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Experience of a fungal infection after cardiac surgery
Infección fúngica tras cirugía cardiaca. Nuestra experiencia
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"apellidos" => "Escribá" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "A." "apellidos" => "Pajares" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 5 => array:3 [ "nombre" => "P." "apellidos" => "Argente" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitario y Politécnico La Fe, Valencia, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Medicina Interna, Hospital Universitario y Politécnico La Fe, Valencia, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Infección fúngica tras cirugía cardiaca. Nuestra experiencia" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 813 "Ancho" => 1667 "Tamanyo" => 73295 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Distribution of the causative species of confirmed invasive candidiasis.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Candida</span> spp. is a common commensal in humans. It can be found in the skin, digestive system, sputum, in the genital tract and in the urine of patients with urinary catheters. These yeasts have also been isolated in animals, certain objects, hospital environments, and food. A large number of <span class="elsevierStyleItalic">Candida</span> species are known and are grouped under <span class="elsevierStyleItalic">C. albicans</span> and <span class="elsevierStyleItalic">C. no albicans</span>, many of which can cause disease in humans. Recently, a new, uncommon species called <span class="elsevierStyleItalic">Candida auris</span> has been described, which has intrinsic resistance to azole antifungals and is associated with a high rate of mortality.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The number of cases of candidaemia in critical patients has increased in recent years due to the increase in both the population at risk and life expectancy. Other factors have also contributed to this situation, such as exposure to a greater number of invasive procedures, immunosuppressive states, widespread routine use of broad spectrum antibiotics, or abdominal surgery, among others. However, the importance of fungal infections in critically ill patients lies not in their high incidence, but in their prognostic impact, with 40–50% mortality in patients with candidaemia.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">1,2</span></a> This is why it is so essential to prevent onset of colonisation, and when it does occur, to start treatment immediately.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">3</span></a> Risk factors for invasive candidiasis (IC) in intensive care units (ICUs) have been widely studied, leading to the creation of scales to guide empirical treatment, such as the <span class="elsevierStyleItalic">Candida Score</span>.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">4</span></a> This, according to the recent Jávea consensus guidelines on the management of peritoneal candidiasis, is still considered a useful tool by most experts.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Patients undergoing heart surgery present several comorbidities, and these, together with the aggressiveness of the intervention, lead to a large number of postoperative complications, of which infections are the most common non cardiac complications.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">6</span></a> Several factors could predispose these patients to postoperative complications, including exposure to complex interventions requiring multiple vascular lines, invasive procedures, frequent transfusions, the need for hypothermia and cardiopulmonary bypass (CPB) and, in complicated cases, parenteral nutrition or prolonged mechanical ventilation, among others. It is reasonable, therefore, to consider this population as a possible risk group for fungal infection.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Very little evidence has been published on post-cardiac surgery fungal infections, hence the importance of studies focussing on this group of patients and the need for protocols to improve outcomes. In 2013, Michalopoulos et al.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">7</span></a> described the following factors as predictors of candidaemia: mechanical ventilation<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>10 days, the presence of bacterial infection, CPB time<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>120<span class="elsevierStyleHsp" style=""></span>min, and diabetes mellitus. In 2011, Pasero et al.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">8</span></a> identified severe sepsis, simplified acute physiology score (SAPS) II, and hospital stay greater than 20 days as independent risk factors for candidaemia. The only statistically significant risk factor identified by Fortsner et al.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">9</span></a> was the sequential organ failure Assessment (SOFA) score, which the authors found to be correlated with the factors already described by Michalopoulos.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The aim of this study has been to investigate the incidence, severity and outcomes of fungal infections in patients undergoing cardiac surgery. We analysed risk factors of fungal infection based on the hypothesis that, in addition to known risk factors for this type of infection, other factors more specific to cardiac surgery, such as multiple transfusions and prolonged CPB times, could be associated with IC, thereby increasing the risk in this population group.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Patients and study site</span><p id="par0030" class="elsevierStylePara elsevierViewall">This prospective observational study was performed from April 2016 to December 2017 at the La Fe University and Polytechnic Hospital, a tertiary centre with 36 post-anaesthesia intensive care (PAIC) beds, which performs approximately 700 scheduled cardiac surgeries per year, plus around 300 urgent cardiac interventions.</p><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Inclusion criteria</span><p id="par0035" class="elsevierStylePara elsevierViewall">All patients over 14 years of age, scheduled for cardiac surgery, including coronary revascularization, valvular surgery (both open procedures, such as transcatheter or transapical aortic valve implantation (TAVI), and interventions that included aortic repair if associated with valvular surgery) or combined valve replacement and coronary bypass surgery were included in the study.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Exclusion criteria</span><p id="par0040" class="elsevierStylePara elsevierViewall">Exclusion criteria were: emergency surgery, age under 14 years, heart transplants, transfemoral TAVI, ventricular assist placement or the placement of extra corporeal membrane oxygenation (ECMO) systems, except when placement was indicated due to cardiogenic shock after the type of scheduled surgery described in the inclusion criteria.</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Definitions</span><p id="par0045" class="elsevierStylePara elsevierViewall">The following definitions were used in this study.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Fungaemia was defined as an infection of the blood caused by a fungus, called candidemia, when this fungus is of the <span class="elsevierStyleItalic">Candida</span> species. Candidemia was defined as the isolation of <span class="elsevierStyleItalic">Candida</span> spp. in blood culture.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">10</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Diagnosis of IC is difficult due to the absence of pathognomonic symptoms and the low sensitivity (around 50–60%) of blood cultures for the detection of <span class="elsevierStyleItalic">Candida</span> spp. Sensitivity may be even lower in neutropenic patients or in those with a history of antifungal treatment.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">11</span></a> Given these difficulties, some authors have defined probable and possible IC.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">12</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Diagnosis criteria for IC were discussed by a multidisciplinary team from our hospital, and the following definitions were established for the purpose of including patients with high suspicion of IC in the study.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Confirmed invasive candidiasis (CIC) was defined as the presence of candidaemia or fungal isolation in a sterile site related to the site of infection. Probable invasive candidiasis was defined as the multifocal isolation of <span class="elsevierStyleItalic">Candida</span> that includes urine, plus septic shock in the absence of bacterial isolation in blood or catheter. The combination of confirmed and probable IC was defined as IC.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Preoperative kidney injury was defined as a glomerular filtration rate of less than 60<span class="elsevierStyleHsp" style=""></span>ml/min.</p><p id="par0075" class="elsevierStylePara elsevierViewall">Acute postoperative kidney injury was defined as stage 1 kidney injury according to AKIN criteria, based on glomerular filtration rate (creatinine increased 1.5 fold, or greater or equal to 0.3<span class="elsevierStyleHsp" style=""></span>mg/dL increase).</p><p id="par0080" class="elsevierStylePara elsevierViewall">Sepsis/septic shock was defined in accordance with the third international conference definition.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">13</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Multiple transfusion was defined as the administration of more than 4 units of blood products.</p><p id="par0090" class="elsevierStylePara elsevierViewall">Only CPB times in the first surgery were included in the analysis, without taking into account those of subsequent surgeries, in the case of reoperation.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Procedures</span><p id="par0095" class="elsevierStylePara elsevierViewall">Patients included in this study received the standard treatment given to cardiac surgery patients in our hospital. The only study-specific procedure was the extraction of blood and other samples for culture (selective bronchial suctioning, trachael, urine, rectal and nasal samples) on admission to the PAIC unit. Subsequent cultures were requested if infection was suspected, or were taken weekly in the case of patients with prolonged hospitalisation. Several different variables collected preoperatively, intraoperatively and postoperatively were analysed as possible risk factors, and are listed in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Statistical analysis</span><p id="par0100" class="elsevierStylePara elsevierViewall">The clinical data were summarised using mean (standard deviation) and median (first, third quartile) in the case of continuous variables, and absolute and relative frequency in the case of categorical variables. Heatmaps were created to show potential risk factors, representing the presence or absence of these in the case of categorical variables (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) and by standardisation (mean 0) in the case of quantitative variables. Variables were clustered using the Euclidean distance matrix. We analysed the variables that were most representative of fungal infection in the heat map using logistic regression models to identify risk factors associated with IC and CIC. Univariate logistic regression models were developed for each of the variables tested. Given the small number of cases collected, multivariate analysis was not performed. Despite this, we performed logistic regression analysis on 2 variables: multiple transfusion, and CPB time. All analyses were performed using the statistical <span class="elsevierStyleItalic">software</span> R (version 3.5.0) and the NMF (version 0.21.0), brglm2 (version 0.1.8) and clicR (version 0.3.64) packages. Statistical significance was set at <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.05.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Results</span><p id="par0105" class="elsevierStylePara elsevierViewall">Between April 2016 and December 2017, 669 patients were selected based on the inclusion criteria. Median age was 68 years (range 59–75), and 61% were men. Most patients were overweight, with a mean BMI of 27.2<span class="elsevierStyleHsp" style=""></span>kg/m<span class="elsevierStyleSup">2</span> (SD 4). Of these, 355 patients (53%) underwent valve surgery, 178 (26.6%) underwent coronary artery surgery, and 136 (20.4%) underwent combined procedures.</p><p id="par0110" class="elsevierStylePara elsevierViewall">The most common comorbidity was hypertension (63%), followed by diabetes mellitus (33.7%), glycosylated haemoglobin (median 5.9%), kidney injury (median 25%) and chronic obstructive pulmonary disease (median 10%); 40% presented other respiratory diseases or were smokers; 7.3% had a history of cancer; and 7% had presented an infection in the months prior to surgery that was already resolved at the time of intervention. Most study patients (80%) presented good preoperative left and right ventricular ejection fraction, while 24% had previously been admitted to the hospital (stay longer than 2 days).</p><p id="par0115" class="elsevierStylePara elsevierViewall">Median operating time (time between entry and exit from operating room) was 360<span class="elsevierStyleHsp" style=""></span>min (range 300–433), with a median CPB time 122<span class="elsevierStyleHsp" style=""></span>min (92, 153). Half of the sample required catecholamines during weaning from CPB. The mean acute physiology and chronic health evaluation (APACHE II) score was 15 (SD 6). Intraoperative incidents were reported in 11.8% of patients. During their hospital stay, 11% required reoperation (including reinterventions for dehiscence and surgical wound infections), 5.8% due to postoperative bleeding. Over half (64%) of the patients received some kind of intraoperative or postoperative transfusion. Only 2.5% developed septic shock.</p><p id="par0120" class="elsevierStylePara elsevierViewall">The incidence of IC among study patients during this period was 2.69% (18 cases), with 12 confirmed cases (1.79% of the total sample analysed).</p><p id="par0125" class="elsevierStylePara elsevierViewall">Analysing the cases of CIC showed that 50% were caused by <span class="elsevierStyleItalic">C. auris</span> (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>6), a species responsible for the vast majority of cases in our unit, to the detriment of other species. The other <span class="elsevierStyleItalic">Candida</span> spp. species isolated are shown in <a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>. The median time from surgery to the development of candidaemia was 37 days (range 13–73).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0130" class="elsevierStylePara elsevierViewall">Two of the 18 (11%) patients with IC and 1 of the 12 (8%) with CIC died in the immediate postoperative period. These figures increased to 4/18 (22%) and 3/12 (25%), respectively, at 30 days of admission.</p><p id="par0135" class="elsevierStylePara elsevierViewall">The variables that presented a statistically significant correlation with IC are shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>. The univariate study confirmed our hypothesis, namely, both multiple transfusion and prolonged CPB times show a statistically significant correlation with IC. However, after testing both variables using logistic regression analysis, only multiple transfusion was found to correlate with IC (OR 11.5, 95% CI: 3.4–52.7; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001) irrespective of CPB time. We also found a statistically significant correlation with other risk factors already described in other operated patients, including prolonged hospital and ICU stay, postoperative kidney failure, parenteral nutrition, and score on the APACHE II scale. Microbiology tests showed a statistically significant relationship between multifocal colonisation by <span class="elsevierStyleItalic">Candida</span> spp. and the use of a greater number of antibiotics. These results also show a statistically significant relationship in patients with CIC, with the exception of prolonged CPB time.</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Discussion</span><p id="par0140" class="elsevierStylePara elsevierViewall">Candidaemia colonisation in critical patients has increased in recent years. However, its importance lies not so much in its incidence, which is very low in comparison with bacterial infections, as in its association with high morbidity and mortality and poorer prognosis. Patients undergoing cardiac surgery have multiple comorbidities, and the aggressive and invasive procedures they undergo can increase the risk of IC. For this reason, it is important to study this disease in this particular group of patients.</p><p id="par0145" class="elsevierStylePara elsevierViewall">In our patients, incidence of IC was 2.69%, and CIC was 1.79%. The latter is slightly higher than that described in previous studies.<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">8,9</span></a> This could be related to an outbreak of <span class="elsevierStyleItalic">C. auris</span> in our hospital, which triggered a high number of cases of colonisation and infection in the PAIC unit, and increased the number of infections due to this species, to the detriment of other more common species. The outbreak persisted during the entire study recruitment period. Although <span class="elsevierStyleItalic">Candida</span> spp. is more widespread, the most commonly isolated species causing candidaemia in our unit is <span class="elsevierStyleItalic">C. auris</span>, which was first described in Japan in 2009, and is resistant to fluconazole and voriconazole. Echinocandins are the treatment of choice, but sensitivity to posaconazole, itraconazole and amphotericin B has also been observed. Candidaemia caused by this species has a high rate of mortality.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">14</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">Mortality among patients with IC in the immediate postoperative period was 11%, which increased to 22% at 30 days of admission. These values were lower than expected, based on the existing literature, which reports mortality figures of around 30–50%.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">1,8,10</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">Patients diagnosed with IC in our study had an average CPB time of 155<span class="elsevierStyleHsp" style=""></span>min (85) compared to 124<span class="elsevierStyleHsp" style=""></span>min (SD 62) in unaffected individuals. This suggests that CPB, which is typically used in patients undergoing cardiac surgery, could be a specific risk factor for IC in this group of patients. Prolonged CPB can lead to splanchnic and intestinal hypoperfusion that increases the permeability of the intestinal mucosa. This in turn facilitates bacterial and fungal translocation, which increases the risk of infection. This situation could explain the relationship found by other authors, such as Michalopoulos et al.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">7</span></a> In our study, however, in spite of the correlation between IC and prolonged CPB times in the univariate analysis, this relationship was not confirmed in the logistic regression analysis of this IC with multiple transfusions. Neither were other factors such as previous cardiac dysfunction related with the increased risk of candidiasis.</p><p id="par0160" class="elsevierStylePara elsevierViewall">Risk of transfusion-induced infection is usually considered to be very low. However, multiple-transfused patients tend to have undergone more complex surgeries and present a more complicated postoperative status, which leads to respiratory distress and a longer stay in the ICU. All this could explain the higher risk of infection. In this study, despite mean preoperative haemoglobin levels of 13<span class="elsevierStyleHsp" style=""></span>g/dL, 83% (15/18) of patients with CI and 100% with CIC received multiple transfusions. The multiple transfusion variable showed a statistically significant relationship with IC in the univariate study, which was confirmed after this variable was tested against CPB time using logistic regression analysis.</p><p id="par0165" class="elsevierStylePara elsevierViewall">Mechanical ventilation time has been described in the literature as a risk factor for IC. It is evident that prolonged mechanical ventilation is linked to a situation of severity and chronicity that favours the onset of any type of infection, in addition to the implicit risk of associated pneumonia. Patients with IC received prolonged mechanical ventilation, with a median of 11 days (range 2–27) compared to a period of less than 24<span class="elsevierStyleHsp" style=""></span>h (range 0–0) in non-affected patients. Of the 18 patients with IC, 7 required tracheotomy (39%) compared to 2.7% of non-affected patients. For the same reason, prolonged hospital and ICU stay seems to facilitate the risk of infection and complications, possibly because it implies greater exposure to microorganisms and antibiotics, as well as the greater number of diagnostic and therapeutic interventions performed in patients with an increasingly deteriorated physical condition.</p><p id="par0170" class="elsevierStylePara elsevierViewall">Our patients with IC had a median stay in the PAIC unit of 26 days (range 18–38) compared to 3 days (2, 5) in non-affected patients, and a mean hospital stay of 58 days (SD 33) compared to 16 in non-affected patients (SD 12). The latter variable was considered a risk factor for candidaemia in a multicentre study conducted in Colombia in 2016, where affected patients had hospital stays or around 35 days.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">15</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall">Postoperative kidney injury, both acute and acute on chronic, was related to fungal infection. This was also described by Ortiz<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">15</span></a> and Ostrosky-Zeichner<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">2</span></a> in a large retrospective cohort study in patients admitted to critical units for at least 4 days in 9 hospitals in the United States and Brazil. Postoperative kidney injury was detected in 14/18 (77%) of our patients with IC, compared to 24% of non-affected patients; 22% of these patients required renal replacement therapy.</p><p id="par0180" class="elsevierStylePara elsevierViewall">Candiduria was found in 11 of the 12 patients with CIC (91%). Yeasts, such as <span class="elsevierStyleItalic">Candida</span> spp. can colonise the urinary tract and spread to the kidneys. In an at-risk patient, therefore, this could be interpreted as a status prior to candidaemia, mainly in cases of associated sepsis.</p><p id="par0185" class="elsevierStylePara elsevierViewall">Seven of the 18 patients with IC (39%) received parenteral nutrition, compared to 3% of non-affected patients. Parenteral nutrition is a known risk factor for fungal infection in hospitalised patients, and is included in the Candida Score. One explanation for this association is that the absence of enteral nutrition favours bacterial and fungal translocation in the digestive system.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">15</span></a></p><p id="par0190" class="elsevierStylePara elsevierViewall">Combined bacterial and fungal colonisation in the same patient was associated with IC in our patients, and was found in 12/18 affected patients (66.6%) compared to 8.6% of non-affected patients. The presence of prior colonisation by the same bacteria in some cultures performed on admission to the ICU was not associated with the subsequent development of IC, so performing culture on admission to the ICU does not appear to be useful. However, CIC was associated with multifocal colonisation by <span class="elsevierStyleItalic">Candida</span> spp. (75% affected patients vs. 8% non-affected). This confirms that performing follow-up cultures to monitor colonisation during the hospital stay is extremely useful in guiding the choice of early empirical treatment in the case of suspected fungal infection. Experts have recommended studying colonisation rates to predict CI after abdominal surgery.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">5</span></a></p><p id="par0195" class="elsevierStylePara elsevierViewall">Fungal invasion requires mechanisms of adhesion and colonisation that seem to be inhibited by other germs, which could explain the relationship between the use of broad spectrum antibiotics and the high risk of fungal infection. This relationship has been observed in several studies in patients admitted to the ICU, although only the overall use of broad-spectrum antibiotics is evaluated, not the number of antibiotics used.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">15</span></a> The group of patients with IC in this study received more antibiotics than non-affected patients, with a mean of 3 (SD 1) drugs compared to 1.2 (SD 0.79).</p><p id="par0200" class="elsevierStylePara elsevierViewall">A high APACHE II score at admission indicates greater severity, and was also associated with an increase in IC. More severe disease at admission leads to a greater risk of poor response to treatment and longer postoperative period, and is associated with an increase in the risk of infection.</p><p id="par0205" class="elsevierStylePara elsevierViewall">Other risk factors for CI described in the literature, such as diabetes mellitus, did not reach statistical significance in our study.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">7</span></a> A history of cancer did not correlate with an increased risk of invasive fungal infection.</p><p id="par0210" class="elsevierStylePara elsevierViewall">In terms of treatment of patients with IC over the study period, echinocandins were the antifungal agent of choice due to the outbreak of <span class="elsevierStyleItalic">C.</span><span class="elsevierStyleItalic">auris</span> in our unit, and the high incidence of azole resistance. In addition, the association observed between IC and kidney injury makes echinocandins the ideal drug, since it does not require dose adjustment.</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Limitations of the study</span><p id="par0215" class="elsevierStylePara elsevierViewall">This was a single-centre study. The timing of the study coincided with an outbreak of <span class="elsevierStyleItalic">C. auris</span>, and this could have altered the incidence data. Multivariate analysis could not be included among the statistical tests used because of the small number of cases, but will be included in future studies. Instead, a univariate analysis of the variables shown in the heatmap was performed.</p><p id="par0220" class="elsevierStylePara elsevierViewall">Our study is interesting, however, insofar as we found no published studies in which culture data are systematically collected on admission to the ICU. This allowed us to analyse the relationship between prior colonisation and the risk of IC.</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Conclusion</span><p id="par0225" class="elsevierStylePara elsevierViewall">Despite its low incidence, IC is associated with a high rate of mortality and prolonged hospital and ICU stays. We believe protocols for monitoring fungal infection in patients with risk factors for IC scheduled for cardiac surgery should be implemented in hospitals with a high incidence of candidiasis.</p><p id="par0230" class="elsevierStylePara elsevierViewall">In addition to the IC risk factors described, other factors more specific to cardiac surgery, such as multiple transfusions, can also increase the risk of IC in this group of patients. In a patient presenting septic shock after cardiac surgery, multiple transfusions along with other risk factors underline the need to evaluate the need for early empirical antifungal therapy. More studies are needed with a larger sample size that permit multivariate logistic regression analysis to confirm the results of our investigation.</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Funding</span><p id="par0235" class="elsevierStylePara elsevierViewall">This study has been funded by the <span class="elsevierStyleGrantSponsor" id="gs1">Astellas Pharma Spain laboratory</span>.</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Conflicts of interest</span><p id="par0240" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:14 [ 0 => array:3 [ "identificador" => "xres1196195" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction and objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1114593" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1196194" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción y objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1114592" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Material and methods" "secciones" => array:4 [ 0 => array:3 [ "identificador" => "sec0015" "titulo" => "Patients and study site" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Inclusion criteria" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Exclusion criteria" ] ] ] 1 => array:2 [ "identificador" => "sec0030" "titulo" => "Definitions" ] 2 => array:2 [ "identificador" => "sec0035" "titulo" => "Procedures" ] 3 => array:2 [ "identificador" => "sec0040" "titulo" => "Statistical analysis" ] ] ] 6 => array:2 [ "identificador" => "sec0045" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0050" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0055" "titulo" => "Limitations of the study" ] 9 => array:2 [ "identificador" => "sec0060" "titulo" => "Conclusion" ] 10 => array:2 [ "identificador" => "sec0065" "titulo" => "Funding" ] 11 => array:2 [ "identificador" => "sec0070" "titulo" => "Conflicts of interest" ] 12 => array:2 [ "identificador" => "xack409189" "titulo" => "Acknowledgements" ] 13 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-10-11" "fechaAceptado" => "2019-01-23" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1114593" "palabras" => array:6 [ 0 => "Cardiac surgery" 1 => "Fungal infection" 2 => "Candidiasis" 3 => "Multiple transfusions" 4 => "Extracorporeal circulation" 5 => "Post-operative complications" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1114592" "palabras" => array:6 [ 0 => "Cirugía cardiaca" 1 => "Infección fúngica" 2 => "Candidiasis" 3 => "Politransfusión" 4 => "Circulación extracorpórea" 5 => "Complicaciones postoperatorias" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction and objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Patients undergoing cardiac surgery can have post-operative complications, including infections. The aim of this article was to study the incidence, severity and risk factors of invasive candidiasis in these patients, based on the hypothesis that several factors (multiple transfusions and time on extracorporeal circulation) are related to invasive candidiasis.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The study included a prospective analysis of 669 patients undergoing scheduled cardiac surgery from April 2016 to December 2017. Control cultures were collected on admittance to the Surgical Intensive Care Unit.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The incidence of invasive candidiasis was 2.69%, being confirmed in 1.79% of cases. The most frequently isolated <span class="elsevierStyleItalic">Candida</span> species was <span class="elsevierStyleItalic">Candida auris</span>. Mortality rate in the invasive candidiasis group was 11% in the immediate post-operative period and 22% at 30 days. After the univariate study, a statistically significant relationship was found between invasive candidiasis and multiple transfusions (OR 15.86; 95% CI: 5.15–69.4; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001). A statistically significant relationship was also found with other known risk factors in hospitalised patients.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Multiple transfusions are associated with an increased risk of invasive candidiasis. Surveillance measures for fungal infection in patients with risk factors undergoing cardiac surgery should be implemented in hospitals with a high incidence of candidiasis.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction and objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducción y objetivos</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Los pacientes operados de cirugía cardiaca presentan numerosas complicaciones postoperatorias, entre ellas, infecciosas. El objetivo de este estudio es investigar la incidencia, gravedad y factores de riesgo de candidiasis invasiva en estos pacientes, partiendo de la hipótesis de que factores como la politransfusión y los tiempos prolongados de circulación extracorpórea están relacionados con ella.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se analizó prospectivamente a 669 pacientes operados de cirugía cardiaca programada desde abril de 2016 hasta diciembre de 2017. Se procedió a la extracción de cultivos de vigilancia al ingreso en la Unidad de Cuidados Intensivos de Anestesia, así como cultivos posteriores.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">La incidencia de candidiasis invasiva fue del 2,69%, confirmada en el 1,79% de los casos. La especie de <span class="elsevierStyleItalic">Candida</span> más frecuentemente aislada fue <span class="elsevierStyleItalic">Candida auris</span>. La mortalidad en el postoperatorio inmediato fue del 11% en la candidiasis invasiva, que aumentó al 22% al mes de ingreso. Tras el estudio univariable se encontró una relación estadísticamente significativa entre la candidiasis invasiva y la politransfusión (OR 15,86; IC %: 5,15-69,14; p <<span class="elsevierStyleHsp" style=""></span>0,001). Asimismo, también se encontró una relación estadísticamente significativa con otros factores de riesgo conocidos en pacientes hospitalizados.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La politransfusión se asocia a un mayor riesgo de candidiasis invasiva. Es necesario implementar medidas de vigilancia para la infección fúngica en pacientes con factores de riesgo que vayan a ser operados mediante cirugía cardiaca en hospitales con elevada incidencia de candidiasis.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción y objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Vicente-Martínez L, Vicente-Guillen R, Calabuig E, Escribá F, Pajares A, Argente P. Infección fúngica tras cirugía cardiaca. Nuestra experiencia. Rev Esp Anestesiol Reanimac. 2019;66:307–314.</p>" ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1206 "Ancho" => 2084 "Tamanyo" => 272758 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Heat map showing the correlation between candidiasis and dichotomous variables. The rows represent the variables analysed; the columns represent patients and differentiate between presence of invasive candidiasis and absence of invasive candidiasis. Black indicates the presence and grey the absence of the variable in the patient.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 813 "Ancho" => 1667 "Tamanyo" => 73295 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Distribution of the causative species of confirmed invasive candidiasis.</p>" ] ] 2 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">AKI: acute kidney injury; APACHE: Acute Physiology And Chronic Health Evaluation; ATB: antibiotics; BMI: body mass index; CBP: cardiopulmonary bypass; CKD: chronic kidney disease; COPD: chronic obstructive pulmonary disease; EF: ejection fraction; HbA1C: glycosylated haemoglobin; HTN: hypertension; ICU: intensive care unit; RRT: renal replacement therapy; SBS: selective bronchial suctioning.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="3" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Preoperative, intraoperative and postoperative variables</th></tr><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Preoperative \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Intraoperative \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Postoperative \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Age \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">Type of surgery: \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">Blood products \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sex \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">- Valvular \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">Mechanical ventilation time \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">BMI \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">- Coronary artery \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">Tracheotomy \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">HTN \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">- Combined \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">Bleeding complications \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">HbA1C \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">Duration of surgery \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">Reintervention due to bleeding \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Diabetes mellitus \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">CPB time \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">Kidney complications: AKI/AKI on CKD/RRT \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Kidney injury. \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">Blood products \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">Parenteral nutrition \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">COPD \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">Need for catecholamines \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">Cultures on admission: SBS/trachael/urine/rectal/nasal/blood count \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Other respiratory diseases or smoking habit \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">Intraoperative complications \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">Subsequent cultures \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Preoperative haemoglobin \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \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">Multifocal <span class="elsevierStyleItalic">Candida</span> colonisation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Preoperative EF \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \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">Septic shock \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Previous/scheduled admission \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \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">Both bacterial and fungal isolates \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Infections prior to surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \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">Length of stay in PAIC unit \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cancer \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \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">Length of hospital stay \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="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \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">Survival: immediate/30-day \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="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \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">APACHE II \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="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \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">Number of ATBs \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2042193.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Study variables analysed.</p>" ] ] 3 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">APACHE: Acute Physiology And Chronic Health Evaluation.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Univariate models \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Invasive candidiasis OR; (95% CI); <span class="elsevierStyleItalic">p</span> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Confirmed candidiasis OR; (95% CI); <span class="elsevierStyleItalic">p</span> \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">APACHE II \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.102; (1.03–1.172); 0.002 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.098; (1.016–1.18); 0.013 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Length of hospitalisation logarithm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15.953; (7.235–40.944); <0.001 \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">17.48; (6.859–55.393); <0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Length of ICU stay logarithm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9.119; (5.077–18.753); <0.001 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9.623; (4.839–23.566); <0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Number of antibiotics \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.175; (1.692–2.828); <0.001 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.163; (1.635–2.886); <0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Extracorporeal circulation time logarithm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.801; (1.034–14.141); 0.046 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.571; (0.363–7.482); 0.567 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Parenteral nutrition \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">19.091; (6.476–53.69); <0.001 \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">28.864; (8.426–99.483); <0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Multifocal <span class="elsevierStyleItalic">Candida</span> colonisation \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">41.79; (14.385–151.769); <0.001 \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">32.618; (9.425–150.256); <0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Kidney injury \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10.226; (3.61–36.463); <0.001 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14.324; (3.729–93.803); 0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Multiple transfusion \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15.865; (5.154–69.14); <0.001 \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">12; (4.2–40); 0.002 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mechanic ventilation \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">22.10; (7.73–79.33); <0.001 \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">30.32; (7.84–199.33); <0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2042194.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Results of the analysis of study variables that were most representative of fungal infection in the heatmap using logistic regression models.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:15 [ 0 => array:3 [ "identificador" => "bib0080" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Impact of therapeutic strategies on the prognosis of candidemia in the ICU" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M. Puig-Asensio" 1 => "J. Pemán" 2 => "R. Zaragoza" 3 => "J. Garnacho-Montero" 4 => "E. Martín-Mazuelos" 5 => "M. Cuenca-Estrella" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/CCM.0000000000000221" "Revista" => array:6 [ "tituloSerie" => "Crit Care Med" "fecha" => "2014" "volumen" => "42" "paginaInicial" => "1423" "paginaFinal" => "1432" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24557426" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0085" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clinical prediction rules for invasive candidiasis in the ICU: ready for prime time?" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "L. Ostrosky-Zeichner" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1186/cc10422" "Revista" => array:5 [ "tituloSerie" => "Crit Care" "fecha" => "2011" "volumen" => "15" "paginaInicial" => "189" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21943066" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0090" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Delaying the empiric treatment of candida bloodstream infection until positive blood culture results are obtained: a potential risk factor for hospital mortality" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "M. Morrell" 1 => "V.J. Fraser" 2 => "M.H. Kollef" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1128/AAC.49.9.3640-3645.2005" "Revista" => array:6 [ "tituloSerie" => "Antimicrob Agents Chemother" "fecha" => "2005" "volumen" => "49" "paginaInicial" => "3640" "paginaFinal" => "3645" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16127033" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0095" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A bedside scoring system (‘Candida score’) for early antifungal treatment in non-neutropenic critically ill patients with Candida colonization" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "C. Leon" 1 => "S. Ruiz-Santana" 2 => "P. Saavedra" 3 => "B. Almirante" 4 => "J. Nolla-Salas" 5 => "F. Alvarez-Lerma" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/01.CCM.0000202208.37364.7D" "Revista" => array:6 [ "tituloSerie" => "Crit Care Med" "fecha" => "2006" "volumen" => "34" "paginaInicial" => "730" "paginaFinal" => "737" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16505659" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0100" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Jávea consensus guidelines for the treatment of Candida peritonitis and other intra-abdominal fungal infections in non-neutropenic critically ill adult patients" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J. Pemán" 1 => "G. Aguilar" 2 => "J. Valía" 3 => "M. Salavert" 4 => "D. Navarro" 5 => "R. Zaragoza" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.riam.2016.12.001" "Revista" => array:7 [ "tituloSerie" => "Rev Iberoam Micol" "fecha" => "2017" "volumen" => "34" "paginaInicial" => "130" "paginaFinal" => "142" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28579084" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S1552526015029155" "estado" => "S300" "issn" => "15525260" ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0105" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Management practices and major infections after cardiac surgery" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A.C. Gelijns" 1 => "A.J. Moskowitz" 2 => "M.A. Acker" 3 => "M. Argenziano" 4 => "N.L. Geller" 5 => "J.D. Puskas" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jacc.2014.04.052" "Revista" => array:6 [ "tituloSerie" => "J Am Coll Cardiol" "fecha" => "2014" "volumen" => "64" "paginaInicial" => "372" "paginaFinal" => "381" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25060372" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0110" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Determinants of candidemia and candidemia-related death in cardiothoracic ICU patients" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "A.S. Michalopoulos" 1 => "S. Geroulanos" 2 => "S.D. Mentzelopoulos" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1378/chest.124.6.2244" "Revista" => array:6 [ "tituloSerie" => "Chest" "fecha" => "2003" "volumen" => "124" "paginaInicial" => "2244" "paginaFinal" => "2255" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/14665507" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0115" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Candidemia after cardiac surgery in the intensive care unit: an observational study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "D. Pasero" 1 => "F.G. de Rosa" 2 => "N.K. Rana" 3 => "L. Fossati" 4 => "A. Davi" 5 => "M. Rinaldi" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1510/icvts.2010.257931" "Revista" => array:6 [ "tituloSerie" => "Interact Cardiovasc Thorac Surg" "fecha" => "2011" "volumen" => "12" "paginaInicial" => "374" "paginaFinal" => "378" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21183505" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0120" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A prospective analysis of invasive candidiasis following cardiac surgery: severity markers are predictive" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "C. Forstner" 1 => "A. Lassnigg" 2 => "S. Tobudic" 3 => "A. Schiferer" 4 => "H. Fischer" 5 => "W. Graninger" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jinf.2013.02.003" "Revista" => array:6 [ "tituloSerie" => "J Infect" "fecha" => "2013" "volumen" => "66" "paginaInicial" => "528" "paginaFinal" => "535" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23438944" "web" => "Medline" ] ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0125" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Espinosa Sierra C. Patrones de cambio clínico epidemiológicos, factores pronósticos e influencia del tratamiento antifúngico precoz en su evolución [Tesis de máster]. Murcia: Universidad de Murcia; 2008." ] ] ] 10 => array:3 [ "identificador" => "bib0130" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Avances en el diagnóstico y tratamiento de las infecciones por levaduras: papel de los nuevos antifúngicos" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "J. Peman" 1 => "B. Almirante" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Enferm Infecc Microbiol Clin" "fecha" => "2008" "volumen" => "26" "paginaInicial" => "38" "paginaFinal" => "46" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19195437" "web" => "Medline" ] ] ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib0135" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Invasive candidiasis in critically ill patients: a prospective cohort study in two tertiary care centers" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "H.M. Al-Dorzi" 1 => "H. Sakkijha" 2 => "R. Khan" 3 => "T. Aldabbagh" 4 => "A. Toledo" 5 => "P. Ntinika" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1177/0885066618767835" "Revista" => array:3 [ "tituloSerie" => "J Intensive Care Med" "fecha" => "2018" "volumen" => "1" ] ] ] ] ] ] 12 => array:3 [ "identificador" => "bib0140" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The third international consensus definitions for sepsis and septic shock (sepsis-3)" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M. Singer" 1 => "C.S. Deutschman" 2 => "C.W. Seymour" 3 => "M. Shankar-Hari" 4 => "D. Annane" 5 => "M. Bauer" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1001/jama.2016.0287" "Revista" => array:6 [ "tituloSerie" => "JAMA" "fecha" => "2016" "volumen" => "315" "paginaInicial" => "801" "paginaFinal" => "810" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26903338" "web" => "Medline" ] ] ] ] ] ] ] ] 13 => array:3 [ "identificador" => "bib0145" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Nosocomial fungemia by <span class="elsevierStyleItalic">Candida auris</span>: first four reported cases in continental Europe" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A.C. Ruiz Gaitan" 1 => "A. Moret" 2 => "J.L. Lopez Hontangas" 3 => "J.M. Molina" 4 => "A.I. Aleixandre López" 5 => "A.H. Cabezas" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.riam.2016.11.002" "Revista" => array:7 [ "tituloSerie" => "Rev Iberoam Micol" "fecha" => "2017" "volumen" => "34" "paginaInicial" => "23" "paginaFinal" => "27" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28131716" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S1552526011000999" "estado" => "S300" "issn" => "15525260" ] ] ] ] ] ] ] 14 => array:3 [ "identificador" => "bib0150" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Factores de riesgo asociados a candidemia en pacientes críticos no neutropénicos en Colombia" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "G. Ortiz Ruiz" 1 => "J. Osorio" 2 => "S. Valderrama" 3 => "D. Álvarez" 4 => "R. Elías-Díaz" 5 => "J. Calderón" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.medin.2015.08.001" "Revista" => array:6 [ "tituloSerie" => "Med Intensiva" "fecha" => "2016" "volumen" => "40" "paginaInicial" => "139" "paginaFinal" => "144" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26725105" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack409189" "titulo" => "Acknowledgements" "texto" => "<p id="par0250" class="elsevierStylePara elsevierViewall">We would like to thank the doctors and nurses of the Critical Care Unit of our hospital, as well as the Microbiology Service for volunteering their help in this project.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/23411929/0000006600000006/v1_201905290656/S2341192919300885/v1_201905290656/en/main.assets" "Apartado" => array:4 [ "identificador" => "34051" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Original articles" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23411929/0000006600000006/v1_201905290656/S2341192919300885/v1_201905290656/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192919300885?idApp=UINPBA00004N" ]
