when they published their prognostic scale &#40;PSI&#41; in 1997&#46; The scale sought to stratify patients with CAP into subgroups based on outcome criteria&#46;<a class="elsevierStyleCrossRef" href="#bib0665"><span class="elsevierStyleSup">53</span></a> Since then&#44; there have been an extraordinary number of published articles with new prognostic scales&#44; with variants of the same or to validate these scales for various goals and in certain patient subpopulations&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Due to its simplicity&#44; the CURB-65 scale has been added to the PSI scale&#46; The inclusion of various biomarkers or the substitution of some of the 5 variables of the CURB-65 scale by others that take into account&#44; for example&#44; oxygen saturation and comorbidity&#44; seem to increase&#44; in a number of studies&#44; the scale&#39;s predictive value&#44; although there is no sign that they will substitute the scale&#46;<a class="elsevierStyleCrossRef" href="#bib0670"><span class="elsevierStyleSup">54</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">The main success of these 2 scales has been to facilitate objective data to ensure that patients do not require extended hospitalization&#46; As expected&#44; however&#44; when employed for making other decisions&#44; the scales&#8217; predictive value has been lower&#46; Thus&#44; other criteria have had to be employed to select patients who require hospitalization in the ICU&#46;<a class="elsevierStyleCrossRef" href="#bib0675"><span class="elsevierStyleSup">55</span></a> Other predictive scales have proliferated for this purpose&#44; the most widely used of which was published a few years ago in the CAP management guidelines of the American Thoracic Society and Infectious Diseases Society of America&#46;<a class="elsevierStyleCrossRef" href="#bib0610"><span class="elsevierStyleSup">42</span></a> This scale has been validated in various studies&#44; a number of which have incorporated certain variants that will have difficulty succeeding&#46;<a class="elsevierStyleCrossRefs" href="#bib0495"><span class="elsevierStyleSup">19&#44;56</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">Ever since the high percentage of patients with cardiovascular complications during the acute phase of CAP was recognized&#44; there has been a search for prognostic markers of such events&#46; Thus&#44; high troponin levels at admission&#44; some interleukins and certain clinical factors&#44; which have not been consistent among various authors&#44; have been associated with cardiovascular risk&#46;<a class="elsevierStyleCrossRefs" href="#bib0685"><span class="elsevierStyleSup">57&#44;58</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">Numerous factors have been individually related to a poor short-term prognosis&#58; age&#44; chronic renal failure&#44; low weight&#44; delirium&#44; empyema&#44; bacteremia&#44; low albumin and pO<span class="elsevierStyleInf">2</span> levels&#44; leukopenia&#44; high glycemia and pCO<span class="elsevierStyleInf">2</span> levels and a number of biomarkers &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0405"><span class="elsevierStyleSup">1&#44;2&#44;14&#44;42</span></a> In contrast&#44; no correlation had been found between poorer outcomes and obesity&#44; COPD or inhaled corticosteroid treatment&#46; In terms of inhaled corticosteroid treatment&#44; a beneficial effect has also been suggested&#46;<a class="elsevierStyleCrossRef" href="#bib0695"><span class="elsevierStyleSup">59</span></a> The presence of specific units for managing patients with CAP could increase survival rates&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Achieving clinical stability&#44; i&#46;e&#46;&#44; the normalization of basic constants&#44; is the main objective for hospitalized patients&#46; Its failure results in an increased risk of complications and death&#46; For those patients who persist with clinical manifestations&#44; mainly fever&#44; but with no clinical deterioration&#44; biomarker analysis can be useful for discriminating a slow resolution &#40;showing a significant reduction in biomarker levels&#41; from poor evolution &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0605"><span class="elsevierStyleSup">41&#44;60&#44;61</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">Finally&#44; numerous authors have evaluated longer-term patient outcomes&#44; either at 90 days or 1 year after the CAP&#46; In all cases&#44; the mortality risk was associated with the patient&#39;s characteristics&#44; i&#46;e&#46;&#44; the underlying diseases&#44; more than with the characteristics of the acute episode&#46;<a class="elsevierStyleCrossRef" href="#bib0710"><span class="elsevierStyleSup">62</span></a> In a number of studies&#44; the onset of cardiac complications during hospitalization&#44; aspiration pneumonia and the need for intensive care were also predictive of greater long-term mortality&#46;<a class="elsevierStyleCrossRefs" href="#bib0690"><span class="elsevierStyleSup">58&#44;63&#44;64</span></a> Similar circumstances also determine increased subsequent morbidity and the risk of early readmission&#46;<a class="elsevierStyleCrossRef" href="#bib0725"><span class="elsevierStyleSup">65</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">The diagnosis of CAP offers an opportunity to diagnose previously unknown underlying diseases such as diabetes mellitus &#40;e&#46;g&#46;&#44; among patients who have presented hyperglycemia during hospitalization&#41;&#44; COPD&#44; lung neoplasia and immunosuppressive conditions such as HIV infection and hematologic neoplasia&#46; However&#44; the study that requires the screening of these processes has not been established&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Treatment</span><p id="par0175" class="elsevierStylePara elsevierViewall">The publication of consensus guidelines from the various medical societies has resulted in significant improvement in the management of CAP&#44; mainly thanks to the standardization of antibiotic treatment and its application to the various patient subgroups&#46;<a class="elsevierStyleCrossRefs" href="#bib0405"><span class="elsevierStyleSup">1&#44;42</span></a> Several studies have shown that compliance with the guidelines and consensus protocols improves the patients&#8217; medical care&#44; which translates into all evolutionary parameters&#44; including mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">1</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">There are 2 types of criteria that should be employed for selecting the most appropriate treatment&#58; the severity of the clinical condition and the personal circumstances of the affected patient &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46; The assessment of the clinical severity is based on the previously mentioned prognostic scales&#44; preferably the CURB-65&#44; and especially on correct clinical judgment&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0185" class="elsevierStylePara elsevierViewall">Therefore&#44; in the first group we would find patients who experience mild CAP&#46; These patients&#44; generally young and with no underlying diseases&#44; may be treated at home&#44; perhaps after a short period of observation&#46; The infection will most likely be caused by pneumococcus or one of the atypical agents&#46; Treatment with amoxicillin and azithromycin would be indicated&#46; If this regimen cannot be followed then quinolone&#44; preferentially moxifloxacin&#44; may be employed&#46; The use of beta-lactam agents could involve clinical and environmental benefits &#40;development of resistance&#41; and precedes the use of quinolones as the first choice&#46; In selected cases where a pneumococcal etiology appears highly likely&#44; clinicians may dispense with the macrolide&#46; Subgroups of patients with mild CAP can have significant underlying diseases that could result in an increased risk of more resistant pathogens&#44; mainly <span class="elsevierStyleItalic">H&#46; influenzae&#46;</span> For these groups&#44; replacing amoxicillin with amoxicillin-clavulanate or cefditoren seems reasonable&#46;<a class="elsevierStyleCrossRefs" href="#bib0405"><span class="elsevierStyleSup">1&#44;19&#44;42&#44;66&#44;67</span></a></p><p id="par0190" class="elsevierStylePara elsevierViewall">In the second group&#44; we would find patients with severe CAP&#44; who require hospitalization in conventional wards&#46; The spectrum of potential pathogens should be broadened to include <span class="elsevierStyleItalic">H&#46; influenzae</span> and a number of Gram-negative bacilli&#46; The recommended regimen in the majority of guidelines is the combination of a beta-lactam agent &#40;ceftriaxone or amoxicillin-clavulanate&#41; with a macrolide&#46;<a class="elsevierStyleCrossRefs" href="#bib0405"><span class="elsevierStyleSup">1&#44;19&#44;42&#44;67</span></a> As with the previous group&#44; quinolones with pneumococcal activity are the most reasonable alternative&#46; However&#44; this general regimen is not without controversy&#46; There is a debate on the need to include the macrolide in this initial empiric regimen&#46; On one hand&#44; we have the alleged cardiotoxicity associated with macrolides&#44;<a class="elsevierStyleCrossRef" href="#bib0740"><span class="elsevierStyleSup">68</span></a> and on the other&#44; we have its potential benefits&#44; both in terms of increasing the antimicrobial coverage and its anti-inflammatory effects&#46; We can conclude that although most studies favor the combined treatment&#44; these studies are usually observational&#46;<a class="elsevierStyleCrossRef" href="#bib0745"><span class="elsevierStyleSup">69</span></a> A recently published&#44; prospective randomized trial with more than 2000 patients assigned to 3 branches &#40;beta-lactam agent&#47;beta-lactam agent plus macrolide&#47;quinolone&#41; found no differences in terms of mortality at 90 days&#46;<a class="elsevierStyleCrossRef" href="#bib0750"><span class="elsevierStyleSup">70</span></a></p><p id="par0195" class="elsevierStylePara elsevierViewall">Furthermore&#44; the use of parenteral corticosteroids has generated significant controversy&#46; Although the results are conflicting&#44; these corticosteroids could provide certain benefits for patients with more severe CAP&#44; both in terms of survival and earlier functional recovery&#46;<a class="elsevierStyleCrossRefs" href="#bib0735"><span class="elsevierStyleSup">67&#44;71&#44;72</span></a></p><p id="par0200" class="elsevierStylePara elsevierViewall">Finally&#44; there are other minor points of discussion&#46; The use of statins combined with antibiotic treatment has generated certain expectations that seem as if they will not be confirmed&#46;<a class="elsevierStyleCrossRef" href="#bib0765"><span class="elsevierStyleSup">73</span></a> In another vein&#44; the results of noninvasive mechanical ventilation do not seem encouraging&#46;<a class="elsevierStyleCrossRef" href="#bib0770"><span class="elsevierStyleSup">74</span></a></p><p id="par0205" class="elsevierStylePara elsevierViewall">The reference general empiric antibiotic regimen should undergo changes for patients with particular risk factors&#46; Patients with aspiration pneumonia therefore require effective treatment against anaerobes and Gram-negative bacilli&#46; It would therefore be preferable to employ a regimen that includes amoxicillin-clavulanate as a beta-lactam agent or&#44; for severely ill patients or those with underlying diseases&#44; piperacillin&#8211;tazobactam or a carbapenem&#46;<a class="elsevierStyleCrossRefs" href="#bib0405"><span class="elsevierStyleSup">1&#44;75</span></a> A similar reasoning should be applied to patients with empyema&#44; in whom the coverage of anaerobes and Gram-positive germs is a priority&#46;<a class="elsevierStyleCrossRef" href="#bib0630"><span class="elsevierStyleSup">46</span></a></p><p id="par0210" class="elsevierStylePara elsevierViewall">The regimen should also be modified depending on the microorganism responsible &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46; Thus&#44; a diagnosis or high suspicion of pneumonia by <span class="elsevierStyleItalic">P&#46; aeruginosa</span> or by resistant Gram-negative bacilli&#44; mainly in immunosuppressed patients or those who meet various criteria associated with this pathogen &#40;recent hospitalization&#44; previous antibiotic treatment&#44; advanced COPD&#44; bronchiectasis or systemic corticosteroid treatment&#41;&#44; requires the preferential application of an antipseudomonal beta-lactam agent&#44; combined perhaps with amikacin&#46;<a class="elsevierStyleCrossRefs" href="#bib0405"><span class="elsevierStyleSup">1&#44;24&#44;42&#44;67</span></a> For treating pneumonia by methicillin-resistant <span class="elsevierStyleItalic">S&#46; aureus</span>&#44; the efficacy of linezolid appears to be superior to that of vancomycin&#44; although ceftaroline&#44; which has recently been approved&#44; could very well take its place&#46;<a class="elsevierStyleCrossRefs" href="#bib0780"><span class="elsevierStyleSup">76&#44;77</span></a> In those areas where the resistance of <span class="elsevierStyleItalic">M&#46; pneumoniae</span> to macrolides is high&#44; tetracyclines appear to be an effective alternative&#46;<a class="elsevierStyleCrossRef" href="#bib0790"><span class="elsevierStyleSup">78</span></a> Regarding Legionnaires&#8217; disease&#44; it is likely that the efficacies of quinolone and azithromycin are comparable&#59; however&#44; experience recommends using the former when dealing with severely ill patients&#46;<a class="elsevierStyleCrossRef" href="#bib0550"><span class="elsevierStyleSup">30</span></a> Finally&#44; oseltamivir should be added when the epidemiological circumstances or microbiological results recommend its use&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0215" class="elsevierStylePara elsevierViewall">The antibiotic treatment regimens for patients hospitalized in ICU or for those who met healthcare-associated pneumonia criteria do not differ considerably from the recommendations for patients included in the previous section&#44; although the clinical severity will favor the use of regimens with greater coverage in a higher percentage of cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0405"><span class="elsevierStyleSup">1&#44;19&#44;42&#44;79</span></a> The combination of a broad-spectrum beta-lactam agent and a quinolone has frequently been used for critically ill patients&#46; A recent study&#44; however&#44; found no differences compared with the beta-lactam agent plus macrolide regimen&#46;<a class="elsevierStyleCrossRef" href="#bib0800"><span class="elsevierStyleSup">80</span></a></p><p id="par0220" class="elsevierStylePara elsevierViewall">Lastly&#44; it is worth noting that antibiotic treatment should be started as soon as possible&#44; within the emergency department&#44; which commonly uses excessively long treatment regimens&#46; It has been shown that treatment lasting 5&#8211;7 days&#44; for patients lacking local complications &#40;empyema or cavitations&#41; and with good clinical evolution&#44; would be sufficient&#46;<a class="elsevierStyleCrossRefs" href="#bib0405"><span class="elsevierStyleSup">1&#44;19</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conflicts of interest</span><p id="par0225" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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          "identificador" => "xres797713"
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            0 => "Community-acquired pneumonia"
            1 => "Risk factors"
            2 => "Epidemiology"
            3 => "Clinical manifestations"
            4 => "Diagnosis"
            5 => "Biomarkers"
            6 => "Prognosis"
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            0 => "Neumon&#237;a adquirida en la comunidad"
            1 => "Factores de riesgo"
            2 => "Epidemiolog&#237;a"
            3 => "Manifestaciones cl&#237;nicas"
            4 => "Diagn&#243;stico"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">This article not only reviews the essential aspects of community-acquired pneumonia for daily clinical practice&#44; but also highlights the controversial issues and provides the newest available information&#46; Community-acquired pneumonia is considered in a broad sense&#44; without excluding certain variants that&#44; in recent years&#44; a number of authors have managed to delineate&#44; such as healthcare-associated pneumonia&#46; The latter form is nothing more than the same disease that affects more frail patients&#44; with a greater number of risk factors&#44; both sharing an overall common approach&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">El presente art&#237;culo no revisa &#250;nicamente aquellos aspectos de la neumon&#237;a adquirida en la comunidad fundamentales para la pr&#225;ctica cl&#237;nica diaria&#44; sino que incide en los temas pol&#233;micos&#44; y aporta la informaci&#243;n m&#225;s novedosa disponible&#46; Se considera la neumon&#237;a adquirida en la comunidad en un sentido amplio&#44; sin excluir ciertas variantes que&#44; durante los &#250;ltimos a&#241;os&#44; algunos autores han llegado a deslindar&#44; como la neumon&#237;a asociada a cuidados sanitarios&#46; Esta &#250;ltima no es m&#225;s que la misma enfermedad que incide en pacientes m&#225;s fr&#225;giles&#44; con un mayor n&#250;mero de factores de riesgo&#44; compartiendo ambas un planteamiento global com&#250;n&#46;</p></span>"
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0035">Please cite this article as&#58; Falguera M&#44; Ram&#237;rez MF&#46; Neumon&#237;a adquirida en la comunidad&#46; Rev Clin Esp&#46; 2015&#59;215&#58;458&#8211;467&#46;</p>"
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          "leyenda" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Abbreviations</span>&#58; COPD&#44; chronic obstructive pulmonary disease&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Microorganisms&nbsp;\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">Epidemiological data&nbsp;\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">Clinical and radiological data&nbsp;\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"><span class="elsevierStyleItalic">Streptococcus pneumoniae</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">The most common in any situation&#46; Winter predominance&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Typical clinical condition&#58; chills&#44; rust-colored sputum&#44; pleuritic pain&#44; leukocytes&nbsp;\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">Haemophilus influenzae</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Individuals with underlying diseases&#44; especially smokers and patients with COPD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Typical clinical condition&#58; chills&#44; rust-colored sputum&#44; pleuritic pain&#44; leukocytes&nbsp;\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">Staphylococcus aureus</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Drug addiction&#44; previous influenza virus infection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Very severe conditions with bilateral infiltrates&#44; cavitations and pleural effusion&#46; Frequent bacteremia&nbsp;\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">Methicillin-resistant <span class="elsevierStyleItalic">Staphylococcus aureus</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Healthcare centers with a high rate of colonization&#44; previous antibiotic therapy&#44; recent hospitalization&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Very severe conditions with bilateral infiltrates&#44; cavitations and pleural effusion&#46; Frequent bacteremia&nbsp;\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">Gram-negative bacilli and <span class="elsevierStyleItalic">Pseudomonas aeruginosa</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Immunosuppression&#44; patients with advanced COPD&#44; treatment with systemic corticosteroids or bronchiectasis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Very severe clinical condition with septic shock&#46; Radiological cavitation&nbsp;\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">Anaerobes and oral cavity flora&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Patients with aspiration pneumonia &#40;altered level of consciousness or swallowing disorder&#41;&#44; alcoholism or poor oral hygiene&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cavitated infiltrate with foul-smelling sputum&#46; Presence of empyema or complicated pleural effusion&nbsp;\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">Mycoplasma pneumoniae</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Young individuals with no underlying diseases&#46; Outbreaks in communities or relatives&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Generally mild clinical condition and slightly symptomatic &#40;atypical clinical condition&#41;&nbsp;\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">Chlamydophila pneumoniae</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Equally affects all population subgroups&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Clinical condition without particular characteristics&nbsp;\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">Coxiella burnetii</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">More common in mountainous regions&#59; contact with livestock&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mildly symptomatic conditions or febrile syndrome without focus&#46; Hepatic disorder&nbsp;\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">Legionella pneumophila</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Predominantly summer&#44; related to rainy periods&#46; Disease outbreaks&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Severe clinical conditions&#46; Neurological and gastrointestinal &#40;diarrhea&#41; disorders&#44; hyponatremia&nbsp;\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">Virus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Disease outbreaks&#46; During pandemics&#44; obese individuals and pregnant women are mostly affected&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Upper respiratory tract symptoms and headache Patchy multilobar infiltrate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab1337986.png"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Microorganisms responsible for community-acquired pneumonia and their correlation with specific clinical and epidemiological characteristics&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:3 [
          "leyenda" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Abbreviations</span>&#58; MMP&#44; matrix metalloproteinase&#59; TIMP&#44; tissue inhibitor of metalloproteinase&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Biomarkers&nbsp;\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">Clinical diagnosis<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\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">Etiological diagnosis<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a>&nbsp;\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">Complications and mortality&nbsp;\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">Progress monitoring&nbsp;\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">Albumin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\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">Beta-defensin 2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\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">Leukocyte count&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\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">Leukocyte count&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\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">Leukocyte count&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\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">Copeptin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\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">Cortisol&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\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">D dimers&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\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">Tumor necrosis factor&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\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">Interleukin 6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\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">Interleukin 8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\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">Interleukin 10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\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">Kallistatin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\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">Lactate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\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">Lipocalin 2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\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">MMP-9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\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">MMP-9&#47;TIMP-1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\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">pCO<span class="elsevierStyleInf">2</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\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">Natriuretic peptide&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\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">pH<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>7&#46;30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\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">Proadrenomedullin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\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">Procalcitonin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\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">C-Reactive Protein&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\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">O<span class="elsevierStyleInf">2</span> saturation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\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">Sodium&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\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">Urea&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\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">Vitamin D &#40;deficiency&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab1337988.png"
              ]
            ]
          ]
          "notaPie" => array:3 [
            0 => array:3 [
              "identificador" => "tblfn0005"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Pneumonia versus tuberculosis&#46;</p>"
            ]
            1 => array:3 [
              "identificador" => "tblfn0010"
              "etiqueta" => "b"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Pneumonia versus acute bronchitis or COPD exacerbation&#46;</p>"
            ]
            2 => array:3 [
              "identificador" => "tblfn0015"
              "etiqueta" => "c"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Bacterial exacerbation versus viral pneumonia or by atypical agents&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Potential usefulness of various plasma biomarkers in managing patients with community-acquired pneumonia&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Patient subgroup&nbsp;\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">Most likely microorganisms&nbsp;\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">Recommended empiric treatment&nbsp;\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">Mild pneumonia with no underlying diseases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Streptococcus pneumoniae</span>&#44; atypical agents and virus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Option&#58; amoxicillin<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>macrolide<br>Alternative&#58; quinolone&nbsp;\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">Mild pneumonia with underlying diseases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Streptococcus pneumoniae</span>&#44; atypical agents and virus&#44; <span class="elsevierStyleItalic">Haemophilus influenzae</span>&#44; Gram-negative bacilli&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Option&#58; amoxicillin-clavulanate or cefditoren<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>macrolide<br>Alternative&#58; quinolone&nbsp;\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">Severe pneumonia with no risk factors&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Streptococcus pneumoniae</span>&#44; atypical agents and virus&#44; <span class="elsevierStyleItalic">Haemophilus influenzae</span>&#44; Gram-negative bacteria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Option&#58; ceftriaxone<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>macrolide<br>Alternative&#58; quinolone&nbsp;\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">Very severe pneumonia with risk factors for <span class="elsevierStyleItalic">Pseudomonas aeruginosa</span> or Gram-negative bacilli&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Streptococcus pneumoniae</span>&#44; atypical agents and virus&#44;<br><span class="elsevierStyleItalic">Haemophilus influenzae</span>&#44;<br>Gram-negative bacteria&#44;<br><span class="elsevierStyleItalic">Pseudomonas aeruginosa</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Option&#58; cefepime or piperacillin&#8211;tazobactam or carbapenem<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>macrolide or quinolone&nbsp;\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">Aspiration pneumonia or empyema&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Streptococcus pneumoniae</span>&#44;<br>other Gram-positive cocci&#44; anaerobic&#44; Gram-negative bacilli&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Option&#58; amoxicillin-clavulanate or piperacillin&#8211;tazobactam or carbapenem<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">a</span></a><br>Alternative&#58; quinolone<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>clindamycin&nbsp;\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">Pneumonia with criteria of methicillin-resistant <span class="elsevierStyleItalic">Staphylococcus aureus</span> infection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Streptococcus pneumoniae</span>&#44;<br>atypical agents and virus&#44;<br><span class="elsevierStyleItalic">Haemophilus influenzae</span>&#44;<br>Gram-negative bacteria&#44;<br><span class="elsevierStyleItalic">Pseudomonas aeruginosa</span>&#44;<br><span class="elsevierStyleItalic">Staphylococcus aureus</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Option&#58; amoxicillin-clavulanate or ceftriaxone or piperacillin&#8211;tazobactam or carbapenem<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>macrolide<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>linezolid or vancomycin<br>Alternative&#58; ceftaroline<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>macrolide&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab1337985.png"
              ]
            ]
          ]
          "notaPie" => array:1 [
            0 => array:3 [
              "identificador" => "tblfn0020"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0020">Depending on the relative risk of other microorganisms&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Etiology and recommended empiric treatment according to the various patient subgroups&#46;</p>"
        ]
      ]
      3 => array:7 [
        "identificador" => "tbl0020"
        "etiqueta" => "Table 4"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Microorganism isolated&nbsp;\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">Recommended treatment&nbsp;\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"><span class="elsevierStyleItalic">Streptococcus pneumoniae</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Option&#58; amoxicillin<br>Alternative&#58; quinolone&nbsp;\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">Legionella pneumophila</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Option&#58; quinolone<br>Alternative&#58; azithromycin&nbsp;\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">Mycoplasma pneumoniae</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Option&#58; macrolide<br>Alternatives&#58; tetracyclines<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">a</span></a>&nbsp;\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">Methicillin-resistant <span class="elsevierStyleItalic">Staphylococcus aureus</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Option&#58; linezolid<br>Alternatives&#58; vancomycin or ceftaroline&nbsp;\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">Pseudomonas aeruginosa</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Antipseudomonal beta-lactam<a class="elsevierStyleCrossRef" href="#tblfn0030"><span class="elsevierStyleSup">b</span></a><span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>amikacin<br>Alternative&#58; quinolone&nbsp;\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">Influenza virus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Ceftriaxone<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>macrolide<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>oseltamivir<br>Alternative&#58; quinolone<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>oseltamivir&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab1337987.png"
              ]
            ]
          ]
          "notaPie" => array:2 [
            0 => array:3 [
              "identificador" => "tblfn0025"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0025">In areas with high rates of resistance to macrolides&#46;</p>"
            ]
            1 => array:3 [
              "identificador" => "tblfn0030"
              "etiqueta" => "b"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0030">Based on the results of the antibiogram&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Targeted treatment depending on the microorganism isolated&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:80 [
            0 => array:3 [
              "identificador" => "bib0405"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:3 [
                  "comentario" => "e1&#8211;19"
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Gu&#237;a multidisciplinar para la valoraci&#243;n pron&#243;stica&#44; diagn&#243;stico y tratamiento de la neumon&#237;a adquirida en la comunidad"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "A&#46; Torres"
                            1 => "J&#46; Barber&#225;n"
                            2 => "M&#46; Falguera"
                            3 => "R&#46; Men&#233;ndez"
                            4 => "J&#46; Molina"
                            5 => "P&#46; Olaechea"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:4 [
                        "tituloSerie" => "Med Clin &#40;Barc&#41;"
                        "fecha" => "2013"
                        "volumen" => "140"
                        "paginaInicial" => "223"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0410"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Epidemiology of community-acquired pneumonia"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "M&#46;I&#46; Irizar Aramburu"
                            1 => "M&#46;A&#46; Arrondo Beguiristain"
                            2 => "M&#46;J&#46; Insausti Carretero"
                            3 => "J&#46; Mujica Campos"
                            4 => "P&#46; Etxabarri Perez"
                            5 => "R&#46; Ganzarain Gorosabel"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.aprim.2013.05.003"
                      "Revista" => array:6 [
                        "tituloSerie" => "Aten Primaria"
                        "fecha" => "2013"
                        "volumen" => "45"
                        "paginaInicial" => "503"
                        "paginaFinal" => "513"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23910056"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
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Review
Community-acquired pneumonia
Neumonía adquirida en la comunidad
M. Falguera
Corresponding author
falguera@medicina.udl.cat

Corresponding author.
, M.F. Ramírez
Servicio de Medicina Interna, Hospital Universitari Arnau de Vilanova, Lleida, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Background</span><p id="par0005" class="elsevierStylePara elsevierViewall">According to recent studies&#44; the incidence of community-acquired pneumonia &#40;CAP&#41; in adults is 3&#8211;20 cases per 1000 inhabitants&#47;year&#44; with an upward trend&#46;<a class="elsevierStyleCrossRefs" href="#bib0405"><span class="elsevierStyleSup">1&#44;2</span></a> There is an indisputable relationship between the incidence of CAP and advanced age&#44; tobacco or alcohol consumption&#44; low weight &#40;body mass index &#60;16&#41; and&#44; probably&#44; morbid obesity and close contact with children&#46;<a class="elsevierStyleCrossRefs" href="#bib0405"><span class="elsevierStyleSup">1&#8211;4</span></a> Chronic obstructive pulmonary disease &#40;COPD&#41;&#44; cerebrovascular disorders&#44; advanced human immunodeficiency virus &#40;HIV&#41; infection and&#44; probably&#44; cardiovascular diseases increase the risk 2 to 4-fold&#46;<a class="elsevierStyleCrossRefs" href="#bib0405"><span class="elsevierStyleSup">1&#44;5</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We can cautiously include the fact that a number of authors have found relationships between CAP and a work environment subject to dust and abrupt temperature changes and between CAP and poor dental hygiene&#44; relationships that seem reasonable&#46;<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">6</span></a> The seasonal relationship between Legionnaires&#8217; disease and warm periods is perfectly documented&#59; however&#44; a recent study also established a relationship with rainy climate conditions&#44; while winter causes an increase in the incidence of pneumococcal pneumonia&#46;<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">7</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">An intense debate has arisen regarding certain drugs and the increased or decreased incidence of CAP&#46; The controversy is not resolved&#44; but perhaps if we put aside the possible pernicious role of inhaled corticosteroids and the consumption of benzodiazepines&#44; the evidence does not side with the increased risk that proton pump inhibitors can play or with the reduction in risk attributable to angiotensin <span class="elsevierStyleSmallCaps">II</span> inhibitors and statins&#46;<a class="elsevierStyleCrossRefs" href="#bib0425"><span class="elsevierStyleSup">5&#44;8&#8211;13</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Aspiration pneumonia deserves a separate chapter&#46; As its name suggests&#44; this condition requires the presence of a number of predisposing factors that have been well established for decades&#44; including alcoholism&#44; neurological disease&#44; gastrointestinal disease that impedes upper intestinal transit and conditions that cause a reduced level of consciousness&#46;<a class="elsevierStyleCrossRef" href="#bib0470"><span class="elsevierStyleSup">14</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The hopes placed in the pneumococcal polysaccharide vaccination&#44; which has been available for decades&#44; have been largely frustrated by numerous studies that&#44; at best&#44; attribute to it a slight benefit in terms of severity indicator parameters but not in terms of incidence and mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">15</span></a> The excellent results published after the massive vaccination of the pediatric population with the conjugate vaccination have renewed hopes for the adult population&#46; Preliminary studies have suggested that the pneumococcal vaccine achieves a significant reduction in pneumococcal infections caused by the vaccine serotypes but has less impact on the overall incidence of CAP&#46;<a class="elsevierStyleCrossRef" href="#bib0480"><span class="elsevierStyleSup">16</span></a> Similarly&#44; the benefits of the influenza vaccination are undebatable&#44; although they appear to be limited&#46;<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">17</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Approximately 30&#8211;40&#37; of patients with CAP require hospitalization&#44; and 2&#8211;10&#37; require hospitalization in an intensive care unit &#40;ICU&#41;&#46; The overall mortality rate during hospitalization is 2&#46;7&#37;&#44; a figure that increases significantly if we include the immediate aftermath &#40;8&#37; at 90 days&#44; 21&#37; at 12 months and 36&#37; at 5 years&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0405"><span class="elsevierStyleSup">1&#44;2&#44;18</span></a> All of this results in very high overall healthcare expenditures&#44; particularly in terms of hospitalization expenses&#44; which represent more than 90&#37; of the total cost&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Clinical diagnosis</span><p id="par0035" class="elsevierStylePara elsevierViewall">The medical history is the key element in the diagnosis of the disease&#46; The presence of 2 or more symptoms or clinical signs &#40;fever&#44; cough&#44; expectoration&#44; dyspnea&#44; pleuritic pain and characteristic physical signs&#41; is considered essential in any study that assesses patients with CAP&#46; Any clinician with certain experience knows that a simple reduction in the level of consciousness in an elderly individual could be due to pneumonia&#46; The same is true when faced with a patient with fever with no respiratory manifestations&#46;<a class="elsevierStyleCrossRef" href="#bib0495"><span class="elsevierStyleSup">19</span></a> However&#44; the lack of specific clinical data forces us to rule out other diagnostic options&#46; The presence of pleuritic pain or very obvious symptomatology can be of considerable use&#46;<a class="elsevierStyleCrossRefs" href="#bib0405"><span class="elsevierStyleSup">1&#44;19&#44;20</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Chest radiography confirms the clinical diagnosis&#44; with findings that are easy to recognize in young patients with no previous respiratory diseases and when the X-rays are performed in good conditions&#46;<a class="elsevierStyleCrossRef" href="#bib0495"><span class="elsevierStyleSup">19</span></a> Nevertheless&#44; we are not always faced with such circumstances&#46; Small condensations&#44; which are difficult to observe in a plain X-ray&#44; are obvious if we conduct chest computed tomography&#46; Chest ultrasonography is an alternative diagnostic technique in the hands of experts and it enables us to detect the presence of pleural effusion with increased accuracy&#46;<a class="elsevierStyleCrossRef" href="#bib0505"><span class="elsevierStyleSup">21</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The differentiation between patients with typical or atypical clinical conditions &#40;based on the presence or absence&#44; respectively&#44; of 3 or more of the following manifestations&#58; sudden onset&#44; chills&#44; pleuritic pain&#44; purulent expectoration&#44; marked symptomatology and leukocytosis&#41; has no absolute predictive usefulness&#46; However&#44; the differentiation correlates with a greater or lesser probability of conventional or atypical bacterial agents and is still of practical usefulness&#44; particularly for patients with nonsevere CAP&#46;<a class="elsevierStyleCrossRefs" href="#bib0510"><span class="elsevierStyleSup">22&#44;23</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Apart from these general clinical variables&#44; various pathogens have been correlated with specific clinical and epidemiological findings &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; Recent studies have shown that <span class="elsevierStyleItalic">Streptococcus pneumoniae</span> &#40;<span class="elsevierStyleItalic">S</span>&#46; <span class="elsevierStyleItalic">pneumoniae</span>&#41; is still the most common etiological agent&#44; followed by conventional bacteria and&#44; particularly among individuals with underlying diseases&#44; <span class="elsevierStyleItalic">Haemophilus influenzae</span> &#40;<span class="elsevierStyleItalic">H&#46; influenzae</span>&#41;&#44; <span class="elsevierStyleItalic">Staphylococcus aureus</span> &#40;<span class="elsevierStyleItalic">S&#46; aureus</span>&#41;&#44; <span class="elsevierStyleItalic">Moraxella catarrhalis</span>&#44; <span class="elsevierStyleItalic">Pseudomonas aeruginosa</span> &#40;<span class="elsevierStyleItalic">P&#46; aeruginosa</span>&#41; and other Gram-negative bacilli&#46;<a class="elsevierStyleCrossRefs" href="#bib0405"><span class="elsevierStyleSup">1&#44;19</span></a><span class="elsevierStyleItalic">P&#46; aeruginosa</span> and Gram-negative enteric bacilli frequently appear in patients with severe CAP&#44; immunosuppression&#44; advanced COPD and bronchiectasis and in those treated systemically with corticosteroids&#44; although cases of pneumonia by <span class="elsevierStyleItalic">P&#46; aeruginosa</span> and <span class="elsevierStyleItalic">Acinetobacter spp</span>&#46; have been documented in previously healthy individuals&#46;<a class="elsevierStyleCrossRefs" href="#bib0520"><span class="elsevierStyleSup">24&#44;25</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">Among the atypical agents&#44; <span class="elsevierStyleItalic">Mycoplasma pneumoniae</span> &#40;<span class="elsevierStyleItalic">M</span>&#46; <span class="elsevierStyleItalic">pneumoniae</span>&#41; constitutes the prototype microorganism responsible for clinical conditions with few symptoms&#44; affecting young individuals and causing a subacute clinical condition with low severity&#46; However&#44; severe or fulminant episodes have been reported&#46;<a class="elsevierStyleCrossRefs" href="#bib0405"><span class="elsevierStyleSup">1&#44;26</span></a> Its epidemic character&#44; at times within the same family group&#44; is well known but is often not taken into account&#46;<a class="elsevierStyleCrossRef" href="#bib0535"><span class="elsevierStyleSup">27</span></a><span class="elsevierStyleItalic">Chlamydophila pneumoniae</span>&#44; <span class="elsevierStyleItalic">Chlamydophila psittaci</span> and <span class="elsevierStyleItalic">Coxiella burnetii</span> complete the spectrum of these agents&#44; with greater of lesser relative importance according to epidemiological studies based on the diagnostic tests performed&#44; the presence of disease outbreaks and the geographical regions considered&#46;<a class="elsevierStyleCrossRefs" href="#bib0495"><span class="elsevierStyleSup">19&#44;28</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Legionella pneumophila</span> deserves special mention&#46; This agent is associated with severe clinical conditions that frequently require hospitalization in ICUs and can be associated with particular clinical manifestations&#46; A number of centers have fairly accurate predictive scales for this etiology&#46;<a class="elsevierStyleCrossRef" href="#bib0545"><span class="elsevierStyleSup">29</span></a> Neurological or gastrointestinal abnormalities or hyponatremia constitute factors that have been typically related to this pathogen&#44; along with the previously mentioned epidemiological characteristics &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0405"><span class="elsevierStyleSup">1&#44;30</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">The importance of the virus as a direct cause of CAP is undebatable after the recent pandemic caused by the influenza virus H1N1&#44; which was responsible for very severe multilobar processes&#46; Even in these cases&#44; however&#44; the association with other pathogenic bacteria &#40;mainly <span class="elsevierStyleItalic">S&#46; pneumoniae</span> and <span class="elsevierStyleItalic">S&#46; aureus</span>&#41; was common&#46;<a class="elsevierStyleCrossRef" href="#bib0555"><span class="elsevierStyleSup">31</span></a> Studies based on molecular diagnostic techniques dramatically raise the frequency with which the virus is isolated in patients with CAP&#44; but the actual relationship between the virus and pulmonary involvement is more questionable&#46; The presence of extrapulmonary manifestations&#44; such as headache and rhinorrhea&#44; or a bilateral patchy image suggest a viral etiology&#46;<a class="elsevierStyleCrossRef" href="#bib0560"><span class="elsevierStyleSup">32</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">In individuals infected by HIV&#44; <span class="elsevierStyleItalic">S&#46; pneumoniae</span> is the most common etiology when immunity is acceptable and <span class="elsevierStyleItalic">Pneumocystis jiroveci</span> when immunodeficiency is intense &#40;CD4&#43; lymphocyte count below 200&#47;mm<span class="elsevierStyleSup">3</span>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0565"><span class="elsevierStyleSup">33</span></a> The relative importance of anaerobes and oropharyngeal flora is debatable&#44; and their role might be greater than previously thought&#44; even apart from patients with aspiration pneumonia&#46;<a class="elsevierStyleCrossRef" href="#bib0570"><span class="elsevierStyleSup">34</span></a><span class="elsevierStyleItalic">S&#46; aureus</span> is characterized by the severe clinical conditions it causes&#44; with bilateral infiltrates&#44; often cavitated and associated with pleural effusion and previous influenza virus infection&#46; Its potential methicillin resistance increases the relevance of this microorganism&#46;<a class="elsevierStyleCrossRef" href="#bib0575"><span class="elsevierStyleSup">35</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Finally&#44; there have been various studies in recent years that compared CAP with pulmonary tuberculosis&#46; The latter disease is characterized by a more overlapping clinical condition whose evolution is long and at times afebrile&#46; The disease is associated with anorexia and weight loss and with a clear predilection for affecting the upper lobes&#46;<a class="elsevierStyleCrossRef" href="#bib0580"><span class="elsevierStyleSup">36</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Additional tests</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Biomarkers</span><p id="par0080" class="elsevierStylePara elsevierViewall">Over the last decade&#44; numerous studies have assessed the diagnostic and prognostic usefulness of biomarkers in CAP&#46; C-reactive protein &#40;CRP&#41; has been used to differentiate pneumonia from other respiratory infections such as tuberculosis&#44; which express lower values&#46; CRP has also been used to differentiate CAP of bacterial etiology from CAP of viral etiology or CAP caused by atypical microorganisms&#44; which are also characterized by lower values&#46;<a class="elsevierStyleCrossRefs" href="#bib0405"><span class="elsevierStyleSup">1&#44;23&#44;37</span></a> Applied to pleural fluid samples&#44; CRP is useful for differentiating patients with simple pleural effusion from those with complicated pleural effusion&#46;<a class="elsevierStyleCrossRef" href="#bib0590"><span class="elsevierStyleSup">38</span></a> Procalcitonin appears to fulfill similar functions and even shows more favorable results&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Both CRP and procalcitonin have been incorporated into prognostic scales&#44; thereby increasing their predictive value&#46;<a class="elsevierStyleCrossRef" href="#bib0595"><span class="elsevierStyleSup">39</span></a> Higher levels are associated with increased severity&#44; more aggressive etiologies and a risk of bacteremia or empyema&#46; Their greatest practical usefulness probably lies in monitoring patient progress&#46; The lack of a significant reduction during the patient&#39;s evolution warns of the possibility of complications and is associated with a poorer prognosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0600"><span class="elsevierStyleSup">40&#44;41</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">It is difficult to list all the remaining parameters that have been associated in some way with the diagnosis and prognosis of CAP &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; Among the most investigated are proadrenomedullin&#44; various interleukins&#44; dimer-D&#44; copeptin and natriuretic peptides&#46; The more routine substances and values that have also shown predictive ability include pH values&#44; pCO<span class="elsevierStyleInf">2</span> and vitamin D&#46; Although they have actual prognostic ability&#44; it is very unlikely that most of these markers will end up being used in actual clinical applications&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Microbiological studies</span><p id="par0095" class="elsevierStylePara elsevierViewall">Ultimately&#44; we have no truly useful technique for establishing the etiological diagnosis of CAP&#44; although we still should use these techniques in certain circumstances&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Blood cultures are recommended for all patients who require hospitalization&#59; however&#44; only approximately 10&#37; will present bacteremia&#46;<a class="elsevierStyleCrossRefs" href="#bib0405"><span class="elsevierStyleSup">1&#44;42</span></a> According to certain studies&#44; it seems reasonable to limit its use to patients with more severe CAP&#44; particularly if they have septic shock&#44; are immunosuppressed or have a clinical condition suggestive of bacterial infection&#46; If this is not the case&#44; the recent use of antibiotics will reduce its benefits&#46;<a class="elsevierStyleCrossRefs" href="#bib0405"><span class="elsevierStyleSup">1&#44;43</span></a> We should consider that samples aimed at isolating the microorganism through cultures should be extracted before starting antibiotic treatment&#46; Thus&#44; the laboratory results predictive of bacteremia&#44; the case for some biomarkers&#44; will have little importance in practice&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">The controversy over the use of sputum examination has dogged CAP for several decades and no short-term outcome is in sight&#46; In certain centers experienced in obtaining good quality samples and that have microbiologists on call 24<span class="elsevierStyleHsp" style=""></span>h a day&#44; good results have been achieved with Gram staining and subsequent culture&#59; however&#44; saliva samples or late processed samples are not cost-effective&#46; Obtaining samples using invasive methods&#44; particularly from patients in ICU&#44; improves the results&#46;<a class="elsevierStyleCrossRef" href="#bib0620"><span class="elsevierStyleSup">44</span></a> It has been reported that the absence of <span class="elsevierStyleItalic">S&#46; aureus</span> in nasal smears rules out this microorganism as a potential pathogen&#46;<a class="elsevierStyleCrossRef" href="#bib0625"><span class="elsevierStyleSup">45</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">The presence of pleural fluid in sufficient quantities&#44; which occurs in approximately 20&#37; of patients&#44; requires a sample to detect patients with empyema or complicated pleural effusion&#46; The microbiological study of the fluid provides valuable information in approximately 20&#37; of cases&#46;<a class="elsevierStyleCrossRef" href="#bib0630"><span class="elsevierStyleSup">46</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">Antigen detection in urine is another regularly used technique&#46; This test undoubtedly provides a greater number of diagnoses among patients with pneumococcal pneumonia&#44; increasing by 11&#37; the number of cases detected by the other techniques&#46; According to a recent study&#44; this test enables the identification of the pneumococcal serotype involved&#46;<a class="elsevierStyleCrossRefs" href="#bib0635"><span class="elsevierStyleSup">47&#44;48</span></a> Taking warfarin &#40;but not antibiotics&#41; could reduce the sensitivity of the technique&#44; which has high specificity&#46;<a class="elsevierStyleCrossRef" href="#bib0645"><span class="elsevierStyleSup">49</span></a> However&#44; this test has 2 fundamental disadvantages&#58; &#40;1&#41; it does not provide information on antibacterial sensitivity and &#40;2&#41; it only enables the detection of the presence of this microorganism&#44; whose coverage is always considered in any empirical regimen&#46; Consequently&#44; at best we can only expect benefits related to a reduction in the antibacterial spectrum of the treatment and in the adverse effects associated with the treatment&#44; but no benefits in terms of survival&#46; Additionally&#44; the price of the test is higher than that of the antibiotic regimens employed&#44; and a calculation of the cost-benefit balance turns out negative&#44; especially if used indiscriminately&#44; as happens in many centers&#46;<a class="elsevierStyleCrossRefs" href="#bib0405"><span class="elsevierStyleSup">1&#44;50</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">For its part&#44; detecting the <span class="elsevierStyleItalic">Legionella</span> antigen in urine has become virtually the technique of choice for diagnosing this etiology&#44; given that the remaining tests are cumbersome and lack of good sensitivity&#46; Nevertheless&#44; the test shares the same drawbacks we mentioned for the pneumococcus antigen&#44; and the cost-benefit balance is also unfavorable&#46;<a class="elsevierStyleCrossRef" href="#bib0655"><span class="elsevierStyleSup">51</span></a> Therefore&#44; a number of centers reserve this test for patients with criteria suggestive of <span class="elsevierStyleItalic">Legionella</span> infection&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">The polymerase chain reaction &#40;PCR&#41; technique represents the eternal promise that it can resolve&#44; once and for all&#44; the etiological diagnosis of CAP&#46; There is no doubt that its sensitivity is superior to that of the other diagnostic methods&#46; However&#44; PCR requires a specific study of each pathogen&#44; which represents its principal disadvantage&#44; moreover if we consider that what is most useful clinically is the isolation of certain unusual microorganisms that require specific treatments&#44; such as <span class="elsevierStyleItalic">P&#46; aeruginosa</span> and <span class="elsevierStyleItalic">S&#46; aureus</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0495"><span class="elsevierStyleSup">19</span></a> At present&#44; PCR has not achieved a defined role within the routinely employed diagnostic techniques&#44; if we exclude the influenza virus infection&#46; It has also been suggested that PCR could be of clinical importance in detecting the resistance of <span class="elsevierStyleItalic">M&#46; pneumoniae</span> to macrolides&#46;<a class="elsevierStyleCrossRef" href="#bib0660"><span class="elsevierStyleSup">52</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">We will end by stating that serologies represent the past&#44; when compared with PCR&#46; There are those who still support the usefulness of IgM in diagnosing <span class="elsevierStyleItalic">M&#46; pneumoniae</span> infection&#44; although it does not appear that it will become a reference technique&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Prognosis</span><p id="par0135" class="elsevierStylePara elsevierViewall">We should emphasize the extraordinary success that Fine et al&#46; had when they published their prognostic scale &#40;PSI&#41; in 1997&#46; The scale sought to stratify patients with CAP into subgroups based on outcome criteria&#46;<a class="elsevierStyleCrossRef" href="#bib0665"><span class="elsevierStyleSup">53</span></a> Since then&#44; there have been an extraordinary number of published articles with new prognostic scales&#44; with variants of the same or to validate these scales for various goals and in certain patient subpopulations&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Due to its simplicity&#44; the CURB-65 scale has been added to the PSI scale&#46; The inclusion of various biomarkers or the substitution of some of the 5 variables of the CURB-65 scale by others that take into account&#44; for example&#44; oxygen saturation and comorbidity&#44; seem to increase&#44; in a number of studies&#44; the scale&#39;s predictive value&#44; although there is no sign that they will substitute the scale&#46;<a class="elsevierStyleCrossRef" href="#bib0670"><span class="elsevierStyleSup">54</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">The main success of these 2 scales has been to facilitate objective data to ensure that patients do not require extended hospitalization&#46; As expected&#44; however&#44; when employed for making other decisions&#44; the scales&#8217; predictive value has been lower&#46; Thus&#44; other criteria have had to be employed to select patients who require hospitalization in the ICU&#46;<a class="elsevierStyleCrossRef" href="#bib0675"><span class="elsevierStyleSup">55</span></a> Other predictive scales have proliferated for this purpose&#44; the most widely used of which was published a few years ago in the CAP management guidelines of the American Thoracic Society and Infectious Diseases Society of America&#46;<a class="elsevierStyleCrossRef" href="#bib0610"><span class="elsevierStyleSup">42</span></a> This scale has been validated in various studies&#44; a number of which have incorporated certain variants that will have difficulty succeeding&#46;<a class="elsevierStyleCrossRefs" href="#bib0495"><span class="elsevierStyleSup">19&#44;56</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">Ever since the high percentage of patients with cardiovascular complications during the acute phase of CAP was recognized&#44; there has been a search for prognostic markers of such events&#46; Thus&#44; high troponin levels at admission&#44; some interleukins and certain clinical factors&#44; which have not been consistent among various authors&#44; have been associated with cardiovascular risk&#46;<a class="elsevierStyleCrossRefs" href="#bib0685"><span class="elsevierStyleSup">57&#44;58</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">Numerous factors have been individually related to a poor short-term prognosis&#58; age&#44; chronic renal failure&#44; low weight&#44; delirium&#44; empyema&#44; bacteremia&#44; low albumin and pO<span class="elsevierStyleInf">2</span> levels&#44; leukopenia&#44; high glycemia and pCO<span class="elsevierStyleInf">2</span> levels and a number of biomarkers &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0405"><span class="elsevierStyleSup">1&#44;2&#44;14&#44;42</span></a> In contrast&#44; no correlation had been found between poorer outcomes and obesity&#44; COPD or inhaled corticosteroid treatment&#46; In terms of inhaled corticosteroid treatment&#44; a beneficial effect has also been suggested&#46;<a class="elsevierStyleCrossRef" href="#bib0695"><span class="elsevierStyleSup">59</span></a> The presence of specific units for managing patients with CAP could increase survival rates&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Achieving clinical stability&#44; i&#46;e&#46;&#44; the normalization of basic constants&#44; is the main objective for hospitalized patients&#46; Its failure results in an increased risk of complications and death&#46; For those patients who persist with clinical manifestations&#44; mainly fever&#44; but with no clinical deterioration&#44; biomarker analysis can be useful for discriminating a slow resolution &#40;showing a significant reduction in biomarker levels&#41; from poor evolution &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0605"><span class="elsevierStyleSup">41&#44;60&#44;61</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">Finally&#44; numerous authors have evaluated longer-term patient outcomes&#44; either at 90 days or 1 year after the CAP&#46; In all cases&#44; the mortality risk was associated with the patient&#39;s characteristics&#44; i&#46;e&#46;&#44; the underlying diseases&#44; more than with the characteristics of the acute episode&#46;<a class="elsevierStyleCrossRef" href="#bib0710"><span class="elsevierStyleSup">62</span></a> In a number of studies&#44; the onset of cardiac complications during hospitalization&#44; aspiration pneumonia and the need for intensive care were also predictive of greater long-term mortality&#46;<a class="elsevierStyleCrossRefs" href="#bib0690"><span class="elsevierStyleSup">58&#44;63&#44;64</span></a> Similar circumstances also determine increased subsequent morbidity and the risk of early readmission&#46;<a class="elsevierStyleCrossRef" href="#bib0725"><span class="elsevierStyleSup">65</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">The diagnosis of CAP offers an opportunity to diagnose previously unknown underlying diseases such as diabetes mellitus &#40;e&#46;g&#46;&#44; among patients who have presented hyperglycemia during hospitalization&#41;&#44; COPD&#44; lung neoplasia and immunosuppressive conditions such as HIV infection and hematologic neoplasia&#46; However&#44; the study that requires the screening of these processes has not been established&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Treatment</span><p id="par0175" class="elsevierStylePara elsevierViewall">The publication of consensus guidelines from the various medical societies has resulted in significant improvement in the management of CAP&#44; mainly thanks to the standardization of antibiotic treatment and its application to the various patient subgroups&#46;<a class="elsevierStyleCrossRefs" href="#bib0405"><span class="elsevierStyleSup">1&#44;42</span></a> Several studies have shown that compliance with the guidelines and consensus protocols improves the patients&#8217; medical care&#44; which translates into all evolutionary parameters&#44; including mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">1</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">There are 2 types of criteria that should be employed for selecting the most appropriate treatment&#58; the severity of the clinical condition and the personal circumstances of the affected patient &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46; The assessment of the clinical severity is based on the previously mentioned prognostic scales&#44; preferably the CURB-65&#44; and especially on correct clinical judgment&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0185" class="elsevierStylePara elsevierViewall">Therefore&#44; in the first group we would find patients who experience mild CAP&#46; These patients&#44; generally young and with no underlying diseases&#44; may be treated at home&#44; perhaps after a short period of observation&#46; The infection will most likely be caused by pneumococcus or one of the atypical agents&#46; Treatment with amoxicillin and azithromycin would be indicated&#46; If this regimen cannot be followed then quinolone&#44; preferentially moxifloxacin&#44; may be employed&#46; The use of beta-lactam agents could involve clinical and environmental benefits &#40;development of resistance&#41; and precedes the use of quinolones as the first choice&#46; In selected cases where a pneumococcal etiology appears highly likely&#44; clinicians may dispense with the macrolide&#46; Subgroups of patients with mild CAP can have significant underlying diseases that could result in an increased risk of more resistant pathogens&#44; mainly <span class="elsevierStyleItalic">H&#46; influenzae&#46;</span> For these groups&#44; replacing amoxicillin with amoxicillin-clavulanate or cefditoren seems reasonable&#46;<a class="elsevierStyleCrossRefs" href="#bib0405"><span class="elsevierStyleSup">1&#44;19&#44;42&#44;66&#44;67</span></a></p><p id="par0190" class="elsevierStylePara elsevierViewall">In the second group&#44; we would find patients with severe CAP&#44; who require hospitalization in conventional wards&#46; The spectrum of potential pathogens should be broadened to include <span class="elsevierStyleItalic">H&#46; influenzae</span> and a number of Gram-negative bacilli&#46; The recommended regimen in the majority of guidelines is the combination of a beta-lactam agent &#40;ceftriaxone or amoxicillin-clavulanate&#41; with a macrolide&#46;<a class="elsevierStyleCrossRefs" href="#bib0405"><span class="elsevierStyleSup">1&#44;19&#44;42&#44;67</span></a> As with the previous group&#44; quinolones with pneumococcal activity are the most reasonable alternative&#46; However&#44; this general regimen is not without controversy&#46; There is a debate on the need to include the macrolide in this initial empiric regimen&#46; On one hand&#44; we have the alleged cardiotoxicity associated with macrolides&#44;<a class="elsevierStyleCrossRef" href="#bib0740"><span class="elsevierStyleSup">68</span></a> and on the other&#44; we have its potential benefits&#44; both in terms of increasing the antimicrobial coverage and its anti-inflammatory effects&#46; We can conclude that although most studies favor the combined treatment&#44; these studies are usually observational&#46;<a class="elsevierStyleCrossRef" href="#bib0745"><span class="elsevierStyleSup">69</span></a> A recently published&#44; prospective randomized trial with more than 2000 patients assigned to 3 branches &#40;beta-lactam agent&#47;beta-lactam agent plus macrolide&#47;quinolone&#41; found no differences in terms of mortality at 90 days&#46;<a class="elsevierStyleCrossRef" href="#bib0750"><span class="elsevierStyleSup">70</span></a></p><p id="par0195" class="elsevierStylePara elsevierViewall">Furthermore&#44; the use of parenteral corticosteroids has generated significant controversy&#46; Although the results are conflicting&#44; these corticosteroids could provide certain benefits for patients with more severe CAP&#44; both in terms of survival and earlier functional recovery&#46;<a class="elsevierStyleCrossRefs" href="#bib0735"><span class="elsevierStyleSup">67&#44;71&#44;72</span></a></p><p id="par0200" class="elsevierStylePara elsevierViewall">Finally&#44; there are other minor points of discussion&#46; The use of statins combined with antibiotic treatment has generated certain expectations that seem as if they will not be confirmed&#46;<a class="elsevierStyleCrossRef" href="#bib0765"><span class="elsevierStyleSup">73</span></a> In another vein&#44; the results of noninvasive mechanical ventilation do not seem encouraging&#46;<a class="elsevierStyleCrossRef" href="#bib0770"><span class="elsevierStyleSup">74</span></a></p><p id="par0205" class="elsevierStylePara elsevierViewall">The reference general empiric antibiotic regimen should undergo changes for patients with particular risk factors&#46; Patients with aspiration pneumonia therefore require effective treatment against anaerobes and Gram-negative bacilli&#46; It would therefore be preferable to employ a regimen that includes amoxicillin-clavulanate as a beta-lactam agent or&#44; for severely ill patients or those with underlying diseases&#44; piperacillin&#8211;tazobactam or a carbapenem&#46;<a class="elsevierStyleCrossRefs" href="#bib0405"><span class="elsevierStyleSup">1&#44;75</span></a> A similar reasoning should be applied to patients with empyema&#44; in whom the coverage of anaerobes and Gram-positive germs is a priority&#46;<a class="elsevierStyleCrossRef" href="#bib0630"><span class="elsevierStyleSup">46</span></a></p><p id="par0210" class="elsevierStylePara elsevierViewall">The regimen should also be modified depending on the microorganism responsible &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46; Thus&#44; a diagnosis or high suspicion of pneumonia by <span class="elsevierStyleItalic">P&#46; aeruginosa</span> or by resistant Gram-negative bacilli&#44; mainly in immunosuppressed patients or those who meet various criteria associated with this pathogen &#40;recent hospitalization&#44; previous antibiotic treatment&#44; advanced COPD&#44; bronchiectasis or systemic corticosteroid treatment&#41;&#44; requires the preferential application of an antipseudomonal beta-lactam agent&#44; combined perhaps with amikacin&#46;<a class="elsevierStyleCrossRefs" href="#bib0405"><span class="elsevierStyleSup">1&#44;24&#44;42&#44;67</span></a> For treating pneumonia by methicillin-resistant <span class="elsevierStyleItalic">S&#46; aureus</span>&#44; the efficacy of linezolid appears to be superior to that of vancomycin&#44; although ceftaroline&#44; which has recently been approved&#44; could very well take its place&#46;<a class="elsevierStyleCrossRefs" href="#bib0780"><span class="elsevierStyleSup">76&#44;77</span></a> In those areas where the resistance of <span class="elsevierStyleItalic">M&#46; pneumoniae</span> to macrolides is high&#44; tetracyclines appear to be an effective alternative&#46;<a class="elsevierStyleCrossRef" href="#bib0790"><span class="elsevierStyleSup">78</span></a> Regarding Legionnaires&#8217; disease&#44; it is likely that the efficacies of quinolone and azithromycin are comparable&#59; however&#44; experience recommends using the former when dealing with severely ill patients&#46;<a class="elsevierStyleCrossRef" href="#bib0550"><span class="elsevierStyleSup">30</span></a> Finally&#44; oseltamivir should be added when the epidemiological circumstances or microbiological results recommend its use&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0215" class="elsevierStylePara elsevierViewall">The antibiotic treatment regimens for patients hospitalized in ICU or for those who met healthcare-associated pneumonia criteria do not differ considerably from the recommendations for patients included in the previous section&#44; although the clinical severity will favor the use of regimens with greater coverage in a higher percentage of cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0405"><span class="elsevierStyleSup">1&#44;19&#44;42&#44;79</span></a> The combination of a broad-spectrum beta-lactam agent and a quinolone has frequently been used for critically ill patients&#46; A recent study&#44; however&#44; found no differences compared with the beta-lactam agent plus macrolide regimen&#46;<a class="elsevierStyleCrossRef" href="#bib0800"><span class="elsevierStyleSup">80</span></a></p><p id="par0220" class="elsevierStylePara elsevierViewall">Lastly&#44; it is worth noting that antibiotic treatment should be started as soon as possible&#44; within the emergency department&#44; which commonly uses excessively long treatment regimens&#46; It has been shown that treatment lasting 5&#8211;7 days&#44; for patients lacking local complications &#40;empyema or cavitations&#41; and with good clinical evolution&#44; would be sufficient&#46;<a class="elsevierStyleCrossRefs" href="#bib0405"><span class="elsevierStyleSup">1&#44;19</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conflicts of interest</span><p id="par0225" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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          "identificador" => "xres797713"
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          "palabras" => array:7 [
            0 => "Community-acquired pneumonia"
            1 => "Risk factors"
            2 => "Epidemiology"
            3 => "Clinical manifestations"
            4 => "Diagnosis"
            5 => "Biomarkers"
            6 => "Prognosis"
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            0 => "Neumon&#237;a adquirida en la comunidad"
            1 => "Factores de riesgo"
            2 => "Epidemiolog&#237;a"
            3 => "Manifestaciones cl&#237;nicas"
            4 => "Diagn&#243;stico"
            5 => "Biomarcadores"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">This article not only reviews the essential aspects of community-acquired pneumonia for daily clinical practice&#44; but also highlights the controversial issues and provides the newest available information&#46; Community-acquired pneumonia is considered in a broad sense&#44; without excluding certain variants that&#44; in recent years&#44; a number of authors have managed to delineate&#44; such as healthcare-associated pneumonia&#46; The latter form is nothing more than the same disease that affects more frail patients&#44; with a greater number of risk factors&#44; both sharing an overall common approach&#46;</p></span>"
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">El presente art&#237;culo no revisa &#250;nicamente aquellos aspectos de la neumon&#237;a adquirida en la comunidad fundamentales para la pr&#225;ctica cl&#237;nica diaria&#44; sino que incide en los temas pol&#233;micos&#44; y aporta la informaci&#243;n m&#225;s novedosa disponible&#46; Se considera la neumon&#237;a adquirida en la comunidad en un sentido amplio&#44; sin excluir ciertas variantes que&#44; durante los &#250;ltimos a&#241;os&#44; algunos autores han llegado a deslindar&#44; como la neumon&#237;a asociada a cuidados sanitarios&#46; Esta &#250;ltima no es m&#225;s que la misma enfermedad que incide en pacientes m&#225;s fr&#225;giles&#44; con un mayor n&#250;mero de factores de riesgo&#44; compartiendo ambas un planteamiento global com&#250;n&#46;</p></span>"
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0035">Please cite this article as&#58; Falguera M&#44; Ram&#237;rez MF&#46; Neumon&#237;a adquirida en la comunidad&#46; Rev Clin Esp&#46; 2015&#59;215&#58;458&#8211;467&#46;</p>"
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          "leyenda" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Abbreviations</span>&#58; COPD&#44; chronic obstructive pulmonary disease&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Microorganisms&nbsp;\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">Epidemiological data&nbsp;\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">Clinical and radiological data&nbsp;\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"><span class="elsevierStyleItalic">Streptococcus pneumoniae</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">The most common in any situation&#46; Winter predominance&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Typical clinical condition&#58; chills&#44; rust-colored sputum&#44; pleuritic pain&#44; leukocytes&nbsp;\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">Haemophilus influenzae</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Individuals with underlying diseases&#44; especially smokers and patients with COPD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Typical clinical condition&#58; chills&#44; rust-colored sputum&#44; pleuritic pain&#44; leukocytes&nbsp;\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">Staphylococcus aureus</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Drug addiction&#44; previous influenza virus infection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Very severe conditions with bilateral infiltrates&#44; cavitations and pleural effusion&#46; Frequent bacteremia&nbsp;\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">Methicillin-resistant <span class="elsevierStyleItalic">Staphylococcus aureus</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Healthcare centers with a high rate of colonization&#44; previous antibiotic therapy&#44; recent hospitalization&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Very severe conditions with bilateral infiltrates&#44; cavitations and pleural effusion&#46; Frequent bacteremia&nbsp;\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">Gram-negative bacilli and <span class="elsevierStyleItalic">Pseudomonas aeruginosa</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Immunosuppression&#44; patients with advanced COPD&#44; treatment with systemic corticosteroids or bronchiectasis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Very severe clinical condition with septic shock&#46; Radiological cavitation&nbsp;\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">Anaerobes and oral cavity flora&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Patients with aspiration pneumonia &#40;altered level of consciousness or swallowing disorder&#41;&#44; alcoholism or poor oral hygiene&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cavitated infiltrate with foul-smelling sputum&#46; Presence of empyema or complicated pleural effusion&nbsp;\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">Mycoplasma pneumoniae</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Young individuals with no underlying diseases&#46; Outbreaks in communities or relatives&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Generally mild clinical condition and slightly symptomatic &#40;atypical clinical condition&#41;&nbsp;\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">Chlamydophila pneumoniae</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Equally affects all population subgroups&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Clinical condition without particular characteristics&nbsp;\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">Coxiella burnetii</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">More common in mountainous regions&#59; contact with livestock&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mildly symptomatic conditions or febrile syndrome without focus&#46; Hepatic disorder&nbsp;\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">Legionella pneumophila</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Predominantly summer&#44; related to rainy periods&#46; Disease outbreaks&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Severe clinical conditions&#46; Neurological and gastrointestinal &#40;diarrhea&#41; disorders&#44; hyponatremia&nbsp;\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">Virus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Disease outbreaks&#46; During pandemics&#44; obese individuals and pregnant women are mostly affected&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Upper respiratory tract symptoms and headache Patchy multilobar infiltrate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab1337986.png"
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Microorganisms responsible for community-acquired pneumonia and their correlation with specific clinical and epidemiological characteristics&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:3 [
          "leyenda" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Abbreviations</span>&#58; MMP&#44; matrix metalloproteinase&#59; TIMP&#44; tissue inhibitor of metalloproteinase&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Biomarkers&nbsp;\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">Clinical diagnosis<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\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">Etiological diagnosis<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a>&nbsp;\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">Complications and mortality&nbsp;\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">Progress monitoring&nbsp;\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">Albumin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\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">Beta-defensin 2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\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">Leukocyte count&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\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">Leukocyte count&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\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">Leukocyte count&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\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">Copeptin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\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">Cortisol&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\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">D dimers&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\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">Tumor necrosis factor&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\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">Interleukin 6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\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">Interleukin 8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\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">Interleukin 10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\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">Kallistatin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\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">Lactate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\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">Lipocalin 2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\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">MMP-9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\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">MMP-9&#47;TIMP-1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\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">pCO<span class="elsevierStyleInf">2</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\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">Natriuretic peptide&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\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">pH<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>7&#46;30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\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">Proadrenomedullin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\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">Procalcitonin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\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">C-Reactive Protein&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\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">O<span class="elsevierStyleInf">2</span> saturation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\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">Sodium&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\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">Urea&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\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">Vitamin D &#40;deficiency&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab1337988.png"
              ]
            ]
          ]
          "notaPie" => array:3 [
            0 => array:3 [
              "identificador" => "tblfn0005"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Pneumonia versus tuberculosis&#46;</p>"
            ]
            1 => array:3 [
              "identificador" => "tblfn0010"
              "etiqueta" => "b"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Pneumonia versus acute bronchitis or COPD exacerbation&#46;</p>"
            ]
            2 => array:3 [
              "identificador" => "tblfn0015"
              "etiqueta" => "c"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Bacterial exacerbation versus viral pneumonia or by atypical agents&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Potential usefulness of various plasma biomarkers in managing patients with community-acquired pneumonia&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Patient subgroup&nbsp;\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">Most likely microorganisms&nbsp;\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">Recommended empiric treatment&nbsp;\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">Mild pneumonia with no underlying diseases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Streptococcus pneumoniae</span>&#44; atypical agents and virus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Option&#58; amoxicillin<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>macrolide<br>Alternative&#58; quinolone&nbsp;\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">Mild pneumonia with underlying diseases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Streptococcus pneumoniae</span>&#44; atypical agents and virus&#44; <span class="elsevierStyleItalic">Haemophilus influenzae</span>&#44; Gram-negative bacilli&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Option&#58; amoxicillin-clavulanate or cefditoren<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>macrolide<br>Alternative&#58; quinolone&nbsp;\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">Severe pneumonia with no risk factors&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Streptococcus pneumoniae</span>&#44; atypical agents and virus&#44; <span class="elsevierStyleItalic">Haemophilus influenzae</span>&#44; Gram-negative bacteria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Option&#58; ceftriaxone<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>macrolide<br>Alternative&#58; quinolone&nbsp;\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">Very severe pneumonia with risk factors for <span class="elsevierStyleItalic">Pseudomonas aeruginosa</span> or Gram-negative bacilli&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Streptococcus pneumoniae</span>&#44; atypical agents and virus&#44;<br><span class="elsevierStyleItalic">Haemophilus influenzae</span>&#44;<br>Gram-negative bacteria&#44;<br><span class="elsevierStyleItalic">Pseudomonas aeruginosa</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Option&#58; cefepime or piperacillin&#8211;tazobactam or carbapenem<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>macrolide or quinolone&nbsp;\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">Aspiration pneumonia or empyema&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Streptococcus pneumoniae</span>&#44;<br>other Gram-positive cocci&#44; anaerobic&#44; Gram-negative bacilli&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Option&#58; amoxicillin-clavulanate or piperacillin&#8211;tazobactam or carbapenem<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">a</span></a><br>Alternative&#58; quinolone<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>clindamycin&nbsp;\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">Pneumonia with criteria of methicillin-resistant <span class="elsevierStyleItalic">Staphylococcus aureus</span> infection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Streptococcus pneumoniae</span>&#44;<br>atypical agents and virus&#44;<br><span class="elsevierStyleItalic">Haemophilus influenzae</span>&#44;<br>Gram-negative bacteria&#44;<br><span class="elsevierStyleItalic">Pseudomonas aeruginosa</span>&#44;<br><span class="elsevierStyleItalic">Staphylococcus aureus</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Option&#58; amoxicillin-clavulanate or ceftriaxone or piperacillin&#8211;tazobactam or carbapenem<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>macrolide<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>linezolid or vancomycin<br>Alternative&#58; ceftaroline<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>macrolide&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab1337985.png"
              ]
            ]
          ]
          "notaPie" => array:1 [
            0 => array:3 [
              "identificador" => "tblfn0020"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0020">Depending on the relative risk of other microorganisms&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Etiology and recommended empiric treatment according to the various patient subgroups&#46;</p>"
        ]
      ]
      3 => array:7 [
        "identificador" => "tbl0020"
        "etiqueta" => "Table 4"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Microorganism isolated&nbsp;\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">Recommended treatment&nbsp;\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"><span class="elsevierStyleItalic">Streptococcus pneumoniae</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Option&#58; amoxicillin<br>Alternative&#58; quinolone&nbsp;\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">Legionella pneumophila</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Option&#58; quinolone<br>Alternative&#58; azithromycin&nbsp;\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">Mycoplasma pneumoniae</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Option&#58; macrolide<br>Alternatives&#58; tetracyclines<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">a</span></a>&nbsp;\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">Methicillin-resistant <span class="elsevierStyleItalic">Staphylococcus aureus</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Option&#58; linezolid<br>Alternatives&#58; vancomycin or ceftaroline&nbsp;\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">Pseudomonas aeruginosa</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Antipseudomonal beta-lactam<a class="elsevierStyleCrossRef" href="#tblfn0030"><span class="elsevierStyleSup">b</span></a><span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>amikacin<br>Alternative&#58; quinolone&nbsp;\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">Influenza virus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Ceftriaxone<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>macrolide<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>oseltamivir<br>Alternative&#58; quinolone<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>oseltamivir&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab1337987.png"
              ]
            ]
          ]
          "notaPie" => array:2 [
            0 => array:3 [
              "identificador" => "tblfn0025"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0025">In areas with high rates of resistance to macrolides&#46;</p>"
            ]
            1 => array:3 [
              "identificador" => "tblfn0030"
              "etiqueta" => "b"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0030">Based on the results of the antibiogram&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Targeted treatment depending on the microorganism isolated&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:80 [
            0 => array:3 [
              "identificador" => "bib0405"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:3 [
                  "comentario" => "e1&#8211;19"
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Gu&#237;a multidisciplinar para la valoraci&#243;n pron&#243;stica&#44; diagn&#243;stico y tratamiento de la neumon&#237;a adquirida en la comunidad"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "A&#46; Torres"
                            1 => "J&#46; Barber&#225;n"
                            2 => "M&#46; Falguera"
                            3 => "R&#46; Men&#233;ndez"
                            4 => "J&#46; Molina"
                            5 => "P&#46; Olaechea"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:4 [
                        "tituloSerie" => "Med Clin &#40;Barc&#41;"
                        "fecha" => "2013"
                        "volumen" => "140"
                        "paginaInicial" => "223"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0410"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Epidemiology of community-acquired pneumonia"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "M&#46;I&#46; Irizar Aramburu"
                            1 => "M&#46;A&#46; Arrondo Beguiristain"
                            2 => "M&#46;J&#46; Insausti Carretero"
                            3 => "J&#46; Mujica Campos"
                            4 => "P&#46; Etxabarri Perez"
                            5 => "R&#46; Ganzarain Gorosabel"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.aprim.2013.05.003"
                      "Revista" => array:6 [
                        "tituloSerie" => "Aten Primaria"
                        "fecha" => "2013"
                        "volumen" => "45"
                        "paginaInicial" => "503"
                        "paginaFinal" => "513"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23910056"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0415"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Tobacco smoking increases the risk for death from pneumococcal pneumonia"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "S&#46; Bello"
                            1 => "R&#46; Menendez"
                            2 => "A&#46; Torres"
                            3 => "S&#46; Reyes"
                            4 => "R&#46; Zalacain"
                            5 => "A&#46; Capelastegui"
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