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CARTA AL EDITOR
Réplica: Perfil clínico, tratamiento antibiótico y riesgo de ictus en pacientes con endocarditis infecciosa
Reply: Clinical profile, antibiotic treatment and risk of stroke in patients with infective endocarditis
J. Rodríguez-Montolioa,
Autor para correspondencia
jrodriguezm@salud.aragon.es

Autor para correspondencia.
, D. Meseguer-Gonzálezb, M. Almeida-Zuritaa, S. Santos-Lasaosaa
a Servicio de Neurología del Hospital Clínico Universitario Lozano Blesa, Zaragoza, España
b Servicio de Cardiología del Hospital Clínico Universitario Lozano Blesa, Zaragoza, España
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Hemos le&#237;do con mucha atenci&#243;n la carta al editor de Mart&#237;nez-Sell&#233;s<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">1</span></a> sobre el art&#237;culo &#171;Prevalencia de las complicaciones neurol&#243;gicas en la endocarditis infecciosa&#187;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">2</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">En respuesta a sus comentarios&#44; los objetivos de esta nueva publicaci&#243;n son analizar con mayor profundidad las comorbilidades de los pacientes incluidos en el estudio inicial y remarcar la importancia de la antibioterapia precoz para reducir la incidencia de complicaciones neurol&#243;gicas en la endocarditis infecciosa &#40;EI&#41;&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">En el estudio de cohortes retrospectivo se incluyeron 222 pacientes con diagn&#243;stico de EI definida de acuerdo con los criterios modificados de Duke<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">3</span></a>&#46; En la poblaci&#243;n analizada destaca un predominio de varones en la sexta d&#233;cada de la vida con afectaci&#243;n valvular principalmente a&#243;rtica y mitral&#46; Las variables demogr&#225;ficas&#44; cl&#237;nicas y microbiol&#243;gicas se recogen en la <a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#46; Cabe destacar la hipertensi&#243;n arterial como la comorbilidad m&#225;s frecuente en 128 pacientes &#40;57&#44;7&#37;&#41;&#44; seguida de la cardiopat&#237;a estructural en 93 pacientes &#40;41&#44;8&#37;&#41; y de la diabetes mellitus &#40;DM&#41; en 74 pacientes &#40;33&#44;3&#37;&#41;&#46; Un total de nueve pacientes &#40;4&#37;&#41; presentaron endocarditis recurrente<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">4</span></a>&#44; definida como nuevo episodio de EI despu&#233;s de dos meses tras la finalizaci&#243;n del tratamiento antibi&#243;tico&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Tal y como se describi&#243; en la publicaci&#243;n anterior<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">2</span></a>&#44; el ictus isqu&#233;mico fue la complicaci&#243;n neurol&#243;gica m&#225;s frecuente y se present&#243; en 35 pacientes que suponen 15&#44;8&#37; del total de la muestra&#46; El ictus hemorr&#225;gico fue la segunda complicaci&#243;n m&#225;s frecuente en 11 pacientes &#40;4&#44;9&#37;&#41;&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">En la <a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a> se comparan los datos demogr&#225;ficos&#44; cl&#237;nicos y microbiol&#243;gicos por grupos&#46; Profundizando en el perfil cl&#237;nico del paciente destaca en el subgrupo de pacientes con ictus &#40;n &#61; 46&#41;&#44; respecto al resto de pacientes&#44; una mayor prevalencia de DM &#40;43&#44;5 vs&#46; 30&#44;7&#37;&#41; y de tabaquismo activo &#40;32&#44;6 vs&#46; 9&#44;7&#37;&#41;&#44; aunque sin significaci&#243;n estad&#237;stica&#46; En el subgrupo de pacientes con ictus isqu&#233;mico &#40;n &#61; 35&#41; se observ&#243; una mayor implicaci&#243;n del agente etiol&#243;gico <span class="elsevierStyleItalic">Staphylococcus aureus</span> &#40;34&#44;2 vs&#46; 22&#44;7&#37;&#41; y una mayor afectaci&#243;n de la v&#225;lvula mitral &#40;51&#44;4 vs&#46; 42&#44;6&#37;&#41;&#44; pero sin significaci&#243;n estad&#237;stica&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">La mortalidad intrahospitalaria observada fue superior en el subgrupo de pacientes con ictus &#40;31&#44;3 vs&#46; 50&#37;&#44; p &#61; 0&#44;025&#41; y discretamente mayor en el grupo de pacientes con ictus hemorr&#225;gico respecto a aquellos con ictus isqu&#233;mico &#40;54&#44;5 vs<span class="elsevierStyleItalic">&#46;</span> 48&#44;6&#37;&#41;&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">En relaci&#243;n con el tratamiento antibi&#243;tico&#44; todos los pacientes del estudio fueron tratados con terapia antimicrobiana de acuerdo con las recomendaciones de las gu&#237;as de pr&#225;ctica cl&#237;nica<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">3</span></a>&#46; Dado el car&#225;cter retrospectivo del estudio y la ausencia de datos espec&#237;ficos en aquellos pacientes diagnosticados previamente a la informatizaci&#243;n de los datos cl&#237;nicos&#44; no se ha podido determinar la distribuci&#243;n en el tiempo del inicio de la cl&#237;nica neurol&#243;gica en relaci&#243;n con la antibioterapia&#46; No obstante&#44; s&#237; se ha podido establecer que 35&#47;46 pacientes &#40;76&#44;1&#37;&#41; presentaron la cl&#237;nica neurol&#243;gica antes del inicio del tratamiento antibi&#243;tico o durante los primeros d&#237;as&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Las complicaciones neurol&#243;gicas&#44; destacando sobre todo el ictus isqu&#233;mico&#44; son las complicaciones extracardiacas m&#225;s frecuentes en la EI y se asocian a una elevada morbimortalidad<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">5-7</span></a>&#46; Resulta importante identificar factores de riesgo que se asocien tanto al ictus isqu&#233;mico como hemorr&#225;gico en la EI para optimizar el manejo cl&#237;nico precoz de los pacientes y mejorar su pron&#243;stico funcional y vital&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">En relaci&#243;n con el ictus isqu&#233;mico&#44; la afectaci&#243;n de la v&#225;lvula mitral y la implicaci&#243;n de <span class="elsevierStyleItalic">S&#46;</span> a<span class="elsevierStyleItalic">ureus</span> como agente etiol&#243;gico se han definido como factores de riesgo<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">5-7</span></a>&#46; Estos datos son similares a los descritos en nuestro trabajo&#44; aunque no encontramos significaci&#243;n estad&#237;stica&#46; Destacamos tambi&#233;n una mayor prevalencia de DM en el subgrupo de pacientes con ictus isqu&#233;mico&#44; como en el estudio de Valenzuela et al&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">6</span></a> y de acuerdo con el comentario de Mart&#237;nez-Sell&#233;s<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">1</span></a>&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Respecto al ictus hemorr&#225;gico&#44; en el estudio de Valenzuela et al&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">6</span></a> se identificaron el sexo masculino&#44; la cardiopat&#237;a de origen reum&#225;tico y la infecci&#243;n f&#250;ngica como factores de riesgo&#46; En nuestro trabajo destacamos mayor tabaquismo en este subgrupo de pacientes&#44; si bien no se ha descrito previamente como factor de riesgo ni hemos encontrado significaci&#243;n estad&#237;stica&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Los eventos emb&#243;licos son una de las principales causas de morbimortalidad en la EI y suelen ocurrir antes o durante la primera semana de tratamiento antibi&#243;tico<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">7</span></a>&#46; En nuestro estudio&#44; 76&#44;1&#37; de los pacientes con ictus presentaron la cl&#237;nica neurol&#243;gica antes del inicio del antibi&#243;tico&#44; o bien durante los primeros d&#237;as&#44; datos similares a los reportados por Garc&#237;a-Cabrera et al&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">5</span></a> &#40;86&#37;&#41; y Valenzuela et al&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">6</span></a> &#40;80&#37;&#41;&#46; Dadas las limitaciones del estudio ya descritas&#44; no hemos podido analizar la incidencia y reducci&#243;n de eventos neurol&#243;gicos durante el transcurso de la antibioterapia&#46; No obstante&#44; en otros estudios se ha demostrado que el riesgo de embolismo disminuye aproximadamente 50&#37; tras una semana de antibioterapia efectiva&#44; por lo que es fundamental su inicio precoz<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">3&#44;7&#44;8</span></a>&#46; Creemos que es esencial un manejo multidisciplinar de los pacientes con EI para optimizar su manejo y tratamiento y reducir la morbimortalidad de la enfermedad y sus complicaciones emb&#243;licas&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Financiaci&#243;n</span><p id="par0060" class="elsevierStylePara elsevierViewall">Esta investigaci&#243;n no ha recibido financiaci&#243;n&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflicto de intereses</span><p id="par0065" class="elsevierStylePara elsevierViewall">Los autores no declaran ning&#250;n conflicto de intereses&#46;</p></span></span>"
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                  \t\t\t\t">66&#44;4 &#177; 14&#44;2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">128 &#40;57&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Diabetes mellitus&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">74 &#40;33&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Dislipemia&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">57 &#40;25&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Fibrilaci&#243;n auricular&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">56 &#40;25&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Insuficiencia cardiaca&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">35 &#40;15&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cardiopat&#237;a estructural&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">93 &#40;41&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Enfermedad renal cr&#243;nica&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">47 &#40;21&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Tabaquismo activo&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">32 &#40;14&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Consumo de drogas v&#237;a parenteral&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">7 &#40;3&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Neoplasia activa&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">35 &#40;15&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>EI previa&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">9 &#40;4&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Origen comunitario n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">168 &#40;75&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">55 &#40;24&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>A&#243;rtica&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">30&#47;55 &#40;54&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Mitral&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13&#47;55 &#40;23&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t</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&#47;55 &#40;21&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>A&#243;rtica&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">91 &#40;41&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Mitral&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">78 &#40;31&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">18 &#40;9-33&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">ns&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Hipertensi&#243;n arterial&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">18 &#40;51&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">7 &#40;63&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">25 &#40;54&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">103 &#40;58&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Diabetes mellitus&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">16 &#40;45&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">4 &#40;36&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">20 &#40;43&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">54 &#40;30&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Dislipemia&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">6 &#40;17&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2 &#40;18&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">8 &#40;17&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">49 &#40;27&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Fibrilaci&#243;n auricular&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">10 &#40;28&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2 &#40;18&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">12 &#40;26&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">44 &#40;25&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Insuficiencia cardiaca&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">6 &#40;17&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2 &#40;18&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">8 &#40;17&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">27 &#40;15&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cardiopat&#237;a estructural&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">13 &#40;37&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3 &#40;27&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">16 &#40;34&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">77 &#40;43&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Enfermedad renal cr&#243;nica&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">5 &#40;14&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2 &#40;18&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">7 &#40;15&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">40 &#40;22&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Tabaquismo activo&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">10 &#40;28&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">5 &#40;45&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">15 &#40;32&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">17 &#40;9&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Consumo de drogas v&#237;a parenteral&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1 &#40;2&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1 &#40;2&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">6 &#40;3&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Neoplasia activa&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">5 &#40;14&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">4 &#40;36&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">9 &#40;19&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">26 &#40;14&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>EI previa&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1 &#40;2&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1 &#40;2&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">8 &#40;4&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="6" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Origen comunitario n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">29 &#40;82&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Mitra&#243;rtica&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Localizaci&#243;n vegetaci&#243;n n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No se localiza&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">S&#46; epidermidis</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Gramnegativos&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Hemocultivos negativos&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">ns&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Mortalidad intrahospitalaria n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">23 &#40;50&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;025&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "es" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Variables demogr&#225;ficas&#44; cl&#237;nicas y microbiol&#243;gicas de los pacientes con endocarditis infecciosa por subgrupos</p>"
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              "identificador" => "bib0045"
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                0 => array:1 [
                  "referenciaCompleta" => "Mart&#237;nez-Sell&#233;s M&#46; Clinical profile&#44; antibiotic treatment&#44; and risk of stroke in patients with infective endocarditis&#46; Neurologia &#40;Engl Ed&#41;&#46; 2022&#58;S2173-5808&#40;22&#41;00093-1&#46;"
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              "identificador" => "bib0050"
              "etiqueta" => "2"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Prevalencia de las complicaciones neurol&#243;gicas en la endocarditis infecciosa"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "J&#46; Rodr&#237;guez-Montolio"
                            1 => "D&#46; Meseguer-Gonz&#225;lez"
                            2 => "M&#46; Almeida-Zurita"
                            3 => "P&#46; Revilla-Mart&#237;"
                            4 => "S&#46; Santos-Lasaosa"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:3 [
                        "tituloSerie" => "Neurolog&#237;a&#46;"
                        "fecha" => "2022"
                        "itemHostRev" => array:3 [
                          "pii" => "S0735109705002184"
                          "estado" => "S300"
                          "issn" => "07351097"
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ISSN: 02134853
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