Recurrent invasive pneumococcal disease (RIPD) in an immunocompromised patient

Torres Jiménez, Ivonne Andrea; de Miguel García, Sara; Sempere García, Julio; Sanz Moreno, Juan Carlos
doi:10.1016/j.eimce.2024.06.008
 array:23 [
  "pii" => "S2529993X24002272"
  "issn" => "2529993X"
  "doi" => "10.1016/j.eimce.2024.06.008"
  "estado" => "S300"
  "fechaPublicacion" => "2024-11-01"
  "aid" => "2842"
  "copyright" => "Sociedad Espa&#241;ola de Enfermedades Infecciosas y Microbiolog&#237;a Cl&#237;nica"
  "copyrightAnyo" => "2024"
  "documento" => "simple-article"
  "crossmark" => 1
  "subdocumento" => "crp"
  "cita" => "Enferm Infecc Microbiol Clin. 2024;42:533-5"
  "abierto" => array:3 [
    "ES" => false
    "ES2" => false
    "LATM" => false
  ]
  "gratuito" => false
  "lecturas" => array:1 [
    "total" => 0
  ]
  "itemSiguiente" => array:19 [
    "pii" => "S2529993X24001795"
    "issn" => "2529993X"
    "doi" => "10.1016/j.eimce.2024.07.003"
    "estado" => "S300"
    "fechaPublicacion" => "2024-11-01"
    "aid" => "2843"
    "copyright" => "Sociedad Espa&#241;ola de Enfermedades Infecciosas y Microbiolog&#237;a Cl&#237;nica"
    "documento" => "simple-article"
    "crossmark" => 1
    "subdocumento" => "crp"
    "cita" => "Enferm Infecc Microbiol Clin. 2024;42:535-6"
    "abierto" => array:3 [
      "ES" => false
      "ES2" => false
      "LATM" => false
    ]
    "gratuito" => false
    "lecturas" => array:1 [
      "total" => 0
    ]
    "en" => array:10 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">Scientific letter</span>"
      "titulo" => "Oral intolerance&#58; new scenario for parenteral antiretroviral therapy"
      "tienePdf" => "en"
      "tieneTextoCompleto" => "en"
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "535"
          "paginaFinal" => "536"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "es" => array:1 [
          "titulo" => "Intolerancia a v&#237;a oral&#58; nuevo escenario para la terapia antirretroviral parenteral"
        ]
      ]
      "contieneTextoCompleto" => array:1 [
        "en" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "Sergio Ferra Murcia, Ana Bel&#233;n Lozano Serrano, Marta Segura D&#237;az, Antonio Ram&#243;n Collado Romacho"
          "autores" => array:4 [
            0 => array:2 [
              "nombre" => "Sergio"
              "apellidos" => "Ferra Murcia"
            ]
            1 => array:2 [
              "nombre" => "Ana Bel&#233;n"
              "apellidos" => "Lozano Serrano"
            ]
            2 => array:2 [
              "nombre" => "Marta"
              "apellidos" => "Segura D&#237;az"
            ]
            3 => array:2 [
              "nombre" => "Antonio Ram&#243;n"
              "apellidos" => "Collado Romacho"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "Traduccion" => array:1 [
      "es" => array:9 [
        "pii" => "S0213005X24002635"
        "doi" => "10.1016/j.eimc.2024.06.005"
        "estado" => "S200"
        "subdocumento" => ""
        "abierto" => array:3 [
          "ES" => false
          "ES2" => false
          "LATM" => false
        ]
        "gratuito" => false
        "lecturas" => array:1 [
          "total" => 0
        ]
        "idiomaDefecto" => "es"
        "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0213005X24002635?idApp=UINPBA00004N"
      ]
    ]
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2529993X24001795?idApp=UINPBA00004N"
    "url" => "/2529993X/0000004200000009/v1_202411050502/S2529993X24001795/v1_202411050502/en/main.assets"
  ]
  "itemAnterior" => array:19 [
    "pii" => "S2529993X24002223"
    "issn" => "2529993X"
    "doi" => "10.1016/j.eimce.2024.05.012"
    "estado" => "S300"
    "fechaPublicacion" => "2024-11-01"
    "aid" => "2835"
    "copyright" => "Sociedad Espa&#241;ola de Enfermedades Infecciosas y Microbiolog&#237;a Cl&#237;nica"
    "documento" => "article"
    "crossmark" => 1
    "subdocumento" => "crp"
    "cita" => "Enferm Infecc Microbiol Clin. 2024;42:531-2"
    "abierto" => array:3 [
      "ES" => false
      "ES2" => false
      "LATM" => false
    ]
    "gratuito" => false
    "lecturas" => array:1 [
      "total" => 0
    ]
    "en" => array:11 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">Scientific letter</span>"
      "titulo" => "Bacteremia due to <span class="elsevierStyleItalic">Desulfovibrio porci</span>&#46; Novel anaerobic pathogen associated with infectious enterocolitis"
      "tienePdf" => "en"
      "tieneTextoCompleto" => "en"
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "531"
          "paginaFinal" => "532"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "es" => array:1 [
          "titulo" => "Bacteriemia por <span class="elsevierStyleItalic">Desulfovibrio porci</span>&#46; Nuevo pat&#243;geno anaerobio asociado a enterocolitis infecciosa"
        ]
      ]
      "contieneTextoCompleto" => array:1 [
        "en" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "resumenGrafico" => array:2 [
        "original" => 0
        "multimedia" => array:8 [
          "identificador" => "fig0005"
          "etiqueta" => "Fig&#46; 1"
          "tipo" => "MULTIMEDIAFIGURA"
          "mostrarFloat" => true
          "mostrarDisplay" => false
          "figura" => array:1 [
            0 => array:4 [
              "imagen" => "gr1.jpeg"
              "Alto" => 1179
              "Ancho" => 1967
              "Tamanyo" => 125022
            ]
          ]
          "detalles" => array:1 [
            0 => array:3 [
              "identificador" => "at0005"
              "detalle" => "Fig&#46; "
              "rol" => "short"
            ]
          ]
          "descripcion" => array:1 [
            "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Phylogenetic tree made with the 16S rRNA sequences &#40;1245&#8239;bp&#41; of the strains CNM20220034 &#40;case 1&#41; and CNM20231004 &#40;case 2&#41; and with respect to the type strains of the different related species of the genus <span class="elsevierStyleItalic">Desulfovibrio</span> &#40;MEGA7&#44; method Maximum Likelihood based on the Tamura-Nei model&#44; 1000 replicates&#44; branch length calculated based on the number of substitutions per position&#41;&#46; The numbers on the branches indicate the frequency of grouping of the taxa&#46;</p>"
          ]
        ]
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "Jos&#233; Mar&#237;a Saavedra Mart&#237;n, Mar&#237;a Jos&#233; Medina Pascual, Sylvia Valdezate Ramos, Francisco Franco &#193;lvarez de Luna"
          "autores" => array:4 [
            0 => array:2 [
              "nombre" => "Jos&#233; Mar&#237;a"
              "apellidos" => "Saavedra Mart&#237;n"
            ]
            1 => array:2 [
              "nombre" => "Mar&#237;a Jos&#233;"
              "apellidos" => "Medina Pascual"
            ]
            2 => array:2 [
              "nombre" => "Sylvia"
              "apellidos" => "Valdezate Ramos"
            ]
            3 => array:2 [
              "nombre" => "Francisco"
              "apellidos" => "Franco &#193;lvarez de Luna"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "Traduccion" => array:1 [
      "es" => array:9 [
        "pii" => "S0213005X24002507"
        "doi" => "10.1016/j.eimc.2024.05.004"
        "estado" => "S200"
        "subdocumento" => ""
        "abierto" => array:3 [
          "ES" => false
          "ES2" => false
          "LATM" => false
        ]
        "gratuito" => false
        "lecturas" => array:1 [
          "total" => 0
        ]
        "idiomaDefecto" => "es"
        "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0213005X24002507?idApp=UINPBA00004N"
      ]
    ]
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2529993X24002223?idApp=UINPBA00004N"
    "url" => "/2529993X/0000004200000009/v1_202411050502/S2529993X24002223/v1_202411050502/en/main.assets"
  ]
  "en" => array:13 [
    "idiomaDefecto" => true
    "cabecera" => "<span class="elsevierStyleTextfn">Scientific letter</span>"
    "titulo" => "Recurrent invasive pneumococcal disease &#40;RIPD&#41; in an immunocompromised patient"
    "tieneTextoCompleto" => true
    "saludo" => "Dear Editor&#44;"
    "paginas" => array:1 [
      0 => array:2 [
        "paginaInicial" => "533"
        "paginaFinal" => "535"
      ]
    ]
    "autores" => array:1 [
      0 => array:4 [
        "autoresLista" => "Ivonne Andrea Torres Jim&#233;nez, Sara de Miguel Garc&#237;a, Julio Sempere Garc&#237;a, Juan Carlos Sanz Moreno"
        "autores" => array:4 [
          0 => array:3 [
            "nombre" => "Ivonne Andrea"
            "apellidos" => "Torres Jim&#233;nez"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "aff0005"
              ]
            ]
          ]
          1 => array:4 [
            "nombre" => "Sara"
            "apellidos" => "de Miguel Garc&#237;a"
            "email" => array:1 [
              0 => "sarade.miguel@salud.madrid.org"
            ]
            "referencia" => array:3 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "aff0005"
              ]
              1 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">b</span>"
                "identificador" => "aff0010"
              ]
              2 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">&#42;</span>"
                "identificador" => "cor0005"
              ]
            ]
          ]
          2 => array:3 [
            "nombre" => "Julio"
            "apellidos" => "Sempere Garc&#237;a"
            "referencia" => array:2 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">b</span>"
                "identificador" => "aff0010"
              ]
              1 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">c</span>"
                "identificador" => "aff0015"
              ]
            ]
          ]
          3 => array:3 [
            "nombre" => "Juan Carlos"
            "apellidos" => "Sanz Moreno"
            "referencia" => array:2 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">d</span>"
                "identificador" => "aff0020"
              ]
              1 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">e</span>"
                "identificador" => "aff0025"
              ]
            ]
          ]
        ]
        "afiliaciones" => array:5 [
          0 => array:3 [
            "entidad" => "Department of Preventive Medicine&#44; University Hospital 12 de Octubre&#44; Madrid&#44; Spain"
            "etiqueta" => "a"
            "identificador" => "aff0005"
          ]
          1 => array:3 [
            "entidad" => "CIBER de Enfermedades Respiratorias &#40;CIBERES&#41;&#44; Instituto de Salud Carlos III&#44; Madrid&#44; Spain"
            "etiqueta" => "b"
            "identificador" => "aff0010"
          ]
          2 => array:3 [
            "entidad" => "Spanish Pneumococcal Reference Laboratory&#44; National Centre for Microbiology&#44; Instituto de Salud Carlos III&#44; Madrid&#44; Spain"
            "etiqueta" => "c"
            "identificador" => "aff0015"
          ]
          3 => array:3 [
            "entidad" => "Clinical Microbiology Unit&#44; Public Health Regional Laboratory of the Community of Madrid&#44; Directorate General of Public Health&#44; Madrid&#44; Spain"
            "etiqueta" => "d"
            "identificador" => "aff0020"
          ]
          4 => array:3 [
            "entidad" => "CIBER de Epidemiolog&#237;a y Salud P&#250;blica&#44; ISCIII&#44; Spain"
            "etiqueta" => "e"
            "identificador" => "aff0025"
          ]
        ]
        "correspondencia" => array:1 [
          0 => array:3 [
            "identificador" => "cor0005"
            "etiqueta" => "&#8270;"
            "correspondencia" => "Corresponding author&#46;"
          ]
        ]
      ]
    ]
    "titulosAlternativos" => array:1 [
      "es" => array:1 [
        "titulo" => "Enfermedad neumoc&#243;cica invasora recurrente &#40;ENIR&#41; en un paciente inmunodeprimido"
      ]
    ]
    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Currently&#44; up to 105 capsular serotypes of <span class="elsevierStyleItalic">Streptococcus pneumoniae</span> have been described&#44; but only a limited number of them produce the majority of cases of invasive pneumococcal disease &#40;IPD&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> IPD is a vaccine-preventable illness&#59; the vaccines available to date in the region of Madrid have been the 23-valent pneumococcal polysaccharide vaccine &#40;PPV23&#41; since 2001&#44; the 7-valent pneumococcal conjugate vaccine &#40;PCV7&#41; since 2004&#44; and the 13-valent conjugate vaccine &#40;PCV13&#41; since 2010 in the private market&#44; and since 2016 in the national pediatric schedule&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> In our region&#44; the incidence of IPD is 6&#46;36 cases per 100&#44;000 inhabitants&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> In countries that also include conjugate vaccines &#40;initially PCV7 and later PCV13&#41;&#44; and with an IPD incidence rate comparable to ours&#44; it has been estimated that approximately 1&#46;8&#37; of cases may experience a second episode of IPD&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> Recurrent invasive pneumococcal disease &#40;RIPD&#41; is defined as the occurrence of two or more episodes of IPD in the same patient separated by an interval of at least one month in duration&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">5&#44;6</span></a> When the strain causing the episodes is the same&#44; it is considered a relapse&#44; and if the episodes are due to different strains&#44; it is considered reinfection&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In this clinical case&#44; a 67-year-old patient with a diagnosis of RIPD is presented&#46; The patient&#39;s clinical history included chronic kidney disease secondary to Sj&#246;gren&#39;s syndrome associated with treatment with immunosuppressive corticosteroids&#44; chronic hepatitis B being treated with entecavir&#44; and chronic obstructive pulmonary disease emphysematous type&#46; In 2017&#44; the patient was diagnosed with diffuse large B-cell lymphoma with plasmacytoid differentiation and showed a partial response to treatment&#46; In 2018&#44; the patient underwent an autologous hematopoietic stem cell transplant &#40;aHSCT&#41;&#46; The patient had been previously vaccinated before the transplant with a dose of PPV23 &#40;November 2015&#41; and another of PCV13 &#40;December 2017&#41;&#46; After the transplant&#44; he was again vaccinated with a complete sequential schedule of three doses of PCV13 &#40;February&#44; March&#44; and April 2019&#41; and one of PPV23 &#40;September 2019&#41;&#46; Between October 2022 and January 2023&#44; the patient experienced three episodes of IPD caused by different serotypes and different genotypes &#40;associated with different Multilocus Sequence Typing &#91;MLST&#93; scheme sequence type &#91;ST&#93;&#44; clonal complex &#91;CC&#93;&#44; and genetic lineage &#91;GPSC&#93; patterns&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; The first episode was initially treated with ceftriaxone and was maintained after confirming the strain&#39;s sensitivity to the antibiotic&#46; In the second episode&#44; treatment was started with piperacillin&#47;tazobactam&#59; however&#44; after obtaining the antibiogram results&#44; which showed resistance only to erythromycin&#44; treatment was adjusted to ceftriaxone&#46; The last admission was the most severe&#44; requiring ICU assistance with orotracheal intubation&#46; Empirical broad-spectrum treatment was initiated and de-escalated to high-dose ceftriaxone after confirming by antibiogram resistance to erythromycin and susceptible with increased exposure to other antibiotics &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; The patient fully recovered and was discharged&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Thus&#44; the presented case involves an immunosuppressed patient&#44; in whom a different serotype was identified in each episode of IPD&#44; confirming reinfection&#46; These episodes occurred over a span of 3 months&#44; with a 2-month interval between the first &#40;bacteremic pneumonia by serotype 31&#41; and the second episode &#40;bacteremia without focus by serotype 15B&#41;&#44; but with only an 11-day interval between the second and the third episode &#40;bacteremic pneumonia serotype 19A&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; The occurrence of this last episode in such a short period of time is quite striking&#46; Reinfection is typically defined as the occurrence of consecutive episodes separated by at least one month&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">5&#44;6</span></a> However&#44; in this case&#44; the last two episodes of IPD were caused by different serotypes from completely different genetic lineages &#40;serotype 15B ST193&#42;&#47;CC193&#47;GPSC11&#44; and serotype 19A ST17169&#47;CC320&#47;GPSC1&#41;&#46; In the serotype 15B strain&#44; a new <span class="elsevierStyleItalic">ddl</span> allele was identified in its MLST scheme&#44; so is a single locus variant of ST193 still pending new ID assignment&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The patient was adequately vaccinated according to official recommendations for aHSCT patients<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> with the PPV23 pneumococcal vaccine &#40;which includes the 15B and 19A serotypes identified in the second and third episodes&#41; and also had received three doses of the PCV13 vaccine &#40;which includes the 19A serotype identified in the third episode&#41;&#46; Therefore&#44; the second and third episodes were vaccine failures of PPV23&#44; and the third episode was also a failure of PCV13&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The majority of patients suffering from RIPD have predisposing diseases&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">6&#44;8</span></a> However&#44; between 25 and 30&#37; of cases may lack this type of history&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4&#44;8</span></a> RIPD can be particularly favored by immune system alterations that decrease the host&#39;s response to infection&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">8&#44;9</span></a> The rate of vaccine failures in children with a complete series of three doses of PCV13 in these cases has been estimated at 12&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> The occurrence of vaccine failures following immunization with conjugate vaccines has been observed&#44;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4&#44;10</span></a> and RIPD has been described in cases with lymphoma&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a></p></span>"
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "multimedia" => array:1 [
      0 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at1"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">&#42;Serotype 15B strain presented a single nucleotide polymorphism in the <span class="elsevierStyleItalic">ddl</span> gene&#44; being a single locus variant of ST193&#44; and still pending an assignment of a new ID&#46;</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">S&#44; susceptible&#59; I&#44; susceptible with increased exposure&#59; R&#44; resistant&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Date of admission&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th 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" scope="col">ICU admission&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th 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" scope="col">Diagnostic imaging&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th 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" scope="col">Blood culture&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th 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" scope="col">Serotype&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th 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" scope="col">Genotype&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="4" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Antibiotic sensitivity profile MIC &#40;EUCAST criteria&#41;</th><th 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" scope="col" style="border-bottom: 2px solid black">Treatment</th></tr><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th 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" scope="col" style="border-bottom: 2px solid black">Penicillin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th 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" scope="col" style="border-bottom: 2px solid black">Cefotaxime&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th 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" scope="col" style="border-bottom: 2px solid black">Erythromycin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th 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" scope="col" style="border-bottom: 2px solid black">Levofloxacin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th 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" scope="col" style="border-bottom: 2px solid black">First treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th 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" scope="col" style="border-bottom: 2px solid black">Second treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th 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" scope="col" style="border-bottom: 2px solid black">Third treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></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  " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">30&#47;09&#47;22 to 03&#47;10&#47;22</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">X-rays&#58; right-sided lung consolidation</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Streptococcus pneumoniae</span></td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">31</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ST1766&#47;CC3548&#47;GPSC57</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&#46;016<span class="elsevierStyleHsp" style=""></span>mg&#47;L&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&#46;016<span class="elsevierStyleHsp" style=""></span>mg&#47;L&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&#46;094<span class="elsevierStyleHsp" style=""></span>mg&#47;L&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&#46;75<span class="elsevierStyleHsp" style=""></span>mg&#47;L&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  " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ceftriaxone<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>azithromycin &#40;1 tablet&#44; 500<span class="elsevierStyleHsp" style=""></span>mg&#41;</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ceftriaxone &#40;1000<span class="elsevierStyleHsp" style=""></span>mg&#47;24<span class="elsevierStyleHsp" style=""></span>h &#8211; 3 days&#41;</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></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;S&#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;S&#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;S&#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;I&#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="" 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></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">02&#47;12&#47;22 to 14&#47;12&#47;2022</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">X-rays&#58; no pathological findings</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Streptococcus pneumoniae</span></td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15B</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ST193&#42;&#47;CC193&#47;GPSC11</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&#46;016<span class="elsevierStyleHsp" style=""></span>mg&#47;L&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&#46;012<span class="elsevierStyleHsp" style=""></span>mg&#47;L&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">&#62;256<span class="elsevierStyleHsp" style=""></span>mg&#47;L&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&#46;38<span class="elsevierStyleHsp" style=""></span>mg&#47;L&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  " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Piperacillin&#47;tazobactam &#40;4&#46;00<span class="elsevierStyleHsp" style=""></span>mg&#47;500<span class="elsevierStyleHsp" style=""></span>mg i&#46;v&#46; every 12<span class="elsevierStyleHsp" style=""></span>h&#41;</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ceftriaxone &#40;1000<span class="elsevierStyleHsp" style=""></span>mg&#47;24<span class="elsevierStyleHsp" style=""></span>h i&#46;v&#46; &#8211; 10 days&#41;</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></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;S&#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;S&#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;R&#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;I&#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="" 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></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">25&#47;12&#47;22 to 13&#47;01&#47;23</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Yes &#40;from 25&#47;12&#47;2022 to 05&#47;01&#47;2023&#41;</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">CT scan&#58; Consolidation of the apical and posterobasal segments of the left lower lobe&#46; Associated with partial filling with secretions from segmental bronchi of the left middle lobe&#44; intermediate&#44; and left lower lobe&#46;</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Streptococcus pneumoniae</span></td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">19A</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ST17169&#47;CC320&#47;GPSC1</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<span class="elsevierStyleHsp" style=""></span>mg&#47;L&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">1<span class="elsevierStyleHsp" style=""></span>mg&#47;L&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">&#62;256<span class="elsevierStyleHsp" style=""></span>mg&#47;L&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&#46;75<span class="elsevierStyleHsp" style=""></span>mg&#47;L&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  " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Piperacillin&#47;tazobactam &#40;4&#46;00<span class="elsevierStyleHsp" style=""></span>mg&#47;500<span class="elsevierStyleHsp" style=""></span>mg &#8211; 1 vial&#41;</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Linezolid &#40;600<span class="elsevierStyleHsp" style=""></span>mg&#47;12<span class="elsevierStyleHsp" style=""></span>h i&#46;v&#46; for 48<span class="elsevierStyleHsp" style=""></span>h&#41;</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ceftriaxone &#40;2000<span class="elsevierStyleHsp" style=""></span>mg&#47;12<span class="elsevierStyleHsp" style=""></span>h i&#46;v&#46; &#8211; 5 days&#41;</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;I&#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;I&#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;R&#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;I&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab3715583.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Description of admission&#44; therapy&#44; evolution&#44; and microbiological results of the three episodes of invasive pneumococcal disease&#46; Hospital Universitario 12 de Octubre&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0015"
          "bibliografiaReferencia" => array:10 [
            0 => array:3 [
              "identificador" => "bib0055"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Nationwide trends of invasive pneumococcal disease in Spain from 2009 through 2019 in children and adults during the pneumococcal conjugate vaccine era"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "S&#46; de Miguel"
                            1 => "M&#46; Domenech"
                            2 => "F&#46; Gonz&#225;lez-Camacho"
                            3 => "J&#46; Sempere"
                            4 => "D&#46; Vicioso"
                            5 => "J&#46;C&#46; Sanz"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1093/cid/ciaa1483"
                      "Revista" => array:6 [
                        "tituloSerie" => "Clin Infect Dis"
                        "fecha" => "2021"
                        "volumen" => "73"
                        "paginaInicial" => "e3778"
                        "paginaFinal" => "e3787"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/32990303"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0060"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Trends of invasive pneumococcal disease and its serotypes in the Autonomous Community of Madrid"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "P&#46; Latasa Zamalloa"
                            1 => "J&#46;C&#46; Sanz Moreno"
                            2 => "M&#46; Ordob&#225;s Gav&#237;n"
                            3 => "M&#46;D&#46; Barranco Ordo&#241;ez"
                            4 => "E&#46; Ins&#250;a Marisquerena"
                            5 => "&#193;&#46; Gil de Miguel"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Enferm Infecc Microbiol Clin"
                        "fecha" => "2018"
                        "volumen" => "36"
                        "paginaInicial" => "612"
                        "paginaFinal" => "620"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0065"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "BVCM050769&#46;pdf &#91;Internet&#93;&#46; Available from&#58; <a target="_blank" href="https://gestiona3.madrid.org/bvirtual/BVCM050769.pdf">https&#58;&#47;&#47;gestiona3&#46;madrid&#46;org&#47;bvirtual&#47;BVCM050769&#46;pdf</a> &#91;visited 14&#46;2&#46;24&#93;&#46;"
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0070"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Estimating the risk of recurrent invasive pneumococcal disease in Australia&#44; 1991&#8211;2016"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "J&#46;A&#46; Malo"
                            1 => "R&#46;S&#46; Ware"
                            2 => "S&#46;B&#46; Lambert"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.vaccine.2021.08.095"
                      "Revista" => array:6 [
                        "tituloSerie" => "Vaccine"
                        "fecha" => "2021"
                        "volumen" => "39"
                        "paginaInicial" => "5748"
                        "paginaFinal" => "5756"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/34483025"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0075"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Recurrent invasive pneumococcal disease in children&#58; underlying clinical conditions&#44; and immunological and microbiological characteristics"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "L&#46; Alsina"
                            1 => "M&#46;G&#46; Basteiro"
                            2 => "H&#46;D&#46; de Paz"
                            3 => "M&#46; I&#241;igo"
                            4 => "M&#46;F&#46; de Sevilla"
                            5 => "M&#46; Trivi&#241;o"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1371/journal.pone.0118848"
                      "Revista" => array:5 [
                        "tituloSerie" => "PLOS ONE"
                        "fecha" => "2015"
                        "volumen" => "10"
                        "paginaInicial" => "e0118848"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25738983"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib0080"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Clinical features of patients with recurrent invasive <span class="elsevierStyleItalic">Streptococcus pneumoniae</span> disease"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "M&#46;A&#46; Mufson"
                            1 => "J&#46;B&#46; Hao"
                            2 => "R&#46;J&#46; Stanek"
                            3 => "N&#46;B&#46; Norton"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/MAJ.0b013e31822d9860"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Med Sci"
                        "fecha" => "2012"
                        "volumen" => "343"
                        "paginaInicial" => "303"
                        "paginaFinal" => "309"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21934596"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            6 => array:3 [
              "identificador" => "bib0085"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "VacGruposRiesgo&#95;todas&#95;las&#95;edades&#46;pdf &#91;Internet&#93;&#46; Available from&#58; <a target="_blank" href="https://www.sanidad.gob.es/areas/promocionPrevencion/vacunaciones/programasDeVacunacion/riesgo/docs/VacGruposRiesgo_todas_las_edades.pdf">https&#58;&#47;&#47;www&#46;sanidad&#46;gob&#46;es&#47;areas&#47;promocionPrevencion&#47;vacunaciones&#47;programasDeVacunacion&#47;riesgo&#47;docs&#47;VacGruposRiesgo&#95;todas&#95;las&#95;edades&#46;pdf</a> &#91;visited 14&#46;2&#46;24&#93;&#46;"
                ]
              ]
            ]
            7 => array:3 [
              "identificador" => "bib0090"
              "etiqueta" => "8"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Clinical presentations and outcomes of children in Canada with recurrent invasive pneumococcal disease from the IMPACT surveillance network"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "Y&#46; Murad"
                            1 => "T&#46;Y&#46; Hung"
                            2 => "M&#46; Sadarangani"
                            3 => "S&#46;K&#46; Morris"
                            4 => "N&#46; Le Saux"
                            5 => "O&#46;G&#46; Vanderkooi"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/INF.0000000000003454"
                      "Revista" => array:6 [
                        "tituloSerie" => "Pediatr Infect Dis J"
                        "fecha" => "2022"
                        "volumen" => "41"
                        "paginaInicial" => "e166"
                        "paginaFinal" => "e171"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/35093996"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            8 => array:3 [
              "identificador" => "bib0095"
              "etiqueta" => "9"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Treated follicular lymphoma&#44; recurrent invasive pneumococcal disease&#44; nonresponsiveness to vaccination&#44; and a unique pneumococcus"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "C&#46; Murphy"
                            1 => "D&#46; Inverarity"
                            2 => "C&#46; McGoldrick"
                            3 => "L&#46; Mitchell"
                            4 => "P&#46; Paterson"
                            5 => "L&#46; Thom"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1155/2012/386372"
                      "Revista" => array:5 [
                        "tituloSerie" => "Case Rep Hematol"
                        "fecha" => "2012"
                        "volumen" => "2012"
                        "paginaInicial" => "386372"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23365769"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            9 => array:3 [
              "identificador" => "bib0100"
              "etiqueta" => "10"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Pneumococcal conjugate vaccine does not induce humoral response when administrated within the six months after CD19 CAR T-cell therapy"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "D&#46; Lee"
                            1 => "A&#46;I&#46; Jordan"
                            2 => "M&#46;A&#46; Menges"
                            3 => "A&#46; Lazaryan"
                            4 => "T&#46; Nishihori"
                            5 => "S&#46;R&#46; Gaballa"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:3 [
                        "tituloSerie" => "Transplant Cell Ther"
                        "fecha" => "2023"
                        "volumen" => "29"
                      ]
                    ]
                  ]
                ]
              ]
            ]
          ]
        ]
      ]
    ]
  ]
  "idiomaDefecto" => "en"
  "url" => "/2529993X/0000004200000009/v1_202411050502/S2529993X24002272/v1_202411050502/en/main.assets"
  "Apartado" => array:4 [
    "identificador" => "63562"
    "tipo" => "SECCION"
    "en" => array:2 [
      "titulo" => "Scientific letters"
      "idiomaDefecto" => true
    ]
    "idiomaDefecto" => "en"
  ]
  "PDF" => "https://static.elsevier.es/multimedia/2529993X/0000004200000009/v1_202411050502/S2529993X24002272/v1_202411050502/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/"
  "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2529993X24002272?idApp=UINPBA00004N"
]
Indexed in:

Follow us:

Subscribe:

Article

Indexed in:

Follow us:

Subscribe:

Article

Subscribe to our newsletter
