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Épico project. Development of educational recommendations using the DELPHI technique on invasive candidiasis in non-neutropenic critically ill adult patients
Proyecto Épico: Formulación de unas recomendaciones educativas con metodología DELPHI para pacientes adultos críticos no neutropénicos y con candidiasis invasiva
R. Zaragozaa,
Corresponding author
zaragozar@ono.com

Corresponding author.
, P. Llinaresb, E. Masedac, R. Ferrerd, A. Rodrígueze, the Épico Project Group
a Servicio de Medicina Intensiva, Hospital Universitario Dr. Peset, Valencia, Spain
b Unidad de Enfermedades Infecciosas, Complejo Hospitalario Universitario A Coruña, A Coruña, Spain
c Servicio de Anestesiología y Reanimación, Hospital Universitario La Paz, Madrid, Spain
d Servicio de Medicina Intensiva, Hospital Universitario Mútua de Terrasa, Terrasa, Barcelona, Spain
e Servicio de Medicina Intensiva, Hospital Universitario Juan XXIII, Tarragona, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The incidence of candidemia in non-neutropenic critically ill patients has significantly increased in the past years&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#8211;9</span></a> In our country&#44; the estimated incidence of candidemia is 4&#46;3 episodes&#47;10<span class="elsevierStyleSup">5</span> habitants&#44;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> of which 33&#8211;55&#37; of the cases are located in the Intensive Care Units &#40;ICU&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> although this percentage may have decreased in the last few years&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">In addition to the increased incidence&#44; a change in the distribution of the different <span class="elsevierStyleItalic">Candida</span> species has been observed&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">47</span></a><span class="elsevierStyleItalic">Candida albicans</span> continues to be the predominant species in the ICU&#44;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> representing approximately half of the isolates&#46; According to a recent epidemiological study published&#44;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">49</span></a><span class="elsevierStyleItalic">Candida parapsilosis</span> and <span class="elsevierStyleItalic">Candida glabrata</span> are the second and third most common isolated species in our country&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">In addition to the important financial burden on the health systems&#44; <span class="elsevierStyleItalic">Candida</span> infections and candidemia are associated to elevated high mortality rate in critically ill patients&#46; Candidemia is associated in the United States with a 14&#46;5&#37; increase of the mortality rate in adults&#44; and a 10&#37; increase in pediatric patients&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">66</span></a> On the other hand&#44; the crude mortality rates and mortality rates associated to invasive candidiasis have been established at 40&#8211;78&#37; and 20&#8211;40&#37;&#44; respectively&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#44;56</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">During the last few years&#44; new antifungal agents have offered different alternatives in the treatment of invasive candidiasis&#46; However&#44; and due to the heterogeneity of the recommendations from the different scientific societies&#44;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;15&#44;47</span></a> the most effective therapeutic strategy has not yet been established&#44; resulting in a remarkable lack of consensus when establishing the diagnosis and most appropriate treatment for this patient population&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The main objective of this research study is to analyze the present situation in the management of invasive candidiasis in non-neutropenic critically ill patients in our country&#39;s hospitals&#46; For this purpose&#44; between January and September 2012&#44; a panel of specialists from 5 scientific societies was formed &#8211; The Spanish Association of Mycology &#40;AEM&#41; as promoter&#44; the Spanish Society of Infectious Diseases and Clinical Microbiology &#40;SEIMC&#41;&#59; the Spanish Society of Anesthesiology&#44; Reanimation and Pain Therapeutics &#40;SEDAR&#41;&#59; The Spanish Society of Critical&#44; Intensive and Coronary Medicine Units &#40;SEMICYUC&#41;&#59; and the Spanish Society of Chemotherapy &#40;SEQ&#41; &#8211; with extensive experience in the treatment of non-neutropenic critically ill patients&#44; who were requested to complete a questionnaire elaborated by the 5 coordinators responsible for the research&#44; after having made a thorough review of the literature of the last five years&#46; In the cases in which no consensus was reached&#44; the experts detailed the reasons for the divergent opinions&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Once the coordinating group selected several recommendations&#44; a second face to face meeting was held with 80 specialists from the entire national geography&#44; who commonly care for critically ill adult patients with invasive candidiasis&#44; who voted and validated the preselected recommendations&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Methods</span><p id="par0035" class="elsevierStylePara elsevierViewall">The panel of specialists was composed of 25 specialists with a wide geographical distribution in our country&#44; pertaining to the five scientific societies collaborating in the research&#46; The criteria of inclusion were based on their experience in the research of candidemia and on the prognostic and clinical management of non-neutropenic critically ill patients with a suspected or confirmed onset of invasive candidiasis&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The DELPHI technique was used to carry out the study with the objective of optimizing the consultation process of the 25 panel members&#46; Specifically&#44; the DELPHI methodology enables group opinions&#44; and not merely individual opinions&#44; from the experts in the different areas of information provided by the coordinators&#46; A consensus greater than 75&#37; &#40;19&#8211;25 participants&#41; was required in each of the questions formulated&#46; In the cases in which the majority of the responses to a given question were shared by 15&#8211;18 participants&#44; the degree of consensus was established as medium&#44; whereas in those cases in which consensus was only shared by 14 or less experts&#44; the degree of consensus was defined as low&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The 47 total questions elaborated by the coordinators &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41; are distributed in five different sections or specialties&#58; Epidemiological section&#44; 6 questions &#40;developed by E&#46;M&#46; and P&#46;L&#46;&#41;&#59; Scores section&#44; 5 questions &#40;developed by A&#46;R&#46; and R&#46;Z&#46;&#41;&#59; Laboratory diagnosis section&#44; 14 questions &#40;developed by R&#46;Z&#46; and A&#46;R&#46;&#41;&#59; Treatment section&#44; 11 questions &#40;developed by P&#46;L&#46; and E&#46;M&#46;&#41;&#59; and Therapeutic de-escalation section&#44; 9 questions &#40;developed by R&#46;F&#46; and R&#46;Z&#46;&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">The study was carried out in two phases&#46; In the first one&#44; and with the objective of detecting the degree of consensus&#44; between May 18 and 29&#44; 2012&#44; the 25 specialists &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41; completed anonymously on Internet the categorical and metric scale questionnaire &#40;majority&#41;&#46; The coordinators responsible for the systematic search of the literature to elaborate the questions did not answer the questionnaire&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">The questions that did not achieve the necessary consensus &#8211; the answers of the majority of the participants should coincide with at least 19&#8211;25 experts to reach a consensus of 75&#37;&#44; usually required in the DELPHI studies &#8211; were included in the second phase&#44; carried out between June 8 and 14&#44; 2012 on Internet&#44; with the anonymous participation of 22 of the 25 specialists included in the initial phase&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The second phase aimed to identify the reasons that explained for the different opinions among the experts&#46; Likewise&#44; the coordinators&#44; responsible for the analysis and identification of the questions with greatest deviation of opinion&#44; were not included in the second phase&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">After this&#44; as explained above&#44; the list of recommendations was validated in the face to face meeting held on September 15&#44; 2012&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Results</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">First phase &#8211; DELPHI experts</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Epidemiological section</span><p id="par0070" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">1&#46;-Among the risk factors that may affect critically ill patients&#44; in your opinion&#44; to what extent do you believe the development of invasive candidiasis is important&#63;</span></p><p id="par0075" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Rationale</span>&#58; <span class="elsevierStyleItalic">Candida</span> species are a significant cause of infection in critically ill patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">31&#44;34&#44;56&#44;63</span></a> The results of the EPIC II study&#44; carried out with 13&#44;796 adult patients admitted to 1265 ICUs in 76 countries&#44; evidenced that 51&#37; of the patients presented an infectious process&#44; with <span class="elsevierStyleItalic">Candida</span> being the third microorganism responsible of the infection &#40;17&#37; of the patients infected&#41; after <span class="elsevierStyleItalic">Staphylococcus aureus</span> &#40;20&#46;5&#37;&#41; and <span class="elsevierStyleItalic">Pseudomonas</span> &#40;19&#46;9&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> In USA&#44; <span class="elsevierStyleItalic">Candida</span> infection was the main cause of fungal infection in hospitalized patients&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">66</span></a> In addition&#44; the incidence of <span class="elsevierStyleItalic">Candida</span> infections in the ICUs has increased in different countries throughout the last few years&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">A large majority of the experts consulted &#40;88&#37;&#41; confirmed the importance of suffering candidiasis among the risk factors that could affect critically ill patients&#46; Specifically&#44; and based on a 0&#8211;10 point scale&#44; where 10 represents the maximum level of importance&#44; 22 experts granted 7 or more points to candidiasis&#46; The average score was established at 7&#46;7 points&#44; with a standard deviation of 1&#46;9 points&#46; The consensus level achieved was high &#40;&#62;75&#37;&#41;&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">2&#46;-To what extent do you consider candidemia an important factor of mortality associated with critically ill patients&#63;</span></p><p id="par0090" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Rationale&#58;</span> Invasive candidiasis is a major cause of direct and indirect mortality in neutropenic and non-neutropenic critically ill patients&#46; The crude mortality rates associated with invasive candidiasis are 40&#8211;78&#37; and 20&#8211;40&#37;&#44; respectively&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#44;56</span></a> In USA&#44; candidemia is associated with a 14&#46;5&#37; increase of mortality in adults&#44; as well as 10&#37; in pediatric patients&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">66</span></a> Nevertheless&#44; invasive candidiasis in immunocompromised patients with cancer can be a severe marker&#44; whereas it is difficult to differentiate mortality directly attributable to invasive candidiasis from that of a concurrent infection or an underlying tumor disease&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Seventy-six percent of the expert panel members considered candidemia a very important mortality factor associated with critically ill patients&#46; Specifically&#44; and based on a scale of 0&#8211;10 points&#44; 19 experts granted 7 or more points to candidemia as a mortality factor&#46; The average score was 7&#46;4 points&#44; with a standard deviation of 2&#46;2 points&#46; The degree of consensus reached by the experts was high &#40;&#62;75&#37;&#41;&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">3&#46;-To what extent do you consider the distribution of Candida species in the last few decades&#44; as well as its impact on the antifungal susceptibility patterns&#44; important factors&#63;</span></p><p id="par0105" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Rationale&#58;</span> In the last few years&#44; a change in the distribution of <span class="elsevierStyleItalic">Candida</span> species in ICUs has been experimented&#46;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">47&#44;60</span></a><span class="elsevierStyleItalic">C&#46; albicans</span> is still the predominant species in the ICUs&#44;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> followed by <span class="elsevierStyleItalic">C&#46; parapsilosis</span> and <span class="elsevierStyleItalic">C&#46; glabrata</span><a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">59</span></a>&#44; and approximately 15&#37; has a low susceptibility to fluconazole&#46; Also&#44; the distribution of species varies with age&#58; the incidence of candidemia due to <span class="elsevierStyleItalic">C&#46; glabrata</span> increases with age&#44; opposite to what occurs with <span class="elsevierStyleItalic">C&#46; parapsilosis</span> and <span class="elsevierStyleItalic">Candida tropicalis</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">52</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">Approximately 85&#37; of the experts consulted consider the change in the distribution of <span class="elsevierStyleItalic">Candida</span> species in the last few years very relevant&#44; as well as its impact on the antifungal susceptibility patterns&#46; Specifically&#44; and using a 0&#8211;10 point scale&#44; 21 experts granted 7 or more points to the change in the distribution of the <span class="elsevierStyleItalic">Candida</span> species&#46; The average score was 7&#46;6 points&#44; with a standard deviation of 1&#46;8 points&#46; The degree of consensus achieved was high &#40;&#62;75&#37;&#41;&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">4&#46;-To what extent do you consider important the identification of risk factors predisposing to Candida infections when the species might be other than C&#46; albicans&#63;</span></p><p id="par0120" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Rationale&#58;</span> Studies have identified several factors predisposing to infections caused by other species of <span class="elsevierStyleItalic">Candida</span> different from <span class="elsevierStyleItalic">C&#46; albicans</span> &#40;predominantly <span class="elsevierStyleItalic">C&#46; glabrata</span> and <span class="elsevierStyleItalic">Candida krusei</span>&#41;&#46; Among these&#44; prior triazole therapy&#44; gastrointestinal tract surgery in the 30 days prior to the onset of candidemia&#44; as well as patients over 65 years of age&#44; can be highlighted&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">60</span></a> These factors should be taken into account since <span class="elsevierStyleItalic">C&#46; glabrata</span> and <span class="elsevierStyleItalic">C&#46; krusei</span> are both potentially resistant to fluconazole&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> For its part&#44; the emergence of <span class="elsevierStyleItalic">C&#46; parapsilosis</span> has been associated with younger ages&#44; the administration of echinocandins and deficient control practices&#44; while <span class="elsevierStyleItalic">C&#46; tropicalis</span> is particularly common in neutropenic patients with an underlying hematological disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">52&#44;59</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">The vast majority of the specialists consulted &#40;92&#37;&#41; consider the identification of risk factors that may favor the emergence of <span class="elsevierStyleItalic">Candida</span> species&#44; other than <span class="elsevierStyleItalic">C&#46; albicans</span>&#44; of utmost importance&#46; Specifically&#44; being 10 points the highest score and 0 the lowest&#44; 23 experts granted 7 or more points to the importance of identifying these risk factors&#46; The average score was 8&#46;5 points&#44; with a standard deviation of 1&#46;4 points&#46; The degree of consensus achieved was again very high &#40;&#62;75&#37;&#41;&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">5&#46;-To what extent do you consider important the evaluation of the clinical features of critically ill patients&#44; taking into account that they can condition the presentation of invasive candidiasis&#63;</span></p><p id="par0135" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Rationale&#58;</span> Invasive candidiasis can present as isolated candidemia&#44; non-documented invasive candidiasis or a combination of both&#46; Prior surgery and patients with solid tumors are significantly more frequent in patients with invasive candidiasis&#44; while prior antibiotic therapy&#44; neutropenia and hematological tumors are significantly more common in patients with candidemia&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> Additionally&#44; the crude mortality rate due to candidemia in critically ill patients remains high and is related to the host &#40;diagnosis upon admission to the ICU&#41;&#44; and not to the variables of the treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">56</span></a> Metastatic processes occur in a considerable proportion of the patients in the ICU with candidemia and care must be given to possible secondary foci&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">A large majority of the experts consulted &#40;88&#37;&#41; highlighted the importance of evaluating the clinical features of critically ill patients&#44; since they can condition the appearance of candidiasis&#46; Specifically&#44; and based on a scale of 0&#8211;10&#44; where 10 represents the maximum level of importance&#44; 22 experts granted 7 or more points to the evaluation of clinical features&#46; The average score was established at 8&#46;2 points&#44; with a standard deviation of 1&#46;4 points&#46; The degree of consensus reached was high &#40;&#62;75&#37;&#41;&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">6&#46;-Indicate your level of agreement with the following statements&#58; &#40;1&#41; Candida species are a determining factor in mortality associated with invasive candidiasis&#46; &#40;2&#41; The underlying disease is a determining factor in mortality associated with invasive candidiasis</span></p><p id="par0150" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Rationale&#58;</span> In addition to an adequate control of the infectious focus&#44; the infectious process is conditioned by three factors&#58; the susceptibility of the infecting organism<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">23&#44;61</span></a>&#59; the virulence of the organism<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;26</span></a>&#59; and the severity of the underlying disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">20&#44;23</span></a><span class="elsevierStyleItalic">C&#46; krusei</span>&#44; <span class="elsevierStyleItalic">C&#46; tropicalis</span> and <span class="elsevierStyleItalic">C&#46; glabrata</span> have been associated with an elevated rate of mortality&#44; while <span class="elsevierStyleItalic">C&#46; parapsilosis</span> has been associated with a low pathogenicity&#46; The severity of the underlying disease is an important mortality factor and&#44; in fact&#44; the total mortality is greater in candidemic critically ill patients&#44; than in the general population&#46; In the study of Marriott et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a> the age&#44; the diagnoses upon admission to the ICUs &#40;other than polytraumatisms&#41; and the mechanical ventilation upon onset of the candidemia&#44; were independent mortality factors in the multivariate analysis&#46; Recent studies have evidenced that the use of echinocandins and the early administration of antifungal therapy resulted in lower mortality rates of invasive candidiasis&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Perhaps the benefits of optimized antifungal treatment are hidden in ICU patients by a severe underlying disease affecting mortality&#46;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#40;1&#41;</span><p id="par0155" class="elsevierStylePara elsevierViewall">Close to 85&#37; of the panel members consider <span class="elsevierStyleItalic">Candida</span> species a determining factor of mortality associated with candidiasis&#46; Specifically&#44; on a scale of 1&#8211;5 points&#44; in which 5 represents the maximum level of agreement&#44; 21 experts granted 4 or 5 points in favor&#46; The average score was established at 4&#46;1 points&#46; A high degree of consensus was reported &#40;&#62;75&#37;&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#40;2&#41;</span><p id="par0160" class="elsevierStylePara elsevierViewall">When considering an underlying disease as a determining factor of mortality associated with candidiasis&#44; total consensus was achieved&#46; Based on 1&#8211;5 point scale&#44; the 25 experts consulted granted 4 or 5 points in favor&#44; establishing an average of 4&#46;8 points&#46;</p></li></ul></p><p id="par0165" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Score section</span></p><p id="par0170" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">1&#46;-On what factors do you base the initiation of antifungal therapy in patients with severe sepsis&#44; fever&#44; broad-spectrum antibiotic treatment and negative culture results&#63;</span></p><p id="par0175" class="elsevierStylePara elsevierViewall">The coordinators responses&#58; Risk Factors&#44; <span class="elsevierStyleItalic">Candida</span> Score&#44; Multicolonization&#44; Markers&#44; Poor evolution&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">The majority of the experts consulted based the initiation of antifungal treatment in patients with severe sepsis&#44; fever&#44; broad-spectrum antifungal therapy and negative blood culture results on risk factors &#40;8 experts&#41; or the <span class="elsevierStyleItalic">Candida</span> Score &#40;8 experts&#41;&#46; Only 1 specialist claimed to base treatment on markers&#44; while multicolonization or poor evolutions were options selected in each case by 4 of the experts&#46; A medium degree of consensus was achieved &#40;&#62;50&#37; and &#60;75&#37;&#41;&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">2&#46;-Multicolonization is one of the factors contemplated in the Candida Score&#46; Do you consider the evaluation of multicolonization indispensable to use the Candida Score&#63;</span></p><p id="par0190" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Rationale&#58;</span> Studies published in the literature have demonstrated that multicolonization is a prognostic factor in proven candidiasis&#44;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> and the colonization index is directly correlated to invasive fungal infection&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0195" class="elsevierStylePara elsevierViewall">An ample majority of the experts consulted &#40;83&#37;&#41; considered indispensable the evaluation of multicolonization to use the <span class="elsevierStyleItalic">Candida</span> Score&#46; Specifically&#44; based on a 0&#8211;10 point scale&#44; where 10 is of utmost importance&#44; 21 experts granted 7 or more points to the evaluation of clinical features&#46; The average score was 8&#46;0 points&#44; with a standard deviation of 1&#46;9 points&#46; A high degree of consensus was achieved &#40;&#62;75&#37;&#41;&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">3&#46;-To what extent do you use the corrected colonization index &#40;CCI&#41; to guide the treatment of invasive candidiasis&#63;</span></p><p id="par0205" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Rationale&#58;</span> The Pittet Index or CCI &#40;ratio of highly positive samples&#47;total number of samples analyzed&#41; was described in surgical patients and demonstrated that a corrected colonization with a threshold of &#62;0&#46;4 has a positive predictive value<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">54</span></a> and a 100&#37;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">55</span></a> negative predictive value on the development of invasive candidiasis&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">Seventy-six percent of the experts consulted confirmed they do not use the corrected colonization index &#40;CCI&#41; to guide the treatment of invasive candidiasis&#44; or only used it sporadically&#46; Specifically&#44; 10 experts confirmed the use of CCI &#8216;in some cases&#8217; and 9 did not use it &#8216;in any case&#8217;&#44; while 6 admitted its use &#8216;in the majority of the cases&#8217;&#46; A high degree of consensus was reached &#40;&#62;75&#37;&#41;&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">4&#46;-In how many cases out of ten&#44; concerning patients at risk of acquiring invasive fungal infection&#44; do you use the Candida Score to guide the treatment of invasive candidiasis&#63;</span></p><p id="par0220" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Rationale&#58;</span> The Candida Score is useful to evaluate the risk of developing invasive fungal infections&#44; with a low positive predictive value and a very high negative predictive value&#46; Therefore&#44; it is highly improbable that non-neutropenic critically ill patients colonized with <span class="elsevierStyleItalic">Candida</span>&#44; having a Candida Score below 3&#44; are at risk of developing invasive candidiasis&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> Then&#44; only patients with a Candida Score exceeding 2&#46;5 will be benefited from the administration of early antifungal therapy&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a></p><p id="par0225" class="elsevierStylePara elsevierViewall">Seventy-two percent of the experts consulted confirmed the use of the Candida Score to evaluate the risk of developing invasive fungal infections&#46; Specifically&#44; 18 of the experts confirmed that they used this score in at least 7 out of 10 non-neutropenic critically ill patients with <span class="elsevierStyleItalic">Candida</span> spp&#46; colonization&#44; while 3 used it in 6 patients&#44; 2 in 5 patients&#44; 1 in 4 patients and 1 expert in no case&#46; The experts reached a medium degree of consensus &#40;&#62;50&#37; and &#60;75&#37;&#41;&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">Taking into account that the question did not achieve a minimum degree of consensus in accordance with the DELPHI technique&#44; it was included in the second phase&#44; in which the experts were asked to explain why they did not use the Candida Score on a regular basis in these situations&#46; Among the explanations offered&#44; we highlight&#58; &#40;1&#41; &#8216;<span class="elsevierStyleItalic">It has a poor positive predictive value&#59; it&#39;s only useful to not administer antifungal therapy&#44; since the negative predictive value is very good</span>&#8217;&#46; And &#40;2&#41; &#8216;<span class="elsevierStyleItalic">There are difficulties for obtaining surveillance cultures&#59; even when they have been performed&#44; since results are only obtained after 72<span class="elsevierStyleHsp" style=""></span>hours&#44; early treatment that reduces the rate of mortality is impeded</span>&#8217;&#46;</p><p id="par0235" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">5&#46;-To what extent do you agree on only using a rectal sample and urine to detect colonization&#63;</span></p><p id="par0240" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Rationale&#58;</span> An important contribution resulting from the CAVA Study<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> is the independent identification of predictive values of invasive candidiasis&#44; from each of the colonization sample locations&#44; limiting the number of samples for colonization evaluation to those that are significant&#58; rectal sample and urine&#46;</p><p id="par0245" class="elsevierStylePara elsevierViewall">Eighty percent of the experts consulted considered the use of a rectal sample and urine sufficient for detecting colonization&#46; Specifically&#44; based on a 0&#8211;10 point scale&#44; where 10 is the maximum level of importance&#44; 20 experts granted 7 or more points to the exclusive use of both samples&#46; The average score was 7&#46;4 points&#44; with a standard deviation of 2&#46;5 points&#46; A high degree of consensus was achieved&#46;</p><p id="par0250" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Laboratory diagnostic section</span></p><p id="par0255" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">1&#46;-In your opinion&#44; and in suspected cases of invasive candidiasis&#44; which frequency would you recommend to perform blood cultures&#63;</span></p><p id="par0260" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Rationale&#58;</span> At present&#44; hemocultures are the gold standard in diagnosing invasive candidiasis&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;17&#44;51</span></a> However&#44; this technique only offers a sensitivity of 50&#37; in the diagnosis of invasive candidiasis&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">51</span></a> Therefore&#44; a higher number of tests could increase this diagnostic rate&#46;</p><p id="par0265" class="elsevierStylePara elsevierViewall">Ninety-two percent of the experts consulted recommended performing hemocultures on a daily basis or&#44; at least&#44; every two or three days&#46; Specifically&#44; 6 experts advocated performing them on a daily basis and 16 every two or three days&#44; while 1 specialist recommended performing hemocultures once a week&#44; and 2 to perform only one hemoculture and wait for results&#46; A high degree of consensus was achieved &#40;&#62;75&#37;&#41;&#46;</p><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">2&#46;-Indicate to what extent you request each of the following two diagnostic tests to diagnose non-candidemic invasive candidiasis</span><p id="par0270" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">2&#46;1&#46;-Test on sterile fluids and&#47;or tissue specimens</span></p><p id="par0275" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">2&#46;2&#46;-Direct microscopy of sterile fluids and&#47;or tissue specimens</span></p><p id="par0280" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Rationale&#58;</span> Nowadays&#44; it is very difficult to diagnose non-candidemic invasive candidiasis with certainty&#44;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> since it requires the histological identification of <span class="elsevierStyleItalic">Candida</span> tissue invasion and&#47;or evidence of the yeast presence in sterile fluids&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;22</span></a></p><p id="par0285" class="elsevierStylePara elsevierViewall">Regarding question 2&#46;1&#44; the large majority &#40;96&#37;&#41; of the experts consulted considered very important to request the test on sterile fluids and&#47;or tissue to accurately diagnose invasive candidiasis&#46; Specifically&#44; based on a scale of 0&#8211;10 points&#44; where 10 represents the highest level of importance&#44; 24 experts granted 7 or more points to this diagnostic test&#46; The average score was 9&#46;1 points&#44; with a standard deviation of 1&#46;3 points&#46;</p><p id="par0290" class="elsevierStylePara elsevierViewall">With respect to question 2&#46;2&#44; 84&#37; of the experts consulted considered the direct microscopy of sterile fluids and&#47;or tissue samples to diagnose invasive candidiasis very relevant&#46; Specifically&#44; based on a 0 to 10 point scale&#44; 21 experts granted 7 or more points to this diagnostic test&#46; The average score was 8&#46;2 points&#44; with a standard deviation of 1&#46;4 points&#46; Both questions achieved a high degree of consensus &#40;&#62;75&#37;&#41;&#46;</p><p id="par0295" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">2&#46;3&#46;-In the case of a patient with suspected peritonitis caused by</span> Candida&#44; <span class="elsevierStyleItalic">to what extent do you consider necessary sending perioperative samples to the Microbiology laboratory&#63;</span></p><p id="par0300" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Rationale&#58;</span> In cases of suspected peritonitis caused by <span class="elsevierStyleItalic">Candida</span> spp&#46;&#44; the diagnosis should be preferably based on the analysis of perioperative samples of fluid and&#47;or peritoneal tissue&#44;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">43&#44;62&#44;69</span></a> a diagnostic test that has demonstrated a high prognostic value&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a></p><p id="par0305" class="elsevierStylePara elsevierViewall">The complete panel considered necessary sending perioperative samples of fluids and&#47;or peritoneal tissue in cases of suspected peritonitis caused by <span class="elsevierStyleItalic">Candida</span> necessary&#46; In fact&#44; the entire panel granted 7 or more points to this statement&#44; for which a high degree of consensus was achieved&#46;</p><p id="par0310" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">3&#46;-Do you consider the isolation of</span> Candida <span class="elsevierStyleItalic">from respiratory samples a diagnosis of candidiasic pneumonia&#63;</span></p><p id="par0315" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Rationale&#58;</span> Sixty percent of the non-neutropenic critically ill patients are colonized with <span class="elsevierStyleItalic">Candida</span> when the stay in ICU exceeds 7 days&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> However&#44; and despite the remarkable frequency of isolation of <span class="elsevierStyleItalic">Candida</span> in the respiratory tract&#44; Meersseman et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a> in a study that lasted 2 years&#44; observed the complete absence of cases of candidiasic pneumonia in the autopsies performed on patients with evidences of pneumonia&#44; thus confirming that pneumonia caused by <span class="elsevierStyleItalic">Candida</span> is extremely unusual in patients in ICUs&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p><p id="par0320" class="elsevierStylePara elsevierViewall">All of the experts consulted did not consider the isolation of <span class="elsevierStyleItalic">Candida</span> in the respiratory tract samples of critically ill patients sufficient to diagnose candidiasic pneumonia&#46; Specifically&#44; 18 experts did not consider isolation in any case&#44; while 7 confirmed that they could consider this option only in certain specific cases&#46; The highest degree of consensus was reached&#44; 100&#37;&#46;</p><p id="par0325" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">4&#46;-In accordance with the epidemiological changes in invasive candidiasis&#44; do you consider that in cases of proven invasive candidiasis&#44; it is important to know the susceptibility pattern to the different antifungal agents&#63;</span></p><p id="par0330" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Rationale&#58;</span> During the last decades&#44; the main epidemiological trend in invasive candidiasis in ICUs and Oncology Units has been the decrease of <span class="elsevierStyleItalic">Candida albicans</span>&#44; contrasting with the increase of non-<span class="elsevierStyleItalic">C&#46; albicans</span>&#8211;<span class="elsevierStyleItalic">Candida</span> species&#44; very especially <span class="elsevierStyleItalic">C&#46; glabrata</span>&#44; <span class="elsevierStyleItalic">C&#46; tropicalis</span>&#44; <span class="elsevierStyleItalic">C&#46; krusei</span> and <span class="elsevierStyleItalic">C&#46; parapsilosis</span>&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">35&#44;47&#44;60&#44;66</span></a> In this context&#44; the IDSA guidelines published in 2009 established the recommendation of carrying out susceptibility studies only in cases of treatment failure&#44; as well as testing fluconazole in those with <span class="elsevierStyleItalic">C&#46; glabrata</span> isolates&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">47</span></a></p><p id="par0335" class="elsevierStylePara elsevierViewall">The vast majority &#40;96&#37;&#41; of the experts consulted highlighted the relevance of knowing the susceptibility to the different antifungal agents in cases of confirmed invasive candidiasis&#46; Specifically&#44; based on a 0&#8211;10 point scale to value its importance&#44; 24 experts granted 7 or more points to the need of establishing the susceptibility to the drug treatment&#46; The average score was 8&#46;8 points&#44; with a standard deviation of 1&#46;2 points&#46; The level of consensus achieved was high&#44; exceeding 75&#37;&#46;</p><p id="par0340" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">5&#46;-In your opinion&#44; to what extent do you consider useful the measurement of procalcitonin in serum for the diagnosis of suspected candidemia&#63;</span></p><p id="par0345" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Rationale&#58;</span> Procalcitonin measurement in serum seems to be very precise discerning between bacteremia and non-infectious inflammatory conditions in critically ill patients with clinical signs of sepsis&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> Two studies performed in non-neutropenic and&#47;or surgical patients determined that seric procalcitonin is lower in candidemia than in bacteremia&#44; both presenting high negative predictive values below 2 and 5<span class="elsevierStyleHsp" style=""></span>ng&#47;ml&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;37</span></a></p><p id="par0350" class="elsevierStylePara elsevierViewall">Seventy-six percent of the experts consulted highlighted the usefulness of procalcitonin measurement in the diagnosis of suspected candidemia&#46; Specifically&#44; 4 specialists consider it &#8216;very useful&#8217;&#44; while 15 define the procalcitonin measurement as &#8216;quite useful&#8217;&#46; A high degree of consensus was achieved&#44; exceeding 75&#37;&#46;</p><p id="par0355" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">6&#46;-At present&#44; to what extent do you consider the use of non-culture based methods of microbiological diagnostic techniques necessary for the diagnosis of invasive candidiasis&#63;</span></p><p id="par0360" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Rationale&#58;</span> The combination of traditional diagnostic methods with non-culture based microbiological tools could be the clue to improve the diagnosis and prognosis of fungemias in critically ill patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25&#44;50&#44;51&#44;62</span></a> To date&#44; results published on the detection of &#40;1&#44;3&#41;-&#946;-<span class="elsevierStyleSmallCaps">d</span>-glucan&#44; galactomannan&#44; mannan and anti-mannan&#44; <span class="elsevierStyleItalic">Candida albicans</span> germ tube antibodies or nucleic acid are promising and could be very useful to guide early antifungal treatment&#46; In general&#44; it is recommended as screening once or twice a week in critically ill patients with risk factors&#44; especially in surgical patients&#44; after 5&#8211;7 days of hospitalization&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">50</span></a> However&#44; and still today&#44; non-culture based methods for microbiological diagnosis are not available in the majority of the hospitals in our country&#46;</p><p id="par0365" class="elsevierStylePara elsevierViewall">Eighty percent of the experts consulted considered the use of non-culture based methods for the diagnosis of invasive candidiasis very necessary&#46; Specifically&#44; based on a scoring scale of importance from 0 to 10 points&#44; 19 experts granted 7 or more points to the need for this microbiological diagnosis&#46; The average score was 8&#46;0 points&#44; with a standard deviation of 1&#46;7 points&#46; A high degree of consensus was reached&#46;</p><p id="par0370" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">7&#46;-To what extent would you use the combined detection of mannan antigen and antimannan antibodies for the diagnosis of invasive candidiasis&#44; if this technique was available in your hospital&#63;</span></p><p id="par0375" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Rationale&#58;</span> The detection of mannan antigen and antimannan antibodies against <span class="elsevierStyleItalic">Candida</span> antigen in an ELISA format has been useful in the diagnosis of invasive candidiasis<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;51</span></a> and has been commercialized for many years&#46; Also&#44; with the objective of avoiding the poor performance of these techniques when used separately&#44; the joint implementation of these tests in all patients with suspected invasive candidiasis is recommended&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a></p><p id="par0380" class="elsevierStylePara elsevierViewall">The majority of the experts consulted did not share a general opinion regarding the convenience of using combined detection of mannan antigen and anti-mannan antibodies in the diagnosis of invasive candidiasis&#46; Specifically&#44; 5 and 8 specialists&#44; respectively&#44; considered their use in &#8216;almost all cases&#8217; and &#8216;in the majority of the cases&#8217;&#46; On the contrary&#44; 12 experts considered that their use is only convenient &#8216;in some cases&#8217;&#46; A medium degree of consensus was achieved&#44; 52&#37; &#40;&#62;50&#37; and &#60;75&#37;&#41;&#46; Therefore&#44; this question was included in the second phase of the DELPHI study&#46;</p><p id="par0385" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">8&#46;-To what extent do you use the &#40;1&#44;3&#41;-&#946;-<span class="elsevierStyleSmallCaps">d</span>-glucan detection as a diagnostic tool for invasive candidiasis&#63;</span></p><p id="par0390" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Rationale&#58;</span> The detection of betaglucan&#44; by means of a technique presently available in the market&#44; offers high specificity<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;25&#44;42&#44;51</span></a> and positive predictive value &#40;PPV&#41;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;33&#44;45</span></a> in patients with probable or confirmed IFI&#46;</p><p id="par0395" class="elsevierStylePara elsevierViewall">The responses revealed a divergent behavior among the experts consulted with respect to how often &#40;1&#44;3&#41;-&#946;-<span class="elsevierStyleSmallCaps">d</span>-glucan testing should be used in the diagnosis of invasive candidiasis&#46; Specifically&#44; 16 experts&#44; 64&#37; of the sample&#44; considered its use in &#8216;only some cases&#8217; or &#8216;in no case&#8217;&#44; while 7 and 2 specialists responded that it should be used &#8216;in the majority of the cases&#8217; or &#8216;in almost all cases&#8217;&#46; A medium degree of consensus of 64&#37; was reached&#44; so the question was selected for the second phase of the DELPHI study&#46;</p><p id="par0400" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">9&#46;-To what extent do you use the indirect immunofluorescence method &#40;C&#46; albicans IFA IgG&#44; Vircell&#41; for the detection of anti-mycelial antibodies in the diagnosis of invasive candidiasis&#44; if this technique is available in your hospital&#63;</span></p><p id="par0405" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Rationale&#58;</span> Indirect immunofluorescence &#40;<span class="elsevierStyleItalic">C&#46; albicans</span> IFA IgG&#44; Vircell&#41; for the detection of <span class="elsevierStyleItalic">Candida albicans</span> germ tube antibodies &#40;CAGTA&#41; shows high sensitivity and specificity in cases of candidemia&#44;<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">51&#44;67&#44;68</span></a> which could be crucial in the diagnosis of invasive candidiasis in surgical ICU patients&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">59</span></a></p><p id="par0410" class="elsevierStylePara elsevierViewall">The majority of the experts consulted did not share a general pattern of behavior in relation to how often they used CAGTA detection in the diagnosis of invasive candidiasis&#46; Only 13 experts&#44; 52&#37; of the sample&#44; considered its use in &#8216;only some cases&#8217; or &#8216;in no case&#8217;&#44; while 9 and 3 specialists&#44; respectively&#44; responded that they use it &#8216;in the majority of the cases&#8217; or &#8216;almost always&#8217;&#46; A medium degree of consensus was reached&#46; The question was selected for the second phase of the DELPHI Study&#46;</p><p id="par0415" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">10&#46;-To what extent do you use nucleic acids detection in the diagnosis of invasive candidiasis&#44; if molecular methods of polymerase chain reaction &#40;PCR&#41; techniques are available in your hospital&#63;</span></p><p id="par0420" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Rationale&#58;</span> New molecular detection methods of real-time polymerase chain reaction &#40;PCR&#41;&#44; as evidenced in numerous articles in the literature&#44;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;30&#44;38&#44;51&#44;65</span></a> are an interesting alternative for the quick diagnosis of invasive candidiasis&#46;</p><p id="par0425" class="elsevierStylePara elsevierViewall">The answers reveal the absence of a general pattern of behavior among the majority of the experts consulted&#46; Only 13 experts&#44; 52&#37; of the sample&#44; consider the detection of nucleic acids in the diagnosis of invasive candidiasis necessary in &#8216;only some cases&#8217; or &#8216;in no case&#8217;&#44; while 7 and 5 specialists&#44; respectively&#44; answered that it should be performed &#8216;in the majority of the cases&#8217; or &#8216;in almost all cases&#8217;&#46; A medium degree of consensus was achieved&#44; 52&#37;&#44; for which the question was selected to be included in the second phase of the study&#46;</p><p id="par0430" class="elsevierStylePara elsevierViewall">Since the questions regarding the non-culture based method of microbiological techniques&#44; questions 7&#8211;10&#44; did not achieve the minimum consensus in the DELPHI technique&#44; the 22 experts participating in the second phase of the study were consulted on the mannan antigen and anti-mannan antibody techniques&#44; &#40;1&#44;3&#41;-&#946;-<span class="elsevierStyleSmallCaps">d</span>-glucan detection&#44; anti-mycelial antibody detection&#44; and nucleic acids detection&#46; They answered about which of these tests they would recommend for the diagnosis of invasive candidiasis&#46; The responses identified &#40;1&#44;3&#41;-&#946;-<span class="elsevierStyleSmallCaps">d</span>-glucan detection&#44; chosen by 10 experts&#44; and the detection of nucleic acids&#44; chosen by 8 experts&#44; as the techniques most widely recommended by the specialists consulted&#46;</p><p id="par0435" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">11&#46;-Indicate your level of agreement with the following statements&#58; &#40;1&#41; The combination of several non-culture based microbiological methods can provide a better diagnosis of invasive candidiasis and&#44; &#40;2&#41; The combination of scores of clinical prediction&#44; together with the use of nonculture based methods of microbiological techniques&#44; can be adequate strategies to initiate early invasive candidiasis treatment&#46;</span></p><p id="par0440" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Rationale&#58;</span> The use of the different non-culture based methods&#44; such as the mannan antigen&#47;antimannan antibodies&#44; beta-glucan detection and&#44; very especially&#44; the detection of nucleic acids by PCR&#44; may significantly assist in the diagnosis of invasive candidiasis&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Also&#44; the combination of the tests with traditional diagnostic methods could be the clue to improve both the diagnosis&#44; as well as the prognosis of invasive candidiasis in critically ill patients&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">51</span></a><ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#40;1&#41;</span><p id="par0445" class="elsevierStylePara elsevierViewall">Ninety-six percent of the experts consulted indicated that combining various techniques can provide a better diagnosis in invasive candidiasis&#46; Specifically&#44; based on a scale of 1&#8211;5 points&#44; where 5 represents the highest score&#44; 24 experts granted 4 or 5 points to the statement&#46; The average score was 4&#46;8 points&#46; A high degree of consensus was achieved&#44; exceeding 75&#37;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#40;2&#41;</span><p id="par0450" class="elsevierStylePara elsevierViewall">The combination of scores and non-culture based methods of microbiological techniques was considered an adequate strategy&#44; achieving full consensus&#46; Based again on a scale of 1&#8211;5 points&#44; the 25 experts consulted granted 4 or 5 points to the statement&#44; establishing an average of 4&#46;8 points&#46;</p></li></ul></p><p id="par0455" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Treatment section</span></p><p id="par0460" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">1&#46;-Do you consider the use of echinocandins as a first-line choice of treatment for invasive candidiasis&#63;</span></p><p id="par0465" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Rationale&#58;</span> The recommendations established in the Clinical Practice Guidelines of the different national and supranational societies<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;15&#44;47</span></a> have caused some controversy on the treatment of invasive candidiasis&#46; In this context&#44; a work carried out by Andes et al&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> demonstrated that the treatment with echinocandins is associated to a significant decrease of the mortality rate due to invasive candidiasis&#46;</p><p id="par0470" class="elsevierStylePara elsevierViewall">Seventy-six percent of the experts consulted&#44; 19 out of the 25 specialists&#44; consider that echinocandins should be the first-choice antifungal therapy for invasive candidiasis in all cases&#44; regardless of whether the patient had a history of recent azole exposure&#46; A high degree of consensus was reached &#40;&#62;75&#37;&#41;&#46;</p><p id="par0475" class="elsevierStylePara elsevierViewall">The specialists who agreed that echinocandins should be the first-line antifungal therapy only in patients&#44; who have received prior azole therapy&#44; were consulted in the second phase of the study and explained the reasons that justify their answer&#46; We display below two of the reasons offered by the specialists&#58; &#40;1&#41; &#8216;<span class="elsevierStyleItalic">It depends on the epidemiology of the center and the characteristics of the patient&#46; If the patient is stable and has not received previous azole therapy in a hospital with prevalence of</span> C&#46; albicans <span class="elsevierStyleItalic">strains&#44; I find no reason to administer echinocandins</span>&#8217;&#46; And &#40;2&#41; &#8216;<span class="elsevierStyleItalic">It is evident that the affirmative response to the statement&#44; &#8216;do you consider necessary prior azole therapy&#8217; is not correct&#46; I believe that there are certain specific situations in which fluconazole could be indicated in patients with documented candidemia with sensitivity to this antifungal agent &#40;in 70&#8211;80&#37; of the occasions&#41; and with clinical stability &#40;&#8230;&#41;&#8217;&#46;</span></p><p id="par0480" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">2&#46;-To what extent do you agree with the administration of echinocandins at higher doses than the standard recommended for the treatment of endocarditis caused by</span> Candida <span class="elsevierStyleItalic">or other types of invasive candidiasis&#63;</span></p><p id="par0485" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Rationale&#58;</span> Clinical trials have demonstrated the efficacy and confirmed the safety of the echinocandin therapy at higher doses than the standard-dose therapy in the management of invasive candidiasis&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;48</span></a> Thus&#44; IDSA guidelines published in 2009 established the possibility of administering higher doses of echinocandins for the treatment of endocarditis caused by <span class="elsevierStyleItalic">Candida</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">47</span></a></p><p id="par0490" class="elsevierStylePara elsevierViewall">The responses reveal the divergent opinions encountered among the experts consulted with respect to administering higher doses of echinocandins in the treatment of endocarditis caused by <span class="elsevierStyleItalic">Candida</span>&#46; Specifically&#44; based on a scale from 1 to 5 points&#44; where 5 represents the highest level of agreement&#44; only 13 specialists &#40;52&#37;&#41; claimed to be &#8216;somewhat in agreement&#8217; or &#8216;totally in agreement&#8217;&#44; granting 4 or 5 points to the administration of higher doses&#46; The average was 3&#46;4 points and a medium degree of consensus was reached &#40;&#62;50&#37; and &#60;75&#37;&#41;&#46;</p><p id="par0495" class="elsevierStylePara elsevierViewall">The question did not achieve the minimum consensus contemplated in the DELPHI technique&#44; for which it was selected to be included in the second phase of the study&#44; where the experts who favored the administration of higher doses of echinocandins in the treatment of endocarditis caused by <span class="elsevierStyleItalic">Candida</span> or other types of invasive candidiasis&#44; were asked to indicate their motives&#46; We display two of the reasons the specialists mentioned&#58; &#40;1&#41; &#8216;<span class="elsevierStyleItalic">It is considered in clinical trials and experts&#8217; opinions&#46; Also&#44; it is mentioned in the IDSA guidelines published in 2009 regarding the treatment of endocarditis</span>&#46;&#8217; And &#40;2&#41; &#8216;<span class="elsevierStyleItalic">Due to the seriousness of invasive candidiasis or endocarditis&#44; optimization of the treatment&#44; according to the Pk&#47;Pd target based on the AUC&#47;MIC ratio&#44; is a priority in reaching levels of the focus&#46; Also&#44; these drugs have linear pharmacokinetics and few adverse effects&#8217;&#46;</span></p><p id="par0500" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">3&#46;-In the case of a critically ill patient on an echinocandin therapy&#44; with</span> C&#46; parapsilosis <span class="elsevierStyleItalic">isolates detected in blood cultures&#44; please indicate your level of agreement with each of the following two statements&#58; &#40;1&#41; echinocandin therapy should be substituted by fluconazole&#44; regardless of the patient&#39;s clinical evolution&#44; and &#40;2&#41; fluconazole should be administered together with an echinocandin&#44; until clinical improvement is observed&#46;</span></p><p id="par0505" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Rationale&#58;</span> The recommendations established in the Clinical Practice Guidelines of different national societies<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;47</span></a> have raised some controversy regarding the treatment of choice for invasive candidiasis due to <span class="elsevierStyleItalic">C&#46; parapsilosis</span>&#46; In this context&#44; while Pfaller et al&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">53</span></a> concluded that fluconazole was superior to candins in the treatment of <span class="elsevierStyleItalic">C&#46; parapsilosis</span> due to the mutations of the <span class="elsevierStyleItalic">fks</span> genes of <span class="elsevierStyleItalic">Candida</span>&#44; the Kale-Pradhan et al&#46; study demonstrated the non-inferiority of the efficacy of echinocandins against other antifungal agents in the treatment of invasive candidiasis caused by C&#46; parapsilosis&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a><ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#40;1&#41;</span><p id="par0510" class="elsevierStylePara elsevierViewall">Sixty percent of the experts consulted disagreed with the convenience of changing the treatment&#46; Specifically&#44; based on a scale of 1&#8211;5 points&#44; where 5 is the highest score&#44; 15 experts granted 1 or 2 points to this statement&#46; The average score was 2&#46;6 points&#46; A medium degree of consensus was achieved&#46; The question was selected to be included in the second phase of the DELPHI study&#44; in which the degree of divergence was similar&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">&#40;2&#41;</span><p id="par0515" class="elsevierStylePara elsevierViewall">Sixty-four percent of the experts consulted disagreed with the convenience of combining fluconazole and an echinocandin&#46; Specifically&#44; based on a scale of 1&#8211;5 points to evaluate the level of disagreement&#44; 16 experts granted 1 or 2 points to the statement&#46; The average score was established at 2&#46;3 points&#46; A medium degree of consensus was reached&#46;</p></li></ul></p><p id="par0520" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">4&#46;-In case you consider that patients with candidemia should receive an ophthalmological evaluation&#44; when would you carry it out&#63;</span></p><p id="par0525" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Rationale&#58;</span> Few studies in the literature address eye disorders during candidemia&#46; In this context&#44; while chorioretinitis is the most common disorder described &#40;9&#8211;16&#37;&#41;&#44; a much lower percentage of cases of endophthalmitis have been reported &#40;1&#46;6&#37;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">27&#44;46</span></a> However&#44; and contrary to that established in the recommendations of the Clinical Practice Guidelines&#44;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#44;47</span></a> the need for an ophthalmological evaluation in all patients with candidemia is considered in few situations&#46;</p><p id="par0530" class="elsevierStylePara elsevierViewall">The large majority of the experts consulted &#40;96&#37;&#41; considered an ophthalmological evaluation necessary in patients with candidemia&#44; either during the first week or between the first and second weeks&#46; Only one specialist indicated that the ophthalmological evaluation should not be carried out on a conscious patient without clinical signs&#46; Therefore&#44; a high degree of consensus was achieved&#46;</p><p id="par0535" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">5&#46;-In the case of a patient with candidemia on an echinocandin therapy with ocular involvement&#44; should the treatment be switched to another antifungal agent&#63;</span></p><p id="par0540" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Rationale&#58;</span> The eye is a protected compartment&#44; for which the degree of penetration of systemic antifungal agents varies significantly&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">47</span></a> According to evidence reported by Ridell et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">57</span></a> neither echinocandins nor posaconazole achieve adequate therapeutic concentrations in the vitreous&#46; In contrast&#44; voriconazole has been defined as the most effective antifungal agent in the treatment of ocular manifestations&#46;</p><p id="par0545" class="elsevierStylePara elsevierViewall">Seventy-two percent of the experts consulted considered that&#44; in patients with candidemia and ocular involvement treated with echinocandins&#44; treatment should switch to another antifungal agent &#8216;in all cases&#8217; or &#8216;in the majority of the cases&#8217;&#46; On the contrary&#44; 3 specialists considered that the change of treatment should only be made &#8216;in some cases&#8217;&#44; 3 that the change &#8216;does not necessarily need to be made&#8217;&#44; and 1 that the change &#8216;depends on the clinical evolution&#8217;&#46; A high degree of consensus was reached&#46;</p><p id="par0550" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">6&#46;-In your opinion&#44; should the central venous catheter be removed in all critically ill patients with candidemia&#63;</span></p><p id="par0555" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Rationale</span>&#58; The convenience of withdrawing or maintaining the central venous catheter &#40;CVC&#41; in patients with candidemia has raised controversy in different publications&#46; Specifically&#44; and while studies have not demonstrated the benefit associated with the withdrawal of the CVC&#44;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a> several articles confirm that its removal has reported a statistically significant improvement in the survival of the patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;40&#44;60</span></a></p><p id="par0560" class="elsevierStylePara elsevierViewall">Absolute consensus among the experts consulted on the need to withdraw the central venous catheter in all cases of candidemia was achieved &#40;100&#37;&#41;&#46;</p><p id="par0565" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">7&#46;-In your opinion&#44; to what extent does the risk of hepatotoxicity affect the election of a specific echinocandin&#63;</span></p><p id="par0570" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Rationale&#58;</span> The degree of hepatic dysfunction &#40;child&#41; can condition the election and dosage of each of the echinocandins&#44; due to their distinct metabolism and pathway of elimination&#46; The Wang et al&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">64</span></a> study showed that 9&#46;3&#37; of the patients treated with echinocandins presented high liver enzyme levels&#44; although there was no need to interrupt the treatment&#46;</p><p id="par0575" class="elsevierStylePara elsevierViewall">Fifty-six percent of the experts consulted considered that the risk of hepatotoxicity has &#8216;considerable influence&#8217; or &#8216;much influence&#8217; on the election of the type of echinocandin administered&#46; Specifically&#44; based on a scale of 1&#8211;5 points&#44; where 5 is the maximum level of influence&#44; 15 experts granted 4 or 5 points&#46; The average score was established at 2&#46;6 points&#46; A medium degree of consensus was achieved&#46;</p><p id="par0580" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">8&#46;-Please indicate your level of agreement with the following statement&#58; &#8216;Empirical therapy of fluconazole in critically ill patients with invasive candidiasis should not be used&#46; It should only be administered in cases where the species and susceptibility of</span> Candida <span class="elsevierStyleItalic">have been established in hemodynamically stable patients&#8217;</span></p><p id="par0585" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Rationale&#58;</span> The indication for fluconazole treatment in critically ill patients has changed in the last few years&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;15</span></a> Both <span class="elsevierStyleItalic">C&#46; glabrata</span> and <span class="elsevierStyleItalic">C&#46; krusei</span> are potentially fluconazole-resistant&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a></p><p id="par0590" class="elsevierStylePara elsevierViewall">Sixty percent of the specialists consulted agree with the statement&#46; Specifically&#44; based on a scale of 1&#8211;5 points to evaluate the level of agreement&#44; 15 experts granted 4 or 5 points to this statement&#46; The average was 3&#46;6 points and a medium degree of consensus was achieved&#46;</p><p id="par0595" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">9&#46;-Do you consider that all patients with candidemia should be screened for endocarditis by a transesophageal echocardiography&#63;</span></p><p id="par0600" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Rationale&#58;</span> The possibility of candidemia causing an infective endocarditis is a critical component in its clinical management&#44; requiring a longer treatment&#44; and valve surgery should be seriously considered in the majority of the patients&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a></p><p id="par0605" class="elsevierStylePara elsevierViewall">Seventy-two percent of the experts consulted considered that the transesophageal echocardiography for screening endocarditis in patients with candidemia should only be performed in exceptional cases&#46; In contrast&#44; 3 and 4 specialists hold that it should be carried out &#8216;in all cases&#8217; and &#8216;in the majority of the cases&#8217;&#44; respectively&#46; A medium level of consensus was reached&#46;</p><p id="par0610" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">10&#46;-Can the type of antifungal agent administered in the treatment of invasive candidiasis reduce the mortality rate associated to invasive candidiasis&#63;</span></p><p id="par0615" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Rationale</span>&#58; Numerous publications have demonstrated that the election of the antifungal agent plays an essential role in the survival of critically ill patients with invasive candidiasis&#46; Echinocandin therapy is associated with significantly reduced mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> On the other hand&#44; prior therapy with azoles is considered a mortality risk factor&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">26&#44;60</span></a></p><p id="par0620" class="elsevierStylePara elsevierViewall">An ample majority of the experts consulted &#40;92&#37;&#41; considered that the type of antifungal agent used in the treatment of invasive candidiasis can reduce the mortality associated with invasive candidiasis&#46; Therefore&#44; based on a scale of 1&#8211;5 points&#44; where 5 represents the maximum level of agreement&#44; 23 experts granted 4 or 5 points to this statement&#46;</p><p id="par0625" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">11&#46;-Can early invasive candidiasis treatments reduce mortality rates associated with invasive candidiasis&#63;</span></p><p id="par0630" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Rationale</span>&#58; Delayed invasive candidiasis treatment in critically ill patients is associated to increased mortality&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">23&#44;61</span></a> In this context&#44; however&#44; the Marriott et al&#46; study<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a> did not observe any relationship between the rate of mortality and the start date of the treatment&#46;</p><p id="par0635" class="elsevierStylePara elsevierViewall">All the experts consulted &#40;100&#37;&#41; considered that early invasive candidiasis treatment can reduce mortality associated with invasive candidiasis&#46; A high degree of consensus was reached&#46;</p><p id="par0640" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Therapeutic de-escalation section</span></p><p id="par0645" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Rationale</span>&#58; Susceptibility patterns to antifungal agents vary depending on the <span class="elsevierStyleItalic">Candida</span> species&#46; <span class="elsevierStyleItalic">C&#46; albicans</span>&#44; <span class="elsevierStyleItalic">C&#46; tropicalis</span> and <span class="elsevierStyleItalic">C&#46; parapsilosis</span> are usually susceptible to fluconazole&#44; while <span class="elsevierStyleItalic">C&#46; glabrata</span> is generally susceptible dose-dependent or resistant&#44; and <span class="elsevierStyleItalic">C&#46; krusei</span> is intrinsically resistant&#46;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">70</span></a> Fluconazole achieved better results than candins in the treatment of <span class="elsevierStyleItalic">C&#46; parapsilosis</span> due to mutations in the <span class="elsevierStyleItalic">fks</span> genes of <span class="elsevierStyleItalic">Candida</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">53</span></a></p><p id="par0650" class="elsevierStylePara elsevierViewall">In the treatment of candidemia in non-neutropenic patients&#44; fluconazole is recommended in stable patients with no history of azole exposure&#46; In hemodynamically unstable patients &#40;APACHE II<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>15&#41; or patients with criteria of severe sepsis or having received previous azole therapy or suspected azole-resistant candidemia&#44; empirical echinocandin therapy is recommended&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#44;47</span></a></p><p id="par0655" class="elsevierStylePara elsevierViewall">Determining the susceptibility to antifungal agents could be useful for optimizing antifungal treatment&#44; including de-escalation to fluconazole&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14&#44;58</span></a> However&#44; susceptibility <span class="elsevierStyleItalic">in vitro</span> tests are not carried out in all centers for several reasons&#44; such as the delay in receiving the results and their cost&#46; The identification of the species&#44; as well as the determination of the susceptibility to antifungal agents&#44; requires 5 days on average&#46; On the other hand&#44; determining the susceptibility to antifungal agents has proven to be cost-effective in the context of candidemia and could help to identify patients with drug-resistant <span class="elsevierStyleItalic">Candida</span> species receiving inappropriate treatment and patients who would be candidates for de-escalation to fluconazole&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">58</span></a></p><p id="par0660" class="elsevierStylePara elsevierViewall">Based on experts&#8217; opinions&#44; IDSA Guidelines suggest that susceptibility testing of fluconazole should routinely be performed against <span class="elsevierStyleItalic">C&#46; glabrata</span> and other <span class="elsevierStyleItalic">Candida</span> species that do not respond to empirical antifungal therapy or if resistance to azole antifungals is highly suspected&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">47</span></a></p><p id="par0665" class="elsevierStylePara elsevierViewall">The de-escalation of antifungal therapy is not usually well protocolized&#59; it is not done on a regular basis and there is a lack of supportive scientific evidence&#44; especially in critically ill patients&#46; To optimize the appropriate use of antimicrobials to achieve the maximum effectiveness&#44; reduce the adverse effects and administer a cost-effective treatment&#44; we must ensure the correct initial antifungal therapy&#44; but also de-escalate when possible in terms of antimycotic efficacy and reduced costs&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14&#44;58</span></a></p><p id="par0670" class="elsevierStylePara elsevierViewall">Antifungal de-escalation should be guided by microbiological results&#44; antifungal susceptibility&#44; the concomitant medication the patient is taking and clinical evolution&#46; This information is usually not available until after 5 days&#44; so the decision to de-escalate is often taken late&#46;</p><p id="par0675" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">1&#46;-In proven invasive candidiasis caused by</span> C&#46; albicans <span class="elsevierStyleItalic">in patients on empirical echinocandin therapy&#44; should treatment always be de-escalated to fluconazole&#44; regardless of the clinical condition&#63;</span></p><p id="par0680" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Rationale&#58;</span> Antifungal therapy should be based on the <span class="elsevierStyleItalic">Candida</span> species and clinical condition of the patient&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">58</span></a> Therefore&#44; empirical echinocandin therapy is recommended in hemodynamically unstable patients &#40;APACHE II<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>15&#41; or patients with criteria of severe sepsis&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#44;47</span></a> Also&#44; the Andes et al&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> study demonstrated that echinocandin therapy was associated to significantly decreased mortality due to invasive candidiasis&#46;</p><p id="par0685" class="elsevierStylePara elsevierViewall">Seventy-six percent of the experts consulted did not agree that it is always convenient to de-escalate to fluconazole&#44; regardless of the patient&#39;s clinical condition&#44; in proven invasive candidiasis due to <span class="elsevierStyleItalic">C&#46; albicans</span> in patients on empirical echinocandin therapy&#46; Specifically&#44; based on a scale of 1&#8211;5 points&#44; where 5 represents the maximum level of agreement&#44; 19 experts granted 1 or 2 points to the statement&#46; The average score was established at 2&#46;0 points&#46; A high degree of consensus was achieved &#40;&#62;75&#37;&#41;&#46;</p><p id="par0690" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">2&#46;-Can treatment be de-escalated&#44; regardless the isolate is susceptible to fluconazole or not&#44; in proven invasive candidiasis due to</span> C&#46; albicans <span class="elsevierStyleItalic">in patients on empirical echinocandin therapy&#63;</span></p><p id="par0695" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Rationale&#58;</span> The susceptibility of <span class="elsevierStyleItalic">C&#46; albicans</span> to fluconazole is very high&#46; In the study of Zulaga et al&#46;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">70</span></a>&#44; 95&#46;2&#37; of the isolates of <span class="elsevierStyleItalic">C&#46; albicans</span> were susceptible to fluconazole&#44; and no resistant isolates were identified&#46;</p><p id="par0700" class="elsevierStylePara elsevierViewall">Eighty percent of the experts consulted considered that in proven invasive candidiasis due to <span class="elsevierStyleItalic">C&#46; albicans</span> in patients receiving empirical echinocandin therapy de-escalation should not be considered without determining the susceptibility to fluconazole&#46; Specifically&#44; based on a 1&#8211;5 point scale to evaluate the level of agreement&#44; 20 experts granted 1 or 2 points to the statement&#46; The average score was 2&#46;0 points&#44; and a high degree of consensus was achieved&#46;</p><p id="par0705" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">3&#46;-In proven invasive candidiasis caused by</span> C&#46; glabrata <span class="elsevierStyleItalic">in patients receiving empirical echinocandin therapy&#44; always de-escalate to fluconazole&#44; regardless of the patient&#39;s clinical condition&#46;</span></p><p id="par0710" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Rationale&#58;</span> The use of fluconazole is recommended in the treatment of candidemia in non-neutropenic stable patients&#44; without prior azole therapy&#46; The use of empirical echinocandin therapy is recommended in hemodynamically unstable patients &#40;APACHE II<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>15&#41; or those with criteria of severe sepsis&#44; prior azole therapy or suspected invasive candidiasis due to azole-resistant <span class="elsevierStyleItalic">Candida</span>&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#44;47</span></a></p><p id="par0715" class="elsevierStylePara elsevierViewall">The vast majority of the experts consulted &#40;96&#37;&#41; considered that the clinical condition of the patient must be considered before de-escalating to fluconazole in proven invasive candidiasis caused by Candida <span class="elsevierStyleItalic">glabrata</span> in patients receiving empirical echinocandin therapy&#46; Thus&#44; based on a 1&#8211;5 point scale&#44; where 5 represents the maximum level of agreement&#44; 24 experts granted 1 or 2 points to this statement&#46; A high degree of consensus was achieved&#46;</p><p id="par0720" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">4&#46;-In proven invasive candidiasis caused by</span> C&#46; glabrata <span class="elsevierStyleItalic">in patients receiving empirical echinocandin therapy&#44; de-escalation can be performed regardless of determining the susceptibility to fluconazole&#46;</span></p><p id="par0725" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Rationale</span>&#58; The 2009 IDSA guidelines recommend performing antifungal susceptibility tests only in cases of therapeutic failure&#44; although they also recommend these tests for fluconazole susceptibility in those <span class="elsevierStyleItalic">C&#46; glabrata</span> isolates recovered from the patients&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">47</span></a> As reported in the study of Garnacho-Montero et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a><span class="elsevierStyleItalic">C&#46; glabrata</span> is potentially fluconazole-resistant&#46; On the other hand&#44; the study of Collins et al&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> concluded that performing fluconazole susceptibility tests in those <span class="elsevierStyleItalic">C&#46; glabrata</span> isolates from patients with proven invasive candidiasis provided improved outcomes&#44; not only in economic&#44; but clinical terms&#46;</p><p id="par0730" class="elsevierStylePara elsevierViewall">Ninety-six percent of the experts consulted considered that in proven invasive candidiasis due to <span class="elsevierStyleItalic">C&#46; glabrata</span> in patients receiving empirical echinocandin therapy&#44; de-escalation should not be performed without previously determining the fluconazole-susceptibility&#46; Specifically&#44; based on a 1&#8211;5 point scale to evaluate the level of agreement&#44; 24 experts granted 1 or 2 points to the statement&#46; The average score was 1&#46;2 points&#46; Once again&#44; a high degree of consensus was achieved&#46;</p><p id="par0735" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">5&#46;-Patients with infection caused by</span> C&#46; krusei <span class="elsevierStyleItalic">with favorable evolution and receiving empirical echinocandin therapy should be de-escalated to voriconazole&#46;</span></p><p id="par0740" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Rationale&#58; C&#46; krusei</span> is intrinsically fluconazole-resistant&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> On its part&#44; voriconazole presents a superior activity than fluconazole against <span class="elsevierStyleItalic">C&#46; krusei</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a></p><p id="par0745" class="elsevierStylePara elsevierViewall">Seventy-six percent of the specialists consulted considered that in patients with an infection caused by <span class="elsevierStyleItalic">C&#46; krusei</span>&#44; with favorable evolution and on empirical echinocandin therapy&#44; de-escalation to voriconazole is not adequate&#46; Specifically&#44; based on a 1&#8211;5 point scale&#44; where 5 represents the maximum level of agreement&#44; 19 experts granted 1 or 2 points to the statement&#46; The average score was 1&#46;8 points and a high degree of consensus was reached&#46;</p><p id="par0750" class="elsevierStylePara elsevierViewall">The question was selected for the second phase of the DELPHI Study to learn about the reasons why some experts considered de-escalation to voriconazole adequate under the already mentioned circumstances&#46; We display below two of the reasons offered by the specialists&#58; &#40;1&#41; &#8216;<span class="elsevierStyleItalic">If the clinical evolution is good</span>&#44; C&#46; krusei <span class="elsevierStyleItalic">also displays high susceptibility to voriconazole and very low MICs&#44; for which it would be a very good option</span>&#8217;&#46; And &#40;2&#41; &#8216;<span class="elsevierStyleItalic">This is a fully valid alternative&#44; accepted in different guidelines&#46; If there are not contraindications for the use of voriconazole &#40;and as long as we have plasma level determinations&#41;&#44; de-escalating or switching to oral therapy is always an alternative&#46;</span></p><p id="par0755" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">6&#46;-In patients receiving antifungal therapy for suspected but unproven invasive candidiasis&#44; after 5 days of good clinical evolution&#44; what action would you take&#63;</span></p><p id="par0760" class="elsevierStylePara elsevierViewall">The responses showed enormous disparity between the opinions of the experts consulted in relation to the measures to be taken in this situation&#46; Thus&#44; 7 specialists &#40;28&#37;&#41; would opt for suspending the antifungal therapy&#59; 6 experts &#40;24&#37;&#41; would continue with the same treatment during 14 days&#59; 6 specialists would de-escalate to an azole&#59; and 2 experts &#40;8&#37;&#41; did not know what measure to take&#46; In conclusion&#44; a low degree of consensus was achieved &#40;&#60;50&#37;&#41;&#46;</p><p id="par0765" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">7&#46;-In patients receiving antifungal therapy for suspected but unproven invasive candidiasis&#44; after 10 days without good clinical improvement&#44; what action would you take&#63;</span></p><p id="par0770" class="elsevierStylePara elsevierViewall">Seventy-six percent of the experts consulted think that in patients with antifungal therapy due to suspected but unproven invasive candidiasis&#44; in whom clinical improvement is not observed after 10 days&#44; the antifungal therapy should be stopped and the patient should be checked again&#46; Also&#44; 3 specialists assured they would only modify the treatment&#44; while 2 would continue treatment for 14 days and 1 would add another antifungal agent&#46; The degree of consensus achieved was high&#46;</p><p id="par0775" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">8&#46;-In patients with candidemia caused by a fluconazole-susceptible</span> Candida <span class="elsevierStyleItalic">species&#44; initially treated with an echinocandin and being the patient stable&#44; when do you believe the treatment should be changed to fluconazole oral therapy&#63;</span></p><p id="par0780" class="elsevierStylePara elsevierViewall">The large majority of the experts consulted &#40;84&#37;&#41; believe that in patients with candidemia caused by a fluconazole-susceptible species of <span class="elsevierStyleItalic">Candida</span>&#44; who have initially received echinocandin therapy and that are stable&#44; fluconazole oral therapy should be given within a maximum period of two or three days after stabilization&#46; A high degree of consensus was established&#46;</p><p id="par0785" class="elsevierStylePara elsevierViewall">Although the question achieved sufficient consensus in accordance with the DELPHI methodology&#44; the 4 experts that considered necessary a period longer than 2&#8211;3 days after stabilization&#44; were asked in the second phase of the current study to indicate the motives that justify their response&#46; We display below two of the reasons provided by the specialists&#58; &#40;1&#41; &#8216;<span class="elsevierStyleItalic">First of all&#44; in the context of a critically ill patient&#44; oral therapy can only be administered on few occasions&#44; despite its excellent absorption by the digestive tract&#46; In second place&#44; and although there are no supportive studies&#44; I believe that 2 or 3 days is a very short period&#46; The guidelines recommend 7 to 10 days&#46; Personally&#44; I do it after 5&#8211;7 days&#44; as long as the evolution is favorable&#44; the CVC has been removed in case of being the origin of the infection and it is fluconazole</span>-<span class="elsevierStyleItalic">susceptible</span>&#8217;&#46; And &#40;2&#41; &#8216;<span class="elsevierStyleItalic">The basic issue of this question is the underlying belief that the patient can have an infection due to fluconazole-resistant species&#46; The microbiological susceptibility testing in vitro is not exactly equivalent to that in vivo&#46; Therefore&#44; I do not believe that linking the stability of the patient and the antifungal susceptibility to the same result is reasonable</span>&#8217;&#46;</p><p id="par0790" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">9&#46;-In general&#44; critically ill patients with invasive candidiasis should not be de-escalated&#46;</span></p><p id="par0795" class="elsevierStylePara elsevierViewall">Seventy-two percent of the experts consulted considered adequate to de-escalate in invasive candidiasis in critically ill patients&#46; Specifically&#44; based on a 1&#8211;5 point scale&#44; where 5 represents the maximum level of agreement&#44; 18 experts granted 1 or 2 points to the statement&#46; A medium degree of consensus was reached&#44; below 76&#37;&#46;</p></span></span></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">First phase recommendations</span><p id="par0800" class="elsevierStylePara elsevierViewall">After having the results of the DELPHI methodology applied to non-neutropenic critically ill patients with suspected or proven invasive candidiasis&#44; the following 20 recommendations were developed &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41; based on the questions that achieved a high level of agreement&#44; subsequently validated in the meeting in person with the hospital panel experts&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Second phase&#58; in person meeting of hospital experts</span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Final recommendations</span><p id="par0805" class="elsevierStylePara elsevierViewall">Using the same methodology&#44; 80 experts met in person to vote the recommendations described in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#46; Only those that achieved a consensus over 75&#37; were chosen&#46; Please&#44; find the final recommendations in <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Conclusion</span><p id="par0810" class="elsevierStylePara elsevierViewall">The management of patients with suspected or proven invasive candidiasis requires a great deal of knowledge&#46; The recommendations developed&#44; based on the DELPHI methodology&#44; summarize this knowledge for educational purposes and can assist in the early identification of potential patients&#44; standardize its management and improve prognostic performance&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Conflict of interests</span><p id="par0815" class="elsevierStylePara elsevierViewall">This consensus has been sponsored by <span class="elsevierStyleGrantSponsor" id="gs0005">MSD Laboratories&#44; Spain</span>&#46;</p></span></span>"
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          "identificador" => "sec0010"
          "titulo" => "Results"
          "secciones" => array:1 [
            0 => array:3 [
              "identificador" => "sec0015"
              "titulo" => "First phase &#8211; DELPHI experts"
              "secciones" => array:1 [
                0 => array:3 [
                  "identificador" => "sec0020"
                  "titulo" => "Epidemiological section"
                  "secciones" => array:1 [
                    0 => array:2 [
                      "identificador" => "sec0025"
                      "titulo" => "2&#46;-Indicate to what extent you request each of the following two diagnostic tests to diagnose non-candidemic invasive candidiasis"
                    ]
                  ]
                ]
              ]
            ]
          ]
        ]
        6 => array:2 [
          "identificador" => "sec0030"
          "titulo" => "First phase recommendations"
        ]
        7 => array:3 [
          "identificador" => "sec0035"
          "titulo" => "Second phase&#58; in person meeting of hospital experts"
          "secciones" => array:1 [
            0 => array:2 [
              "identificador" => "sec0040"
              "titulo" => "Final recommendations"
            ]
          ]
        ]
        8 => array:2 [
          "identificador" => "sec0045"
          "titulo" => "Conclusion"
        ]
        9 => array:2 [
          "identificador" => "sec0050"
          "titulo" => "Conflict of interests"
        ]
        10 => array:2 [
          "identificador" => "xack62333"
          "titulo" => "Acknowledgements"
        ]
        11 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2013-05-08"
    "fechaAceptado" => "2013-05-14"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec254626"
          "palabras" => array:5 [
            0 => "Invasive candidiasis"
            1 => "DELPHI technique"
            2 => "Non-neutropenic critically ill patients"
            3 => "Educational project"
            4 => "Recommendations"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec254627"
          "palabras" => array:5 [
            0 => "Candidiasis invasiva"
            1 => "Metodolog&#237;a DELPHI"
            2 => "Pacientes no neutrop&#233;nicos en estado cr&#237;tico"
            3 => "Proyecto educativo"
            4 => "Recomendaciones"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0010">Background</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Although there has been an improved management of invasive candidiasis in the last decade&#44; controversial issues still remain&#44; especially in the diagnostic and therapeutic approaches&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0015">Aims</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We sought to identify the core clinical knowledge and to achieve high level agreement recommendations required to care for critically ill adult patients with invasive candidiasis&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0020">Methods</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A prospective Spanish survey reaching consensus by the DELPHI technique was made&#46; It was anonymously conducted by electronic mail in a first term to 25 national multidisciplinary experts in invasive fungal infections from five national scientific societies&#44; including intensivists&#44; anesthesiologists&#44; microbiologists&#44; pharmacologists and infectious diseases specialists&#44; who answered to 47 questions prepared by a coordination group after a strict review of the literature in the last five years&#46; The educational objectives spanned five categories&#44; including epidemiology&#44; diagnostic tools&#44; prediction rules&#44; and treatment and de-escalation approaches&#46; The level of agreement achieved among the panel experts in each item should exceed 75&#37; to be selected&#46; In a second term&#44; after extracting recommendations from the selected items&#44; a face to face meeting was performed where more than 80 specialists in a second round were invited to validate the preselected recommendations&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">In the first term&#44; 20 recommendations were preselected &#40;Epidemiology 4&#44; Scores 3&#44; Diagnostic tools 4&#44; Treatment 6 and De-escalation approaches 3&#41;&#46; After the second round&#44; the following 12 were validated&#58; &#40;1&#41; <span class="elsevierStyleItalic">Epidemiology</span> &#40;2 recommendations&#41;&#58; think about candidiasis in your Intensive Care Unit &#40;ICU&#41; and do not forget that non-<span class="elsevierStyleItalic">Candida albicans</span>&#8211;<span class="elsevierStyleItalic">Candida</span> species also exist&#46; &#40;2&#41; <span class="elsevierStyleItalic">Diagnostic tools</span> &#40;4 recommendations&#41;&#58; blood cultures should be performed under suspicion every 2&#8211;3 days and&#44; if positive&#44; every 3 days until obtaining the first negative result&#46; Obtain sterile fluid and tissue&#44; if possible &#40;direct examination of the sample is important&#41;&#46; Use non-culture based methods as microbiological tools&#44; whenever possible&#46; Determination of antifungal susceptibility is mandatory&#46; &#40;3&#41; <span class="elsevierStyleItalic">Scores</span> &#40;1 recommendation&#41;&#58; as screening tool&#44; use the <span class="elsevierStyleItalic">Candida</span> Score and determine multicolonization in high risk patients&#46; &#40;4&#41; <span class="elsevierStyleItalic">Treatment</span> &#40;4 recommendations&#41;&#58; start early&#46; Choose echinocandins&#46; Withdraw any central venous catheter&#46; Fundoscopy is needed&#46; &#40;5&#41; <span class="elsevierStyleItalic">De-escalation</span> &#40;1 recommendation&#41;&#58; only applied when knowing susceptibility determinations and after 3 days of clinical stability&#46; The higher rate of agreement was achieved in the optimization of microbiological tools and the withdrawal of the catheter&#44; whereas the lower rate corresponded to de-escalation therapy and the use of scores&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0030">Conclusions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">The management of invasive candidiasis in ICU patients requires the application of a broad range of knowledge and skills that we summarize in our recommendations&#46; These recommendations may help to identify the potential patients&#44; standardize their global management and improve their outcomes&#44; based on the DELPHI methodology&#46;</p>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0040">Antecedentes</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Aunque en la &#250;ltima d&#233;cada ha mejorado el manejo de la candidiasis invasiva&#44; todav&#237;a persisten aspectos controvertidos&#44; en especial por lo que respecta a la estrategia diagn&#243;stica y terap&#233;utica&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0045">Objetivos</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Identificar los conocimientos cl&#237;nicos esenciales y formular unas recomendaciones con la obtenci&#243;n de un alto grado de consenso&#44; necesarias en la asistencia de pacientes adultos no neutrop&#233;nicos en estado cr&#237;tico con candidiasis invasiva&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0050">M&#233;todos</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Se prepar&#243; una encuesta prospectiva cuyo texto se redact&#243; en espa&#241;ol&#44; y se obtuvo un consenso mediante t&#233;cnica DELPHI &#40;un m&#233;todo de reestructuraci&#243;n de un proceso de comunicaci&#243;n con el que se obtiene un grado de consenso de los especialistas sobre el problema planteado&#41;&#46; En primer t&#233;rmino&#44; se envi&#243; de forma an&#243;nima por correo electr&#243;nico a 25 especialistas nacionales de diferentes disciplinas m&#233;dicas&#44; expertos en infecciones f&#250;ngicas invasivas&#44; de 5 sociedades cient&#237;ficas nacionales&#44; incluidos intensivistas&#44; anestesistas&#44; microbi&#243;logos&#44; farmac&#243;logos e infect&#243;logos&#44; que respondieron a 47 preguntas preparadas por el grupo de coordinaci&#243;n&#44; tras una revisi&#243;n exhaustiva de los estudios publicados durante los 5 &#250;ltimos a&#241;os&#46; Los objetivos educativos contemplaron 5 categor&#237;as&#58; epidemiolog&#237;a&#44; instrumentos diagn&#243;sticos&#44; <span class="elsevierStyleItalic">scores</span>&#44; estrategias terap&#233;uticas y de desescalada&#46; Para ser seleccionado&#44; el grado de acuerdo alcanzado entre los expertos del panel en cada uno de los &#237;tems deb&#237;a superar el 75&#37;&#46; En segundo t&#233;rmino&#44; despu&#233;s de extraer las recomendaciones de los &#237;tems seleccionados&#44; se celebr&#243; una reuni&#243;n presencial donde se invit&#243; a participar en una segunda ronda a m&#225;s de 80 especialistas y se les solicit&#243; la validaci&#243;n de las recomendaciones preseleccionadas&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0055">Resultados</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">En primer t&#233;rmino&#44; se realiz&#243; una preselecci&#243;n de 20 recomendaciones &#40;epidemiolog&#237;a 4&#44; <span class="elsevierStyleItalic">scores</span> 3&#44; diagn&#243;stico de laboratorio 4&#44; tratamiento 6 y desescalada 3&#41;&#46; Despu&#233;s de la segunda ronda&#44; se validaron las 12 recomendaciones siguientes&#58; 1&#41; <span class="elsevierStyleItalic">Epidemiolog&#237;a</span> &#40;2 recomendaciones&#41;&#58; en la Unidad de Cuidados Intensivos considere la candidiasis y no olvide la existencia de especies de <span class="elsevierStyleItalic">Candida</span> diferentes de <span class="elsevierStyleItalic">Candida albicans</span>&#46; 2&#41; <span class="elsevierStyleItalic">T&#233;cnicas diagn&#243;sticas</span> &#40;4 recomendaciones&#41;&#58; ante la m&#225;s m&#237;nima sospecha&#44; es preciso practicar hemocultivos cada 2&#8211;3 d&#237;as y&#44; en caso de obtener un cultivo positivo&#44; cada 3 d&#237;as&#44; hasta obtener el primer resultado negativo&#46; Si es posible&#44; se obtendr&#225;n muestras de fluidos y tejidos est&#233;riles &#40;es importante el examen microsc&#243;pico directo de las muestras&#41;&#46; Siempre que sea posible&#44; como instrumentos microbiol&#243;gicos&#44; deben emplearse m&#233;todos diferentes del cultivo&#46; La determinaci&#243;n de la sensibilidad antif&#250;ngica es obligatoria&#46; 3&#41; <span class="elsevierStyleItalic">Scores</span> &#40;una recomendaci&#243;n&#41;&#58; como instrumento de cribado&#44; se recomienda utilizar el Candida score y determinar la multicolonizaci&#243;n en pacientes en alto riesgo&#46; 4&#41; <span class="elsevierStyleItalic">Tratamiento</span> &#40;4 recomendaciones&#41;&#58; debe instaurarse el tratamiento de forma precoz&#46; Las equinocandinas son el tratamiento de elecci&#243;n&#46; Es recomendable retirar cualquier v&#237;a venosa central insertada&#46; Debe realizarse un estudio del fondo de ojo&#46; 5&#41; <span class="elsevierStyleItalic">Desescalada</span> &#40;una recomendaci&#243;n&#41;&#58; solo aplicable cuando se confirme la sensibilidad a fluconazol y despu&#233;s del transcurso de 3 d&#237;as de estabilidad cl&#237;nica&#46; El mayor acuerdo se alcanz&#243; en la optimizaci&#243;n de los instrumentos microbiol&#243;gicos y en la retirada del cat&#233;ter&#44; mientras que el menor correspondi&#243; al de desescalada y a los <span class="elsevierStyleItalic">scores</span>&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0060">Conclusiones</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">En pacientes ingresados en la Unidad de Cuidados Intensivos&#44; el manejo de la candidiasis invasiva requiere la aplicaci&#243;n de la amplia serie de conocimientos y habilidades resumidas en nuestras recomendaciones&#46; Estas pueden ayudar a identificar a los pacientes potenciales&#44; estandarizar su manejo global y mejorar su desenlace&#44; en funci&#243;n de la metodolog&#237;a DELPHI&#46;</p>"
      ]
    ]
    "NotaPie" => array:2 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0015">De acuerdo con los autores y los editores&#44; este art&#237;culo se publica simult&#225;neamente y de forma &#237;ntegra en Revista Iberoamericana de Micolog&#237;a <span class="elsevierStyleInterRef" id="intr0005" href="doi:10.1016/j.riam.2013.05.006">doi&#58;10&#46;1016&#47;j&#46;riam&#46;2013&#46;05&#46;006</span></p>"
      ]
      1 => array:2 [
        "etiqueta" => "&#9674;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0020">All members are listed in Appendix 1&#46;</p>"
      ]
    ]
    "apendice" => array:1 [
      0 => array:1 [
        "seccion" => array:1 [
          0 => array:4 [
            "apendice" => "<p id="par0830" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">LIST OF COORDINATORS&#44; PARTICIPANTS AND PRACTICING PHYSICIANS COORDINATORS</span></p> <p id="par0835" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">COORDINATORS</span></p> <p id="par0840" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Rafael Zaragoza Crespo</span></p> <p id="par0845" class="elsevierStylePara elsevierViewall">Servicio de Medicina Intensiva&#44; Hospital Universitario Dr&#46; Peset&#46; Valencia</p> <p id="par0850" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Pedro Llinares Mond&#233;jar</span></p> <p id="par0855" class="elsevierStylePara elsevierViewall">Unidad de Enfermedades Infecciosas&#44; Complejo Hospitalario Universitario A Coru&#241;a</p> <p id="par0860" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Emilio Maseda Garrido</span></p> <p id="par0865" class="elsevierStylePara elsevierViewall">Servicio de Anestesiolog&#237;a&#44; Hospital Universitario La Paz&#46; Madrid&#46;</p> <p id="par0870" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Ricard Ferrer Roca</span></p> <p id="par0875" class="elsevierStylePara elsevierViewall">Servicio de Medicina Intensiva&#44; Hospital Universitario M&#250;tua de Terrasa&#46; Terrasa&#46;</p> <p id="par0880" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Alejandro H&#46; Rodr&#237;guez Oviedo</span></p> <p id="par0885" class="elsevierStylePara elsevierViewall">Servicio de Medicina Intensiva&#44; Hospital Universitario Juan XXIII&#46; Tarragona</p> <p id="par0890" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">EXPERTS</span></p> <p id="par0895" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Benito Almirante Gragera</span></p> <p id="par0900" class="elsevierStylePara elsevierViewall">Enfermedades Infecciosas&#44; Hospital Universitari Vall d&#8217;Hebron&#46; Barcelona</p> <p id="par0905" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Rafael Gonz&#225;lez de Castro</span></p> <p id="par0910" class="elsevierStylePara elsevierViewall">Anestesiolog&#237;a&#44; Hospital Universitario de Le&#243;n&#46; Le&#243;n&#46;</p> <p id="par0915" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Miguel Salavert Llet&#237;</span></p> <p id="par0920" class="elsevierStylePara elsevierViewall">Medicina Interna&#44; Hospital Universitario y Polit&#233;cnico La Fe&#46; Valencia</p> <p id="par0925" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Jos&#233; Mar&#237;a Aguado Garc&#237;a</span></p> <p id="par0930" class="elsevierStylePara elsevierViewall">Enfermedades Infecciosas&#44; Hospital Universitario 12 de Octubre&#58; Madrid</p> <p id="par0935" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Mar&#237;a Izascun Azc&#225;rate Ega&#241;a</span></p> <p id="par0940" class="elsevierStylePara elsevierViewall">Medicina Intensiva&#44; Hospital Universitario de Donostia</p> <p id="par0945" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Jes&#250;s Rico Feijoo</span></p> <p id="par0950" class="elsevierStylePara elsevierViewall">Anestesiolog&#237;a y Reanimaci&#243;n&#44; Hospital Universitario R&#237;o Hortega&#46; Valladolid</p> <p id="par0955" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Crist&#243;bal Le&#243;n Gil</span></p> <p id="par0960" class="elsevierStylePara elsevierViewall">Medicina Intensiva&#44; Hospital Universitario de Valme&#46; Sevilla&#46;</p> <p id="par0965" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Gerardo Aguilar Aguilar</span></p> <p id="par0970" class="elsevierStylePara elsevierViewall">Anestesiolog&#237;a y Reanimaci&#243;n&#44; Hospital Cl&#237;nico Universitario de Valencia</p> <p id="par0975" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Jos&#233; Ignacio G&#243;mez Herreras</span></p> <p id="par0980" class="elsevierStylePara elsevierViewall">Anestesiolog&#237;a y Reanimaci&#243;n&#44; Hospital Cl&#237;nico Universitario de Valladolid</p> <p id="par0985" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Juan Carlos del Pozo Laderas</span></p> <p id="par0990" class="elsevierStylePara elsevierViewall">Medicina Intensiva&#44; Hospital Universitario Reina Sofia&#46; C&#243;rdoba</p> <p id="par0995" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Jos&#233; Garnacho Montero</span></p> <p id="par1000" class="elsevierStylePara elsevierViewall">Medicina Intensiva&#44; Hospital Virgen del Rocio&#46; Sevilla</p> <p id="par1005" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Beatriz Galv&#225;n Guijo</span></p> <p id="par1010" class="elsevierStylePara elsevierViewall">Medicina Intensiva&#44; Hospital Universitario La Paz&#46; Madrid</p> <p id="par1015" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Javier Pem&#225;n Garc&#237;a</span></p> <p id="par1020" class="elsevierStylePara elsevierViewall">Microbiolog&#237;a&#44; Hospital Universitario La Fe&#46; Valencia</p> <p id="par1025" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Guillermo Quind&#243;s Andr&#233;s</span></p> <p id="par1030" class="elsevierStylePara elsevierViewall">Microbiolog&#237;a&#44; Facultad de Medicina y Odontolog&#237;a&#44; Universidad del Pa&#237;s Vasco</p> <p id="par1035" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Manuel Cuenca Estrella</span></p> <p id="par1040" class="elsevierStylePara elsevierViewall">Microbiolog&#237;a&#44; Centro Nacional de Microbiolog&#237;a&#44; Instituto de Salud Carlos III&#46; Madrid&#46;</p> <p id="par1045" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Maria Luisa P&#233;rez del Molino Bernal</span></p> <p id="par1050" class="elsevierStylePara elsevierViewall">Microbiolog&#237;a y Parasatolog&#237;a&#44; Complejo Hospitalario Universitario de Santiago de Compostela</p> <p id="par1055" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Patricia Mu&#241;oz Garc&#237;a</span></p> <p id="par1060" class="elsevierStylePara elsevierViewall">Microbiolog&#237;a y Enfermedades Infecciosas&#44; Hospital Universitario Gregorio Mara&#241;&#243;n&#46; Madrid</p> <p id="par1065" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Francisco &#193;lvarez Lerma</span></p> <p id="par1070" class="elsevierStylePara elsevierViewall">Medicina Intensiva&#44; Hospital del Mar&#46; Barcelona</p> <p id="par1075" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Carmen Fari&#241;as &#193;lvarez</span></p> <p id="par1080" class="elsevierStylePara elsevierViewall">Medicina Interna&#44; Hospital Universitario Marqu&#233;s de Valdecilla&#46; Santander</p> <p id="par1085" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Jes&#250;s Fortun Abete</span></p> <p id="par1090" class="elsevierStylePara elsevierViewall">Enfermedades Infecciosas&#44; Hospital Ram&#243;n y Cajal&#46; Madrid&#46;</p> <p id="par1095" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Rafael Le&#243;n L&#243;pez</span></p> <p id="par1100" class="elsevierStylePara elsevierViewall">Medicina Intensiva&#44; Hospital Universitario Reina Sof&#237;a&#46; C&#243;rdoba</p> <p id="par1105" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">C&#233;sar Arag&#243;n Gonz&#225;lez</span></p> <p id="par1110" class="elsevierStylePara elsevierViewall">Medicina Intensiva&#44; Hospital Carlos Haya&#46; M&#225;laga</p> <p id="par1115" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Juan Carlos Val&#237;a Vera</span></p> <p id="par1120" class="elsevierStylePara elsevierViewall">Anestesia y Reanimaci&#243;n&#44; Consorcio Hospital General Universitario de Valencia</p> <p id="par1125" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Marcio Borges Sa</span></p> <p id="par1130" class="elsevierStylePara elsevierViewall">Medicina Intensiva&#44; Hospital Son Llatzer&#46; Palma de Mallorca</p> <p id="par1135" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Mercedes Bouzada</span></p> <p id="par1140" class="elsevierStylePara elsevierViewall">Servicio de Anestesiolog&#237;a de Reanimaci&#243;n y Tratamiento del Dolor&#46; Hospital Cl&#237;nico Universitario de Santiago de Compostela</p> <p id="par1145" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">PRACTICING PHYSICIANS</span></p> <p id="par1150" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Luis Su&#225;rez Gonzalo</span></p> <p id="par1155" class="elsevierStylePara elsevierViewall">Unidad de Reanimaci&#243;n y Cirug&#237;a Cardiotor&#225;cica&#44; Hospital La Paz&#46; Madrid</p> <p id="par1160" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Cruz Soriano Cuesta</span></p> <p id="par1165" class="elsevierStylePara elsevierViewall">Medicina Intensiva&#44; Hospital La Paz&#46; Madrid</p> <p id="par1170" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Esther L&#243;pez Ramos</span></p> <p id="par1175" class="elsevierStylePara elsevierViewall">Unidad de Cuidados Intensivos&#44; Hospital Universitario Pr&#237;ncipe de Asturias&#46; Alcal&#225; de HENARES&#46;</p> <p id="par1180" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Fernando Arm&#233;star Rodr&#237;guez</span></p> <p id="par1185" class="elsevierStylePara elsevierViewall">Medicina Intensiva&#44; Hospital Germans Trias i Pujol&#46; Badalona</p> <p id="par1190" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Eva Benveniste</span></p> <p id="par1195" class="elsevierStylePara elsevierViewall">Servicio Unidad de Cuidados Intensivos&#44; Hospital Germans Trias i Pujol de Badalona</p> <p id="par1200" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Francisco Javier Gonz&#225;lez de Molina Ortiz</span></p> <p id="par1205" class="elsevierStylePara elsevierViewall">Medicina Intensiva&#44; Hospital Universitario Mutua Terrasa</p> <p id="par1210" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Jordi Vall&#233;s</span></p> <p id="par1215" class="elsevierStylePara elsevierViewall">Medicina Intensiva&#44; Hospital de Sabadell</p> <p id="par1220" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Susana Sancho Chinesta</span></p> <p id="par1225" class="elsevierStylePara elsevierViewall">Unidad de Cuidados Intensivos&#44; Hospital Universitario Dr&#46; Peset&#46; Valencia</p> <p id="par1230" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Roberto Reig Valero</span></p> <p id="par1235" class="elsevierStylePara elsevierViewall">Medicina Intensiva&#44; Hospital General de Castell&#243;</p> <p id="par1240" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Francisco L&#243;pez Medrano</span></p> <p id="par1245" class="elsevierStylePara elsevierViewall">Unidad de Enfermedades Infecciosas&#44; Hospital Universitario 12 de Octubre&#46; Madrid</p> <p id="par1250" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Miguel Angel Alcal&#225; Llorente</span></p> <p id="par1255" class="elsevierStylePara elsevierViewall">Medicina Intensiva&#44; Hospital Universitario Fundaci&#243;n Jimenez D&#237;az&#46; Madrid</p> <p id="par1260" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Mar&#237;a Jos&#233; P&#233;rez-Pedrero S&#225;nchez-Belmonte</span></p> <p id="par1265" class="elsevierStylePara elsevierViewall">Servicio de Medicina Intensiva&#44; Hospital Virgen de la Salud&#46; Toledo</p> <p id="par1270" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Mercedes Catal&#225;n Gonz&#225;lez</span></p> <p id="par1275" class="elsevierStylePara elsevierViewall">Medicina Intensiva&#44; Hospital Universitario 12 de Octubre&#46; Madrid&#46;</p> <p id="par1280" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Paula Vera Artazcoz</span></p> <p id="par1285" class="elsevierStylePara elsevierViewall">Medicina Intensiva&#44; Hospital de Sant Pau&#46; Barcelona</p> <p id="par1290" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Montserrat Vallverdu Vidal</span></p> <p id="par1295" class="elsevierStylePara elsevierViewall">Medicina Intensiva&#44; Hospital Universitario Arnau de Villanova Lleida</p> <p id="par1300" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Alejandra Garc&#237;a</span></p> <p id="par1305" class="elsevierStylePara elsevierViewall">Medicina Intensiva&#44; Hospital Vall d&#8217;Hebron&#46; Barcelona</p> <p id="par1310" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Manuel Jes&#250;s Rodriguez</span></p> <p id="par1315" class="elsevierStylePara elsevierViewall">Unidad de Cuidados Intensivos&#44; Hospital Juan Ram&#243;n Jimenez&#46; Huelva</p> <p id="par1320" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Angel Caballero S&#225;ez</span></p> <p id="par1325" class="elsevierStylePara elsevierViewall">Medicina Intensiva&#44; Hospital San Pedro Alc&#225;ntara</p> <p id="par1330" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Emilio D&#237;az Santos</span></p> <p id="par1335" class="elsevierStylePara elsevierViewall">Medicina Intensiva&#44; Hospital de Sant Joan Despi Moises Broggi&#46; Barcelona</p> <p id="par1340" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Teresa Tabuyo Bello</span></p> <p id="par1345" class="elsevierStylePara elsevierViewall">Unidad de Cuidados Intensivo&#44; Complejo Hospitalario Universitario A Coru&#241;a</p> <p id="par1350" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Juan Ram&#243;n Fern&#225;ndez Villanueva</span></p> <p id="par1355" class="elsevierStylePara elsevierViewall">Medicina Intensiva&#44; Hospital Cl&#237;nico Univertisario de Santiago de Compostela</p> <p id="par1360" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Mar&#237;a Teresa Rey Rilo</span></p> <p id="par1365" class="elsevierStylePara elsevierViewall">Anestesiolog&#237;a&#44; Hospital Universitario Fundaci&#243;n Jimenez D&#237;az-Capio&#46; Madrid</p> <p id="par1370" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Vicente Torres Pedr&#243;s</span></p> <p id="par1375" class="elsevierStylePara elsevierViewall">Anestesiolog&#237;a&#44; Hospital Universitario Son Espases&#46; Palma de Mallorca</p> <p id="par1380" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Mar&#237;a Aranda P&#233;rez</span></p> <p id="par1385" class="elsevierStylePara elsevierViewall">Unidad de Cuidados Intensivos&#44; Hospital Son Llatzer&#46; Palma de Mallorca</p> <p id="par1390" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">&#193;ngel Arenzana</span></p> <p id="par1395" class="elsevierStylePara elsevierViewall">Unidad de Cuidados Intensivos&#44; Hospital Virgen Macarena&#46; Sevilla</p> <p id="par1400" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Rafael Garc&#237;a Hern&#225;ndez</span></p> <p id="par1405" class="elsevierStylePara elsevierViewall">Servicio de Anestesiolog&#237;a&#44; Hospital Universitario&#46; Puerta del Mar&#46; C&#225;diz</p> <p id="par1410" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Antonio Ayelo Navarro</span></p> <p id="par1415" class="elsevierStylePara elsevierViewall">Anestesiolog&#237;a&#44; Hospital General Almansa</p> <p id="par1420" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Jos&#233; Luis Ant&#243;n Pascual</span></p> <p id="par1425" class="elsevierStylePara elsevierViewall">Servicio de Medicina Intensiva&#44; Hospital San Juan de Alicante</p> <p id="par1430" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Carlos Castillo</span></p> <p id="par1435" class="elsevierStylePara elsevierViewall">Unidad de Cuidados Intensivos&#44; Hospital de Txagorritxu&#46; Vitoria</p> <p id="par1440" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Nuria Gonzalez</span></p> <p id="par1445" class="elsevierStylePara elsevierViewall">Unidad de reanimaci&#243;n&#44; Hospital Donostia</p> <p id="par1450" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Francisco Esteve Urbano</span></p> <p id="par1455" class="elsevierStylePara elsevierViewall">Servicio de Medicina Intensiva&#44; Hospital Universitario de Bellvitge&#46; Barcelona</p> <p id="par1460" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Francisco &#193;lvarez Lerma</span></p> <p id="par1465" class="elsevierStylePara elsevierViewall">Servicio de Medicina Intensiva&#44; Hospital del Mar&#46; Barcelona</p> <p id="par1470" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Gonzalo Tamayo Medel</span></p> <p id="par1475" class="elsevierStylePara elsevierViewall">Unidad de reanimaci&#243;n&#44; Hospital Universitario Cruces&#46; Bilbao</p> <p id="par1480" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Unai Bengoetxea</span></p> <p id="par1485" class="elsevierStylePara elsevierViewall">Unidad de reanimaci&#243;n&#44; Hospital de Basurto</p> <p id="par1490" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Juan Carlos Pardo Talavera</span></p> <p id="par1495" class="elsevierStylePara elsevierViewall">Unidad de Cuidado Intensivos&#44; Hospital Morales Meseguer&#46; Murcia</p> <p id="par1500" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Roberto Jim&#233;nez S&#225;nchez</span></p> <p id="par1505" class="elsevierStylePara elsevierViewall">Servicio de Medicina Intensiva&#44; Hospital General Universitario Santa Lucia&#46; Cartagena</p> <p id="par1510" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Guillermo Quind&#243;s Andr&#233;s</span></p> <p id="par1515" class="elsevierStylePara elsevierViewall">Inmunolog&#237;a&#44; Microbiolog&#237;a y Parasitolog&#237;a&#44; Fac&#46; Medicina y Odontolog&#237;a U&#46; Pais Vasco</p> <p id="par1520" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Violeta Fern&#225;ndez Garc&#237;a</span></p> <p id="par1525" class="elsevierStylePara elsevierViewall">Anestesia y Reanimaci&#243;n&#44; Hospital Universitario central de Asturias&#46; Oviedo</p> <p id="par1530" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Pedro Picatto Hern&#225;ndez</span></p> <p id="par1535" class="elsevierStylePara elsevierViewall">Anestesiolog&#237;a y Reanimaci&#243;n&#44; Hospital Universitario central de Asturias&#46; Oviedo</p> <p id="par1540" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Armando Blanco Vicente</span></p> <p id="par1545" class="elsevierStylePara elsevierViewall">Medicina Intensiva&#44; Hospital Universitario central de Asturias&#46; Oviedo</p> <p id="par1550" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Jos&#233; Casta&#241;o P&#233;rez</span></p> <p id="par1555" class="elsevierStylePara elsevierViewall">Unidad de Cuidados Intensivos&#44; Hospital Virgen de las Nieves&#46; Granada</p> <p id="par1560" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Mar&#237;a Victoria de la Torre Prados</span></p> <p id="par1565" class="elsevierStylePara elsevierViewall">Cuidados Cr&#237;ticos y Urgencias&#44; Hospital Virgen de la Victoria&#46; M&#225;laga</p> <p id="par1570" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Jos&#233; Manuel Soto</span></p> <p id="par1575" class="elsevierStylePara elsevierViewall">Medicina Intensiva&#44; Hospital Cl&#237;nico Universitario San Cecilio&#46; Granada</p> <p id="par1580" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">C&#233;sar Arag&#243;n Gonz&#225;lez</span></p> <p id="par1585" class="elsevierStylePara elsevierViewall">Unidad de Cuidados Intensivos&#44; Hospital regional Sas Carlos Haya&#46; M&#225;laga</p> <p id="par1590" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Ana Loza V&#225;zquez</span></p> <p id="par1595" class="elsevierStylePara elsevierViewall">Medicina Intensiva&#44; Hospital Universitario de Valme&#46; Sevilla</p> <p id="par1600" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Fernando Maroto Monserrat</span></p> <p id="par1605" class="elsevierStylePara elsevierViewall">Medicina Intensiva&#44; Hospital San Juan de Dios&#46; Sevilla</p> <p id="par1610" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Jos&#233; Garnacho Montero</span></p> <p id="par1615" class="elsevierStylePara elsevierViewall">Unidad de Cuidados Intensivos&#44; Hospital Virgen del Rocio&#46; Sevilla</p> <p id="par1620" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Estrella Terradillos Mart&#237;n</span></p> <p id="par1625" class="elsevierStylePara elsevierViewall">Anestesiolog&#237;a y Reanimaci&#243;n&#44; Hospital Montecelo- Complejo Hospitalario de Pontevedra</p> <p id="par1630" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Jos&#233; Peral Guti&#233;rrez de Ceballos</span></p> <p id="par1635" class="elsevierStylePara elsevierViewall">Medicina Intensiva&#44; UCI&#44; Hospital General Universitario Gregorio Mara&#241;&#243;n&#46; Madrid</p> <p id="par1640" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Luis Quecedo Guti&#233;rrez</span></p> <p id="par1645" class="elsevierStylePara elsevierViewall">Anestesia&#44; Hospital de la Princesa&#46; Madrid</p> <p id="par1650" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Alejandro Doblas</span></p> <p id="par1655" class="elsevierStylePara elsevierViewall">Servicio de Medicina Intensiva&#44; Hospital Juan Ram&#243;n Jim&#233;nez&#46; Huelva</p> <p id="par1660" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Javier Garc&#237;a Cort&#233;s</span></p> <p id="par1665" class="elsevierStylePara elsevierViewall">Anestesiolog&#237;a y Reanimaci&#243;n&#44; Hospital Universitario de Gran Canaria Dr&#46; Negr&#237;n&#46; Las Palmas de Gran Canaria</p> <p id="par1670" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Catalina S&#225;nchez Ram&#237;rez</span></p> <p id="par1675" class="elsevierStylePara elsevierViewall">Unidad de Medicina Intensiva&#44; Hospital Universitario de Gran Canaria Dr&#46; Negr&#237;n&#46; Las Palamas de Gran Canaria</p> <p id="par1680" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Marta Gurpegui Puente</span></p> <p id="par1685" class="elsevierStylePara elsevierViewall">Medicina Intensiva&#44; UCI Polivalente&#44; Hospital Universitario Miguel Servet&#46; Zaragoza</p> <p id="par1690" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Pilar Luque</span></p> <p id="par1695" class="elsevierStylePara elsevierViewall">Especialista en Medicina Intensiva&#46; Unidad de Cuidados Intensivos&#44; Hospital Cl&#237;nico Universitario &#171;Lozano Blesa&#187; de Zaragoza</p> <p id="par1700" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Mar&#237;a Reyes Iranzo Valero</span></p> <p id="par1705" class="elsevierStylePara elsevierViewall">Anestesia&#44; Hospital Universitario Puerta de Hierro&#46; Madrid</p> <p id="par1710" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Isidro Prieto del Portillo</span></p> <p id="par1715" class="elsevierStylePara elsevierViewall">UVI M&#233;dica&#44; Hospital Ram&#243;n y Cajal&#46; Madrid</p> <p id="par1720" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Luis Gajate Mart&#237;n</span></p> <p id="par1725" class="elsevierStylePara elsevierViewall">Anestesiolog&#237;a y Reanimaci&#243;n&#44; Hospital Ram&#243;n y Cajal&#46; Madrid</p> <p id="par1730" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Manuel Cervera</span></p> <p id="par1735" class="elsevierStylePara elsevierViewall">Servicio de Medicina Intensiva&#44; Hospital Arnau de Vilanova&#46; Valencia</p> <p id="par1740" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Mar&#237;a &#193;ngeles Ballesteros Sanz</span></p> <p id="par1745" class="elsevierStylePara elsevierViewall">Medicina Intensiva&#44; Hospital Universitario Marqu&#233;s de Valdecilla&#46; Santander</p> <p id="par1750" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Mar&#237;a del Valle Ortiz</span></p> <p id="par1755" class="elsevierStylePara elsevierViewall">Unidad de Cuidados Intensivos&#44; Hospital Universitario de Burgos</p> <p id="par1760" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Eduardo Tamayo G&#243;mez</span></p> <p id="par1765" class="elsevierStylePara elsevierViewall">Anestesiolog&#237;a y Reanimaci&#243;n&#44; Hospital Cl&#237;nico de Valladolid</p> <p id="par1770" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Felipe Bobillo de Lamo</span></p> <p id="par1775" class="elsevierStylePara elsevierViewall">Unidad de Cuidados Intensivos&#44; Hospital Cl&#237;nico de Valladolid</p> <p id="par1780" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">C&#233;sar Aldecoa</span></p> <p id="par1785" class="elsevierStylePara elsevierViewall">Anestesia y Reanimaci&#243;n&#44; Hospital del R&#237;o Ortega&#46; Valladolid</p> <p id="par1790" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Miguel Angel Pereira Loureiro</span></p> <p id="par1795" class="elsevierStylePara elsevierViewall">Anestesia&#44; Reanimaci&#243;n y UCI&#44; Complejo Hospitalario de Vigo</p> <p id="par1800" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Mar&#237;a Milagros Cid Manzano</span></p> <p id="par1805" class="elsevierStylePara elsevierViewall">Anestesiolog&#237;a&#44; Complexo Hospitalario de Ourense</p> <p id="par1810" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Mar&#237;a Elena Vilas Otero</span></p> <p id="par1815" class="elsevierStylePara elsevierViewall">Anestesia y Reanimaci&#243;n&#44; Hospital Xeral-C&#237;es</p> <p id="par1820" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Jorge &#193;ngel Pereire Tamayo</span></p> <p id="par1825" class="elsevierStylePara elsevierViewall">Anestesiolog&#237;a y Reanimaci&#243;n&#44; Complejo Hospitalario Universitario de Vigo</p> <p id="par1830" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Marina Varela Duran</span></p> <p id="par1835" class="elsevierStylePara elsevierViewall">Anestesiolog&#237;a y Reanimaci&#243;n&#44; Hospital Montecelo- Complejo Hospitalario de Pontevedra</p> <p id="par1840" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Jos&#233; Ricardo Gimeno Costa</span></p> <p id="par1845" class="elsevierStylePara elsevierViewall">Medicina Intensiva&#44; Hospital Universitai i Politecnic La Fe&#46; Valencia</p> <p id="par1850" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Ignacio Moreno Puigdollers</span></p> <p id="par1855" class="elsevierStylePara elsevierViewall">Reanimaci&#243;n&#44; Hospital La Fe&#46; Valencia</p> <p id="par1860" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Mar&#237;a Teresa Recio</span></p> <p id="par1865" class="elsevierStylePara elsevierViewall">Medicina Intensiva&#44; Complejo Hospitalario de C&#225;ceres</p> <p id="par1870" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Juan Francisco Machado Casas</span></p> <p id="par1875" class="elsevierStylePara elsevierViewall">Unidad de Medicina Intensiva&#44; Complejo Hospitalario de Ja&#233;n</p> <p id="par1880" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Rafael L&#233;on</span></p> <p id="par1885" class="elsevierStylePara elsevierViewall">Medicina Intensiva&#44; Hospital Universitario Reina Sofia&#46; C&#243;rdoba</p> <p id="par1890" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Silverio Salvador</span></p> <p id="par1895" class="elsevierStylePara elsevierViewall">Anestesiolog&#237;a y reanimaci&#243;n&#44; Hospital General Universitario de Alicante</p> <p id="par1900" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Carolina Gim&#233;nez Esparza</span></p> <p id="par1905" class="elsevierStylePara elsevierViewall">Unidad de Cuidados Intensivos&#44; Hospital Vega Baja&#46; Orihuela</p> <p id="par1910" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Joaqu&#237;n Lobo Palanco</span></p> <p id="par1915" class="elsevierStylePara elsevierViewall">Medicina Intensiva&#44; Complejo Hospitalario de Navarra</p>"
            "etiqueta" => "Appendix 1"
            "titulo" => "&#201;<span class="elsevierStyleSmallCaps">pico</span> Study"
            "identificador" => "sec0055"
          ]
        ]
      ]
    ]
    "multimedia" => array:4 [
      0 => array:7 [
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        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:3 [
          "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">EDUSEPSIS&#58; Proyecto Educacional en Sepsis Espa&#241;ol&#46;</p>"
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                  \t\t\t\t" style="border-bottom: 2px solid black">Name&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Scientific society<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Dr&#46; Pedro Llinares Mond&#233;jar&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">SEIMC&#47;SEC&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Dr&#46; Rafael Zaragoza Crespo&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">AEM&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Dr&#46; Emilio Maseda Garrido&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
                  \t\t\t\t\ttop\n
                  \t\t\t\t">SEDAR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dr&#46; Ricard Ferrer Roca&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">SEMICYUC&#47;EDUSEPSIS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dr&#46; Alejandro H&#46; Rodr&#237;guez Oviedo&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">SEMICYUC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab391873.png"
              ]
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          ]
          "notaPie" => array:1 [
            0 => array:3 [
              "identificador" => "tblfn0005"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">The Spanish Association of Mycology &#40;AEM&#41; as promoter&#44; the Spanish Society of Infectious Diseases and Clinical Microbiology &#40;SEIMC&#41;&#59; the Spanish Society of Anesthesiology&#44; Reanimation and Pain Therapeutics &#40;SEDAR&#41;&#59; The Spanish Society of Critical&#44; Intensive and Coronary Medicine Units &#40;SEMICYUC&#41;&#59; and the Spanish Society of Chemotherapy &#40;SEQ&#41;&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleSmallCaps">&#201;pico</span> Study&#46; List of coordinators&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Name&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Scientific society<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dr&#46; Benito Almirante Gragera&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">SEIMC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dr&#46; Rafael Gonz&#225;lez de Castro&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">SEDAR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dr&#46; Miguel Salavert Llet&#237;&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">SEQ&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dr&#46; Jos&#233; Mar&#237;a Aguado Garc&#237;a&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">SEIMC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dra&#46; Mar&#237;a Izascun Azc&#225;rate Ega&#241;a&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">SEMICYUC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dra&#46; Mercedes Bouzada Rodriguez&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">SEDAR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dr&#46; Jes&#250;s Rico Feijoo&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">SEDAR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dr&#46; Crist&#243;bal Le&#243;n Gil&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">SEMICYUC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dr&#46; Gerardo Aguilar Aguilar&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">SEDAR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dr&#46; Jos&#233; Ignacio G&#243;mez Herreras&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">SEDAR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dr&#46; Juan Carlos del Pozo Laderas&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">SEMICYUC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dr&#46; Jos&#233; Garnacho Montero&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">SEMICYUC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dra&#46; Beatriz Galv&#225;n Guijo&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">SEMICYUC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dr&#46; Javier Pem&#225;n Garc&#237;a&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">AEM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dr&#46; Guillermo Quind&#243;s Andr&#233;s&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">AEM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dr&#46; Manuel Cuenca Estrella&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">AEM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dra&#46; Marisa P&#233;rez del Molino Bernal&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">SEIMC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dra&#46; Patricia Mu&#241;oz Garc&#237;a&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">SEIMC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dr&#46; Francisco &#193;lvarez Lerma&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">SEMICYUC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dra&#46; Carmen Fari&#241;as &#193;lvarez&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">SEIMC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dr&#46; Jes&#250;s Fortun Abete&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">SEMICYUC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dr&#46; Rafael Le&#243;n L&#243;pez&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">SEMICYUC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dr&#46; C&#233;sar Arag&#243;n Gonz&#225;lez&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">SEMICYUC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dr&#46; Juan Carlos Val&#237;a Vera&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">SEDAR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dr&#46; Marcio Borges Sa&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">SEMICYUC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab391874.png"
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          "notaPie" => array:1 [
            0 => array:3 [
              "identificador" => "tblfn0010"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0010">The Spanish Association of Mycology &#40;AEM&#41; as promoter&#44; the Spanish Society of Infectious Diseases and Clinical Microbiology &#40;SEIMC&#41;&#59; the Spanish Society of Anesthesiology&#44; Reanimation and Pain Therapeutics &#40;SEDAR&#41;&#59; The Spanish Society of Critical&#44; Intensive and Coronary Medicine Units &#40;SEMICYUC&#41;&#59; and the Spanish Society of Chemotherapy &#40;SEQ&#41;&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">List of experts who participated in the <span class="elsevierStyleSmallCaps">&#201;pico</span> Study&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
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        "tabla" => array:1 [
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              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" 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"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Epidemiological section</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>1&#46; Since the incidence of patients with invasive candidiasis admitted to intensive care units has increased in the last decades&#44; consider early treatment in critically ill patients with an infectious process&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
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>2&#46; The most common fungal infections in critically ill patients are caused by <span class="elsevierStyleItalic">Candida</span> species and&#44; although <span class="elsevierStyleItalic">C&#46; albicans</span> is still the species that produces the majority of the candidiasis&#44; consider that non <span class="elsevierStyleItalic">C&#46; albicans</span>&#8211;<span class="elsevierStyleItalic">Candida</span> species are found with increased frequency&#44; exceeding <span class="elsevierStyleItalic">C&#46; albicans</span> in some series&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>3&#46; While it is essential to know the local epidemiology in critically ill patients with invasive candidiasis&#44; consider the possibility of fluconazole-resistant <span class="elsevierStyleItalic">Candida</span> species in neutropenic patients with chronic renal failure&#44; who have received previous triazole therapy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>4&#46; Since certain <span class="elsevierStyleItalic">Candida</span> species&#44; such as <span class="elsevierStyleItalic">C&#46; tropicalis</span>&#44; <span class="elsevierStyleItalic">C&#46; krusei</span> and <span class="elsevierStyleItalic">C&#46; glabrata</span> have been associated with high mortality in critically ill patients&#44; consider the early use of efficient antifungal agents against these species&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Scores section</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>1&#46; Determining the Candida Score should be a screening tool in all critically ill patients with invasive candidiasis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>2&#46; Investigate the presence of multicolonization in all patients at risk&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>3&#46; Associate biomarkers detection to the Candida Score&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Diagnostic laboratory section</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>1&#46; Perform blood cultures at the time of suspected invasive candidiasis and every 2&#8211;3 days&#44; provided the infection persists&#46; In case of a positive result&#44; perform controls until a negative result is obtained&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>2&#46; Submit sterile fluids and tissues for fungal culture and use direct microscopy whenever possible&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>3&#46; In patients with suspected invasive candidiasis&#44; use the routine non-culture based microbiological technique&#44; if available in your center&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>4&#46; In patients with proven invasive candidiasis&#44; request an antifungal susceptibility study&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Treatment section</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>1&#46; Start early treatment at the time of considering the diagnosis of invasive candidiasis&#44; since early treatment is associated to lower mortality rates&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>2&#46; An echinocandin should be the first-choice empirical treatment in critically ill patients&#44; regardless of prior administration of azole therapy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>3&#46; Only in special situations in hemodynamically stable patients without prior azole therapy and with knowledge of a local epidemiology&#44; treatment with azoles can be considered&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>4&#46; At least one ophthalmological evaluation is recommended in all patients with candidemia at risk of developing chorioretinitis and endophthalmitis&#44; since an ocular involvement is a marker of prolonged treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>5&#46; The antifungal treatment should be changed in patients with ocular involvement and on echinocandin therapy&#44; due to its poor penetration&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>6&#46; Whenever possible&#44; remove the central catheter in patients with candidemia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Therapeutic de-escalation section</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>1&#46; In critically ill patients with proven invasive candidiasis due to <span class="elsevierStyleItalic">C&#46; albicans</span> or <span class="elsevierStyleItalic">C&#46; glabrata</span> receiving empirical echinocandin therapy&#44; consider de-escalating to fluconazole treatment if clinical stability is present and the species is fluconazole-susceptible&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>2&#46; In critically ill patients with proven invasive candidiasis by a fluconazole-susceptible <span class="elsevierStyleItalic">Candida</span> species that are receiving empirical echinocandin therapy&#44; consider de-escalating to fluconazole 2 or 3 days after achieving clinical stability&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>3&#46; In patients receiving antifungal therapy due to suspected invasive candidiasis that has not been proven by the tenth day and show no clinical improvement&#44; suspend the antifungal treatment and reevaluate the patient&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">First 20 recommendations&#46;</p>"
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        "etiqueta" => "Table 4"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
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        "tabla" => array:1 [
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" 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"><span class="elsevierStyleItalic">Epidemiological section</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>1&#46; Since the incidence of patients with invasive candidiasis admitted to intensive care units has increased in the last decades&#44; consider early treatment in critically ill patients with an infectious process&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>2&#46; While it is essential to know the local epidemiology in critically ill patients with invasive candidiasis&#44; consider the possibility of fluconazole-resistant <span class="elsevierStyleItalic">Candida</span> species in neutropenic patients with chronic renal failure&#44; who have received previous triazole therapy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Scores section</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>1&#46; As a screening tool&#44; investigate the presence of candidiasic multicolonization and determine the Candida Score in all critically ill patients with suspected invasive candidiasis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Laboratory diagnostic section</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>1&#46; Perform blood cultures at the time of suspected invasive candidiasis and every 2&#8211;3 days&#44; provided the infection persists&#46; In case of a positive result&#44; perform hemoculture controls until a negative result is obtained&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>2&#46; Submit sterile fluids and tissues for fungal culture and use direct microscopy whenever possible&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>3&#46; In patients with suspected invasive candidiasis&#44; use the routine non-culture based microbiological technique&#44; if available in your center&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>4&#46; In patients with proven invasive candidiasis&#44; request an antifungal susceptibility study&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Treatment section</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>1&#46; Start early treatment&#44; at the time of considering the diagnosis of invasive candidiasis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>2&#46; An echinocandin should be the first-line choice of empirical therapy in critically ill patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>3&#46; At least one ophthalmological evaluation is recommended in all patients with candidemia&#46; In case of ocular involvement&#44; consider the poor penetration of echinocandins&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>4&#46; Whenever possible&#44; remove the central catheter in patients with candidemia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Therapeutic de-escalation section</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>1&#46; In critically ill patients with proven invasive candidiasis by a fluconazole-susceptible <span class="elsevierStyleItalic">Candida</span> species that are receiving empirical echinocandin therapy&#44; consider de-escalating to fluconazole after 2 or 3 days of clinical stability&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">The 12 <span class="elsevierStyleSmallCaps">&#201;pico</span> final recommendations&#46;</p>"
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    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:70 [
            0 => array:3 [
              "identificador" => "bib0005"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Prospective study in critically ill non-neutropenic patients&#58; diagnostic potential of &#40;1&#44;3&#41;-beta-<span class="elsevierStyleSmallCaps">d</span>-glucan assay and circulating galactomannan for the diagnosis of invasive fungal disease"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "J&#46; Acosta"
                            1 => "M&#46; Catal&#225;n"
                            2 => "A&#46; Del Palacio-Perez-Medel"
                            3 => "J&#46;C&#46; Montejo"
                            4 => "J&#46; De-LaCruz-Bertolo"
                            5 => "M&#46;D&#46; Moragues"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s10096-011-1365-0"
                      "Revista" => array:6 [
                        "tituloSerie" => "Eur J Clin Microbiol Infect Dis"
                        "fecha" => "2012"
                        "volumen" => "31"
                        "paginaInicial" => "721"
                        "paginaFinal" => "731"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21811868"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0010"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Recomendaciones sobre el tratamiento de la candidiasis invasora y otras infecciones por levaduras de la Sociedad Espa&#241;ola de Enfermedades Infecciosas y Microbiolog&#237;a cl&#237;nica &#40;SEIMC&#41;&#46; Actualizaci&#243;n 2011"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "J&#46;M&#46; Aguado"
                            1 => "I&#46; Ruiz-Camps"
                            2 => "P&#46; Mu&#241;oz"
                            3 => "J&#46; Mensa"
                            4 => "B&#46; Almirante"
                            5 => "L&#46; V&#225;zquez"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.eimc.2011.01.008"
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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