Blood cultures in the emergency department: Do we need a new approach?

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"tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "455" "paginaFinal" => "459" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Pere Tudela, Montserrat Giménez, Josep María Mòdol, Cristina Prat" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Pere" "apellidos" => "Tudela" "email" => array:1 [ 0 => "ptudela.germanstrias@gencat.net" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Montserrat" "apellidos" => "Giménez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Josep María" "apellidos" => "Mòdol" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "Cristina" "apellidos" => "Prat" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Unidad de Corta Estancia-Observación de Urgencias, Hospital Universitario Germans Trias i Pujol, Badalona, Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Microbiología, Hospital Universitario Germans Trias i Pujol, Badalona, Barcelona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Centros de Investigación Biomédica en Red (CIBER), Instituto de Salud Carlos III, Madrid, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Hemocultivos en los servicios de urgencias, ¿hacia un nuevo enfoque?" ] ] "textoCompleto" => "Emergency departments (EDs) provide care to many patients with infectious diseases; it has been estimated that these account for 14.3% of all visits<a class="elsevierStyleCrossRef" href="#bib0210">1</a> in our community setting. In this context, clinicians often raise the possibility of taking blood cultures, since the detection of bacteraemia is a fact with potential diagnostic, prognostic and therapeutic significance. Clinical practice in this regard is variable in different EDs and extractions range from 1 to 25% of visits.<a class="elsevierStyleCrossRef" href="#bib0215">2</a> However, the indication of blood cultures is still a poorly defined aspect, and subject of several controversies. So far, the indications have been remarkably generic, such as suspected focal infection, sepsis or endocarditis, and the presence of fever, chills, leukocytosis or leukopenia, or multiorgan failure, unclarified. With this approach the fraction of positive blood cultures, variable depending on the series, ranges from 4 to 21%, with a contamination rate of 3–7%. It has been estimated that the acceptable range would be between 5 and 15% positive with a contamination rate of 2–3%.<a class="elsevierStyleCrossRefs" href="#bib0220">3–6</a>But in recent years, many authors have questioned these results, evaluating different aspects.<a class="elsevierStyleCrossRefs" href="#bib0240">7–9</a> On the one hand, it was considered that the criteria for the indication of blood cultures should be more specific than those currently exposed. And those questioned were mainly the ones conducted for EDs patients, without hospital admissions. In addition, their clinical performance could be increased both quantitatively (in percentage of isolates) and qualitatively, since it has been found that positive blood cultures do not always have a healthcare impact, as sometimes they do not modify the therapeutic approach. Do not forget that the practice of these cultures is not without drawbacks. We must assess their economic costs and their workload, and sometimes the problems associated with contamination and its different consequences.The current situation is complex, including numerous clinical studies as well as the emergence of different biomarkers (BM) in an attempt to predict the existence of bacteraemia. Moreover, we should not lose sight of the fact that in the near future the development of new molecular techniques could mean a radical change in the paradigm of all these issues.Predicting bacteraemiaThe key consideration regarding patients with clinically suspected bacteraemia is to assess whether there are risk factors (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>), which are present in 86% of cases, and logically determine the event probability.<a class="elsevierStyleCrossRefs" href="#bib0230">5,10</a> In addition, the possible existence of related factors should be assessed; numerous studies have proposed different clinical and analytical variables as predictors of bacteraemia (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).<a class="elsevierStyleCrossRefs" href="#bib0255">10–20</a> The variability of populations, settings, source of bacteraemia, and lab testing parameter cut-offs has made it difficult to reach a definitive diagnosis scheme in this regard. A comprehensive analysis of different studies shows that the variables with greater predictive power are the presence of chills (defined as “cold feeling with shaking”) and hypotension or shock.<a class="elsevierStyleCrossRef" href="#bib0250">9</a> By contrast, other variables such as clinical suspicion, tachycardia, temperature, leukocytosis (15,000/μl), thrombocytopenia, lymphopenia or the neutrophils/lymphocytes ratio are not useful.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia>The importance of the clinical context is highlighted in the Coburn et al.,<a class="elsevierStyleCrossRef" href="#bib0250">9</a> paper, which allows to stratify the likelihood of bacteraemia in 3 levels. In the low level (2–13%) we have skin infections, pneumonia and fever of unknown origin; at the intermediate level (19–25%), urinary tract infections (UTI); while the high level (38–69%) corresponds to meningitis, sepsis and septic shock. When indicating the practice of blood cultures, the authors propose to estimate the probability depending on the context, not considering their indication in cases of isolated fever or leukocytosis.The tendency of most groups has been to develop predictive models (PM), to estimate the probability of bacteraemia objectively. Recently, in the article by Eliakim-Raz et al.,<a class="elsevierStyleCrossRef" href="#bib0260">11</a> it was proposed to select the models that meet two requirements: firstly, those that incorporate internal validation, and secondly, those that allow stratifying the likelihood of bacteraemia in low or high (arbitrarily defined as less than 3% and above 30%, respectively). 15 studies were analysed; <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> shows the main characteristics of those conducted in patients with fever of undetermined origin. One of the most striking findings of the analysis was that although the diagnostic yield of the models was acceptable, the authors confirmed that none of them had been implemented in clinical practice. The explanation for this finding may be that the PM are complicated, requiring variables that are not available in the EDs, or that clinicians do not want to dispense with the additional information that blood cultures can provide, even when the likelihood is remote. Perhaps we should value more the virtues of the different PM proposed and apply them as support of the clinical assessment.<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>Blood cultures in patients with fever of known focusUntil recently, blood cultures have been systematic in patients diagnosed in the EDs of major infectious syndromes, such as pneumonia, UTI, cellulite and gastroenteritis. However, in recent years, different papers have questioned this practice and is currently under debate. In the case of UTI, for uncomplicated pyelonephritis, different studies show that blood cultures may be irrelevant if identification and sensitivity through urine culture is available. Of the 10–25% of patients who will have bacteraemia, only 1.9% of them will have the treatment modified, that is why some authors have proposed not to use blood cultures.<a class="elsevierStyleCrossRef" href="#bib0310">21</a> On the contrary, complicated pyelonephritis, the difficulty in obtaining a sample for urine culture (or risk of contamination) and the possible existence of resistant organisms would not allow this approach. However, far from establishing a general premise, decisions should always be individualized, considering these various factors in each case.For pneumonia, since the frequency of positive blood cultures is low, around 1–16% depending on the series, systematic indication is also questioned. In fact, it has been shown that only 0–5% of cases experience therapeutic modifications based on blood cultures.<a class="elsevierStyleCrossRef" href="#bib0315">22</a> The general recommendation, therefore, is limited to severe clinical forms, as these conditions are most likely caused by microorganisms other than Streptococcus pneumoniae (such as Staphylococcus aureus, Pseudomonas aeruginosa and other Gram-negative bacilli) which are not covered with the usual guidelines. They are also indicated in patients that are immunocompromised, coming from other health centres and when there is evidence of cavitation or pleural effusion.<a class="elsevierStyleCrossRef" href="#bib0320">23</a> However, it is difficult to establish a recommendation as exhaustive as in UTI cases, given that the etiologic diagnosis of pneumonia is not obtained so easily, only 40–60% of cases.Gastroenteritis could have a similar approach to the UTI, and if we have a sample for stool culture and/or investigation of microorganisms (toxins), blood cultures would not be indicated systematically. Although frequently requested in clinical practice, the fact is that the clinical guides of reference consider their indication only in selected cases.<a class="elsevierStyleCrossRef" href="#bib0325">24</a>Regarding skin and subcutaneous tissue infections, although the overall yield of blood cultures is considered relatively low, it is highly variable depending on the series (4–35%) probably due to differences in patient characteristics. Some factors determine a higher bacteraemia frequency, such as cirrhosis, HIV disease, lymphedema or head and neck cellulitis. Several authors have considered that the impact on therapy is very limited and that they would only be indicated in immunosuppressed patients, of complicated progression or exposed to unusual organisms,<a class="elsevierStyleCrossRef" href="#bib0330">25</a> although this approach is debatable, considering the frequent absence of alternative samples for culture and the growing possibility of resistant microorganisms (Methicillin resistant S. aureus).Blood cultures in patients with fever without a focusPatients with fever without a focus, which have been studied numerous times, still represent a challenge for EDs clinicians. Their frequency is estimated at 7–15% of all patients with fever in the ED; it is therefore a common situation. An important part of these, 33–58% are sent back home, although 9% of these may require hospitalization later. In 13% of cases there is no final diagnosis obtained, and 4% are not infectious, but up to 35% have bacterial infection.<a class="elsevierStyleCrossRefs" href="#bib0335">26–28</a> An interesting study by Gur et al.,<a class="elsevierStyleCrossRef" href="#bib0345">28</a> showed that among patients who had been discharged, most had viral infections, but occasionally bacteraemia and malaria was also detected, and among those admitted, the most frequent diagnoses were bacteraemia and endocarditis. Blood cultures were positive in 12–20% of cases, of which nearly half were bacteraemia of unknown origin.<a class="elsevierStyleCrossRefs" href="#bib0335">26,28</a> Therefore, in most cases with serious diagnoses, blood cultures represented a key element.From the point of view of emergency care, and after ruling out some specific entities (such as primary infection by HIV or malaria, which usually occur in a given context), the key issue is to assess these patients regarding the risk of having primary bacteraemia (PB), leaving aside other entities that do not require preferential treatment (such as viral infections, malignancies, autoimmune diseases). Reference to PB is made when there is no evidence of a clear focus, being sometimes called occult bacteraemia due to its similarity to the paediatric setting, although the latter nomenclature can be confusing because it refers to bacteraemia detected in non-hospitalized patients, which, in most cases, do not correspond to patients without diagnosis and adequate treatment. So the subgroup subject of concern is the one made up of patients with PB, of uncertain origin, who come to represent 15–20% of all non-hospitalized bacteremias.<a class="elsevierStyleCrossRefs" href="#bib0350">29–31</a>Therefore, the question is to be able to indicate blood cultures in patients at risk of PB, but not indiscriminately. In order to achieve this, assessing the presence of risk factors seems the most reasonable approach (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). It should be noted that in cases where blood cultures are already underway, it would be advisable to display an expectant attitude, keeping the patient in observation or short stay units until the results are received. But the indication is much more questionable in those without risk factors, especially if their good general condition points towards a prompt discharge. Many authors have spoken against it, mentioning its low profitability, since less than 3% are positive.<a class="elsevierStyleCrossRef" href="#bib0365">32</a>Blood cultures in patients not admitted to hospitalThe indication of blood cultures has been specially and repeatedly questioned in patients who are discharged from the EDs.<a class="elsevierStyleCrossRef" href="#bib0240">7</a> But the reality is that, quite often, in most EDs, detection of bacteraemia is observed in non-admitted patients, representing 3–29% of all detected. Since the analysis of our initial experience, different studies have provided data and considerations over the years about this issue.<a class="elsevierStyleCrossRefs" href="#bib0350">29–31</a> This wealth of experience allows us to confirm that there are 2 fundamental subgroups that should be interpreted in very different ways: on the one hand, a majority (27–69%) of UTI with almost always appropriate diagnosis and treatment where, as previously raised, blood cultures could have been avoided; and on the other, a 12–39% corresponding to undiagnosed and untreated PB, where the case should always be reconsidered. The processes thus detected are not trivial and include endocarditis, osteomyelitis, catheter infection, cholangitis, diverticulitis and bacteraemia of unknown origin, among others. It is noteworthy that out of the total number of patients, 17–41% required treatment modification, and 14–82% required admission, in some cases to intensive care. Although null in several studies, mortality is not negligible, since in some series it is found between 1.2 and 5%.<a class="elsevierStyleCrossRefs" href="#bib0350">29–31</a> When blood cultures performed on an outpatient basis are specifically analysed, a very low yield is observed, only 2.4%.<a class="elsevierStyleCrossRef" href="#bib0365">32</a> The only variables related to bacteraemia were age and having received health care in the previous 2 weeks. Therefore, the indication is very questionable, especially when considering that, in up to 40% of cases, the initial assumption was that of a non-infectious or probably viral disease.Therefore, we should be able to act with greater discrimination. For patients with a focal infection and no admission, blood cultures would not be indicated in the vast majority of cases. Moreover, in fevers of unknown origin with potential PB, due to existing risk factors, the practice of blood cultures should be accompanied by an expectant attitude in observation or short stay units.<a class="elsevierStyleCrossRef" href="#bib0370">33</a> In cases of fever without a focus and when admission is not anticipated, blood culture indication should be questioned if there are no underlying diseases. In any case, having in place a healthcare circuit that ensures the quick location and reassessment of the patient if necessary is a must.<a class="elsevierStyleCrossRefs" href="#bib0225">4,30,33,34</a> However, it would be advantageous if these clinical decisions could have an additional element of support. It is in this scenario where the infection BM may have a role in helping the EDs.Role of biomarkersOf the more than 170 molecules related to systemic bacterial infection, a small group has been proposed as predictors of bacteraemia and severity. These are cytokines, cell markers or receptors, acute phase proteins, endothelial or vasodilator factors, among others.<a class="elsevierStyleCrossRef" href="#bib0380">35</a> But data and experience on many of them is limited. Interleukins 1 and 6 and tumour necrosis factor α have been evaluated, but they present difficulties due to their lab instability and rapid kinetics. Endocan, nitric oxide and lactate are mainly related to severity. The truth is that most of the studies are centred around C-reactive protein (CRP) and procalcitonin (PCT).<a class="elsevierStyleCrossRefs" href="#bib0380">35,36</a> CRP is a sensitive inflammation marker, but very unspecific and with relatively slow kinetics, both in elevation as well as decline. However, PCT is more specific as a marker for systemic bacterial infection, early elevation and high negative predictive value (NPV). Therefore, numerous studies have proposed PCT determination to rule bacteraemia out. Specifically, a value lower than 0.4–0.5ng/ml has a NPV of 95–98%.<a class="elsevierStyleCrossRefs" href="#bib0380">35–37</a> In our experience, the combination of a Charlson index lower than 2 and a PCT lower than 0.4ng/ml delimits a group (25% of the sample) of low probability of bacteraemia (0 to 2.9%) with a NPV of 95%.<a class="elsevierStyleCrossRef" href="#bib0300">19</a> However, it is worth recalling some limitations such as false positives in cases of multiple injuries and recent surgeries, shock, pancreatitis, autoimmune diseases, paraneoplastic syndromes, heat stroke and immunomodulatory treatments before considering its clinical implementation. And false negatives in infections caused by Mycoplasma, tuberculosis, Chlamydia, Legionella, Candida and Pneumocystis jirovecii.<a class="elsevierStyleCrossRefs" href="#bib0380">35,36</a>Among the new BM, soluble triggering receptor expressed on myeloid cells, soluble urokinase receptor, pentraxin-3 and proadrenomedullin could play a significant role, but more oriented to the prediction of severity. Presepsin seems to be more promising as a diagnostic tool.<a class="elsevierStyleCrossRef" href="#bib0380">35</a> But if we consider its availability, already in many hospitals, the technique's speed and clinical experience, the PCT is, by far, the BM of reference. Admittedly we do not have an ideal BM, probably because to expect great precision from a single molecule is simplify in excess something which is highly complex. We must recall that the response mechanisms to bacterial infection involve multiple cellular mediators, microorganism-specific factors and host-dependent factors. The BM seek, with more or less success, to measure this response. But despite these limitations, and given the difficulty of predicting bacteraemia, the PCT may be useful as complementary data on clinical assessment, given its high NPV, especially in those situations which we described as doubtful in connection with blood culture indication.The problem of contaminationContamination of blood cultures, usually by skin bacteria or via the hands of healthcare staff, have a negative impact on patients and the healthcare system. The main problem derives from the difficulty in differentiating true bacteraemia from contamination, essentially when faced with Staphylococcus epidermidis isolates. When interpreting the result, evaluating the time to positivity of blood cultures can be helpful, as it is usually more than 24h in contamination cases, or the proportion of positive blood cultures, which usually corresponds to only one of the samples in contamination cases. However, these dubious situations tend to involve taking new samples for culture, performing other examinations or starting antibiotic treatment, all really unnecessary and with the risks of adverse reactions, generation of resistance, or opportunist infections. This represents an economic cost estimated at about 4500–10,000USD per contaminated blood culture, and an extended hospital stay of about 1–5 days.EDs are at particular risk of blood culture contamination, and often their rates are above the reference 3%. A high staff turnover, the pressure to start early antibiotic treatment and the department's saturation have been considered as potential causes for this situation. A high level of saturation has been associated with an increase of 23% in the contamination rate.<a class="elsevierStyleCrossRef" href="#bib0395">38</a> Multiple strategies have been developed in order to reduce contamination rates. Of all these, the use of sterile extraction kits and the implementation of phlebotomists teams have shown to be the most cost-effective. For these reasons, it is important to limit the maximum number of contaminated blood cultures.Future prospects and conclusionsMicrobiological diagnosis has experienced significant advances in recent years. One of them is the reduction of time intervals, which can have a positive impact on patient treatment. According to recent findings, a prompt identification based on positive blood culture with mass spectrometry (MALDI-TOF) contributes to treatment improvements. However, blood cultures, which are still the reference method, have a fundamental limitation, that is, the time to positivity detection, which is around 15h on average. In recent years, new molecular methods are being developed to detect nucleic acids using polymerase chain reaction, which allow, directly from the patient's blood, to obtain a result in just 6–8h.<a class="elsevierStyleCrossRef" href="#bib0400">39</a> These also allow the detection of slow-growing microorganisms, non-culturable on artificial media, or in cases where the patient has received antibiotic treatment.In the meantime, while waiting for the further development of these innovative techniques, we will need to optimize the performance of blood cultures using more conventional tools. In some studies, in order to adapt the indication and the blood culture technique, a clinical intervention has been developed through recommendation guides, with positive results.<a class="elsevierStyleCrossRef" href="#bib0405">40</a> We must also consider that there might be a scope for improvement beyond infectious disease indications. This would include patients with unclear diagnosis (nonspecific deterioration, ill-defined signs and symptoms), in which blood cultures are performed randomly, without a clear suspicion of infection. We have found that this section is not negligible.<a class="elsevierStyleCrossRef" href="#bib0410">41</a>Perhaps the best strategy would be to define the subgroup with very low probability of bacteraemia (<3%), in which blood cultures would not be indicated. This subgroup may include up to 25% of patients.<a class="elsevierStyleCrossRef" href="#bib0300">19</a> The PM and some BM are helpful in this regard. Also, in an attempt to outline the different approaches that have been described, we could stratify the indications of blood cultures according to the clinical context and the degree of proven utility. Thus 3 large groups are defined, from less to more controversial (<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>) with group C where the indication is probably not justified.<elsevierMultimedia ident="tbl0020"></elsevierMultimedia>In conclusion, to increase the diagnostic yield of blood cultures, its efficiency, and limit contamination associated complications, better defined indication criteria should be considered. We should also consider an added benefit related to a stricter indication, that of a very likely improvement in the use of antibiotic treatment and hospital admissions. Hopefully, we will be witnessing the development of a new approach to these issues in the near future.Conflict of interestsThe authors declare no conflict of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Predicting bacteraemia" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Blood cultures in patients with fever of known focus" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Blood cultures in patients with fever without a focus" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Blood cultures in patients not admitted to hospital" ] 4 => array:2 [ "identificador" => "sec0025" "titulo" => "Role of biomarkers" ] 5 => array:2 [ "identificador" => "sec0030" "titulo" => "The problem of contamination" ] 6 => array:2 [ "identificador" => "sec0035" "titulo" => "Future prospects and conclusions" ] 7 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflict of interests" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-10-02" "fechaAceptado" => "2015-11-26" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Tudela P, Giménez M, Mòdol JM, Prat C. Hemocultivos en los servicios de urgencias, ¿hacia un nuevo enfoque? Med Clin (Barc). 2016;146:455–459." ] ] "multimedia" => array:4 [ 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" => "Adapted from Reimer et al.<a class="elsevierStyleCrossRef" href="#bib0255">10</a>" "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=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Extreme ages \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hepatic cirrhosis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Chronic renal failure \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Immunodeficiency \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Immunosuppressive or immunomodulatory therapy \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Neoplasm \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cytostatic-induced neutropenia \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Recent surgery \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Chronic ulcers \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Trauma \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Burns \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Diabetes mellitus \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Drug injecting \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Splenectomy \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Endoscopic, urological or bowel procedures \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Vascular catheter \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1201881.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Risk factors for bacteraemia." ] ] 1 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "ESR, erythrocyte sedimentation rate." "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=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Signs and symptoms \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Temperature \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Tachycardia \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hypotension \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Comorbidity \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Shaking chills \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Vomiting \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Acute abdomen \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Altered mental status \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Vascular catheter \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Immunosuppression \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Blood/lab test \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Leukopenia or leukocytosis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Bands \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Lymphopenia \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Thrombocytopenia \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Elevated creatinine \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hypoalbuminemia \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Elevated alkaline phosphatase \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">C-reactive protein \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">ESR \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Procalcitonin \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1201880.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Variables proposed as predictors of bacteraemia in febrile cases." ] ] 2 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "AUC, area under the curve; AP, alkaline phosphatase; HR, heart rate; RR, respiratory rate; RF, renal failure; SBP, systolic blood pressure; CRP, C-reactive protein; PCT, procalcitonin; T, temperature; ESR, erythrocyte sedimentation rate.Adapted from Eliakim-Raz et al.<a class="elsevierStyleCrossRef" href="#bib0260">11</a>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Variables included</th><th class="td" title="table-head " colspan="4" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Diagnostic yield</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Signs of sepsis \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">History \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Laboratory \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">AUC \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Probability \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Low risk, % \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">High risk, % \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Bates et al., 1990<a class="elsevierStyleCrossRef" href="#bib0265">12</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">T>38.3°, shaking chills \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Comorbidity \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1–2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Leibovici et al., 1991<a class="elsevierStyleCrossRef" href="#bib0270">13</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Shaking chills \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Comorbidity \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">RF, ↓ Albumin \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1–5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">65–83 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mozes et al., 1993<a class="elsevierStyleCrossRef" href="#bib0275">14</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">T>39° \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Immunosuppressant \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">↑ AP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4–5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12–38 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Bates et al., 1997<a class="elsevierStyleCrossRef" href="#bib0280">15</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Altered consciousness. Abdominal focus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Liver disease, Hickman catheter \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14–15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">60–64 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Lizarralde et al., 2004<a class="elsevierStyleCrossRef" href="#bib0285">16</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">T>38.3° \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Bands, ESR >70, CRP >12, ↓ platelets, ↑ urea, ↓ albumin \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2–4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">65–80 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Shapiro et al., 2008<a class="elsevierStyleCrossRef" href="#bib0290">17</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">T>39.5°, 38.3–39.4°. Vomiting, SBP <90, chills \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Vascular catheter, suspected endocarditis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Leucocytes >18,000 bands >5%, ↓ platelets, creatinine >2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.6–0.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15–26 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Lipsky et al., 2010<a class="elsevierStyleCrossRef" href="#bib0295">18</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">T<35.6° or >38°. HR<49 or >125. RR<10 or >29 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Health care, male, coronary artery disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Bands >7%, leukocytes >11,000, ↓ Albumin \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3–4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">44–46 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Tudela et al., 2010<a class="elsevierStyleCrossRef" href="#bib0300">19</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Charlson >2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">PCT>0.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0–2.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">27–35 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Jin et al., 2013<a class="elsevierStyleCrossRef" href="#bib0305">20</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Fever, hypothermia, HR ↓, ↓ SBP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Corticoid treatment \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">↑ ↓ leukocytes, CRP or PCT ↑, ↓ platelets, ↓ albumin, ↑ creatinine, ↑ AP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.4–1.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">18–20 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1201882.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Predictive models of bacteraemia in patients with fever of unknown origin." ] ] 3 => array:8 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at4" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "PCT, procalcitonin." "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=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">A. Unquestioned indications \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Suspicion of sepsis, endocarditis or meningitis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pyelonephritis, pneumonia, gastroenteritis, or soft tissue infection with admission criteria \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Fever of unknown origin in patients at risk of bacteraemia \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">B. Controversial indications \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pneumonia or soft tissue infection without admission criteria \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Fever of unknown origin in patients without risk of bacteraemia \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">C. Unclear indication \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pyelonephritis without admission criteria, with appropriate urine culture<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Gastroenteritis without admission criteria, with appropriate stool culture<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Fever of unknown origin in patients without risk of bacteraemia and non-elevated PCT \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Unclear diagnosis, but without evidence of infection \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1201883.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "Suitable sample, obtained from an autonomous and collaborating patient." ] ] ] "descripcion" => array:1 [ "en" => "Blood culture indications according to the clinical context." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:41 [ 0 => array:3 [ "identificador" => "bib0210" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Estudio INFURG-SEMES: epidemiología de las infecciones atendidas en los servicios de urgencias hospitalarios y evolución durante la última década" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M. 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