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DDD: defined daily dose in adults; PeDDD: defined daily dose calculated in pediatrics.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Elio Castagnola, Ines Lorenzi, Paola Barabino, Angela Pistorio" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Elio" "apellidos" => "Castagnola" ] 1 => array:2 [ "nombre" => "Ines" "apellidos" => "Lorenzi" ] 2 => array:2 [ "nombre" => "Paola" "apellidos" => "Barabino" ] 3 => array:2 [ "nombre" => "Angela" "apellidos" => "Pistorio" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0213005X22001811?idApp=UINPBA00004N" "url" => "/0213005X/0000004100000009/v1_202311020958/S0213005X22001811/v1_202311020958/en/main.assets" ] "en" => array:19 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Brief report</span>" "titulo" => "<span class="elsevierStyleItalic">Clostridioides difficile</span> recovered in pleural fluid: Contamination or infection? 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Presentación de un caso probado de empiema y revisión de la literatura" ] ] "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">Clostridioides difficile</span> is a Gram-positive, anaerobe spore forming rod that can form part of the gastrointestinal commensal microbiota in up to 17.5% of healthy adults.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">1</span></a> Firstly identified in 1935, it was originally named <span class="elsevierStyleItalic">Bacillus difficilis</span> because of its difficulty to be isolated in the laboratory.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">2</span></a> It is especially well known because some strains are producers of toxins A and B and cause antibiotic-associated diarrhea, whose severity ranges from a self-limiting infection to a life-threatening pseudomembranous colitis.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Extracolonic <span class="elsevierStyleItalic">C. difficile</span> infection (CDI) is rarely reported and commonly associated with abdominal surgery. Moreover, isolation of <span class="elsevierStyleItalic">C. difficile</span> from extraintestinal locations, found as part of polimicrobial microbiota, is often difficult to interpret and commonly considered as contamination.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">3,4</span></a> Pleural empyema is a very infrequent manifestation of extraintestinal CDI, with just eight cases reported in literature.<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">5–11</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Here we present a rare case of pleural empyema caused by <span class="elsevierStyleItalic">C. difficile</span>, acquired in the community, in a patient without evidence of concomitant gastrointestinal disease. Also, the literature available of this entity is reviewed.</p><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Case report</span><p id="par0020" class="elsevierStylePara elsevierViewall">A 70-year-old male presented to our hospital, a 1000-bed tertiary hospital in northern Spain, with a one-day history of right-sided pleuritic chest pain. He did not report fever, shortness of breath or diarrhea. The weeks before admission, he had received amoxicillin as prophylaxis before a dental extraction. Significant past medical history included complicated diverticulitis and bacteremia by <span class="elsevierStyleItalic">Eggerthella</span><span class="elsevierStyleItalic">lenta</span>.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Physical examination showed diminished breath sounds in the right lower lobe. Blood analysis demonstrated a leukocyte count of 29.96<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>/l (4.5–10<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>/l) and a C reactive protein of 202<span class="elsevierStyleHsp" style=""></span>mg/l (0–5<span class="elsevierStyleHsp" style=""></span>mg/l).</p><p id="par0030" class="elsevierStylePara elsevierViewall">A chest radiograph and computed tomography (CT) revealed a right-sided pleural effusion and atelectasis of the lower lobe of the right lung. There were no pathological findings in upper quadrants of abdomen. Analysis of pleural fluid, obtained after the insertion of a 14-Fr pigtail catheter in the pleural cavity, was suggestive of empyema (pH 6.8, glucose 2<span class="elsevierStyleHsp" style=""></span>mg/dl, lactate dehydrogenase 7591<span class="elsevierStyleHsp" style=""></span>U/l). Empirical treatment with amoxicillin–clavulanate 1000<span class="elsevierStyleHsp" style=""></span>mg/200<span class="elsevierStyleHsp" style=""></span>mg iv q8 hours was started and intrapleural fibrinolytics were administrated, with good clinical and radiological outcome. Cultures of pleural fluid, performed following the Infectious Diseases Society of America (IDSA) recommendations, were positive for two different bacteria identified by MALDI TOF/MS (Bruker Daltonics, Bremen, Germany) as <span class="elsevierStyleItalic">Staphylococcus hominis</span> and <span class="elsevierStyleItalic">C. difficile</span>, which were initially interpreted as contaminants. Antibiogram was performed by Etest strips (bioMérieux, Marcy l’Etoile, France) and interpreted according to 2022 EUCAST <span class="elsevierStyleItalic">C. difficile</span> breakpoints (<a href="https://www.eucast.org/clinical_breakpoints">https://www.eucast.org/clinical_breakpoints</a>) for vancomycin and metronidazole; and CLSI breakpoints for anaerobes<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">12</span></a> for tetracycline, amoxicillin/clavulanate and clindamycin. The isolate was susceptible to all the antimicrobials tested. The patient was discharged home eight days after admission with oral antibiotic therapy (amoxicillin–clavulanate 875/125<span class="elsevierStyleHsp" style=""></span>mg po BID 10 days).</p><p id="par0035" class="elsevierStylePara elsevierViewall">A month and a half later, the patient was readmitted due to worsening general condition. He referred a growing mass in upper right lumbar region, but continued afebrile. A chest CT was performed, showing a multiloculated collection of 4.2<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>7.7<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>6.3<span class="elsevierStyleHsp" style=""></span>cm in the right pleural cavity which extended across the diaphragm into the right retroperitoneal space (5.1<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>7<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>14<span class="elsevierStyleHsp" style=""></span>cm) and infiltrated lumbar paravertebral muscles. Antibiotic therapy with amoxicillin–clavulanate was reinitiated and an 8<span class="elsevierStyleHsp" style=""></span>F catheter was inserted in the retroperitoneal collection, with removal of 250 cm<span class="elsevierStyleSup">3</span> of purulent fluid. Radiological improvement was observed in CT control and subsequent pus cultures were positive for <span class="elsevierStyleItalic">C. difficile</span>, with no other species recovered. Despite the lack of gastrointestinal symptoms, a stool sample was collected, and the FilmArray Gastrointestinal PCR Panel (BioFire Diagnostics, Salt Lake City, UT, USA) was performed, being positive for <span class="elsevierStyleItalic">C. difficile</span> but negative for A<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>B toxin, as well as the isolate recovered from the collection. The patient was readmitted two weeks after his second discharge due to gastrointestinal side effects of amoxicillin–clavulanate, a new retroperitoneal drainage was performed, and then he completed six weeks of oral treatment with doxycycline (100<span class="elsevierStyleHsp" style=""></span>mg PO q12 hours) with complete recovery.</p></span></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Discussion</span><p id="par0040" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">C. difficile</span> is a well-established cause of antibiotic-associated diarrhea. It was firstly identified in 1935, among the normal gastrointestinal microbiota in infants, although its pathogenic potential would not be recognized until the 1970s.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">2</span></a> Although it has been traditionally considered a health-care associated pathogen, there has been an increase in its community incidence in the last years.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">4</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Extraintestinal CDI are infrequent, and tend to appear in hospitalized patients with comorbidities. Many of the cases described in literature occur after abdominal surgery, with the development of intra-abdominal abscesses, peritonitis or abdominal wound infections.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">4</span></a> Brain abscesses, osteomyelitis, reactive arthritis, pyelonephritis, pleural empyema, soft-tissue infection, appendicitis, pericarditis and prosthetic joint infection have also been reported.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">2,4</span></a> These manifestations, not always caused by toxigenic isolates, frequently happen without a recent history of diarrhea, suggesting that their low intestinal virulence allows prolonged carriage which is followed by opportunistic infections.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">2</span></a> Bacteremia by <span class="elsevierStyleItalic">C. difficile</span>, although rarely described, could be implicated as a route of transmission of extraintestinal CDI.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">3,4</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">There are only a few cases of pleural empyema reported in literature (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">5–11</span></a> Smith and King described the two first in 1962, in a series of patients with various extraintestinal CDI. Both cases were attributed to aspiration,<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">5</span></a> which was also the most likely mechanism of infection in most of the other cases described. Patients from other reports had a history of achalasia, gastroesophageal reflux disease or had been previously treated with proton pump inhibitors, as predisposing factors.<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">9,11</span></a> Iatrogenic contamination of pleural space was another hypothesis raised as a source of infection, since in two reports two patients had undergone prior thoracocentesis.<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">6,11</span></a> Hematogenous spread as mechanism of infection was never described.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">As occurred in our patient, previous antibiotic exposure was described in three of the previous reported cases (in the remaining five, this data was not specified). Stool toxin assay was negative in three cases. In the remaining five, this test was not performed or data is unclear. However, one of the patients with negative stool toxin assay had a medical history of <span class="elsevierStyleItalic">C. difficile</span> colitis,<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">8</span></a> and another presented indicative signs of concurrent <span class="elsevierStyleItalic">C. difficile</span> colitis in a CT of abdomen performed after hospital admission.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">10</span></a> Our patient did not have symptoms of concomitant gastrointestinal disease, nor radiological findings suggestive of colitis, furthermore, his stool sample revealed the presence of a non-toxigenic <span class="elsevierStyleItalic">C. difficile</span> strain. The mechanism of infection remains unclear in the case here reported. The patient could have experienced a transient bacteremia with bacterial migration in the pleural space, although this possibility has never been described in literature. In fact, in a review of <span class="elsevierStyleItalic">C. difficile</span> bacteremia by Libby and Bearman, hematogenous spread was not described as a mechanism of pleuropulmonary infection.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">4</span></a> The most plausible hypothesis would be bronchial aspiration of <span class="elsevierStyleItalic">C. difficile</span> spores, subsequent germination and pneumonia development with pleural exudative effusion. <span class="elsevierStyleItalic">C. difficile</span> can be isolated from oral cavity in hospitalized patients, although is not part of the normal microbiota of this area.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">8</span></a> Cultures of the oral cavity were not performed in our patient nor in any of the other cases of pleural empyema, except in the one reported by Hudson et al., in which it was negative.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">8</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">The approach of extra-intestinal CDI treatment is controversial, since antibiotic regimens are not well defined neither in guidelines or in the literature. Previous described cases of empyema by <span class="elsevierStyleItalic">C. difficile</span> were treated with intravenous metronidazole or vancomycin, as well as beta-lactam antibiotics such as amoxicillin–clavulanate or cefazoline. In six of the cases previously reported the patients experienced full recovery (in the remaining two cases, this information is not available).<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">5–11</span></a> Our patient was initially treated with amoxicillin–clavulanate, and completed six weeks of therapy with oral doxycycline, due to gastrointestinal side effects associated to the first antibiotic, with full recovery. Tetracyclines may serve as an alternative or a component of combination therapy for CDI associated diarrhea, and most isolates reported in Europe are susceptible, with resistance rates under 10%. Doxycycline may prevent or attenuate the virulence factors of toxigenic <span class="elsevierStyleItalic">C. difficile</span>.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">13</span></a> Also, this drug has many advantages over other tetracyclines, including less-frequent dosing, improved absorption, greater tissue distribution, longer half-life, and less photosensitivity.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">14</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">In conclusion, pleural empyema is a rare manifestation of extraintestinal <span class="elsevierStyleItalic">Clostridioides</span><span class="elsevierStyleItalic">difficile</span> infection, with just eight cases reported in literature and is a diagnostic challenge, since it is necessary to rule out that the isolation of this microorganism in pleural fluid is not a contamination. Furthermore, more evidence is needed for the treatment of extraintestinal CDI in general, and in empyema in particular since data regarding the treatment of this entity is still scarce.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Funding</span><p id="par0070" class="elsevierStylePara elsevierViewall">This work received no specific grant from any funding agency in the public, commercial.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conflicts of interest</span><p id="par0075" class="elsevierStylePara elsevierViewall">The authors declare no conflicts of interest, regarding this work.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:3 [ "identificador" => "xres2003297" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1716431" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres2003298" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1716430" "titulo" => "Palabras clave" ] 4 => array:3 [ "identificador" => "sec0005" "titulo" => "Introduction" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] ] ] 5 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 6 => array:2 [ "identificador" => "sec0020" "titulo" => "Funding" ] 7 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflicts of interest" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2022-05-16" "fechaAceptado" => "2022-06-15" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1716431" "palabras" => array:5 [ 0 => "Empyema" 1 => "<span class="elsevierStyleItalic">Clostridioides</span> <span class="elsevierStyleItalic">difficile</span>" 2 => "Aspiration" 3 => "Doxycycline" 4 => "Amoxicillin–clavulanate" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1716430" "palabras" => array:5 [ 0 => "Empiema" 1 => "<span class="elsevierStyleItalic">Clostridioides difficile</span>" 2 => "Broncoaspiración" 3 => "Doxiciclina" 4 => "Amoxicilina-clavulánico" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Pleural empyema is an infrequent manifestation of extraintestinal <span class="elsevierStyleItalic">Clostridioides</span><span class="elsevierStyleItalic">difficile</span> infection, with just eight cases reported in literature.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We report a new case in a 70-year-old male without comorbidities or evidence of concomitant gastrointestinal disease, and review the previous cases reported in the literature.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The isolate was susceptible to all antimicrobial tested and was negative for A<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>B toxins. The patient fully recovered after drainages and antimicrobial therapy with amoxicillin–clavulanate and doxycycline.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">As in the previously reported cases, aspiration was the most plausible hypothesis of mechanism of infection in our patient. Empyema by <span class="elsevierStyleItalic">Clostridioides</span><span class="elsevierStyleItalic">difficile</span> is a diagnostic challenge, since it is necessary to rule out that the isolation of this microorganism in pleural fluid is not a contamination. Furthermore, more evidence is needed for its treatment since data regarding this entity are still scarce.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducción</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">El empiema pleural es una manifestación infrecuente de la infección extraintestinal por <span class="elsevierStyleItalic">Clostridioides</span><span class="elsevierStyleItalic">difficile</span>, con sólo ocho casos reportados en la literatura.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Documentamos un nuevo caso de un varón de 70 años sin comorbilidades ni evidencia de enfermedad gastrointestinal concomitante y revisamos los casos previamente descritos en la literatura.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">El aislado fue sensible a todos los antibióticos testados y fue negativo para las toxinas A<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>B. El paciente se recuperó totalmente tras la realización de drenajes y terapia antimicrobiana con amoxicilina-clavulánico y doxiciclina.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusión</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Al igual que en los casos previamente documentados, la broncoaspiración fue la hipótesis más plausible del mecanismo de infección en nuestro paciente. El empiema por <span class="elsevierStyleItalic">Clostridioides</span><span class="elsevierStyleItalic">difficile</span> constituye un reto diagnóstico, ya que es necesario descartar que su aislamiento en líquido pleural no se deba a una contaminación. Además, se necesita más evidencia científica para el tratamiento de esta entidad, ya que los datos sobre la misma aún son escasos.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] ] "NotaPie" => array:1 [ 0 => array:3 [ "etiqueta" => "1" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Both authors have equally contributed to this work.</p>" "identificador" => "fn0005" ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">M, male; F, female; NAFLD, nonalcoholic fatty liver disease.</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">Ref. \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">Age/sex \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">Comorbidities/risk factors \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">Antibiotic exposure \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">Stool A<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>B toxin assay \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">Other isolates \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">Possible transmission \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">Treatment \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">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">65/M \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">Severe acute and chronic pleuritis. \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">Unknown \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">Unknown \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">No \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">Aspiration \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">Unknown \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">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">58/M \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">Pneumothorax. \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">Unknown \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">Unknown \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">No \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">Aspiration \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">Unknown \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">6 \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">46/M \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">Alcoholic cardiomyopathy. \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">Yes \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">Unknown \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">No \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">Iatrogenic contamination \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">Metronidazole \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">7 \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">33/M \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">Bronchogenic cyst (resected 6 days before the appearance of pleural empyema). \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">Unknown \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">Unknown \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"><span class="elsevierStyleItalic">Clostridium cadaveris</span> \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">Aspiration \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">Amoxicillin–clavulanate metronidazole \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">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">65/M \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">Carcinoid syndrome. Previous enteritis by <span class="elsevierStyleItalic">C. difficile</span>. \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">Yes \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">Negative \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">No \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">Aspiration \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">Cefazoline, metronidazole \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">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">53/M \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">Gastroesophageal reflux disease. \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">Unknown \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">Negative \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">No \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">Aspiration \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">Vancomycin, aztreonam, metronidazole \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">10 \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">52/F \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">Concomitant colitis by <span class="elsevierStyleItalic">C. difficile.</span> \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">Unknown \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">Unknown \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">No \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">Unknown \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">Vancomycin, metronidazole \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">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">42/M \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">Achalasia. Obesity. Liver cirrhosis secondary to NAFLD. \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">Yes \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">Negative \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"><span class="elsevierStyleItalic">Klebsiella pneumoniae</span> (only in blood cultures) \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">Aspiration \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">Metronidazole \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">This study \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">70/M \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">None \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">Yes \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">Negative \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">No \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">Unclear \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">Amoxicillin–clavulanate, doxycycline \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3326400.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Clinical features of patients with pleural empyema caused by <span class="elsevierStyleItalic">Clostridioides difficile</span>.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:14 [ 0 => array:3 [ "identificador" => "bib0075" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "<span class="elsevierStyleItalic">Clostridium difficile</span> – from colonization to infection" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "H. 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Brief report
Clostridioides difficile recovered in pleural fluid: Contamination or infection? A case report of a proven empyema and a literature review
Aislamiento de Clostridioides difficile en líquido pleural: ¿contaminación o infección? Presentación de un caso probado de empiema y revisión de la literatura
Carmen Alonso-Lladaa, Maria Soledad Zapico-Gonzálezb, Luis Caminal-Monteroa,c,1, Javier Fernándezb,c,d,e,1,
Autor para correspondencia
a Internal Medicine Department, Hospital Universitario Central de Asturias, Oviedo, Spain
b Clinical Microbiology Department, Hospital Universitario Central de Asturias, Oviedo, Spain
c Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain
d Research & Innovation, Artificial Intelligence and Statistical Department, Pragmatech AI Solutions, Oviedo, Spain
e CIBER-Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain