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in both the hospital inpatient setting and the outpatient center of our institution&#46; Our center provides care for a population of 220&#44;000 inhabitants and has oncology and hematology departments that share a hospital unit and an outpatient center&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">All episodes of pneumococcal infection were included&#44; which were defined as the isolation of <span class="elsevierStyleItalic">S&#46; pneumoniae</span> in any sample from patients over 17 years of age with a history of active or inactive oncohematologic disease&#46; The data were extracted from a database of pneumococcal infection that has been jointly and prospectively compiled since January 2006 by the Microbiology and Internal Medicine departments&#46; We excluded episodes with positive isolates considered to be colonizations with no attributable symptoms&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">A neoplasm was considered active if it met any of the following criteria&#58; &#40;a&#41; new diagnosis or recurrence of a previous neoplasm during hospitalization for pneumococcal infection&#59; &#40;b&#41; surgery&#44; chemotherapy and&#47;or radiation therapy in the 6 months prior to infection&#59; and &#40;c&#41; untreated neoplasm due to patient refusal or as a result of palliative treatment at the physician&#39;s discretion&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The following variables were collected from all patients in the study&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8211;</span><p id="par0055" class="elsevierStylePara elsevierViewall">Demographics&#58; gender and age&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8211;</span><p id="par0060" class="elsevierStylePara elsevierViewall">Origin of the infection&#58; &#40;1&#41; community&#58; if there was no previous contact with the healthcare setting&#59; &#40;2&#41; associated with healthcare&#58; as long as any of the following risk criteria were met&#58; &#40;a&#41; home intravenous treatment &#40;self-administered or otherwise&#41; or injury or ulcer treatment by specialized personnel in the last 30 days&#59; &#40;b&#41; hospital care&#44; intravenous hemodialysis or chemotherapy in the last 30 days&#59; &#40;c&#41; prior hospitalizations lasting 2 or more days in the 90 days prior to the current infectious episode&#44; and &#40;d&#41; residing in an assisted-living home or long-stay hospital and &#40;3&#41; nosocomial&#58; diagnosis of the infection after a minimum of 48<span class="elsevierStyleHsp" style=""></span>h of hospitalization&#46; In cases of transfers from other hospitals&#44; the time was considered from the admission to the first center&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#8211;</span><p id="par0065" class="elsevierStylePara elsevierViewall">Clinical and epidemiological&#58; smoking and alcoholism &#40;active consumption was defined as a period of abstinence of less than a year&#41;&#44; antibiotic treatment in the 6 months prior to the pneumococcal infection&#44; vaccination for pneumococcus with the 23-valent polysaccharide vaccine&#44; location of the infection&#44; FINE stage<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> in the case of pneumonia&#44; degree of comorbidity measured by the Charlson index&#44; type of tumor &#40;solid or hematologic&#41;&#44; evidence of distant metastases&#44; neutropenia at the time of infection &#40;moderate neutropenia&#58; total number of neutrophils in peripheral blood &#60;1000<span class="elsevierStyleHsp" style=""></span>cells&#47;mm&#44;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> severe neutropenia &#60;500<span class="elsevierStyleHsp" style=""></span>cells&#47;mm<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>&#41; and time elapsed since the last dose of chemotherapy&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#8211;</span><p id="par0070" class="elsevierStylePara elsevierViewall">Complementary examinations&#58; blood cultures&#44; cultures of sputum or of other sterile or non-sterile samples&#44; pneumococcal antigen in urine or in other fluids&#44; chest X-ray pattern&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#8211;</span><p id="par0075" class="elsevierStylePara elsevierViewall">Complications and outcome&#58; pleural effusion&#44; empyema&#44; endotracheal intubation&#44; non-invasive mechanical ventilation&#44; septic shock&#44; distant septic metastases&#44; overall mortality during hospitalization and mortality related to the actual pneumococcal infection&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">&#8211;</span><p id="par0080" class="elsevierStylePara elsevierViewall">Microbiological information&#58; antibiogram and serotyping of isolated pneumococcal strains &#40;since January 2009&#44; all <span class="elsevierStyleItalic">S&#46; pneumoniae</span> isolates have been systematically delivered to the Pneumococcal Reference Laboratory&#44; National Microbiology Center&#44; Carlos III Health Institute&#41;&#46; The identification of <span class="elsevierStyleItalic">S&#46; pneumoniae</span> was performed by observing blood from alpha hemolytic&#44; catalase-negative and optochin-sensitive colonies in agar&#46; For inconclusive cases&#44; we used the bile solubility test and the Slidex pneumo-kit<span class="elsevierStyleSup">&#174;</span> &#40;bioM&#233;rieux&#44; Marcy L&#8217;Etoile&#44; France&#41;&#44; which employs agglutination with latex particles coated in specific antiserum&#46; We studied the sensitivity to penicillin&#44; amoxicillin and cefotaxime using the E-test<span class="elsevierStyleSup">&#174;</span> &#40;AB-Biodisk&#44; Solna&#44; Sweden&#41; using cutoff points for non-meningeal isolates&#46; We also studied the sensitivity to erythromycin&#44; tetracycline&#44; telithromycin&#44; vancomycin&#44; cotrimoxazole and levofloxacin using a disc-plate &#40;Oxoid&#41; following the CLSI-2011 criteria&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p></li></ul></p><p id="par0085" class="elsevierStylePara elsevierViewall">We performed a descriptive statistical analysis of the characteristics of the patients with oncohematologic disease using a frequency analysis for quantitative variables and the calculation of means&#44; standard deviations&#44; medians and ranges for quantitative variables&#46; We then conducted a comparative analysis with the adults patients who had no history of oncohematologic disease recorded in the same database using Student&#39;s <span class="elsevierStyleItalic">t</span>-test for quantitative variables and the chi-squared test for qualitative variables&#44; applying Fisher&#39;s exact test when necessary&#46; In this case&#44; we also calculated the corresponding <span class="elsevierStyleItalic">odds ratio</span> &#40;OR&#41; with 95&#37; confidence intervals &#40;95&#37; CI&#41;&#46; All calculations were performed with the SPSS<span class="elsevierStyleSup">&#174;</span> version 12&#46;1 software package&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Results</span><p id="par0090" class="elsevierStylePara elsevierViewall">We studied 131 episodes of incident pneumococcal infection &#40;112 in males and 19 in females&#41; in 122 patients with oncohematologic disease &#40;median age&#58; 67 years&#59; range&#58; 34&#8211;88&#41;&#46; These episodes were compared with 803 incident episodes during the same study period in patients with no oncohematologic disease&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">The majority of the incident infections in oncohematological patients were related to healthcare or nosocomial causes &#40;76 cases&#44; 58&#37;&#41;&#46; In 52 &#40;40&#37;&#41; episodes&#44; and there was a history of receiving antibiotic treatment in the last 6 months&#46; The median of the Charlson comorbidity index was 5 &#40;range&#58; 2&#8211;11&#41;&#46; Only 2 patients with oncohematologic disease and 28 patients in the control group were documented as having received the 23-valent polysaccharide vaccine&#46; The clinical and epidemiological characteristics of the patients are summarized in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">Ninety-three patients &#40;71&#37;&#41; showed active neoplasms&#46; Twenty-two patients had hematologic disease&#44; 108 had solid neoplasms and 1 patient had both types of neoplasm &#40;pulmonary adenocarcinoma and non-Hodgkin&#39;s lymphoma&#41;&#46; The most frequent type of solid neoplasia was lung cancer with 44 cases &#40;40&#46;3&#37;&#41;&#46; The predominant type of hematologic neoplasia was non-Hodgkin&#39;s lymphoma with 8 cases &#40;34&#46;7&#37;&#41;&#44; followed by leukemia with 7 cases &#40;30&#37;&#41; and multiple myeloma with 6 cases &#40;26&#37;&#41;&#46; The list of incident neoplasms is summarized in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">During the 6 months prior to the pneumococcal infection&#44; chemotherapy was administered on 43 occasions &#40;32&#46;8&#37;&#41;&#44; radiation therapy was administered on 1 occasion &#40;0&#46;8&#37;&#41; and surgical eradication was performed on 4 occasions &#40;3&#46;1&#37;&#41;&#46; In 28 &#40;21&#46;3&#37;&#41; episodes&#44; the diagnosis of the neoplasm coincided with the infection&#44; and in 6 &#40;4&#46;6&#37;&#41; episodes&#44; the patient or physician rejected implementation of active cancer treatment&#46; In the remaining 49 episodes&#44; the following circumstances occurred&#58; surgical eradication in 25 &#40;19&#46;1&#37;&#41;&#44; chemotherapy in 10 &#40;7&#46;6&#37;&#41;&#44; and radiation therapy in 6 &#40;4&#46;6&#37;&#41;&#44; more than 6 months before the pneumococcal infection&#59; hormonal therapy was administered on 6 occasions &#40;4&#46;6&#37;&#41;&#44; BCG instillation on 1 occasion &#40;0&#46;8&#37;&#41; and unknown on 1 occasion &#40;0&#46;8&#37;&#41;&#46; In 122 of the episodes &#40;93&#37;&#41;&#44; there was no evidence of neutropenia at the time of the pneumococcal infection&#46; In 3 episodes &#40;2&#46;3&#37;&#41;&#44; the neutropenia was moderate&#44; and in 6 episodes &#40;4&#46;6&#37;&#41;&#44; it was severe&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">The majority of oncohematological patients were diagnosed with pneumonia &#40;52 cases&#44; 40&#37;&#41; or lower respiratory tract infections without consolidation &#40;59 cases&#44; 45&#37;&#41;&#46; The same situation occurred with the control group&#44; with 393 cases of pneumonia &#40;48&#46;9&#37;&#41; and 301 cases &#40;37&#46;5&#37;&#41; of lower respiratory tract infections without consolidation&#44; followed distantly by other types of infection &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46; The majority of pneumonia cases were cataloged as FINE <span class="elsevierStyleSmallCaps">iv-v</span> &#40;37 cases&#44; 71&#46;2&#37;&#41;&#46; The most common radiological pattern was lobar condensation &#40;31 cases&#41;&#44; followed by bilateral condensation in more than one lobe &#40;6 cases&#41;&#44; unilateral condensation in more than one lobe &#40;3 cases&#41;&#44; unilateral condensation with effusion &#40;2 cases&#41; and bilateral condensation with effusion &#40;2 cases&#41;&#46; Other rare patterns &#40;atelectasis&#44; isolated pleural effusion&#44; cavitated condensation&#44; etc&#46;&#41; were seen in 8 cases&#46; The following complications were observed&#58; pleural effusion in 1 case &#40;0&#46;8&#37;&#41;&#44; empyema in 1 case &#40;0&#46;8&#37;&#41;&#44; shock in 7 cases &#40;5&#46;3&#37;&#41; and the need for endotracheal intubation in 8 cases &#40;6&#46;1&#37;&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0115" class="elsevierStylePara elsevierViewall">Sputum samples were collected in only 8 episodes&#44; with 3 resulting positive&#46; Pneumococcal antigen was determined in urine in 60 cases &#40;45&#46;8&#37;&#41; and positive in 22 cases &#40;36&#46;7&#37; of the samples&#41;&#46; The determination of pneumococcal antigens in other fluids was performed in 8 episodes&#44; which resulted positive in 4 episodes &#40;2 in pleural effusions and 2 in cerebrospinal fluid&#41;&#46; The blood cultures were positive in 27 of the 75 episodes &#40;36&#37;&#41; in which blood was extracted&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">When comparing the characteristics of the oncohematological patients with those of the control patients &#40;those with no oncohematologic disease&#41;&#44; we observed that the patients with solid or hematologic neoplasms were more often male &#40;85&#46;5&#37; vs&#46; 70&#46;4&#37;&#59; OR&#58; 2&#46;43&#59; 95&#37; CI&#58; 1&#46;4&#8211;4&#46;1&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; Fifty-eight percent of the oncohematological patients and 30&#46;6&#37; of the controls showed infections associated with healthcare or nosocomial causes &#40;OR&#58; 3&#46;1&#59; 95&#37; CI&#58; 2&#46;1&#8211;4&#46;5&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; The FINE severity indices were higher in patients with neoplasms &#40;82&#37; of cases in patients with oncohematologic disease FINE <span class="elsevierStyleSmallCaps">iv-v</span> vs&#46; 48&#37; of cases in controls&#59; OR&#58; 4&#46;0&#58; 95&#37; CI&#58; 2&#46;0&#8211;10&#46;0&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; The age of the patients with oncohematologic disease was significantly greater than that of the control group &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;02&#41;&#44; but once the 38 patients with inactive neoplasms were excluded from the analysis&#44; these differences disappeared&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Sixteen patients &#40;12&#46;2&#37;&#41; died during hospitalization&#59; 10 of these deaths were considered related to the pneumococcal infection &#40;7&#46;6&#37;&#41;&#46; The mortality not attributable to the pneumococcal infection was significantly higher in patients with no oncohematologic disease &#40;6 &#91;4&#46;5&#37;&#93; vs&#46; 14 &#91;1&#46;7&#37;&#93; cases in each group&#59; OR&#58; 2&#46;25&#59; 95&#37; CI&#58; 1&#46;2&#8211;4&#46;1&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;006&#41;&#46; The rate of bacteremia &#40;36&#37; vs&#46; 40&#46;7&#37; of the episodes in which blood cultures were conducted&#41; and the frequency of complications &#40;15&#46;2&#37; vs&#46; 21&#46;9&#37;&#41; did not vary significantly between the two patient groups&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Among the 38 samples from infections in oncohematological patients in which the serotype was obtained&#44; the predominant serotypes were those not included in the VCN-7 &#40;33 isolates&#44; 86&#46;8&#37;&#41; compared to the non-vaccine serotypes &#40;5 isolates&#44; 13&#46;1&#37;&#41;&#46; Among the vaccine serotypes&#44; the most common was the 23F &#40;2 isolates&#41;&#59; among the non-vaccine serotypes&#44; the most common were 6A&#44; 11A&#44; 19A&#44; 31&#44; and 33F&#44; with 3 cases in each &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0135" class="elsevierStylePara elsevierViewall">When analyzing the results of the sensitivities to the various antibiotics in the population of patients with solid or hematologic neoplasms and comparing them with the group of patients with no neoplastic disease&#44; we observed that the former had a slightly greater risk of reduced sensitivity to levofloxacin &#40;122 &#91;93&#46;1&#37;&#93; sensitive vs&#46; 9 &#91;6&#46;9&#37;&#93; with reduced sensitivity&#59; OR&#58; 0&#46;45&#59; 95&#37; CI&#58; 0&#46;2&#8211;0&#46;99&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;043&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0140" class="elsevierStylePara elsevierViewall">Patients with severe immunosuppression have a high incidence of pneumococcal disease&#44; between 28 and 48 times higher than expected in healthy adults&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> Since the introduction in 2000 &#40;2001 in Spain&#41; of the VCN-7 vaccine in pediatrics&#44; a reduction has been observed in the infections caused by this microorganism and the mortality associated with these infections&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;15&#44;21</span></a> Few studies have been published analyzing the changes caused in patients with oncohematologic conditions&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">The present study provides relevant data on pneumococcal disease in this population during the post-vaccine period and corroborates some of the findings described in other patient groups&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> We can observe a predominance of pneumococcal infection episodes in males &#40;85&#37;&#41;&#44; mainly in respiratory tract infections &#40;pneumonia and non-condensing respiratory infection&#41;&#46; This situation is not surprising given that the most commonly observed solid neoplasm was the pulmonary neoplasm&#44; which is more prevalent in males and that often other factors are present that favor pneumococcal infection&#44; factors such as smoking and underlying pulmonary conditions&#46;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">22&#44;23</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">It should be noted that the most frequent types of hematologic neoplasms were non-Hodgkin&#39;s lymphoma and leukemia&#44; followed by multiple myeloma&#44; a condition that is traditionally described as a risk factor for pneumococcal disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">24&#44;25</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">As expected&#44; the majority of infections were considered to be related to healthcare and nosocomial causes&#44; given that the oncohematological patients maintained regular contact with the healthcare environment&#44; either due to recurrent hospital admissions or periodic care in the outpatient center&#46; Interestingly&#44; pneumococcal infection was not related to the recent administration of chemotherapy and also did not coincide with episodes of neutropenia &#40;in 92&#37; of episodes&#44; the neutrophil count was greater than 1000<span class="elsevierStyleHsp" style=""></span>cells&#47;mm<span class="elsevierStyleSup">3</span>&#41;&#46; This observation supports the concept that&#44; for patients with oncohematologic disease who present episodes of febrile neutropenia&#44; we should select active antibiotics against other gram-positive and gram-negative microorganisms&#44; including non-fermenters&#44; as reflected in the majority of series in the literature&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">26&#44;27</span></a> Based on our findings&#44; we should be cautious when empirically administering quinolones to oncohematological patients who present healthcare- or nosocomial-related pneumonia&#44; lower respiratory tract infections and exacerbations of chronic obstructive pulmonary disease because of the possibility of resistance&#46; This is especially the case if the patients have received prophylaxis or prior treatment with these drugs&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;28</span></a> The data on the sensitivity to the other antibiotics were not significantly different from the rest of the general population&#44; although the percentage of strains with reduced sensitivity to levofloxacin was only 7&#37;&#44; a figure slightly higher than the 5&#46;2&#37; of the general population in our community &#40;unpublished data&#41; and the rest of the beta-lactam antibiotics &#40;third-generation amoxicillin and cephalosporins&#41;&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">The majority of incident pneumococcal pneumonia in oncohematological patients was classified into FINE stages <span class="elsevierStyleSmallCaps">iv-v</span>&#44; which is logical if we consider that this situation usually occurs in elderly patients with associated comorbidity and that the presence of a neoplasm represents adding many points to the calculation of the FINE index&#46; It would have probably been more appropriate to use another infection severity classification such as the APACHE scale&#59; however&#44; given that we are dealing with a database designed in 2006&#44; all of the necessary parameters for calculating this scale were not initially collected&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Although we do not have data from the period immediately before the pediatric implementation of the pneumococcal vaccination with VCN-7&#44; it should be noted that the oncohematological patients did not show an increase in the number of complications of the pneumococcal infection compared with those observed in the controls&#44; nor was there a greater mortality associated with the actual pneumococcal infection&#46; In other immunosuppressed patient groups such as patients with HIV infection&#44; an increase in the severity of pneumococcal infections has been reported in the post-vaccine period&#44; as well as a greater frequency of complications such as empyema&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">It is worth noting that only 2 patients in our series were reported in their histories as having received the 23-valent polysaccharide vaccine&#46; In the control group&#44; only 28 patients had been vaccinated&#46; This is probably due to the fact that&#44; in our community&#44; the at-risk population is under-vaccinated&#46; We cannot rule out the possibility&#44; however&#44; that a number of patients may have been vaccinated while in primary care without it being registered in their medical history&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Although the number of pneumococcal strains that were serotyped in this group of patients was low&#44; our data agree with those reported in other patient groups&#44; which show a shift in the serotypes involved in these infections toward those not included in the VCN-7&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;29&#44;30</span></a> An increase in the incidence of these serotypes has already been reported&#44; especially for 6A in the oncohematologic population<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> when compared with healthy adults&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">The limitations of this study include the fact that it was conducted in a single center and that the results cannot be extrapolated to the entire oncohematological patient population in other communities&#46; In addition&#44; given that our center opened in January 2002&#44; we do not have access to patient data from the pre-vaccination period&#46; The fact that we could only access results from pneumococcal serotypes starting from January 2009 also presents a limitation&#46; Nevertheless&#44; we believe that these limitations do not detract from the validity of our data&#44; given how much they agree with findings reported in the general population and in other groups of immunosuppressed patients&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">In our patient series&#44; the pneumococcal infections in oncohematological patients occurred more frequently in males&#44; especially with lung neoplasms&#44; mainly affecting the respiratory tract and although generally not community acquired&#44; they were not related to recent exposure to chemotherapy or episodes of neutropenia&#46; In general&#44; the predominate serotypes were those not included in the pneumococcal vaccine&#44; and the rates of resistance to antibiotics did not differ from those of the general population except for the case of quinolones&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicts of interest</span><p id="par0190" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle">Objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To know the symptoms and predominant serotypes of pneumococcal infection in patients with oncohematological illness after introduction of 7-valent pneumococcal conjugate vaccine&#46;</p> <span class="elsevierStyleSectionTitle">Patients and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A prospective study &#40;January 2006&#8211;May 2011&#41; was made for all the incident cases of infection in oncohematological patients over 17 years of age in whom <span class="elsevierStyleItalic">Streptococcus pneumoniae</span> was isolated&#46;</p> <span class="elsevierStyleSectionTitle">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A total of 131 episodes of incident cases of pneumococcal infection in 122 patients &#40;median age of 67 years&#41; were detected&#46; Of these&#44; 50&#37; were related to health&#47;nosocomial care &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#44; 39&#46;7&#37; to pneumonias and 45&#46;1&#37; to lower respiratory tract infections&#44; without radiological condensation&#46; In comparison of the 803 incident cases of pneumococcal infection during the same period with patients without oncohematological disease&#44; the oncohematological patients were more frequently males &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#44; who had pneumonia episodes with higher FINE scores &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#44; lower risk of death non-directly associated with pneumococcal infection &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;006&#41; and showed reduced susceptibility to levofloxacin &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;043&#41;&#46; Non-vaccine serotypes predominated&#46;</p> <span class="elsevierStyleSectionTitle">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Pneumococcal infections in oncohematological patients are more frequent in males&#44; mainly with lung neoplasms&#46; They are heath care related&#44; but not related to chemotherapy or neutropenia&#46; After the introduction of heptavalent conjugate vaccines in pediatrics&#44; the non-vaccine serotypes predominate&#46;</p>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span class="elsevierStyleSectionTitle">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Precisar la cl&#237;nica y los serotipos predominantes en las infecciones neumoc&#243;cicas incidentes en pacientes oncohematol&#243;gicos tras la introducci&#243;n de la vacuna conjugada heptavalente&#46;</p> <span class="elsevierStyleSectionTitle">Pacientes y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Serie de casos prospectiva &#40;enero 2006- mayo 2011&#41; de la totalidad de casos de infecci&#243;n&#44; incidentes en pacientes oncohematol&#243;gicos de m&#225;s de 17 a&#241;os de edad&#44; en los que se aisl&#243; <span class="elsevierStyleItalic">Streptococcus pneumoniae</span>&#46;</p> <span class="elsevierStyleSectionTitle">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se detectaron 131 episodios de infecci&#243;n neumoc&#243;cica&#44; incidentes en 122 pacientes &#40;mediana de edad&#58; 67 a&#241;os&#41;&#46; El 50&#37; se relacion&#243; con atenci&#243;n sanitaria&#47;nosocomial&#46; El 39&#44;7&#37; fueron neumon&#237;as y el 45&#44;1&#37; infecciones del tracto respiratorio bajo sin condensaci&#243;n radiol&#243;gica&#46; Con respecto a los 803 casos de infecci&#243;n neumoc&#243;cica&#44; incidentes durante el mismo periodo en pacientes sin enfermedad oncohematol&#243;gica&#44; los pacientes oncohematol&#243;gicos fueron m&#225;s frecuentemente varones &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; presentaron neumon&#237;as con &#237;ndices de FINE m&#225;s altos &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; una mortalidad no atribuible a la infecci&#243;n menor &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;006&#41; y una mayor probabilidad de sensibilidad disminuida a levofloxacino &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;043&#41;&#46; Predominaron los serotipos no vacunales&#46;</p> <span class="elsevierStyleSectionTitle">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Las infecciones neumoc&#243;cicas incidentes en pacientes oncohematol&#243;gicos se presentan predominantemente en varones&#44; afectos de c&#225;nceres de pulm&#243;n&#46; Se relacionan con la atenci&#243;n sanitaria&#44; pero no con exposici&#243;n reciente a quimioterapia o neutropenia&#46; Tras la introducci&#243;n de la vacuna pedi&#225;trica heptavalente conjugada predominan los serotipos no vacunales&#46;</p>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara">Please cite this article as&#58; P&#233;rez de la Blanca-Burgos M&#44; et al&#46; Infecci&#243;n neumoc&#243;cica en pacientes oncohematol&#243;gicos tras la introducci&#243;n de la vacuna conjugada&#46; Rev Clin Esp&#46; 2013&#59;213&#58;8&#8211;15&#46;</p>"
      ]
    ]
    "multimedia" => array:6 [
      0 => array:7 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:3 [
          "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">95&#37; CI&#58; 95&#37; confidence interval&#59; OR&#58; <span class="elsevierStyleItalic">odds ratio</span>&#59; PDU&#58; parenteral drug user&#59; HIV&#58; human immunodeficiency virus&#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"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Variable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Oncohematologic patients &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>131&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Non-oncohematologic patients &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>803&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Significance&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Male&#47;female&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">112&#47;19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">565&#47;238&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">OR&#58; 2&#46;43&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">95&#37; CI&#58; 1&#46;4&#8211;4&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Age&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">67 &#40;range&#58; 34&#8211;88&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">66 &#40;range&#58; 15&#8211;97&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;02&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">HIV infection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">54 &#40;6&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;02&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Active PDU<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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">30 &#40;3&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;02&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Active smoking<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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">39 &#40;29&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">272 &#40;33&#46;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Active alcoholism<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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15 &#40;11&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">93 &#40;11&#46;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">23-Valent vaccine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;1&#46;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">28 &#40;3&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Heart failure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14 &#40;10&#46;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">122 &#40;15&#46;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Chronic respiratory disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">72 &#40;55&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">448 &#40;55&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Liver disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14 &#40;10&#46;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">89 &#40;11&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Diabetes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">39 &#40;29&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">192 &#40;24&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab53205.png"
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            0 => array:3 [
              "identificador" => "tblfn0005"
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            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Clinical and epidemiological characteristics of the patients in the study&#46;</p>"
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        "mostrarFloat" => true
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">One patient had both a solid neoplasm and a hematologic neoplasm simultaneously&#46;</p>"
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">Neoplasm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t">Percentage&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">131&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Solid neoplasms</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">109&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">83&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Lung&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">44&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Prostate-testicular&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">6&#46;1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Liver&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">5&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Stomach&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2&#46;3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Esophagus&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#46;5&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Breast&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2&#46;3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Skin&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Others&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Hematologic neoplasms</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">17&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Non-Hodgkin&#39;s lymphoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">6&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Multiple myeloma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">4&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Hodgkin&#39;s lymphoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Leukemia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                  \t\t\t\t">Controls &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>803&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Statistical significance&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">393 &#40;48&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">NS&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">6 &#40;4&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NS&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Bronchiectasis superinfection&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">NS&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">38 &#40;4&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">NA&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">33 &#40;70&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">79&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Amoxicillin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">94&#46;6&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">96&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Cefotaxime&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">95&#46;4&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Erythromycin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">64&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">71&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Tetracycline&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">76&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">79&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Vancomycin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cotrimoxazole&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">67&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">70&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Levofloxacin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">93&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">96&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;04&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab53206.png"
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          "en" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Sensitivity to the various antibiotics in oncohematological patients &#40;cases&#41; and in the controls with no oncohematologic condition&#46;</p>"
        ]
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      5 => array:5 [
        "identificador" => "tb0005"
        "tipo" => "MULTIMEDIATEXTO"
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        "texto" => array:1 [
          "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">What we know</span><p id="par0010" class="elsevierStylePara elsevierViewall">Since the authorization to use the heptavalent pneumococcal conjugate vaccine in children&#44; there has been a reduction in the incidence of invasive pneumococcal disease in various patient populations in both children and adults&#46; There has also been a reduction in the rates of pneumonia and otitis and in the infections caused by the serotypes included in the vaccine&#46; However&#44; few data are available on oncohematological patients&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">What this article provides</span><p id="par0015" class="elsevierStylePara elsevierViewall">The incident pneumococcal infection in the oncohematological patients included in this study predominantly affected males&#44; especially as a lower respiratory tract infection&#46; These were frequently nosocomial infections&#44; i&#46;e&#46;&#44; related to the healthcare provided&#46; They were not related to the administration of chemotherapy or neutropenia and did not show a greater rate of complications or mortality&#46; The prevalent serotypes were different from those included in the vaccine&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The Editors</p></span></span>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:30 [
            0 => array:3 [
              "identificador" => "bib0005"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Pneumococcal conjugate vaccine for childhood immunization&#58; WHO position paper"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "World Health Organization"
                          ]
                        ]
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                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Wkly Epidemiol Rec"
                        "fecha" => "2007"
                        "volumen" => "82"
                        "paginaInicial" => "93"
                        "paginaFinal" => "104"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17380597"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0010"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "<span class="elsevierStyleItalic">Streptococcus pneumoniae</span> colonisation&#58; the key to pneumococcal disease"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "D&#46; Bogaert"
                            1 => "R&#46; De Groot"
                            2 => "P&#46;W&#46; Hermans"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/S1473-3099(04)00938-7"
                      "Revista" => array:6 [
                        "tituloSerie" => "Lancet Infect Dis"
                        "fecha" => "2004"
                        "volumen" => "4"
                        "paginaInicial" => "144"
                        "paginaFinal" => "154"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/14998500"
                            "web" => "Medline"
                          ]
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                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0015"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Practice guidelines for the management of community-acquired pneumonia in adults"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "J&#46;G&#46; Bartlett"
                            1 => "S&#46;F&#46; Dowell"
                            2 => "L&#46;A&#46; Mandell"
                            3 => "T&#46;M&#46; File Jr&#46;"
                            4 => "D&#46;M&#46; Musher"
                            5 => "M&#46;J&#46; Fine"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1086/313954"
                      "Revista" => array:6 [
                        "tituloSerie" => "Clin Infect Dis"
                        "fecha" => "2000"
                        "volumen" => "31"
                        "paginaInicial" => "347"
                        "paginaFinal" => "382"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10987697"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
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                ]
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              "identificador" => "bib0020"
              "etiqueta" => "4"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Direct and indirect effects of routine vaccination of children with 7-valent pneumococcal conjugate vaccine on incidence of invasive pneumococcal disease &#8211; United States&#44; 1998&#8211;2003"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "Centers for Disease Control and Prevention &#40;CDC&#41;"
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                      ]
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                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "MMWR Morb Mortal Wkly Rep"
                        "fecha" => "2005"
                        "volumen" => "54"
                        "paginaInicial" => "893"
                        "paginaFinal" => "897"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16163262"
                            "web" => "Medline"
                          ]
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              "etiqueta" => "5"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Active Bacterial Core Surveillance of the Emerging Infections Program Network&#46; Effect of introduction of the pneumococcal conjugate vaccine on drug-resistant <span class="elsevierStyleItalic">Streptococcus pneumoniae</span>"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "M&#46;H&#46; Kyaw"
                            1 => "R&#46; Lynfield"
                            2 => "W&#46; Schaffner"
                            3 => "A&#46;S&#46; Craig"
                            4 => "J&#46; Hadler"
                            5 => "A&#46; Reingold"
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                    0 => array:2 [
                      "doi" => "10.1056/NEJMoa051642"
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                        "tituloSerie" => "N Engl J Med"
                        "fecha" => "2006"
                        "volumen" => "354"
                        "paginaInicial" => "1455"
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16598044"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Changing epidemiology of invasive pneumococcal disease among older adults in the era of pediatric pneumococcal conjugate vaccine"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "C&#46;A&#46; Lexau"
                            1 => "R&#46; Lynfield"
                            2 => "R&#46; Danila"
                            3 => "T&#46; Pilishvili"
                            4 => "R&#46; Facklam"
                            5 => "M&#46;M&#46; Farley"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "J Am Med Assoc"
                        "fecha" => "2005"
                        "volumen" => "294"
                        "paginaInicial" => "2043"
                        "paginaFinal" => "2051"
                      ]
                    ]
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              "etiqueta" => "7"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Neumon&#237;a neumoc&#243;cica en la era de la vacuna conjugada heptavalente"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "A&#46; Payeras"
                            1 => "A&#46; Villoslada"
                            2 => "M&#46; Garau"
                            3 => "M&#46; Borras"
                            4 => "A&#46; Pareja"
                            5 => "D&#46; Beingolea"
                          ]
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                      ]
                    ]
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.eimc.2010.09.014"
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                        "tituloSerie" => "Enferm Infecc Microbiol Clin"
                        "fecha" => "2011"
                        "volumen" => "29"
                        "paginaInicial" => "250"
                        "paginaFinal" => "256"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21342730"
                            "web" => "Medline"
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                0 => array:2 [
                  "contribucion" => array:1 [
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                      "titulo" => "Decline in invasive pneumococcal disease after the introduction of protein-polysaccharide conjugate vaccine"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "C&#46;G&#46; Whitney"
                            1 => "M&#46;M&#46; Farley"
                            2 => "J&#46; Hadler"
                            3 => "L&#46;H&#46; Harrison"
                            4 => "N&#46;M&#46; Bennet"
                            5 => "R&#46; Lynfield"
                          ]
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                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "N Engl Med"
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                        "paginaInicial" => "1737"
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              "etiqueta" => "9"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Epidemiology of invasive pneumococcal disease among adult patients in Barcelona before and after pediatric 7-valent pneumococcal conjugate vaccine introduction&#44; 1997&#8211;2007"
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                        0 => array:2 [
                          "etal" => false
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                            0 => "C&#46; Ardanuy"
                            1 => "F&#46; Tubau"
                            2 => "R&#46; Pallares"
                            3 => "L&#46; Calataud"
                            4 => "M&#46;A&#46; Dom&#237;nguez"
                            5 => "D&#46; ET-AL&#62; Rolo"
                          ]
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                      ]
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                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1086/594125"
                      "Revista" => array:6 [
                        "tituloSerie" => "Clin Infect Dis"
                        "fecha" => "2009"
                        "volumen" => "48"
                        "paginaInicial" => "57"
                        "paginaFinal" => "64"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19035779"
                            "web" => "Medline"
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            9 => array:3 [
              "identificador" => "bib0050"
              "etiqueta" => "10"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Effect of the seven-valent conjugate pneumococcal vaccine on carriage and drug resistance of <span class="elsevierStyleItalic">Streptococcus pneumoniae</span> in healthy children attending day-care centers in Lisbon"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "N&#46; Frazao"
                            1 => "A&#46; Brito-Avo"
                            2 => "C&#46; Simas"
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Original article
Pneumococcal infections in oncohematological patients after the introduction of conjugate vaccine
Infección neumocócica en pacientes oncohematológicos tras la introducción de la vacuna conjugada
M. Pérez de la Blanca-Burgosa,
Corresponding author
mariaperezdela@hotmail.com

Corresponding author.
, A. Villoslada-Gelaberta, M. Garau-Colomb, A. González-Michelouda, M.C. Gallegos-Álvarezb, A. Payeras-Cifrea
a Servicio de Medicina Interna, Hospital Son Llátzer, Palma de Mallorca, Spain
b Servicio de Microbiología, Hospital Son Llátzer, Palma de Mallorca, Spain

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