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Clinical and microbiological characteristics of community-acquired pneumonia associated with Streptococcus pneumoniae in adult patients in Mexico
Características clínicas y microbiológicas de la neumonía adquirida en la comunidad asociada con Streptococcus pneumoniae en pacientes adultos en México
Gabriela Echaniz-Avilesa, Elvira Garza-Gonzálezb, Alma Lucía Román-Manchac, Rayo Morfín-Oterod, Eduardo Rodríguez-Noriegad, Juan Jacobo Ayala-Gaytáne, Claudia Elena Guajardo-Larae, Araceli Soto-Noguerona, Maria Noemí Carnalla-Barajasa, Adrián Camacho-Ortizc,
Corresponding author
acamacho_md@yahoo.com

Corresponding author.
a Instituto Nacional de Salud Pública, Cuernavaca, Morelos, Mexico
b Servicio de Gastroenterología y Departamento de Patología Clínica, Hospital Universitario “Dr. José Eleuterio González”, Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, Mexico
c Coordinación de Epidemiología Hospitalaria, Hospital Universitario “Dr. José Eleuterio González”, Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, Mexico
d Departamento de Infectología, Hospital Civil Fray Antonio Alcalde, e Instituto de Patología Infecciosa, Guadalajara, Jalisco, Mexico
e Hospital San José Tec de Monterrey, Monterrey, Nuevo León, Mexico
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Distinctive bacterial pathogens that cause CAP include <span class="elsevierStyleItalic">S&#46; pneumoniae</span>&#44; and <span class="elsevierStyleItalic">Haemophilus influenzae</span>&#59; the first species being a leading causative agent<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">9&#44;17</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">As a consequence of extensive antibiotic use&#44; the incidence of <span class="elsevierStyleItalic">S&#46; pneumoniae</span> drug resistance has increased alarmingly&#59; up to 30&#37; of <span class="elsevierStyleItalic">S&#46; pneumoniae</span> strains worldwide are now considered to be multidrug-resistant<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">11&#44;12</span></a>&#46; Thus&#44; surveillance of the drug resistance of this microorganism in various populations and age groups is important<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">15</span></a>&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">In 2006&#44; the first vaccine for the prevention of infections associated with <span class="elsevierStyleItalic">S&#46; pneumoniae</span> in children was introduced in Mexico&#46; The heptavalent conjugated pneumococcal vaccine &#40;PCV7&#41; included seven serotypes &#40;4&#44; 6B&#44; 9V&#44; 14&#44; 18C&#44; 19F&#44; and 23F&#41; and was distributed in lower-income municipalities&#46; It was incorporated into the Mexican universal immunization program in 2008<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">15</span></a> and was replaced in 2011 by PCV13&#44; which additionally includes serotypes 1&#44; 3&#44; 5&#44; 6A&#44; 7F&#44; and 19A in a 2<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>1 schedule<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">6&#44;14</span></a>&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">For the prevention of disease in adults aged &#8805;65 years&#44; the pneumococcal polysaccharide vaccine &#40;PPSV 23&#41; is recommended as part of the Mexican universal immunization program since 1983&#46; This vaccine protects against 23 serotypes &#40;1&#44; 2&#44; 3&#44; 4&#44; 5&#44; 6B&#44; 7F&#44; 8&#44; 9N&#44; 9V&#44; 10A&#44; 11A&#44; 12F&#44; 14&#44; 15B&#44; 17F&#44; 18C&#44; 19A&#44; 19F&#44; 20&#44; 22F&#44; 23F and 33F&#41;&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Epidemiological surveillance of pathogens associated with vaccine-preventable diseases in specific populations and age groups is relevant to detect changes in epidemiology over time and to guide public health policy and the development of control strategies<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">5</span></a>&#46; Vaccine coverage for a targeted adult population is based on surveys<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">5</span></a>&#46; Information about circulating <span class="elsevierStyleItalic">S&#46; pneumoniae</span> serotypes in adult patients in Mexico with CAP and the drug susceptibility of these serotypes is scarce&#44; as the <span class="elsevierStyleItalic">Sistema Regional de Vacunas</span> Laboratory Surveillance Program initially focused on children with invasive pneumococcal infections<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">8</span></a>&#46; Thus&#44; there remains a huge need to describe the clinical and microbiological characteristics of CAP in adult patients in Mexico&#46; This need is supported by the Mexican data requirement for the authorized introduction of PCV13 for adults&#46; The aim of this study was to assess the risk factors&#44; microbiology&#44; and antibiotic resistance of CAP in adult patients in Mexico&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Design&#44; setting&#44; and patients</span><p id="par0040" class="elsevierStylePara elsevierViewall">Data and samples from patients who presented to three tertiary care hospitals over a 15-year period &#40;January 2000&#8211;September 2015&#41; were included in this study&#46; The institutions were the Hospital Universitario Dr&#46; Jos&#233; Eleuterio Gonz&#225;lez&#44; a 500-bed public hospital in the city of Monterrey&#59; the Hospital San Jos&#233;&#44; Tec de Monterrey&#44; a 220-bed private hospital&#59; and the Hospital Civil Fray Antonio Alcalde de Guadalajara&#44; a 1000-bed public hospital&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Cases with clinical and radiological evidence of CAP were detected through a retrospective review of all respiratory samples received from the microbiology laboratory of each hospital&#46; Inclusion criteria were age &#8805;18 years&#44; lower respiratory tract &#40;LRT&#41; sample obtained within 48<span class="elsevierStyleHsp" style=""></span>h of hospital admission&#44; radiographic evidence of new infiltrate&#44; and three or more of the following symptoms&#58; dyspnea&#44; hemoptysis&#44; cough&#44; sputum production&#44; chest pain&#44; fever&#44; headache&#44; and abnormalities on chest auscultation or percussion&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Only patients with radiological changes consistent with pneumonia radiology reports were included&#46; Clinical data&#44; including outcomes&#44; comorbidities&#44; and antibiotic prescriptions&#44; were recovered retrospectively from the patients&#8217; hospital records&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Patients with at least one positive <span class="elsevierStyleItalic">S&#46; pneumoniae</span> culture and a clinical diagnosis of pneumonia were included&#46; We also included patients with invasive disease for the comparison of clinical and microbiological data&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Clinically relevant non-invasive CAP isolates were defined as those from sputum&#44; transtracheal aspiration&#44; or bronchoalveolar lavage and others in which <span class="elsevierStyleItalic">S&#46; pneumoniae</span> grew as a single or predominant colony&#46; Sputum samples with&#62;25 leukocytes and &#60;10 epithelial cells per low-power field were processed&#46; The clinical diagnosis of pneumonia was based on &#40;a&#41; positive <span class="elsevierStyleItalic">S&#46; pneumoniae</span> culture&#44; &#40;b&#41; positive radiographic findings&#44; &#40;c&#41; and clinical data indicating pneumonia&#46; Invasive isolates were isolated from blood&#44; cerebrospinal fluid&#44; pleural fluid&#44; and ascites&#46; Specimens were processed according to the guidelines described in the Clinical Microbiology Procedures Handbook&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Patients for whom clinical information was available were included&#46; Sex&#44; age&#44; length of hospital stay&#44; and overall mortality rate&#44; as well as comorbidities and laboratory results&#44; were analyzed&#46; Two different periods were analyzed&#58; the pre-PCV7 period considered from the year 2000 to 2007 and the post-PCV7&#8211;PCV13 period from 2008 to 2015&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">This work was approved by the Ethical Committee of Universidad de Guadalajara&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Microbiological and susceptibility testing</span><p id="par0070" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">S&#46; pneumoniae</span> isolates were identified by standard procedures and characteristics&#44; including Gram staining&#44; negative catalase results&#44; sensitivity to optochin&#44; and bile solubility testing&#46; Serotyping was performed using the Quellung reaction and serum from the Statens Serum Institut &#40;Copenhagen&#44; Denmark&#41;&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Susceptibility testing was performed by broth microdilution following the guidelines of the Clinical and Laboratory Standards Institute<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">3</span></a>&#46; Susceptibility to penicillin&#44; erythromycin&#44; chloramphenicol&#44; cefotaxime&#44; trimethoprim&#47;sulfamethoxazole&#44; and vancomycin was tested&#46; <span class="elsevierStyleItalic">S&#46; pneumoniae</span> ATCC 4919 was used as a control strain&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Statistical analysis</span><p id="par0080" class="elsevierStylePara elsevierViewall">We used conventional dispersion methods for description and non-parametric tests for comparison of the data&#46; The chi-squared test was used to compare dichotomous variables&#44; and the Wilcoxon rank-sum test was used for linear variables&#46; <span class="elsevierStyleItalic">p</span> values &#8804;0&#46;05 were considered to be significant&#46; Analyses were conducted using SPSS software &#40;version 18&#59; SPSS Inc&#46;&#44; Chicago&#44; IL&#44; USA&#41;&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Results</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Isolates&#44; study population&#44; and clinical data</span><p id="par0085" class="elsevierStylePara elsevierViewall">A total of 96 <span class="elsevierStyleItalic">S&#46; pneumoniae</span> isolates with the patients&#8217; clinical information were included in the study&#46; Sites of isolation were non-invasive LRT secretions &#40;CAP&#59; n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>66&#41;&#59; other non-invasive clinical samples &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>5&#41; and invasive specimens &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>25&#41;&#58; blood &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>12&#41;&#44; cerebrospinal fluid &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>6&#41;&#44; ascites &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#41;&#44; pleural fluid &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>5&#41;&#44; and brain abscess &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#41;&#46; The CAP group included more men &#40;74&#46;6&#37;&#41; than the invasive group &#40;52&#37;&#41;&#46; The median patient age was 43 years &#40;range&#44; 18&#8211;94 years&#41;&#44; and 66 &#40;68&#46;7&#37;&#41; patients were male&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">The length of hospital stay ranged from 0 to 115 days &#40;median&#44; 10 days&#59; <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; Head trauma was the most frequent comorbidity in patients with LRT <span class="elsevierStyleItalic">S&#46; pneumoniae</span> &#40;21&#46;12&#37;&#41;&#44; and neoplasms were most frequent in patients with invasive strains &#40;12&#37;&#41;&#46; Demographic and clinical characteristics are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Serotypes and drug susceptibility</span><p id="par0095" class="elsevierStylePara elsevierViewall">All pneumococcal isolates were serotyped with twenty-nine serotypes identified&#59; 4 strains were considered non-typable&#46; Serotype 19A was the most common serotype &#40;19&#47;19&#46;8&#37;&#41;&#44; followed by serotypes 3 &#40;11&#47;11&#46;4&#37;&#41; and 23F &#40;7&#47;7&#46;3&#37;&#41;&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">We detected serotypes included in any of the four available vaccines &#40;3&#44; 4&#44; 6B&#44; 9V&#44; 14&#44; 19F&#44; 23F&#44; 19A&#44; 9N&#44; 11A&#44; 15B&#44; 17F&#44; 20&#44; 22F&#44; and 35B&#41; and 13 serotypes not included in any currently available vaccine &#40;6C&#44; 7C&#44; 13&#44; 15&#44; 15A&#44; 18A&#44; 15C&#44; 16F&#44; 23A&#44; 23B&#44; 24F&#44; 28A&#44; and 38&#41;&#46; We also detected serotype 6A&#44; which is included in PCV13 but not in the polyvalent PPSV23 recommended for the adult population &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; Serotypes 1&#44; 5&#44; 7F&#44; 2&#44; 8&#44; 10A&#44; 12F&#44; and 18C&#44; which are included in any of the PCV7&#44; PCV10&#44; PCV13&#44; or PPSV23 vaccines&#44; were not detected&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">When examined by the pre- and post PCV7 periods&#44; we found 18 pneumococcal isolates in the pre-PCV7 and 78 in the post-PCV7&#8211;PCV13 period&#46; The circulation of PCV7 serotypes declined after 2008 &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;0003&#41;&#44; whereas no reduction was observed for the PCV13 serotypes&#46; A slight but non-significant increase in the circulation of serotype 19A in the post-PCV period was detected &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; There were 4 &#40;22&#46;2&#37;&#41; invasive pneumococcal infections in the pre-PCV7 period and 20 &#40;25&#46;6&#37;&#41; in the post-PCV7-PCV13 period compared to 14 &#40;77&#46;7&#37;&#41; and 58 &#40;74&#46;3&#37;&#41; non-invasive infections&#44; respectively&#44; as shown in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#46; Isolates not included in any vaccine were only found in the post-PCV7-PCV13 period&#46; No significant differences were found between serotypes causing invasive and non-invasive diseases as shown in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#44; with serotypes 3 and 19A as the most frequent serotypes in both infections&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">There were 6 pneumococcal meningitis cases reported in the post PCV7 period&#44; and 3 of them showed resistance to penicillin&#46; All of them were susceptible to cefotaxime&#46; For non-meningitis isolates&#44; an important reduction in susceptibility to all antimicrobials except vancomycin &#40;100&#37; in all isolates&#41; during the study period was observed &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#44; particularly for erythromycin and TMP&#47;SMX&#46; Most of the increase in antimicrobial resistance was due to serotype 19A in the post-PCV7-PCV13 period &#40;data not shown&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Discussion</span><p id="par0115" class="elsevierStylePara elsevierViewall">In this study&#44; we aimed to assess the risk factors and microbiological characteristics of CAP in adult patients from three tertiary teaching hospitals in Mexico over a period of 15 years&#46; The most frequent comorbidity in patients with CAP <span class="elsevierStyleItalic">S&#46; pneumoniae</span> was head trauma&#46; This association is difficult to explain&#44; as head trauma is viewed as a risk factor for infection with invasive isolates&#44; rather than CAP isolates&#46; The most frequent comorbidities in patients with non-respiratory strains were neoplasms&#44; which is not surprising because invasive disease &#40;septicemia&#41; caused by <span class="elsevierStyleItalic">S&#46; pneumoniae</span> is a common complication of cancer&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Invasive pneumococcal disease is common in Latin America<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">2&#44;4&#44;16</span></a>&#44; and the effectiveness of PPSV23 in adult patients varies significantly&#46; Thus&#44; adequate information about circulating serotypes is crucial to define vaccination strategies and aid vaccine development&#46; In this study&#44; we analyzed <span class="elsevierStyleItalic">S&#46; pneumoniae</span> serotype frequencies according to vaccine periods&#46; The changes detected before and after PCV7 and PCV13 were smaller in these adults than in those reported for children&#44; in whom increases in serotypes 19A and 7C and a dramatic reduction in serotype 19A after the introduction of PCV13 have been detected<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">7</span></a>&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Theoretical serotype vaccine coverage for the pre-PCV7 and the post-PCV7&#8211;PCV13 periods were 55&#46;5&#37; and 12&#46;8&#37; for PCV7&#59; 77&#46;8&#37; and 34&#46;6&#37; for PCV13 and 94&#46;4&#37; and 60&#46;3&#37; for PPS23 respectively&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">The most prevalent serotype in this study during the period before the introduction of PCV7 was 23F&#44; followed by serotypes 6B&#44; 19A&#44; and 19F&#46; After the introduction of PCV7&#44; the frequencies of serotypes 23F and 6B decreased&#44; and serotypes 19A and 15B predominated&#46; With the introduction of PVC13&#44; serotype 19A continued to be predominant&#44; followed by serotypes 3 and 23A&#46; Although the prevalence of serotype 19A declined after the introduction of PCV13 in children&#44; no such effect was observed in the adults in this study&#59; on the contrary&#44; the frequency of this serotype increased slightly&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Even with the recent changes in dosing regimens for PCV<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">10</span></a>&#44; an epidemiological impact is apparent in adults&#44; with a reduction in PCV7 serotypes after 2008&#46; In the current study&#44; we detected no reduction in PCV13 or PPSV23 serotypes&#46; This finding has also been reported for the Japanese population<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">15</span></a>&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">After the introduction of PCV7 for children under 2 years&#44; there has been a decrease in the transmission of the included serotypes to adults&#46; This could be due to a herd effect but cannot be concluded with certainty&#46; Serotypes 3 and 19A have low immunogenicity &#40;PCV13&#41;&#44; so they do not manage to generate a decrease in colonization of vaccinated children&#44; so they continue to be transmitted to adults&#46; It underscores the need for surveillance of specific populations&#44; particularly adults &#40;including those with CAP&#41;&#44; because this population may be a reservoir for different serotypes and the effects seen in children do not reflect protection of older and susceptible community members&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">In one of the largest and most recent studies of the antimicrobial susceptibility of <span class="elsevierStyleItalic">S&#46; pneumoniae</span> conducted in Latin America<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">12</span></a>&#44; 182 <span class="elsevierStyleItalic">S&#46; pneumoniae</span> isolates were found to be predominantly non-susceptible to penicillin &#40;51&#46;6&#37;&#41;&#44; with the highest rates of resistance observed in Mexico &#40;84&#46;8&#37;&#41; and Venezuela &#40;81&#46;2&#37;&#41;&#46; Similarly&#44; elevated non-susceptibility rates for ceftriaxone were detected in both countries &#40;21&#46;1&#8211;43&#46;7&#37;&#41;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">12</span></a>&#46; We identified a notable increase in non-susceptibility to penicillin in our isolates and a steady decrease in susceptibility to cephalosporins&#59; both changes are much greater than previously reported<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">8</span></a>&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">For community meningitis in our population&#44; cefotaxime or ceftriaxone plus vancomycin are used&#46; For NAC&#44; levofloxacin or ceftriaxone plus a macrolide are used&#46; If there is suspicion of penicillin-resistant <span class="elsevierStyleItalic">S&#46; pneumoniae</span>&#44; then vancomycin is added&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Lower susceptibility to trimethoprim&#47;sulfamethoxazole and similar susceptibility to erythromycin have been found in isolates collected from children<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">1</span></a>&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">This study has several limitations&#46; As we were not able to document the patients&#8217; immunization status&#44; the influence of vaccination on the selection of individual serotypes remains unclear&#46; In addition&#44; we included sputum samples&#44; which are practical&#44; but imperfect&#44; specimens for the microbiological investigation of CAP&#46; Microscopic examination of sputum quality was performed for all samples&#44; and only mucopurulent material was tested&#46; Nevertheless&#44; sputum is always at risk of contamination with oropharyngeal microbiota&#46; Despite these limitations&#44; national guidelines recommend sputum investigation for patients admitted to hospital with moderate to severe CAP&#44; to aid microbiological diagnosis<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">13</span></a>&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">In this study&#44; more patients with CAP than with invasive disease were male&#44; and head trauma was the most common comorbidity in the CAP group&#46; The most prevalent serotype was 19A&#44; and the proportion of PCV7 serotypes declined after 2008&#59; no reduction in PCV13 serotypes was observed&#46; Decreased susceptibility to most antimicrobials tested was observed&#46; Our results underscore the need for surveillance of the adult population to aid in the control of diseases associated with <span class="elsevierStyleItalic">S&#46; pneumoniae</span>&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Conflict of interest</span><p id="par0175" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The aim of this study was to assess the risk factors and clinical and microbiological characteristics of community-acquired pneumonia &#40;CAP&#41; in adult patients in Mexico&#46; <span class="elsevierStyleItalic">Streptococcus pneumoniae</span> classified as the causative agent of CAP in adult patients and patients with invasive <span class="elsevierStyleItalic">S&#46; pneumoniae</span> isolates presented to three tertiary teaching hospitals during the 15-year study period were selected&#46; Serotyping and susceptibility testing were performed for all included isolates&#46; Clinical and demographic data were recorded&#46; A total of 96 patients infected with <span class="elsevierStyleItalic">S&#46; pneumoniae</span> &#40;71 with CAP&#44; 25 with invasive disease&#41; were included&#46; The CAP group involved more males &#40;74&#46;6&#37;&#41; than the invasive disease group &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;03&#41;&#46; Head trauma was more common in the CAP group &#40;21&#46;1&#37;&#41; than in the invasive disease group &#40;4&#46;0&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;03&#41;&#46; The most prevalent serotype was 19A&#44; followed by serotypes 3 and 23F&#46; After the introduction of the heptavalent conjugated pneumococcal vaccine &#40;PCV7&#41;&#44; the prevalence of included serotypes declined significantly&#59; no such change was found after the introduction of the PCV13 vaccine&#44; including in the prevalence of serotype 19A&#46; Susceptibility to all antimicrobials tested except vancomycin declined over the study period&#46; In conclusion&#44; head trauma was the most common comorbidity in the CAP group&#46; The most prevalent serotype was 19A&#46; Decreased susceptibility to most antimicrobials tested was observed&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">El objetivo de este estudio fue evaluar los factores de riesgo y las caracter&#237;sticas cl&#237;nicas y microbiol&#243;gicas de la neumon&#237;a adquirida en la comunidad &#40;NAC&#41; en pacientes adultos en M&#233;xico&#46; Se seleccionaron pacientes adultos con NAC con <span class="elsevierStyleItalic">Streptococcus pneumoniae</span> como agente causal y pacientes con aislamientos invasivos de <span class="elsevierStyleItalic">S&#46; pneumoniae</span> que concurrieron a tres hospitales de ense&#241;anza de tercer nivel durante el per&#237;odo de estudio de 15 a&#241;os &#40;2000-2015&#41;&#46; Se realizaron pruebas de serotipificaci&#243;n y sensibilidad con todos los aislados incluidos&#46; Se colectaron los datos cl&#237;nicos y demogr&#225;ficos&#46; Se incluyeron en total 96 pacientes infectados con <span class="elsevierStyleItalic">S&#46; pneumoniae</span> &#40;71 con NAC y 25 con enfermedad invasiva&#41;&#46; El grupo con NAC inclu&#237;a m&#225;s varones &#40;74&#44;6&#37;&#41; que el grupo de enfermedad invasiva &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;03&#41;&#46; El traumatismo craneoencef&#225;lico fue m&#225;s frecuente en el grupo NAC &#40;21&#44;1&#37;&#41; que en el grupo con enfermedad invasiva &#40;4&#44;0&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;03&#41;&#46; El serotipo m&#225;s frecuente fue 19A&#44; seguido de los serotipos 3 y 23F&#46; Despu&#233;s de la introducci&#243;n de la vacuna antineumoc&#243;cica conjugada heptavalente &#40;PCV7&#41;&#44; la prevalencia de los serotipos incluidos en aquella disminuy&#243; significativamente&#59; no sucedi&#243; lo mismo despu&#233;s de la introducci&#243;n de la PCV13&#44; incluso en relaci&#243;n con la prevalencia del serotipo 19A&#46; La sensibilidad a todos los antimicrobianos evaluados&#44; excepto la vancomicina&#44; disminuy&#243; durante el per&#237;odo de estudio&#46;</p><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">En conclusi&#243;n&#44; el traumatismo craneoencef&#225;lico fue la comorbilidad m&#225;s frecuente en el grupo con NAC&#46; El serotipo m&#225;s frecuente fue el 19A&#44; y se observ&#243; disminuci&#243;n de la sensibilidad a la mayor&#237;a de los antimicrobianos probados a lo largo del per&#237;odo considerado&#46;</p></span>"
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          "leyenda" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">LOS&#44; length of stay&#59; HIV&#47;AIDs&#44; human immunodeficiency virus infection&#47;acquired immunodeficiency syndrome&#46; LRT&#58; Lower respiratory tract&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Characteristic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Totaln<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>96&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">CAP &#40;LRT Non-invasive-isolates&#41;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>66&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Invasive isolatesn<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Male&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">66 &#40;68&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">53 &#40;74&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13 &#40;52&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;03&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Median age y &#40;range&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">43 &#40;94&#8211;14&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">42 &#40;94&#8211;14&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">48 &#40;80&#8211;16&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">LOS &#40;days&#41; &#40;mean</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#177;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">SD&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10 &#40;115&#8211;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11 &#40;115&#8211;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8 &#40;52&#8211;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;32&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">28-Day mortality&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14 &#40;14&#46;58&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8 &#40;11&#46;26&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6 &#40;24&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Primarily medical diagnosis&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">65 &#40;66&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">44&#40;61&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">20 &#40;80&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Comorbidities</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Diabetes&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11 &#40;15&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9 &#40;12&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;8&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;72&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>HIV&#47;AIDs&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4 &#40;4&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;4&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;4&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;96&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cancer&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8 &#40;8&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;7&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;12&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;72&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Head trauma&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16 &#40;16&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15 &#40;21&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;4&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;03&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Renal insufficiency&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;3&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;4&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Pregnancy&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;2&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;1&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;4&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;45&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Laboratory results &#40;mean</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#177;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">SD&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  """
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              ]
              "imagenFichero" => array:1 [
                0 => "xTab2120354.png"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Distribution of pneumococcal serotypes isolated from invasive and non-invasive diseases by vaccine period in adult population in Mexico&#46;</p>"
        ]
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      3 => array:8 [
        "identificador" => "tbl0020"
        "etiqueta" => "Table 4"
        "tipo" => "MULTIMEDIATABLA"
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        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at4"
            "detalle" => "Table "
            "rol" => "short"
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          "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">The following breakpoints were used for the interpretation of penicillin susceptibility&#46; For non-meningeal cases&#58; S&#58; susceptible&#44; S&#44; &#8804;2<span class="elsevierStyleHsp" style=""></span>mg&#47;l&#59; I&#44; 4<span class="elsevierStyleHsp" style=""></span>mg&#47;l&#59; and R&#44; &#8805;8<span class="elsevierStyleHsp" style=""></span>mg&#47;l&#46; For meningeal cases&#58; S&#44; &#8804;0&#46;06<span class="elsevierStyleHsp" style=""></span>mg&#47;l&#44; and R&#44; &#8805;0&#46;12<span class="elsevierStyleHsp" style=""></span>mg&#47;l&#46; The following breakpoints were used for cefotaxime&#46; For non-meningeal cases&#58; S&#44; &#8804;1<span class="elsevierStyleHsp" style=""></span>mg&#47;l&#59; I&#44; 2<span class="elsevierStyleHsp" style=""></span>mg&#47;l&#59; and R&#44; &#8805;4<span class="elsevierStyleHsp" style=""></span>mg&#47;l&#46; For meningeal cases&#58; S&#44; &#8804;0&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;l&#59; I&#44; 1<span class="elsevierStyleHsp" style=""></span>mg&#47;l&#59; and R&#44; &#8805;2<span class="elsevierStyleHsp" style=""></span>mg&#47;l&#46;</p><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">S&#58; susceptible&#44; I&#58; intermediate&#59; R&#58; resistant&#59; PEN&#58; Penicillin&#59; CTX&#58; cefotaxime&#59; ERY&#58; erythromycin&#59; CHL&#58; chloramphenicol&#59; TMP&#47;SXT&#44; trimethoprim&#47;sulfamethoxazole&#46; All isolates were susceptible to vancomycin&#46;</p><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Value <span class="elsevierStyleItalic">p</span> represents significance in decreased susceptibility&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
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                0 => """
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Vaccine period&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">PEN meningitis &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">ERY &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>96&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">4 &#40;4&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1 &#40;1&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">11 &#40;11&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="8" align="left" valign="\n
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                  \t\t\t\t  " colspan="8" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Post-PCV7 &#40;n</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#61;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">78&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>S&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">41 &#40;45&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">49 &#40;51&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">58 &#40;60&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>I&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">20 &#40;22&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18 &#40;20&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15 &#40;15&#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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>R&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">3 &#40;50&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">0 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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ISSN: 03257541
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos