Beta-lactamic antibiotics allergy in cataract surgery. Prevalence and preoperative characteristics of allergic patients | Archivos de la Sociedad Española de Oftalmología (English Edition)

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with the result that only 0&#46;05&#37; turned out to be allergic&#46; This result matched the description of the smaller proportion of allergies for this antibiotic and with low rates of crossed allergy reactions of cefuroxime with other &#946;-lactamic antibiotics&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#8211;20</span></a> However&#44; a very severe anaphylactic reaction was described in 2003 after intracameral injection of 1<span class="elsevierStyleHsp" style=""></span>mg cefuroxime at the end of the cataract surgery in a patient who was allergic to ampicillin&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> A subsequent study on the Spanish population<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> described that 15&#37; of patients operated for cataracts who were allergic to &#946;-lactamic antibiotics were also allergic to cefuroxime&#46; However&#44; the prevalence of allergy to cefuroxime or other &#946;-lactamic was not provided&#46; Recently&#44; another case of severe anaphylaxis after intracameral cefuroxime prophylaxis was described in a patient allergic to &#946;-lactamics but not to cefuroxime&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Even though there are very few publications reporting anaphylaxis due to intracameral cefuroxime&#44; the recommendation of the <span class="elsevierStyleItalic">European Society of Cataracts and Refractive Surgeons</span> &#40;ESCRS&#41; to avoid said prophylaxis for patients who are allergic to &#946;-lactamic being intervened for cataracts<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> seems convenient&#46; The prevalence of said allergy in the cataract surgery population is highly variable &#40;from 0&#46;0 5 to 16&#37;&#41; in the small number of analyzed studies<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;13&#44;14</span></a> probably due to the availability and use of antibiotics in different countries&#46; In the geographical area of the authors this prevalence is unknown&#46; For this reason&#44; the objective of this study is to determine the proportion of patients who are allergic to &#946;-lactamic antibiotics in our health region and the prevalence of conjunctival bacteria of said patients in order to assess the adequacy of alternative treatments for intracameral cefuroxime&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Subjects&#44; materials and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Study design</span><p id="par0015" class="elsevierStylePara elsevierViewall">A transversal retrospective study which included all the patients admitted consecutively to cataract surgery from July 11&#44; 2005 to November 13&#44; 2012&#46; Said patients underwent pre-surgery assessments comprising basic blood analysis and chest X-ray and&#44; between one and 3 weeks prior to surgery and in coincident dates&#44; microbiological analysis of conjunctival bacteria was carried out together with assessment for anesthesia&#46; Said assessments included a number of predetermined questions on the diseases the patient had been diagnosed with&#44; the medication taken during that period and any known allergies&#46; The only allergies to &#946;-lactamic taken into account were documented or where the patient described highly suggestive reactions&#46; All the data were systematically recorded in Access Microsoft Office 2003 database together with demographic data&#44; clinical history code&#44; indicated surgery type&#44; assessment dates&#44; results of analytical tests and anomalies observed in the chest X-ray&#46; The criteria for defining comorbidity are described in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; Identified bacteria were recorded together with the patient history code and the sample dates in the lab database which was retrospectively exported to Microsoft Office 2003 Access database &#40;Microsoft<span class="elsevierStyleSup">&#174;</span>&#44; Redmond&#44; WA&#44; USA&#41;&#46; The 2 resulting databases were linked around patient history code&#46; Any discrepancy in the records was reviewed by the computerized system of visits&#44; hospitalizations and surgical procedures of the hospital and the review of clinical histories when necessary&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The microbiological study excluded records corresponding to surgeries other than cataracts in the first eye &#40;to identify possible surgeries of a patient after the cataract surgery in the first 6 months of the study&#44; the anesthesia assessment date was used for the 6 months prior to beginning the study&#44; as the culture is made for all cataract surgery patients but the assessment for anesthesia is not&#41;&#46; The microbiological study also excluded patients who underwent cataract surgery in combination with other ocular surgeries as well as patients under 18 years of age due to the difficulty in obtaining samples for culturing under the same baseline conditions as adult cataract surgery on its own&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The publication of this study&#44; which was carried out in accordance with the Helsinki declaration&#44; was accepted by the ethic committee on clinical research of our hospital&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Microbiological method</span><p id="par0030" class="elsevierStylePara elsevierViewall">Samples were taken with three 1<span class="elsevierStyleHsp" style=""></span>&#956;l plastic totes&#44; extending their contents directly on each one of the 3 utilized culturing media as described above&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> Blood and MacConkey agar were incubated in aerobiosis and agar-chocolate with 6&#37; CO<span class="elsevierStyleInf">2</span>&#44; all at 36<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1<span class="elsevierStyleHsp" style=""></span>&#176;<span class="elsevierStyleSmallCaps">C</span>&#46; A first reading of the plates was made at 48<span class="elsevierStyleHsp" style=""></span>hours of incubation&#44; re-incubating agar chocolate 5 more days with 6&#37; CO<span class="elsevierStyleInf">2</span> to isolate slow growing microaerophilic bacteria&#46; All isolations of mannitol-positive <span class="elsevierStyleItalic">Staphylococci</span>&#44; as well as mannitol-negative isolated in quantities exceeding 5 colony-forming units &#40;CFU&#41; per &#956;l&#44; and <span class="elsevierStyleItalic">Enterococci</span> were identified with PC23 or PC 22 panels or with mannitol&#44; coagulase and bile-esculin&#59; fast-growing gram-negative bacilli which were not demanding were identified with PC37 or PC38 panels or with API-20E and API-20NE galleries&#59; and gram-negative <span class="elsevierStyleItalic">Haemophilus</span> and <span class="elsevierStyleItalic">Diplococci</span> were identified with HNID panels&#46; The panels were read in the AutoScan4 analyzer by Dade-Behring &#40;later on&#44; Siemens Healthcare&#41;&#44; as well as the panels&#46; The <span class="elsevierStyleItalic">Streptococci</span> isolations were identified by their hemolysis production and sensitivity to optochin&#46; The remaining bacteria were identified by colony morphology&#44; growth characteristics and gram staining&#46; All the bacteria were grouped to obtain sample sizes enabling statistical comparison&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Statistical method</span><p id="par0035" class="elsevierStylePara elsevierViewall">The Access database tools were utilized for selecting the patient groups and for calculating the mean age of each&#46; Said tools were also used to select bacterian classes&#46; The Epidat version 3&#46;1 statistical software &#40;produced by the <span class="elsevierStyleItalic">PanAmerican Health Organization</span>&#44; Washington&#44; DC&#44; USA and the Health Bureau of the Galicia Autonomic government&#44; A Coru&#241;a&#44; Spain&#59; <a id="intr0010" class="elsevierStyleInterRef" href="http://dxsp.sergas.is/">http&#58;&#47;&#47;dxsp&#46;sergas&#46;is</a>&#41; was utilized for calculating the confidence interval of percentages of the studied clinical characteristics and the classes of defined bacteria&#46; The mean age of allergic and non-allergic patients was compared&#44; as well as the prevalence of the clinical characteristics and of each bacteria class in both groups&#46; In addition&#44; the odds ratio of each bacteria class was calculated between the 2 groups of patients&#46; Values of <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05 were taken to be statistically significant&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Results</span><p id="par0040" class="elsevierStylePara elsevierViewall">The prevalence of allergy to &#946;-lactamic antibiotics in 28 patients under 18 operated on cataracts was of 0&#37;&#44; while for patients over 17 it amounted to 6&#46;01&#37; in 582 patients with surgery cataracts combined with vitrectomy or trabeculectomy&#46; Finally&#44; said prevalence was of 6&#46;96&#37; in 12&#44;409 patients with uncombined surgery &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">As shown in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#44; in the group of 12&#44;409 adults with uncombined surgery the mean age of 862 allergic patients &#40;74&#46;45<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8&#46;87 years&#41; was statistically higher &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;005&#41; compared to non-allergic patients &#40;73&#46;56<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>9&#46;29 years&#41;&#46; The proportion of allergic females &#40;71&#46;4&#37;&#41; was considerably higher than allergic males &#40;28&#46;7&#37;&#41;&#46; Obstructive pulmonary diseases were statistically higher and cardiac insufficiency cases were more prevalent in the group of patients who were allergic to &#946;-lactamic antibiotics&#46; Overall&#44; 1&#46;93&#37; of all selected patients were not aware of the medication they were taking and were accounted as not taking any medication&#44; and this could have an impact on the incidence of diseases diagnosed by the medication&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a> shows the prevalence of bacteria groups defined in allergic and non-allergic patients as well as a prevalence comparison of each bacteria group and the odds ratio calculation&#44; which exceeded 1 in the more pathogenic bacteria groups&#46; The isolation of non-fermenting gram-negative bacilli &#40;NFGNB&#41;&#44; which were more prevalent in patients allergic to &#946;-lactamic antibiotics&#44; is shown in <a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>&#46; A higher prevalence of <span class="elsevierStyleItalic">Pseudomonas aeruginosa</span> amongst allergic patients is a significant finding&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><elsevierMultimedia ident="tbl0025"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Discussion</span><p id="par0055" class="elsevierStylePara elsevierViewall">Up to 2006&#44; allergy to &#946;-lactamic antibiotics was the most prevalent of all drug allergies&#44;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25&#44;26</span></a> with a prevalence estimated between 5&#37; and 10&#37; of the population&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> However&#44; the same authors<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> observed that 2&#47;3 of the patients labeled as allergic to &#946;-lactamic who referred a vague history of symptoms gave negative results for that allergy&#46; This study describes for the first time the prevalence of allergies to these antibiotics among patients operated for cataracts in our geography &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; The results of this study&#44; i&#46;e&#46;&#44; 6&#46;96&#37; of adult intervened in a single cataract operation&#44; is comprised between the above-mentioned range&#46; The prevalence of allergies was not assessed in patients less than 18 years of age due to the small size of the sample or in patients operated in combined surgeries due to their being a diverse and biased population&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The epidemiological study on the prevalence of allergies to medications in Spain&#44; <span class="elsevierStyleItalic">Alergol&#243;gica</span>-<span class="elsevierStyleItalic">2005</span>&#44;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> emphasizes the fact that only 2&#37; of the patients diagnosed with allergy to &#946;-lactamic &#40;47&#37; of all allergies to drugs&#41; were due to cephalosporins&#46; This finding is of interest to determine whether this proportion changes with the increased use of these antibiotics&#46; In fact&#44; it has been determined that the use of second-generation cephalosporins increased 20&#37; in Europe from 1997 to 2009&#44; particularly at the expense of cefuroxime&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> Said increased use could involve an increase of cefuroxime allergies due to radical R<span class="elsevierStyleInf">1</span> &#40;uncommon with the majority of &#946;-lactamic antibiotics&#41; and not attributable to the lactamic ring&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#8211;20</span></a> In this regard it must be noted that the proportion of cefuroxime allergies within the group of &#946;-lactamic allergic patients who were operated for cataracts in our environment<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> was of 15&#37; in the period comprised between September 2007 and September 2008&#46; This difference with the 2&#37; reported in the <span class="elsevierStyleItalic">Alergol&#243;gica-2005</span> study could be explained due to the increased use of cefuroxime in the years elapsed between both studies&#44; in addition to the higher mean age &#40;74&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8&#46;87 years&#41; and proportion of female patients &#40;71&#46;4&#37;&#41; in our study &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41; vis-&#224;-vis the <span class="elsevierStyleItalic">Alergol&#243;gica-2005</span> study &#40;62&#37; of female patients and a mean age of 41&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>19&#46;4 years&#41;&#46; The higher prevalence of obstructive pulmonary diseases in our group of allergic patients &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41; could be related to the predominance of female patients and those with asthma&#46; The association of ASP that met with female patients has been evidenced in several studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">29&#8211;31</span></a> It should also be noticed that the prevalence of smokers in the group of allergic patients is lower than in the non-allergic group&#46; The predominance of non-smokers among asthmatics is observed in one of the cited epidemiological studies&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> However&#44; in recent decades chronic obstructive pulmonary disease has been associated to tobacco smoking&#44;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> which in turn predominated in men&#46; In some studies it is accepted that the allergic reaction in asthma patients is expressed with extremely severe clinical forms&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;33</span></a> Accordingly&#44; the presence of asthmatics amongst &#946;-lactamic allergy patients could constitute an alert for a potential predisposition to severe allergic reactions&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">The number of adults &#40;12&#44;409&#41; operated for cataracts in the first eye with uncombined surgery has allowed the authors to compare the prevalence of conjunctival bacteria in the &#946;-lactamic allergy and non-allergy groups &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46; The authors have not found similar studies&#44; but lower prevalence of the normal conjunctival flora &#40;staphylococci coagulase negative&#44; <span class="elsevierStyleItalic">Corynebacterium xerosis</span> and <span class="elsevierStyleItalic">Propionibacterium</span> spp&#46;&#41; in allergic patients is a noteworthy finding and matches the lower prevalence of these bacteria in female patients&#44; as reported in previous studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">34&#44;35</span></a> However&#44; conjunctival flora associated to a higher pathogenic power in post-surgery infections<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">36&#44;37</span></a> &#40;<span class="elsevierStyleItalic">Bacillus</span> spp&#46;&#44; <span class="elsevierStyleItalic">Enterococcus</span> spp&#46;&#44; <span class="elsevierStyleItalic">Staphylococcus aureus</span>&#44; <span class="elsevierStyleItalic">Streptococcus pneumoniae</span> and gram-negative bacilli&#41; was more prevalent in allergic patients&#44; particularly for <span class="elsevierStyleItalic">Bacillus</span> spp&#46; and the NFGNB category &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46; Within this bacteria category it is important to emphasize the prevalence of <span class="elsevierStyleItalic">Pseudomonas aeruginosa</span> in allergic patients &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>&#41;&#46; The greater presence of these bacterium could be attributed to the higher proportion of obstructive pulmonary diseases in said patients&#44; who frequently require anti-infectious and immuno-suppressant treatment&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Taking into account the bacterian pattern of allergic patients &#40;<a class="elsevierStyleCrossRefs" href="#tbl0020">Tables 4 and 5</a>&#41;&#44; the risk of intraocular contamination with highly pathogenic bacteria during cataract surgery is higher than in the nonallergic group&#46; Due to antibiotic resistance observed in the conjunctival bacteria of our patients&#44;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a> it can be assumed that intracameral vancomycin &#40;used as an alternative to intracameral cefuroxime&#41; used for prophylactic purposes in cataract surgery has the added advantage of preventing the devastating post-surgery infection caused by <span class="elsevierStyleItalic">Enterococci</span>&#44; but also adds the disadvantage of diminishing protection against gram-negative bacilli&#44; which are more prevalent in &#946;-lactamic allergic patients&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">The possible limitations of this study are due to its retrospective design&#46; However&#44; this limitation is diminished in our hospital due to the peculiarity of concentrating programmed cataract surgery in a differentiated hospital&#44; thus facilitating the recording and retrieval of patient data&#46; Other limitations derived from the retrospective nature of the study include the inability to differentiate asthma cases from other obstructive diseases or the possible existence of undiagnosed diseases unknown by patients&#46; On the other hand&#44; the effect of accounting patients with a history highly suggestive of allergy of &#946;-lactamic in the group of allergics in addition to those who have said allergy documented could be inexact&#46; However&#44; it seems usual practice to take the decision to administer intracameral cefuroxime at the end of cataract surgery on the basis of the allergic reaction described by the patient&#44; documented or not&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">To conclude&#44; patients who are allergic to &#946;-lactamic antibiotics exhibit a characteristic clinical profile within the population who undergoes cataract surgery in our health region&#44; with asthma being a disease to be taken into account in surgery prophylaxis&#46; The prevalence of gram-negative bacteria in the conjunctival flora of these allergic patients justifies the search for alternative or supplementary prophylactic treatments for intracameral vancomycin&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conflict of interests</span><p id="par0085" class="elsevierStylePara elsevierViewall">No conflict of interests has been declared by the authors&#46;</p></span></span>"
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          "clase" => "keyword"
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            0 => "Beta-lactams allergy"
            1 => "Allergy prevalence"
            2 => "Cefuroxime allergy"
            3 => "Cataract surgery"
            4 => "Surgery prophylaxis"
            5 => "Intracameral prophylaxis"
            6 => "Asthma prevalence"
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            0 => "Alergia a &#946;-lact&#225;micos"
            1 => "Prevalencia de alergia"
            2 => "Alergia a cefuroxima"
            3 => "Cirug&#237;a de cataratas"
            4 => "Profilaxis quir&#250;rgica"
            5 => "Profilaxis intracameral"
            6 => "Prevalencia del asma"
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        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To describe the proportion of patients allergic to &#946;-lactam antibiotics and the prevalence of preoperative conjunctival bacteria among those undergoing cataract surgery in our area&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0015">Method</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Retrospective cross-sectional study of prevalence of &#946;-lactam allergic patients consecutively scheduled for cataract surgery from 11 July 2005 to November 2012&#46; For studying the prevalence of conjunctival bacteria and clinical characteristics in the patients&#8217; preoperative examination&#44; those under 18 years and those with cataract surgery combined with other eye surgeries were excluded&#46; Data from the first preoperative examination of the remaining patients were selected&#46; Clinical data were extracted from the database generated in the evaluation made for anesthetic purposes&#44; and the microbiological data from the laboratory database&#46; Both bases were linked through a patient history code&#46; A comparison was made between the prevalence of conjunctival bacteria and clinical characteristics in allergic and non-allergic patients&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">From 12&#44;409 adults selected for the bacteriological study&#44; 862 &#40;6&#46;96&#37;&#41; were allergic to &#946;-lactams&#59; their mean age &#40;74&#46;45 years&#41; was higher than those who were non-allergic &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;005&#41;&#46; The proportion of women &#40;71&#46;4&#37;&#41; in the allergic patient group was much higher than that of men&#46; The prevalence of pathogenic bacteria &#40;especially <span class="elsevierStyleItalic">Bacillus</span> spp and <span class="elsevierStyleItalic">Pseudomonas aeruginosa</span>&#41;&#44; lung disease and heart failure&#44; was higher in allergic patients&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The prevalence of allergy to &#946;-lactams in this study is within the range described in other populations&#46; The higher prevalence of pathogenic bacteria and the predominance of women in those allergic to &#946;-lactams are useful data to guide their surgical prophylaxis&#46;</p>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Describir la proporci&#243;n de pacientes al&#233;rgicos a antibi&#243;ticos &#946;-lact&#225;micos y su flora conjuntival entre los admitidos a cirug&#237;a de cataratas en nuestro entorno&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todo</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio retrospectivo transversal de prevalencia de pacientes al&#233;rgicos a &#946;-lact&#225;micos admitidos consecutivamente a cirug&#237;a de cataratas del 11 de julio de 2005 al 13 de noviembre de 2012&#46; Para estudiar la prevalencia de bacterias conjuntivales y de carac-ter&#237;sticas cl&#237;nicas en el examen preoperatorio de los pacientes se excluyeron los menores de 18 a&#241;os y aquellos con operaciones de cataratas combinadas con otras cirug&#237;as ocula res&#44; seleccionando los datos del primer preoperatorio de los pacientes restantes&#46; Los datos cl&#237;nicos se extrajeron de la base de datos generada en la consulta de evaluaci&#243;n para anes tesia&#44; y los microbiol&#243;gicos de la base de datos del laboratorio&#46; Ambas bases se vincularon mediante el c&#243;digo de historia cl&#237;nica&#46; Se compar&#243; la prevalencia de bacterias conjuntivales y de caracter&#237;sticas cl&#237;nicas entre al&#233;rgicos y no-al&#233;rgicos&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">De 12&#46;409 adultos seleccionados para estudio bacteriano&#44; 862 &#40;6&#44;96&#37;&#41; eran al&#233;r gicos a &#946;-lact&#225;micos&#44; su edad media era de 74&#44;45 a&#241;os&#44; superior a la de los no-al&#233;rgicos &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;005&#41;&#46; En los al&#233;rgicos la proporci&#243;n de mujeres &#40;71&#44;4&#37;&#41; fue muy superior a la de hom bres&#46; La prevalencia de bacterias pat&#243;genas &#40;especialmente <span class="elsevierStyleItalic">Bacillus</span> spp&#46; y <span class="elsevierStyleItalic">Pseudomonas aeruginosa</span>&#41;&#44; enfermedades pulmonares e insuficiencia cardiaca fue mayor en los al&#233;rgicos&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La prevalencia de al&#233;rgicos a &#946;-lact&#225;micos de este estudio est&#225; comprendida en el rango descrito en otras poblaciones&#46; La mayor prevalencia de bacterias pat&#243;genas y el predominio de mujeres en los al&#233;rgicos a &#946;-lact&#225;micos son datos &#250;tiles para pautar su profilaxis quir&#250;rgica&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Please cite this article as&#58; Fern&#225;ndez-Rubio ME&#44; Cuesta-Rodr&#237;guez T&#44; Urcelay-Segura JL&#44; Cort&#233;s-Vald&#233;s C&#46; Alergia a antibi&#243;ticos &#946;-lact&#225;micos en cirug&#237;a de cataratas&#46; Prevalencia y caracter&#237;sticas preoperatorias de los pacientes al&#233;rgicos&#46; Arch Soc Esp Oftalmol&#46; 2014&#59;89&#58;92&#8211;98&#46;</p>"
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          "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">COPD&#44; chronic obstructive pulmonary disease&#46;</p>"
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                  \t\t\t\t">Allergy to &#946;-lactamic antibiotics&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Patients with documented allergy to any &#946;-lactamic antibiotic&#44; or when the description of the allergy episode in reaction to any of said antibiotics is highly suggestive of a significant reaction&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Diabetes&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">Patients who reported being diagnosed and&#47;or administered hypoglycemia drugs and&#47;or those who in fasting exhibited a glucose level in blood of 126<span class="elsevierStyleHsp" style=""></span>mg&#47;dl or more&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">Obstructive pulmonary 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">Patients diagnosed with asthma and&#47;or COPD&#44; and&#47;or used inhalers&#44; required oxygen supply&#44; were taking specific medication for asthma on demand and&#47;or exhibited atypical COPD in chest X-ray&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">Smokers and former smokers&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">Classified according to patient information&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">Kidney insufficiency&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">Patients who reported being diagnosed and&#47;or exhibited a creatinine level in blood of 1&#46;2<span class="elsevierStyleHsp" style=""></span>mg&#47;dl or more&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">Ischemic cardiopathies&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">Patients who reported some type of cardiopathy or previous surgical treatment&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">Cardiac insufficiency&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">Patients who reported some degree of said deficiency and were assessed by an internist physician&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Data used for defining patient comorbidity&#46;</p>"
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              "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">Age&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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Under 18 years&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  " colspan="2" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">From 18 to 98 years</td></tr><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">Surgery type&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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Various<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-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Cataract of first eye not combined with other ocular surgery&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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Cataract surgery combined with vitrectomy or trabeculectomy&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">Number of patients&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">28&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&#44;049&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">582&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">Number of allergics&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&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">862&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">35&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">&#37; of allergics&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&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&#46;96&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&#46;01&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \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">Mean age&#44; in years&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;89&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">73&#46;62&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">72&#46;60&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Standard deviation&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">4&#46;63&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;26&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&#46;25&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">&#37; of males&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">60&#46;71&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">43&#46;20&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">44&#46;33&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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            0 => array:3 [
              "identificador" => "tblfn0005"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Congenital cataract&#44; traumatic&#44; combined with other ocular surgeries and relocation of intraocular lens&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Prevalence of allergy to &#946;-lactamics in patients operated on for cataracts&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">CI&#44; confidence interval&#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">Clinical characteristics&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  " colspan="3" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">All patients</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="2" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Allergic</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="2" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Nonallergic</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Comparison&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-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">Number of patients&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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">12&#46;409&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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">CI of &#37; &#40;95&#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-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">862&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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&#37;&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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">11&#46;547&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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&#37;&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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span> &#40;95&#37;&#41;&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">Mean 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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">73&#46;624&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">74&#46;454&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">73&#46;562&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;005&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">Standard deviation of 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="char" valign="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Males&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">43&#46;24&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">&#40;42&#46;36&#8211;44&#46;11&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">247&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">28&#46;65&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">5&#46;118&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">44&#46;32&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">&#60;0&#46;001&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">Females&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">7&#46;044&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">56&#46;77&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">&#40;55&#46;89&#8211;57&#46;64&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">615&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">71&#46;35&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&#46;429&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">55&#46;68&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">&#60;0&#46;001&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;158&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">25&#46;45&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">&#40;24&#46;68&#8211;26&#46;22&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">209&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">24&#46;25&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&#46;949&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">25&#46;54&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;424&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">Pulmonary diseases&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;797&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14&#46;48&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">&#40;13&#46;86&#8211;15&#46;11&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">174&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">20&#46;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="char" valign="\n
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                  \t\t\t\t">1&#46;623&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">14&#46;06&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">&#60;0&#46;001&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">Smokers<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>exsmokers&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">3&#46;035&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">24&#46;46&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">&#40;23&#46;70&#8211;25&#46;22&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">173&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">20&#46;07&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&#46;862&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">24&#46;79&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;002&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">Kidney insufficiency&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;044&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&#46;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">&#40;7&#46;92&#8211;8&#46;91&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">69&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&#46;00&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">975&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&#46;44&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;701&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">Cardiopathies&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;657&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">13&#46;35&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">&#40;12&#46;75&#8211;13&#46;96&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">112&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&#46;99&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;544&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">13&#46;37&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;792&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">Cardiac insufficiency&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><span class="elsevierStyleItalic">Streptococcus pneumoniae</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Other <span class="elsevierStyleItalic">Streptococcus</span> spp&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Diplococci</span> gram negativos&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#40;1&#46;06&#8211;1&#46;56&#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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                  """
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