Community acquired pneumonia caused by Legionella pneumophila: Study of 136 cases

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"autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Eva Romay-Lema, Juan Corredoira-Sánchez, Pablo Ventura-Valcárcel, Iria Iñiguez-Vázquez, María-José García Pais, Fernando García-Garrote, Ramón Rabuñal Rey" "autores" => array:7 [ 0 => array:4 [ "nombre" => "Eva" "apellidos" => "Romay-Lema" "email" => array:1 [ 0 => "eva.maria.romay.lema@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Juan" "apellidos" => "Corredoira-Sánchez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Pablo" "apellidos" => "Ventura-Valcárcel" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "Iria" "apellidos" => "Iñiguez-Vázquez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "María-José" "apellidos" => "García Pais" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 5 => array:3 [ "nombre" => "Fernando" "apellidos" => "García-Garrote" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "d" "identificador" => "aff0020" ] ] ] 6 => array:3 [ "nombre" => "Ramón" "apellidos" => "Rabuñal Rey" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Servicio de Medicina Interna, Hospital Universitario Lucus Augusti, Lugo, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Unidad de Enfermedades Infecciosas, Hospital Universitario Lucus Augusti, Lugo, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Medicina Interna, Hospital da Costa, Lugo, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Servicio de Microbiología, Hospital Universitario Lucus Augusti, Lugo, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Neumonía comunitaria por Legionella pneumophila: estudio de 136 casos" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1163 "Ancho" => 2459 "Tamanyo" => 106365 ] ] "descripcion" => array:1 [ "en" => "Number of cases per year in the period 2001–2015." ] ] ] "textoCompleto" => "IntroductionLegionella spp. are intracellular gram-negative bacilli primarily transmitted through the inhalation of contaminated water aerosols. Although more than 58 species and 70 serogroups have been described, Legionella pneumophila serogroup 1, is responsible for 70–90% of the infection cases.<a class="elsevierStyleCrossRefs" href="#bib0155">1–3</a> Since the microorganism was first identified in 1976, it has been recognized as a relatively common cause of community-acquired pneumonia, causing between 2% and 9% of infections.<a class="elsevierStyleCrossRef" href="#bib0160">2</a> An increase in global incidence has been observed in the last decades, probably in relation to a greater reporting of the disease, the improvement of the diagnostic tests and a change in weather patterns.<a class="elsevierStyleCrossRef" href="#bib0155">1</a> Its incidence has important geographical and seasonal variations. In Spain, in the past decade, the rate was 22–35 cases per 1,000,000 inhabitants,<a class="elsevierStyleCrossRef" href="#bib0170">4</a> with a higher incidence of cases in the eastern Mediterranean area and in the north-eastern part of the Peninsula. In this study, the incidence in Galicia is below the national average; however, more recent analyses show an increase of incidence in this community.<a class="elsevierStyleCrossRefs" href="#bib0175">5,6</a>Although the Legionella urinary antigen test is limited to the detection of serogroup 1, this is the first-line diagnostic test since its introduction in 1995. In Europe, the proportion of cases diagnosed thanks to this test has increased from 15% in 1995 to more than 90% in 2006.<a class="elsevierStyleCrossRef" href="#bib0185">7</a> In the United States, the diagnosis is made through the antigen, and only 5% of cases are confirmed by culture.<a class="elsevierStyleCrossRef" href="#bib0190">8</a>In our hospital, Legionella antigenuria started in the year 2001. Previously, only serology was performed, and the number of diagnoses was trivial. Since then, the number of cases has been increasing progressively, with a significant figure in recent years. Based on these data, we decided to analyse the epidemiological and clinical profile of pneumonia caused by Legionella in our health area since the introduction of antigenuria as a diagnostic test.MethodRetrospective study of all patients with positive Legionella antigenuria who were treated at the Lucus Augusti University Hospital between January 2001 and December 2015. The diagnosis of pneumonia caused by Legionella was considered when patients presented with a compatible symptomatology and radiological pattern and a positive urinary antigen test for serogroup 1 of L. pneumophila. The detection of L. pneumophila antigen serogroup1 was carried out from 2001 to March 2015 using the immunochromatographic test (Binax NOW® Legionella Urinary Antigen; Alere),<a class="elsevierStyleCrossRef" href="#bib0195">9</a> after urine concentration with an ultrafiltration device (Millipore). An immunofluorescence test was used from April 2015 until the end of the study (Sofia Legionella FIA, Quidel).<a class="elsevierStyleCrossRef" href="#bib0200">10</a> From the time the immunofluorescence test started to be used until the end of the study period, all positive urine samples were confirmed by repeating the test after boiling and subsequent centrifugation of the urine.The epidemiological data, the risk factors and the clinical data were analysed, as well as the radiological and laboratory patterns. The antibiotic treatment administered as well as the patient's progression were recorded. The prognostic index was established using the FINE score. The qualitative variables were expressed as absolute value and percentage. The quantitative variables were expressed as mean and their corresponding standard deviation. We studied the relationship between the independent variables analysed and an unfavourable clinical progression, understood as the need to enter the intensive care unit (ICU) or death. The chi-square test was used for comparing qualitative variables, and the Student's t-test was used for the comparison of two quantitative variables. The statistically significant variables were included in a logistic regression analysis. The statistical analysis was carried out with the SPSS software 18Results136 cases with pneumonia caused by Legionella were included. Of the 145 patients with positive antigenuria, 9 were excluded. Of these, 7 were interpreted as Pontiac fever because they had compatible symptomatology and 2 had suffered from pneumonia caused by Legionella in the previous months, so they were assumed as false positives. One hundred and fifteen (84.6%) were men and 21 (13.6%) women, with a mean age of 64.1 years (SD 16.9). 46.3% were over 65 years of age.There were 41.2 cases/1,000,000 inhabitants. <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a> shows the number of cases per year, showing an increase in diagnoses throughout the period studied, increasing the rate from 10.9 in the first 5 years of the study to 64.5 cases/1,000,000 in the last 5 years of the study. Also, the number of antigenuria determination tests performed increased 3.4 times between these two periods. During the 3 five-year periods of the study, the percentage of pneumonias caused by Legionella compared to the rest of pneumonias kept increasing, going from 0.9 to 2.9 and 15%, respectively. Almost 50% of the cases took place between the months of September and November. In contrast, other bacterial pneumonias occurred predominantly between January and March (31%).<elsevierMultimedia ident="fig0005"></elsevierMultimedia>Considering the form of acquisition, none of the cases studied presented a nosocomial origin; 121 were sporadic cases and 15 were linked to two outbreaks. Of the latter, 11 took place in 2014, observing the presence of Legionella in the hot water circuits of 2 nursing homes. Only 4 of the sporadic cases were associated with travel.A predisposing condition was found in 82.3% (112/136) of the patients, with smoking being the most frequent (59.6%, 81/136) followed by COPD and alcoholism (both 22.1%, 30/136). 21.32% (29/136) of the patients had cancer, HIV or another type of immunosuppression. <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the risk factors and comorbidities in order of frequency. In terms of gender distribution, men were younger (62.7±16.6 vs. 71.9±17.3; p<0.022) and consumed alcohol (26.1% vs. 0%; p<0.008) and smoked (67.8% vs. 14.3%; p<0.001) more frequently.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia><a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the clinical data, and <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>, the laboratory findings analysed. The most common symptoms were fever (96%, 131/136), myalgias (51.5%, 70/136) and cough (57.4%, 78/136). 39% (53/136) had confusion. Although 49.3% (68/136) had hyponatremia, a moderate (or severe) degree was only demonstrated by 9.6% (13/136) of the cases (sodium <130). 57.8% had hypertransaminasemia and 54.4% had microscopic haematuria. 30% (41/136) had no respiratory symptomatology. The most common radiological image was a single lobe consolidation (70.6%, 96/136). 11.8% (16/136) were multilobar, 8% (11/136) had a pleural effusion and only one case of cavitation.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia>Almost 60% (80/136) were diagnosed in the first 24h and 88.9% in the first 72h. 85% (116/136) needed hospital admission, with an average stay of 11 days. The days of admission were reduced over the years, so that the average stay went from 12.5 days between 2001–2008 to 10.4 days between 2009–2015. Likewise, while in the first period all patients were admitted, in the second, 19% were managed on an outpatient basis (p=0.007). Regarding the prognosis, 53.7% (73/136) received the classification of FINE IV–V pneumonias. In the analysis by age groups, patients over 65 years of age showed FINE IV–V stages in 77% of cases, while in those under 65 years of age it was 30%.80.1% (109/136) of the patients received an adequate empirical antimicrobial treatment. The other 19.9% (27/136) were initially treated only with a beta-lactam, modifying said treatment after receiving the antigenuria results, usually obtained within the first 24h. This circumstance was not associated with a worse prognosis (p=ns). The average duration of therapy was 13.6±4.6 days, with levofloxacin being the most used antibiotic (95.6%, 130/136). A second active drug was combined against Legionella in 13.2% of cases. The most commonly used combination was levofloxacin and azithromycin, with 11.8% (16/136).11.7% (16/136) required admission to the ICU and 4.4% (6/136) died. In the univariate analysis, the presence of smoking, COPD, dyspnoea, confusion, low SO2, FINE ≥IV and diagnostic delay (<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>) were associated with an unfavourable progression (admission to the ICU or death). Of these, only COPD (OR 4.7, IC 95% 1.4–15.4), an O2 saturation on admission lower than 90% (OR 6.9, CI 95% 2.0–23.3) and FINE ≥IV (OR 9.8, CI 95% 1.2–82.8) were independent risk factors in the multivariate analysis, with an area under the ROC curve obtained from 0.874 (IC 95% 0.798–0.949, p<0.001).<elsevierMultimedia ident="tbl0020"></elsevierMultimedia>DiscussionIn our environment, Legionella is an increasingly common cause of community acquired pneumonia, with rates that, in recent years, are among the highest in Spain. The elderly male population is the predominant group, with a high percentage of comorbidities. Regarding symptoms, radiological pattern and treatment, our data are generally consistent with what has been published to date. Although mortality has been reduced, it continues to be a common pathogen in pneumonias that require admission to the ICU.Pneumonia caused by Legionella is an underdiagnosed and underreported entity worldwide. The incidence in the United States has increased by 286% from 2000 to 2014,<a class="elsevierStyleCrossRef" href="#bib0205">11</a> and in Europe it has gone from 4 cases/1,000,000 in 1995 to 13,5 in 2014.<a class="elsevierStyleCrossRef" href="#bib0210">12</a> France, Germany, Italy and Spain represent 70.3% of all cases, as these are countries where the disease is of compulsory reporting (notifiable disease).<a class="elsevierStyleCrossRef" href="#bib0215">13</a>For years, the incidence in our country is among the highest in Europe,<a class="elsevierStyleCrossRef" href="#bib0220">14</a> although there are important regional differences. Since the introduction and the progressive increase of antigenuria requests in our centre, the incidence has increased remarkably, in a similar way to other areas of our country. However, in other autonomous communities the incidence has stabilized.<a class="elsevierStyleCrossRef" href="#bib0225">15</a> In the last years of the study our incidence equals that of Catalonia, which in 2014 had the highest incidence in Spain.<a class="elsevierStyleCrossRef" href="#bib0175">5</a> We do not know what the causes of this sustained case increase are regarding our study, but having one of the oldest populations in Spain (more than 30% are over 65 years of age)<a class="elsevierStyleCrossRef" href="#bib0180">6</a> can contribute to this, given the linear relationship between age and incidence in legionellosis.<a class="elsevierStyleCrossRef" href="#bib0230">16</a> Other factors, such as the change in weather conditions, with an increase in temperatures in our environment in recent years,<a class="elsevierStyleCrossRef" href="#bib0235">17</a> and the recent increase in the use of devices that produce aerosols, could also be involved. As in other studies,<a class="elsevierStyleCrossRefs" href="#bib0240">18,19</a> our cases have increased in the autumn, unlike other pneumonias, which predominantly occur in the winter months.Due to the high average age of our patients, these also have a higher comorbidity when compared to other series,<a class="elsevierStyleCrossRef" href="#bib0250">20</a> so that more than 70% have some underlying disease, with COPD and diabetes being the most common. As in other series,<a class="elsevierStyleCrossRef" href="#bib0255">21</a> the main risk factor is smoking, followed by alcohol consumption, especially when we analyse the male sex separately. Other predisposing factors described in other series, such as haematological diseases, HIV infection or other immunodepression states,<a class="elsevierStyleCrossRef" href="#bib0260">22</a> were less prevalent.Regarding symptomatology, our series does not differ substantially from that described in the literature,<a class="elsevierStyleCrossRef" href="#bib0155">1</a> with less pulmonary and more extrapulmonary manifestations than in pneumococcal pneumonia.<a class="elsevierStyleCrossRef" href="#bib0225">15</a> Some common laboratory abnormalities were also found, such as microhematuria, which is rarely found in other types of pneumonias. Some clinical findings, such as relative bradycardia, or laboratory findings, such as hypophosphatemia, not analysed in our study, have also been associated with pneumonia caused by Legionella with greater specificity according to some authors.<a class="elsevierStyleCrossRef" href="#bib0265">23</a>Regarding the radiological pattern, Benito et al.<a class="elsevierStyleCrossRef" href="#bib0255">21</a> describes multilobar involvement in more than 50% of cases and pleural effusion in 13.4%. In our series, these figures are lower: more than one lung lobe were affected in 29.4%, and only 8% developed pleural effusion.The most severe pneumonia according to the FINE score occurred in the older age groups. Clinically severe conditions were recorded in more than half of the cases, which means that hospital management is predominantly required and that a significant percentage of patients require intensive care. However, in our study this percentage was slightly lower than in other series<a class="elsevierStyleCrossRef" href="#bib0270">24</a> and there was a progressive decrease in the number of patients admitted to the ICU during the period studied (26% in the first five years compared to 10% in the last 5 years).In comparison with other older series in our country,<a class="elsevierStyleCrossRef" href="#bib0250">20</a> the low mortality of our case series stands out, despite the high average age and high percentage of comorbidities in our patients and the relative frequency of inadequate empirical treatment. An increasingly early diagnosis, the inclusion of milder cases thanks to an increasingly frequent use of antigenuria, and an increasing use of double treatment with beta-lactam and quinolone probably explain these findings.<a class="elsevierStyleCrossRef" href="#bib0275">25</a>However, in a time of great concern about healthcare expenditure and the increase in bacterial resistance, the overuse of diagnostic tests and antibiotics can be a problem.Concerning the use of antigenuria, in our centre they increased by 320% since its introduction, and in the last year of the study only 1.7% were positive (25/1481). While some authors<a class="elsevierStyleCrossRef" href="#bib0280">26</a> suggest that this test should only be used if there are clinical predictors suggestive of the disease, the IDSA-ATS guidelines are much less restrictive.<a class="elsevierStyleCrossRef" href="#bib0285">27</a> Even with these guidelines, it seems clear that there is an overuse of this test in our environment.Regarding the use of antimicrobials in our centre, a high percentage of patients are admitted with a combination of beta-lactam and quinolone from the emergency department, and in many of these cases an etiological diagnosis will not be obtained. Since 2004, in cases of atypical pneumonias, our unit administers 14 days of levofloxacin, which are reduced to 10 days in rapid response cases and in the absence of immunosuppression. However, some authors recommend shorter treatments: 5–10 days with levofloxacin<a class="elsevierStyleCrossRef" href="#bib0290">28</a> and 3–5 days with azithromycin.<a class="elsevierStyleCrossRef" href="#bib0295">29</a> On the other hand, other authors recommend extended regimens because Legionella is an intracellular pathogen and short therapies can result in recurrence.<a class="elsevierStyleCrossRef" href="#bib0280">26</a>The main limitation of the study is its retrospective nature. In addition, patients have been treated in various hospital services, which implies differences in data collection. On the other hand, an exhaustive etiological study was not carried out on all patients with pneumonia. In addition, the only technique used by us was antigenuria, which has a specificity of 100% and a sensitivity for L. pneumophila serogroup 1 that varies between 56 and 99%.<a class="elsevierStyleCrossRef" href="#bib0230">16</a> However, it has a low sensitivity for subtype Lp1 Mab 3/1-negative (approximately 15% of the serogroup 1) and does not detect other serogroups or species, so that a percentage of patients with this type of pneumonia have not been included. New techniques, such as PCR, would include different serotypes and serogroups, with a higher sensitivity than culture and a greater speed, although they are not yet validated to be applied in routine clinical practice.<a class="elsevierStyleCrossRef" href="#bib0300">30</a> In any case, our data are similar to those published in other studies, which is why we consider that they are close to the disease reality in our environment.In any case, it is clear from the data analysed that the incidence of pneumonia caused by Legionella has increased during the period studied and is very high in recent years. The average age and the percentage of comorbidities are higher than in other series in our country. Despite this, mortality has been reduced, probably due to early diagnosis, thanks to the increasingly common use of antigenuria and the use of quinolones. In our centre, since the introduction of antigenuria detection, serology has lost utility in the diagnosis of this disease, making it necessary to better define the indications for the antigenuria test and which patients with pneumonia can benefit from the use of quinolones.Conflict of interestsThe authors declare no conflict of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres1099623" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Method" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1040813" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1099622" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Método" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1040812" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Method" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflict of interests" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-10-30" "fechaAceptado" => "2018-03-08" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1040813" "palabras" => array:3 [ 0 => "Legionella" 1 => "Atypical pneumonia" 2 => "Antigenuria" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1040812" "palabras" => array:3 [ 0 => "Legionella" 1 => "Neumonía atípica" 2 => "Antigenuria" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "ObjectiveMost of the data on Legionella pneumonia in our country come from the Mediterranean area, and there are few studies from the Northwest area. This study tries to assess the situation of this infection in this area. MethodRetrospective study of all patients with positive Legionella antigenuria treated at the University Hospital Lucus Augusti in Lugo (Spain) from 2001, the year in which this test was introduced in our centre, until 2015. We analysed epidemiological data, risk factors, clinical, radiological and biochemical findings, and clinical outcome. ResultsThe sampled included 136 patients. When comparing the first five years of the study with the last five, the incidence increased from 10.9 to 64.5 cases/1,000,000; the number of antigenuria requests increased 3.4 times, and compared to other pneumonia aetiologies Legionella increased from 0.9% to 15%. The mean age was 64.1 years and 84.6% were males; 74.3% had comorbidities. Males were significantly younger (62.7±16.6 vs. 71.9±17.3) and consumed more alcohol (26.1% vs. 0%) and tobacco (67.8% vs. 14.3%). Diagnosis was established within the first 72h in 88.9% of cases and most received levofloxacin (95.6%). Hospitalisation was needed in 85% of cases, 11.7% in ICU and 4.4% died. ConclusionsAfter the introduction of antigenuria there was an increase in the incidence of Legionella pneumonia recorded in our health area. Its rate in recent years has been one of the highest in our country. Despite the fact that the patients had advanced age and comorbidities, mortality was low." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Method" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "ObjetivoLa mayoría de los datos de la neumonía por Legionella en nuestro país proceden del área mediterránea, y apenas existen estudios en la zona del Noroeste. Con este trabajo se pretende conocer la situación de la infección en nuestro medio. MétodoEstudio retrospectivo de todos los pacientes con antigenuria positiva para Legionella en el Hospital Universitario Lucus Augusti de Lugo desde 2001, año en que se introdujo la antigenuria como prueba diagnóstica en nuestro centro, hasta 2015. Se analizaron datos epidemiológicos, factores de riesgo, hallazgos clínicos, radiológicos, analíticos y evolutivos. ResultadosSe registraron 136 pacientes. Si comparamos los primeros 5 años del estudio con los 5últimos, la incidencia aumentó de 10,9 a 64,5 casos/1.000.000, el número de peticiones de antigenuria se incrementó 3,4 veces, y con respecto a otras neumonías, Legionella pasó del 0,9 al 15% de ellas. La edad media fue de 64,1años, y el 84,6% fueron varones. El 74,3% tenían comorbilidades. Los varones fueron significativamente más jóvenes (62,7±16,6 vs 71,9±17,3) y consumían más alcohol (26,1% vs 0%) y tabaco (67,8% vs 14,3%). El 88,9% se diagnosticaron dentro de las primeras 72h y la mayoría recibió levofloxacino (95,6%). El 85% necesitaron ingreso hospitalario, el 11,7% en UCI y el 4,4% fallecieron. ConclusionesCoincidiendo con la introducción de la antigenuria, se observa un aumento de incidencia de neumonía por Legionella en nuestra área sanitaria, con tasas en los últimos años que se sitúan entre las más altas de nuestro país. A pesar de tener pacientes con elevada edad media y un alto porcentaje de comorbilidades, la mortalidad fue reducida." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Método" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Romay-Lema E, Corredoira-Sánchez J, Ventura-Valcárcel P, Iñiguez-Vázquez I, García Pais MJ, García-Garrote F, et al. Neumonía comunitaria por Legionella pneumophila: estudio de 136 casos. Med Clin (Barc). 2018;151:265–269." ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1163 "Ancho" => 2459 "Tamanyo" => 106365 ] ] "descripcion" => array:1 [ "en" => "Number of cases per year in the period 2001–2015." ] ] 1 => 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" => "Source: Pérez et al.<a class="elsevierStyleCrossRef" href="#bib0235">17</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="left" valign="top" scope="col" style="border-bottom: 2px solid black">Risk factors \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">n (%) \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">Smoking \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">81 (59.6) \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">Consumption of alcohol \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">30 (22.1) \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">Underlying disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">101 (74.3) \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">COPD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">30 (22.1) \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 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">27 (19.9) \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><td class="td" title="table-entry " align="char" valign="top">17 (12.5) \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 kidney disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 (11) \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">Other \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 (8.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1880615.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Risk factors for pneumonia caused by Legionella pneumophila." ] ] 2 => 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:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Clinical data \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">n (%) \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">Fever \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">131 (96.3) \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">Cough \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">78 (57.4) \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">Myalgia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">70 (51.5) \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">Confusion \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">53 (39) \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">Dyspnoea \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">50 (36.8) \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">Chest pain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">24 (17.6) \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">Expectoration \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">24 (17.6) \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">Digestive symptoms \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">23 (16.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1880616.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Clinical data on admission." ] ] 3 => 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:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Laboratory data \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">n (%) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Leukocytes</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><5000 cells/μl \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (2.9) \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">5000–12,000 cells/μl \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">59 (43.4) \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">>12,000 cells/μl \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">73 (53.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Platelets</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">≤150,000 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">33 (24.3) \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">>150,000–≤400,000 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">103 (75.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Baseline O2saturation</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">≤90% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">40 (29.4) \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">>90% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">96 (70.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Sodium</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">≥135 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">69 (50.7) \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">129–134 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">54 (39.7) \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">125–129 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 (7.4) \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"><125 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (2.2) \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">Hypertransaminasemia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">78 (57.8) \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">Microscopic haematuria \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">50 (36.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1880614.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Laboratory data on admission." ] ] 4 => 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:1 [ "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="2" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">ICU or death</th><th class="td" title="table-head " rowspan="2" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">OR</th><th class="td" title="table-head " rowspan="2" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">IC 95%</th><th class="td" title="table-head " rowspan="2" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">p</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">No \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">Yes \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">O2 saturation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">92.4±3.9% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">85.3±6.8% \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="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.000 \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">O2 saturation <90% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">20.9% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">70% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.1–25.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.000 \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">FINE \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3.1±1.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4.7±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="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.000 \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">FINE ≥IV \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">47% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">94.7% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.6–157.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.000 \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">Relationship with outbreak \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12.2% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0–3.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.346 \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">Mellitus diabetes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">19.1% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">25% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.5–4.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.545 \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 kidney disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10.4% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">15% \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">0.4–5.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.549 \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><td class="td" title="table-entry " align="left" valign="top">11.3% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">15% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.4–5.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.637 \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">Alcoholism \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">20.9% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">25% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.4–3.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.678 \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">Smoking \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">55.7% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">80% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1–10.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.041 \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">COPD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">15.7% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">55% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.4–18.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.000 \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">Dyspnoea \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">33% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">60% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.1–8.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.021 \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">Confusion \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">33.9% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">65% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.3–9.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.008 \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 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">96.5% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">95% \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="char" valign="top">0.1–6.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.739 \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">Respiratory symptoms \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">69.6% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">75% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.4–3.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.623 \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">Digestive symptoms \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">14.8% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">30% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.8–7.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.095 \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">Myalgia/arthralgias \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">49.6% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">60% \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">0.6–4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.389 \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">Hypertransaminasemia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">55.1% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">75% \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">0.8–7.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.098 \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">Hyponatremia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">47.8% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">60% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.6–4.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.315 \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">Haematuria \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">33% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">55% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.9–6.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.059 \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">Pleural effusion \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7.8% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5% \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="char" valign="top">0.1–5.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.656 \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">Incorrect antibiotic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">20% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">20% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.3–2.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1880613.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Univariate analysis of prognostic factors related to unfavourable progression." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:30 [ 0 => array:3 [ "identificador" => "bib0155" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Legionnaires’ disease" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "B.A. Cunha" 1 => "A. 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Community acquired pneumonia caused by Legionella pneumophila: Study of 136 cases

Neumonía comunitaria por Legionella pneumophila: estudio de 136 casos

Eva Romay-Lemaa,

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eva.maria.romay.lema@gmail.com

Corresponding author.

, Juan Corredoira-Sánchezb, Pablo Ventura-Valcárcelc, Iria Iñiguez-Vázqueza, María-José García Paisb, Fernando García-Garroted, Ramón Rabuñal Reyb

a Servicio de Medicina Interna, Hospital Universitario Lucus Augusti, Lugo, Spain

b Unidad de Enfermedades Infecciosas, Hospital Universitario Lucus Augusti, Lugo, Spain

c Servicio de Medicina Interna, Hospital da Costa, Lugo, Spain

d Servicio de Microbiología, Hospital Universitario Lucus Augusti, Lugo, Spain

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Legionella</span> spp&#46; are intracellular gram-negative bacilli primarily transmitted through the inhalation of contaminated water aerosols&#46; Although more than 58 species and 70 serogroups have been described&#44; <span class="elsevierStyleItalic">Legionella pneumophila</span> serogroup 1&#44; is responsible for 70&#8211;90&#37; of the infection cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">1&#8211;3</span></a> Since the microorganism was first identified in 1976&#44; it has been recognized as a relatively common cause of community-acquired pneumonia&#44; causing between 2&#37; and 9&#37; of infections&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">2</span></a> An increase in global incidence has been observed in the last decades&#44; probably in relation to a greater reporting of the disease&#44; the improvement of the diagnostic tests and a change in weather patterns&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">1</span></a> Its incidence has important geographical and seasonal variations&#46; In Spain&#44; in the past decade&#44; the rate was 22&#8211;35 cases per 1&#44;000&#44;000 inhabitants&#44;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">4</span></a> with a higher incidence of cases in the eastern Mediterranean area and in the north-eastern part of the Peninsula&#46; In this study&#44; the incidence in Galicia is below the national average&#59; however&#44; more recent analyses show an increase of incidence in this community&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">5&#44;6</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Although the <span class="elsevierStyleItalic">Legionella</span> urinary antigen test is limited to the detection of serogroup 1&#44; this is the first-line diagnostic test since its introduction in 1995&#46; In Europe&#44; the proportion of cases diagnosed thanks to this test has increased from 15&#37; in 1995 to more than 90&#37; in 2006&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">7</span></a> In the United States&#44; the diagnosis is made through the antigen&#44; and only 5&#37; of cases are confirmed by culture&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">8</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">In our hospital&#44; <span class="elsevierStyleItalic">Legionella</span> antigenuria started in the year 2001&#46; Previously&#44; only serology was performed&#44; and the number of diagnoses was trivial&#46; Since then&#44; the number of cases has been increasing progressively&#44; with a significant figure in recent years&#46; Based on these data&#44; we decided to analyse the epidemiological and clinical profile of pneumonia caused by <span class="elsevierStyleItalic">Legionella</span> in our health area since the introduction of antigenuria as a diagnostic test&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Method</span><p id="par0020" class="elsevierStylePara elsevierViewall">Retrospective study of all patients with positive <span class="elsevierStyleItalic">Legionella</span> antigenuria who were treated at the Lucus Augusti University Hospital between January 2001 and December 2015&#46; The diagnosis of pneumonia caused by <span class="elsevierStyleItalic">Legionella</span> was considered when patients presented with a compatible symptomatology and radiological pattern and a positive urinary antigen test for serogroup 1 of <span class="elsevierStyleItalic">L&#46; pneumophila</span>&#46; The detection of <span class="elsevierStyleItalic">L&#46; pneumophila</span> antigen serogroup<span class="elsevierStyleHsp" style=""></span>1 was carried out from 2001 to March 2015 using the immunochromatographic test &#40;Binax NOW<span class="elsevierStyleSup">&#174;</span> Legionella Urinary Antigen&#59; Alere&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">9</span></a> after urine concentration with an ultrafiltration device &#40;Millipore&#41;&#46; An immunofluorescence test was used from April 2015 until the end of the study &#40;Sofia Legionella FIA&#44; Quidel&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">10</span></a> From the time the immunofluorescence test started to be used until the end of the study period&#44; all positive urine samples were confirmed by repeating the test after boiling and subsequent centrifugation of the urine&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The epidemiological data&#44; the risk factors and the clinical data were analysed&#44; as well as the radiological and laboratory patterns&#46; The antibiotic treatment administered as well as the patient&#39;s progression were recorded&#46; The prognostic index was established using the FINE score&#46; The qualitative variables were expressed as absolute value and percentage&#46; The quantitative variables were expressed as mean and their corresponding standard deviation&#46; We studied the relationship between the independent variables analysed and an unfavourable clinical progression&#44; understood as the need to enter the intensive care unit &#40;ICU&#41; or death&#46; The chi-square test was used for comparing qualitative variables&#44; and the Student&#39;s <span class="elsevierStyleItalic">t</span>-test was used for the comparison of two quantitative variables&#46; The statistically significant variables were included in a logistic regression analysis&#46; The statistical analysis was carried out with the SPSS software 18</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0030" class="elsevierStylePara elsevierViewall">136 cases with pneumonia caused by <span class="elsevierStyleItalic">Legionella</span> were included&#46; Of the 145 patients with positive antigenuria&#44; 9 were excluded&#46; Of these&#44; 7 were interpreted as Pontiac fever because they had compatible symptomatology and 2 had suffered from pneumonia caused by <span class="elsevierStyleItalic">Legionella</span> in the previous months&#44; so they were assumed as false positives&#46; One hundred and fifteen &#40;84&#46;6&#37;&#41; were men and 21 &#40;13&#46;6&#37;&#41; women&#44; with a mean age of 64&#46;1 years &#40;SD 16&#46;9&#41;&#46; 46&#46;3&#37; were over 65 years of age&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">There were 41&#46;2 cases&#47;1&#44;000&#44;000 inhabitants&#46; <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a> shows the number of cases per year&#44; showing an increase in diagnoses throughout the period studied&#44; increasing the rate from 10&#46;9 in the first 5 years of the study to 64&#46;5 cases&#47;1&#44;000&#44;000 in the last 5 years of the study&#46; Also&#44; the number of antigenuria determination tests performed increased 3&#46;4 times between these two periods&#46; During the 3 five-year periods of the study&#44; the percentage of pneumonias caused by <span class="elsevierStyleItalic">Legionella</span> compared to the rest of pneumonias kept increasing&#44; going from 0&#46;9 to 2&#46;9 and 15&#37;&#44; respectively&#46; Almost 50&#37; of the cases took place between the months of September and November&#46; In contrast&#44; other bacterial pneumonias occurred predominantly between January and March &#40;31&#37;&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">Considering the form of acquisition&#44; none of the cases studied presented a nosocomial origin&#59; 121 were sporadic cases and 15 were linked to two outbreaks&#46; Of the latter&#44; 11 took place in 2014&#44; observing the presence of <span class="elsevierStyleItalic">Legionella</span> in the hot water circuits of 2 nursing homes&#46; Only 4 of the sporadic cases were associated with travel&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">A predisposing condition was found in 82&#46;3&#37; &#40;112&#47;136&#41; of the patients&#44; with smoking being the most frequent &#40;59&#46;6&#37;&#44; 81&#47;136&#41; followed by COPD and alcoholism &#40;both 22&#46;1&#37;&#44; 30&#47;136&#41;&#46; 21&#46;32&#37; &#40;29&#47;136&#41; of the patients had cancer&#44; HIV or another type of immunosuppression&#46; <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the risk factors and comorbidities in order of frequency&#46; In terms of gender distribution&#44; men were younger &#40;62&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>16&#46;6 vs&#46; 71&#46;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>17&#46;3&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;022&#41; and consumed alcohol &#40;26&#46;1&#37; vs&#46; 0&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;008&#41; and smoked &#40;67&#46;8&#37; vs&#46; 14&#46;3&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; more frequently&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the clinical data&#44; and <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#44; the laboratory findings analysed&#46; The most common symptoms were fever &#40;96&#37;&#44; 131&#47;136&#41;&#44; myalgias &#40;51&#46;5&#37;&#44; 70&#47;136&#41; and cough &#40;57&#46;4&#37;&#44; 78&#47;136&#41;&#46; 39&#37; &#40;53&#47;136&#41; had confusion&#46; Although 49&#46;3&#37; &#40;68&#47;136&#41; had hyponatremia&#44; a moderate &#40;or severe&#41; degree was only demonstrated by 9&#46;6&#37; &#40;13&#47;136&#41; of the cases &#40;sodium &#60;130&#41;&#46; 57&#46;8&#37; had hypertransaminasemia and 54&#46;4&#37; had microscopic haematuria&#46; 30&#37; &#40;41&#47;136&#41; had no respiratory symptomatology&#46; The most common radiological image was a single lobe consolidation &#40;70&#46;6&#37;&#44; 96&#47;136&#41;&#46; 11&#46;8&#37; &#40;16&#47;136&#41; were multilobar&#44; 8&#37; &#40;11&#47;136&#41; had a pleural effusion and only one case of cavitation&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">Almost 60&#37; &#40;80&#47;136&#41; were diagnosed in the first 24<span class="elsevierStyleHsp" style=""></span>h and 88&#46;9&#37; in the first 72<span class="elsevierStyleHsp" style=""></span>h&#46; 85&#37; &#40;116&#47;136&#41; needed hospital admission&#44; with an average stay of 11 days&#46; The days of admission were reduced over the years&#44; so that the average stay went from 12&#46;5 days between 2001&#8211;2008 to 10&#46;4 days between 2009&#8211;2015&#46; Likewise&#44; while in the first period all patients were admitted&#44; in the second&#44; 19&#37; were managed on an outpatient basis &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;007&#41;&#46; Regarding the prognosis&#44; 53&#46;7&#37; &#40;73&#47;136&#41; received the classification of FINE IV&#8211;V pneumonias&#46; In the analysis by age groups&#44; patients over 65 years of age showed FINE IV&#8211;V stages in 77&#37; of cases&#44; while in those under 65 years of age it was 30&#37;&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">80&#46;1&#37; &#40;109&#47;136&#41; of the patients received an adequate empirical antimicrobial treatment&#46; The other 19&#46;9&#37; &#40;27&#47;136&#41; were initially treated only with a beta-lactam&#44; modifying said treatment after receiving the antigenuria results&#44; usually obtained within the first 24<span class="elsevierStyleHsp" style=""></span>h&#46; This circumstance was not associated with a worse prognosis &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>ns&#41;&#46; The average duration of therapy was 13&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#46;6 days&#44; with levofloxacin being the most used antibiotic &#40;95&#46;6&#37;&#44; 130&#47;136&#41;&#46; A second active drug was combined against <span class="elsevierStyleItalic">Legionella</span> in 13&#46;2&#37; of cases&#46; The most commonly used combination was levofloxacin and azithromycin&#44; with 11&#46;8&#37; &#40;16&#47;136&#41;&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">11&#46;7&#37; &#40;16&#47;136&#41; required admission to the ICU and 4&#46;4&#37; &#40;6&#47;136&#41; died&#46; In the univariate analysis&#44; the presence of smoking&#44; COPD&#44; dyspnoea&#44; confusion&#44; low SO<span class="elsevierStyleInf">2</span>&#44; FINE &#8805;IV and diagnostic delay &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41; were associated with an unfavourable progression &#40;admission to the ICU or death&#41;&#46; Of these&#44; only COPD &#40;OR 4&#46;7&#44; IC 95&#37; 1&#46;4&#8211;15&#46;4&#41;&#44; an O<span class="elsevierStyleInf">2</span> saturation on admission lower than 90&#37; &#40;OR 6&#46;9&#44; CI 95&#37; 2&#46;0&#8211;23&#46;3&#41; and FINE &#8805;IV &#40;OR 9&#46;8&#44; CI 95&#37; 1&#46;2&#8211;82&#46;8&#41; were independent risk factors in the multivariate analysis&#44; with an area under the ROC curve obtained from 0&#46;874 &#40;IC 95&#37; 0&#46;798&#8211;0&#46;949&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0070" class="elsevierStylePara elsevierViewall">In our environment&#44; <span class="elsevierStyleItalic">Legionella</span> is an increasingly common cause of community acquired pneumonia&#44; with rates that&#44; in recent years&#44; are among the highest in Spain&#46; The elderly male population is the predominant group&#44; with a high percentage of comorbidities&#46; Regarding symptoms&#44; radiological pattern and treatment&#44; our data are generally consistent with what has been published to date&#46; Although mortality has been reduced&#44; it continues to be a common pathogen in pneumonias that require admission to the ICU&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Pneumonia caused by <span class="elsevierStyleItalic">Legionella</span> is an underdiagnosed and underreported entity worldwide&#46; The incidence in the United States has increased by 286&#37; from 2000 to 2014&#44;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">11</span></a> and in Europe it has gone from 4 cases&#47;1&#44;000&#44;000 in 1995 to 13&#44;5 in 2014&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">12</span></a> France&#44; Germany&#44; Italy and Spain represent 70&#46;3&#37; of all cases&#44; as these are countries where the disease is of compulsory reporting &#40;notifiable disease&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">13</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">For years&#44; the incidence in our country is among the highest in Europe&#44;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">14</span></a> although there are important regional differences&#46; Since the introduction and the progressive increase of antigenuria requests in our centre&#44; the incidence has increased remarkably&#44; in a similar way to other areas of our country&#46; However&#44; in other autonomous communities the incidence has stabilized&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">15</span></a> In the last years of the study our incidence equals that of Catalonia&#44; which in 2014 had the highest incidence in Spain&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">5</span></a> We do not know what the causes of this sustained case increase are regarding our study&#44; but having one of the oldest populations in Spain &#40;more than 30&#37; are over 65 years of age&#41;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">6</span></a> can contribute to this&#44; given the linear relationship between age and incidence in legionellosis&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">16</span></a> Other factors&#44; such as the change in weather conditions&#44; with an increase in temperatures in our environment in recent years&#44;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">17</span></a> and the recent increase in the use of devices that produce aerosols&#44; could also be involved&#46; As in other studies&#44;<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">18&#44;19</span></a> our cases have increased in the autumn&#44; unlike other pneumonias&#44; which predominantly occur in the winter months&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Due to the high average age of our patients&#44; these also have a higher comorbidity when compared to other series&#44;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">20</span></a> so that more than 70&#37; have some underlying disease&#44; with COPD and diabetes being the most common&#46; As in other series&#44;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">21</span></a> the main risk factor is smoking&#44; followed by alcohol consumption&#44; especially when we analyse the male sex separately&#46; Other predisposing factors described in other series&#44; such as haematological diseases&#44; HIV infection or other immunodepression states&#44;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">22</span></a> were less prevalent&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Regarding symptomatology&#44; our series does not differ substantially from that described in the literature&#44;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">1</span></a> with less pulmonary and more extrapulmonary manifestations than in pneumococcal pneumonia&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">15</span></a> Some common laboratory abnormalities were also found&#44; such as microhematuria&#44; which is rarely found in other types of pneumonias&#46; Some clinical findings&#44; such as relative bradycardia&#44; or laboratory findings&#44; such as hypophosphatemia&#44; not analysed in our study&#44; have also been associated with pneumonia caused by <span class="elsevierStyleItalic">Legionella</span> with greater specificity according to some authors&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">23</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Regarding the radiological pattern&#44; Benito et al&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">21</span></a> describes multilobar involvement in more than 50&#37; of cases and pleural effusion in 13&#46;4&#37;&#46; In our series&#44; these figures are lower&#58; more than one lung lobe were affected in 29&#46;4&#37;&#44; and only 8&#37; developed pleural effusion&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">The most severe pneumonia according to the FINE score occurred in the older age groups&#46; Clinically severe conditions were recorded in more than half of the cases&#44; which means that hospital management is predominantly required and that a significant percentage of patients require intensive care&#46; However&#44; in our study this percentage was slightly lower than in other series<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">24</span></a> and there was a progressive decrease in the number of patients admitted to the ICU during the period studied &#40;26&#37; in the first five years compared to 10&#37; in the last 5 years&#41;&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">In comparison with other older series in our country&#44;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">20</span></a> the low mortality of our case series stands out&#44; despite the high average age and high percentage of comorbidities in our patients and the relative frequency of inadequate empirical treatment&#46; An increasingly early diagnosis&#44; the inclusion of milder cases thanks to an increasingly frequent use of antigenuria&#44; and an increasing use of double treatment with beta-lactam and quinolone probably explain these findings&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">25</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">However&#44; in a time of great concern about healthcare expenditure and the increase in bacterial resistance&#44; the overuse of diagnostic tests and antibiotics can be a problem&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Concerning the use of antigenuria&#44; in our centre they increased by 320&#37; since its introduction&#44; and in the last year of the study only 1&#46;7&#37; were positive &#40;25&#47;1481&#41;&#46; While some authors<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">26</span></a> suggest that this test should only be used if there are clinical predictors suggestive of the disease&#44; the IDSA-ATS guidelines are much less restrictive&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">27</span></a> Even with these guidelines&#44; it seems clear that there is an overuse of this test in our environment&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Regarding the use of antimicrobials in our centre&#44; a high percentage of patients are admitted with a combination of beta-lactam and quinolone from the emergency department&#44; and in many of these cases an etiological diagnosis will not be obtained&#46; Since 2004&#44; in cases of atypical pneumonias&#44; our unit administers 14 days of levofloxacin&#44; which are reduced to 10 days in rapid response cases and in the absence of immunosuppression&#46; However&#44; some authors recommend shorter treatments&#58; 5&#8211;10 days with levofloxacin<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">28</span></a> and 3&#8211;5 days with azithromycin&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">29</span></a> On the other hand&#44; other authors recommend extended regimens because <span class="elsevierStyleItalic">Legionella</span> is an intracellular pathogen and short therapies can result in recurrence&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">26</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">The main limitation of the study is its retrospective nature&#46; In addition&#44; patients have been treated in various hospital services&#44; which implies differences in data collection&#46; On the other hand&#44; an exhaustive etiological study was not carried out on all patients with pneumonia&#46; In addition&#44; the only technique used by us was antigenuria&#44; which has a specificity of 100&#37; and a sensitivity for <span class="elsevierStyleItalic">L&#46; pneumophila</span> serogroup 1 that varies between 56 and 99&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">16</span></a> However&#44; it has a low sensitivity for subtype Lp1 Mab 3&#47;1-negative &#40;approximately 15&#37; of the serogroup 1&#41; and does not detect other serogroups or species&#44; so that a percentage of patients with this type of pneumonia have not been included&#46; New techniques&#44; such as PCR&#44; would include different serotypes and serogroups&#44; with a higher sensitivity than culture and a greater speed&#44; although they are not yet validated to be applied in routine clinical practice&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">30</span></a> In any case&#44; our data are similar to those published in other studies&#44; which is why we consider that they are close to the disease reality in our environment&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">In any case&#44; it is clear from the data analysed that the incidence of pneumonia caused by <span class="elsevierStyleItalic">Legionella</span> has increased during the period studied and is very high in recent years&#46; The average age and the percentage of comorbidities are higher than in other series in our country&#46; Despite this&#44; mortality has been reduced&#44; probably due to early diagnosis&#44; thanks to the increasingly common use of antigenuria and the use of quinolones&#46; In our centre&#44; since the introduction of antigenuria detection&#44; serology has lost utility in the diagnosis of this disease&#44; making it necessary to better define the indications for the antigenuria test and which patients with pneumonia can benefit from the use of quinolones&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conflict of interests</span><p id="par0135" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest&#46;</p></span></span>"
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            1 => "Neumon&#237;a at&#237;pica"
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    "resumen" => array:2 [
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Most of the data on <span class="elsevierStyleItalic">Legionella</span> pneumonia in our country come from the Mediterranean area&#44; and there are few studies from the Northwest area&#46; This study tries to assess the situation of this infection in this area&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Method</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Retrospective study of all patients with positive <span class="elsevierStyleItalic">Legionella</span> antigenuria treated at the University Hospital Lucus Augusti in Lugo &#40;Spain&#41; from 2001&#44; the year in which this test was introduced in our centre&#44; until 2015&#46; We analysed epidemiological data&#44; risk factors&#44; clinical&#44; radiological and biochemical findings&#44; and clinical outcome&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The sampled included 136 patients&#46; When comparing the first five years of the study with the last five&#44; the incidence increased from 10&#46;9 to 64&#46;5 cases&#47;1&#44;000&#44;000&#59; the number of antigenuria requests increased 3&#46;4 times&#44; and compared to other pneumonia aetiologies <span class="elsevierStyleItalic">Legionella</span> increased from 0&#46;9&#37; to 15&#37;&#46; The mean age was 64&#46;1 years and 84&#46;6&#37; were males&#59; 74&#46;3&#37; had comorbidities&#46; Males were significantly younger &#40;62&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>16&#46;6 vs&#46; 71&#46;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>17&#46;3&#41; and consumed more alcohol &#40;26&#46;1&#37; vs&#46; 0&#37;&#41; and tobacco &#40;67&#46;8&#37; vs&#46; 14&#46;3&#37;&#41;&#46; Diagnosis was established within the first 72<span class="elsevierStyleHsp" style=""></span>h in 88&#46;9&#37; of cases and most received levofloxacin &#40;95&#46;6&#37;&#41;&#46; Hospitalisation was needed in 85&#37; of cases&#44; 11&#46;7&#37; in ICU and 4&#46;4&#37; died&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">After the introduction of antigenuria there was an increase in the incidence of <span class="elsevierStyleItalic">Legionella</span> pneumonia recorded in our health area&#46; Its rate in recent years has been one of the highest in our country&#46; Despite the fact that the patients had advanced age and comorbidities&#44; mortality was low&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La mayor&#237;a de los datos de la neumon&#237;a por <span class="elsevierStyleItalic">Legionella</span> en nuestro pa&#237;s proceden del &#225;rea mediterr&#225;nea&#44; y apenas existen estudios en la zona del Noroeste&#46; Con este trabajo se pretende conocer la situaci&#243;n de la infecci&#243;n en nuestro medio&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todo</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio retrospectivo de todos los pacientes con antigenuria positiva para <span class="elsevierStyleItalic">Legionella</span> en el Hospital Universitario Lucus Augusti de Lugo desde 2001&#44; a&#241;o en que se introdujo la antigenuria como prueba diagn&#243;stica en nuestro centro&#44; hasta 2015&#46; Se analizaron datos epidemiol&#243;gicos&#44; factores de riesgo&#44; hallazgos cl&#237;nicos&#44; radiol&#243;gicos&#44; anal&#237;ticos y evolutivos&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se registraron 136 pacientes&#46; Si comparamos los primeros 5 a&#241;os del estudio con los 5<span class="elsevierStyleHsp" style=""></span>&#250;ltimos&#44; la incidencia aument&#243; de 10&#44;9 a 64&#44;5 casos&#47;1&#46;000&#46;000&#44; el n&#250;mero de peticiones de antigenuria se increment&#243; 3&#44;4 veces&#44; y con respecto a otras neumon&#237;as&#44; <span class="elsevierStyleItalic">Legionella</span> pas&#243; del 0&#44;9 al 15&#37; de ellas&#46; La edad media fue de 64&#44;1<span class="elsevierStyleHsp" style=""></span>a&#241;os&#44; y el 84&#44;6&#37; fueron varones&#46; El 74&#44;3&#37; ten&#237;an comorbilidades&#46; Los varones fueron significativamente m&#225;s j&#243;venes &#40;62&#44;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>16&#44;6 vs 71&#44;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>17&#44;3&#41; y consum&#237;an m&#225;s alcohol &#40;26&#44;1&#37; vs 0&#37;&#41; y tabaco &#40;67&#44;8&#37; vs 14&#44;3&#37;&#41;&#46; El 88&#44;9&#37; se diagnosticaron dentro de las primeras 72<span class="elsevierStyleHsp" style=""></span>h y la mayor&#237;a recibi&#243; levofloxacino &#40;95&#44;6&#37;&#41;&#46; El 85&#37; necesitaron ingreso hospitalario&#44; el 11&#44;7&#37; en UCI y el 4&#44;4&#37; fallecieron&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Coincidiendo con la introducci&#243;n de la antigenuria&#44; se observa un aumento de incidencia de neumon&#237;a por <span class="elsevierStyleItalic">Legionella</span> en nuestra &#225;rea sanitaria&#44; con tasas en los &#250;ltimos a&#241;os que se sit&#250;an entre las m&#225;s altas de nuestro pa&#237;s&#46; A pesar de tener pacientes con elevada edad media y un alto porcentaje de comorbilidades&#44; la mortalidad fue reducida&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Romay-Lema E&#44; Corredoira-S&#225;nchez J&#44; Ventura-Valc&#225;rcel P&#44; I&#241;iguez-V&#225;zquez I&#44; Garc&#237;a Pais MJ&#44; Garc&#237;a-Garrote F&#44; et al&#46; Neumon&#237;a comunitaria por <span class="elsevierStyleItalic">Legionella pneumophila</span>&#58; estudio de 136 casos&#46; Med Clin &#40;Barc&#41;&#46; 2018&#59;151&#58;265&#8211;269&#46;</p>"
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Risk factors&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Smoking</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">81 &#40;59&#46;6&#41;&nbsp;\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"><span class="elsevierStyleItalic">Consumption of alcohol</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">30 &#40;22&#46;1&#41;&nbsp;\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"><span class="elsevierStyleItalic">Underlying disease</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">101 &#40;74&#46;3&#41;&nbsp;\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"><span class="elsevierStyleHsp" style=""></span>COPD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">30 &#40;22&#46;1&#41;&nbsp;\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"><span class="elsevierStyleHsp" style=""></span>Diabetes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27 &#40;19&#46;9&#41;&nbsp;\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"><span class="elsevierStyleHsp" style=""></span>Neoplasm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">17 &#40;12&#46;5&#41;&nbsp;\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"><span class="elsevierStyleHsp" style=""></span>Chronic kidney disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15 &#40;11&#41;&nbsp;\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"><span class="elsevierStyleHsp" style=""></span>Other&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12 &#40;8&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Clinical data&nbsp;\t\t\t\t\t\t\n
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                  \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">Fever&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cough&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">50 &#40;36&#46;8&#41;&nbsp;\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">Chest pain&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Digestive symptoms&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">23 &#40;16&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Laboratory data&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Leukocytes</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#60;5000 cells&#47;&#956;l&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;2&#46;9&#41;&nbsp;\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"><span class="elsevierStyleHsp" style=""></span>5000&#8211;12&#44;000 cells&#47;&#956;l&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">59 &#40;43&#46;4&#41;&nbsp;\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"><span class="elsevierStyleHsp" style=""></span>&#62;12&#44;000 cells&#47;&#956;l&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">73 &#40;53&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Platelets</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8804;150&#44;000&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">33 &#40;24&#46;3&#41;&nbsp;\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"><span class="elsevierStyleHsp" style=""></span>&#62;150&#44;000&#8211;&#8804;400&#44;000&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">103 &#40;75&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Baseline O</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">2</span></span><span class="elsevierStyleItalic">saturation</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8804;90&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">40 &#40;29&#46;4&#41;&nbsp;\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"><span class="elsevierStyleHsp" style=""></span>&#62;90&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">96 &#40;70&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Sodium</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8805;135&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">69 &#40;50&#46;7&#41;&nbsp;\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"><span class="elsevierStyleHsp" style=""></span>129&#8211;134&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">54 &#40;39&#46;7&#41;&nbsp;\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"><span class="elsevierStyleHsp" style=""></span>125&#8211;129&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10 &#40;7&#46;4&#41;&nbsp;\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"><span class="elsevierStyleHsp" style=""></span>&#60;125&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3 &#40;2&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">78 &#40;57&#46;8&#41;&nbsp;\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"><span class="elsevierStyleItalic">Microscopic haematuria</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">50 &#40;36&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                  <table border="0" frame="\n
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">92&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;9&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">85&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6&#46;8&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;000&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">20&#46;9&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">70&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#46;1&#8211;25&#46;5&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;000&nbsp;\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">FINE &#8805;IV&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">94&#46;7&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;6&#8211;157&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;000&nbsp;\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">Relationship with outbreak&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12&#46;2&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#8211;3&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;346&nbsp;\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">Mellitus diabetes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">19&#46;1&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">25&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;5&#8211;4&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;545&nbsp;\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 kidney disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10&#46;4&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">15&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;4&#8211;5&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;549&nbsp;\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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">11&#46;3&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">15&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;4&#8211;5&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;637&nbsp;\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">Alcoholism&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">20&#46;9&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">25&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;4&#8211;3&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;678&nbsp;\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">Smoking&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">55&#46;7&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">80&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#8211;10&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;041&nbsp;\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">COPD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">15&#46;7&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">55&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;4&#8211;18&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;000&nbsp;\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">Dyspnoea&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">33&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">60&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;1&#8211;8&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;021&nbsp;\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">Confusion&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">33&#46;9&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">65&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;3&#8211;9&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;008&nbsp;\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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">96&#46;5&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">95&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;1&#8211;6&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;739&nbsp;\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">Respiratory symptoms&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">69&#46;6&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">75&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;4&#8211;3&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;623&nbsp;\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">Digestive symptoms&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">14&#46;8&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">30&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;8&#8211;7&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;095&nbsp;\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">Myalgia&#47;arthralgias&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">49&#46;6&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">60&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;6&#8211;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;389&nbsp;\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">Hypertransaminasemia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">55&#46;1&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">75&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;8&#8211;7&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;098&nbsp;\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">Hyponatremia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">47&#46;8&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">60&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;6&#8211;4&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;315&nbsp;\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">Haematuria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">33&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">55&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;9&#8211;6&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;059&nbsp;\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">Pleural effusion&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&#46;8&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;1&#8211;5&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;656&nbsp;\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">Incorrect antibiotic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">20&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">20&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;3&#8211;2&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Univariate analysis of prognostic factors related to unfavourable progression&#46;</p>"
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      ]
    ]
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      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0015"
          "bibliografiaReferencia" => array:30 [
            0 => array:3 [
              "identificador" => "bib0155"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Legionnaires&#8217; disease"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "B&#46;A&#46; Cunha"
                            1 => "A&#46; Burillo"
                            2 => "E&#46; Bouza"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "The Lancet"
                        "fecha" => "2016"
                        "volumen" => "387"
                        "paginaInicial" => "376"
                        "paginaFinal" => "385"
                      ]
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Legionellosis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "J&#46;E&#46; Stout"
                            1 => "V&#46;L&#46; Yu"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1056/NEJM199709043371006"
                      "Revista" => array:6 [
                        "tituloSerie" => "N Engl J Med"
                        "fecha" => "1997"
                        "volumen" => "337"
                        "paginaInicial" => "682"
                        "paginaFinal" => "687"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9278466"
                            "web" => "Medline"
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              "etiqueta" => "3"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Legionnaires&#8217; disease&#58; report of sixty-five nosocomially acquired cases and review of the literature"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "B&#46;D&#46; Kirby"
                            1 => "K&#46;M&#46; Snyder"
                            2 => "R&#46;D&#46; Meyer"
                            3 => "S&#46;M&#46; Finegold"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Medicine &#40;Baltimore&#41;"
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                        "volumen" => "59"
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                        "paginaFinal" => "205"
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              "etiqueta" => "4"
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                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "La evaluaci&#243;n de costes aplicada a los brotes de legionelosis&#58; una aproximaci&#243;n XII Congreso Espa&#241;ol de Salud Ambiental y VIII Conferencia Nacional de Disruptores Endocrinos"
                      "autores" => array:1 [
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Article information

ISSN: 23870206
Original language: English

DOI:10.1016/j.medcle.2018.08.004

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