Case report
Pleural Effusion Due to Streptococcus milleri: Case Descriptions
Descripción de casos de derrame pleural secundario a Streptococcus milleri
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Derrame pleural submasivo derecho loculado en la parte posteroinferior de la cavidad pleural derecha de 17<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>7<span class="elsevierStyleHsp" style=""></span>cm de diámetro.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Claudia Janeth Madrid-Carbajal, Luis Molinos, Marta García-Clemente, Ana Pando-Sandoval, Ana Fleites, Pere Casan-Clarà" "autores" => array:6 [ 0 => array:2 [ "nombre" => "Claudia Janeth" "apellidos" => "Madrid-Carbajal" ] 1 => array:2 [ "nombre" => "Luis" "apellidos" => "Molinos" ] 2 => array:2 [ "nombre" => "Marta" "apellidos" => "García-Clemente" ] 3 => array:2 [ "nombre" => "Ana" "apellidos" => "Pando-Sandoval" ] 4 => array:2 [ "nombre" => "Ana" "apellidos" => "Fleites" ] 5 => array:2 [ "nombre" => "Pere" "apellidos" => "Casan-Clarà" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S1579212914002031" "doi" => "10.1016/j.arbr.2014.06.022" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1579212914002031?idApp=UINPBA00003Z" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0300289613003669?idApp=UINPBA00003Z" "url" => "/03002896/0000005000000009/v1_201409030058/S0300289613003669/v1_201409030058/es/main.assets" ] ] "itemSiguiente" => array:19 [ "pii" => "S157921291400247X" "issn" => "15792129" "doi" => "10.1016/j.arbr.2014.08.001" "estado" => "S300" "fechaPublicacion" => "2014-09-01" "aid" => "896" "copyright" => "SEPAR" "documento" => "simple-article" "crossmark" => 0 "subdocumento" => "crp" "cita" => "Arch Bronconeumol. 2014;50:407-9" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 3032 "formatos" => array:3 [ "EPUB" => 137 "HTML" => 2229 "PDF" => 666 ] ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Clinical Report</span>" "titulo" => "Effective Management of Hemoptysis Via Endobronchial Application of Ankaferd Hemostat" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "407" "paginaFinal" => "409" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Tratamiento efectivo de la hemoptisis mediante aplicación endobronquial del hemostásico Ankaferd" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Oguz Uzun, Levent Erkan, Ibrahim C. 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Bronconeumol. 2014;50:397-403" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 2379 "formatos" => array:3 [ "EPUB" => 146 "HTML" => 1617 "PDF" => 616 ] ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Special article</span>" "titulo" => "Respiratory Diseases Registries in the National Registry of Rare Diseases" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "397" "paginaFinal" => "403" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Registros de enfermedades respiratorias integrados en el Registro Nacional de Enfermedades Raras" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => 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class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Área de Gestión Clínica de Pulmón, Instituto Nacional de Silicosis, Hospital Universitario Central de Asturias, Facultad de Medicina, Universidad de Oviedo, Oviedo, Asturias, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Microbiología, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Descripción de casos de derrame pleural secundario a <span class="elsevierStyleItalic">Streptococcus milleri</span>" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 786 "Ancho" => 1025 "Tamanyo" => 118183 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Radiological features. Right submassive pleural effusion in the posteroinferior region of the right pleural cavity, 17<span class="elsevierStyleHsp" style=""></span>cm×7<span class="elsevierStyleHsp" style=""></span>cm in diameter.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The term <span class="elsevierStyleItalic">Streptococcus milleri</span>, traditionally classified under the <span class="elsevierStyleItalic">viridans</span> group, is a heterogeneous group of microorganisms that includes <span class="elsevierStyleItalic">Streptococcus anginosus</span>, <span class="elsevierStyleItalic">intermedius</span> and <span class="elsevierStyleItalic">constellatus</span>. They are oral, nasopharyngeal, gastrointestinal and genitourinary mucosa saprophytes and are pathological in patients with predisposing factors.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In contrast to the patterns observed some decades ago, bacteria in this group are now the most common pathogens in the etiology of community-acquired pleural infections.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> The aim of our study is to analyze the clinical characteristics, associated factors, and clinical course of patients with <span class="elsevierStyleItalic">S. milleri</span> empyema.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Patients and Methods</span><p id="par0010" class="elsevierStylePara elsevierViewall">This was a retrospective study performed in patients with a diagnosis of pleural empyema in whom <span class="elsevierStyleItalic">S. milleri</span> was isolated in pleural fluid in our hospital between January 2011 and March 2013. The variables studied were age, sex, associated factors, smoking habit, consumption of alcohol, previous endoscopic procedures, symptoms, clinical laboratory and radiological changes, treatment and clinical course.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The SPSS 12.0 statistical software package was used for statistical analysis. A descriptive analysis was performed with qualitative variables expressed as simple frequencies and quantitative variables as mean and standard deviation.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Results</span><p id="par0020" class="elsevierStylePara elsevierViewall">A total of 7 patients were studied, of which 6 (86%) were male. Mean age was 60.2 years (55–67; SD: 3.7). Three were smokers (43%) and 2 were ex-smokers (27%). Most common associated factors were alcoholism in 4 patients (57%), previous pneumonia in 3 (43%) and diabetes mellitus in 3 (43%). None of the patients had neurological disease or swallowing disorders. The main symptoms were fever in 5 patients (71%), pleuritic pain in 4 (57%) and cough with purulent expectoration in 3 (43%). Elevated C-reactive protein (CRP) was found in all patients, with a mean level of 36<span class="elsevierStyleHsp" style=""></span>mg/l (SD: 15). Only 2 patients (29%) had raised procalcitonin (PCT); the mean value was 0.8<span class="elsevierStyleHsp" style=""></span>ng/ml (SD: 0.8). Empyema was primary with no evidence of consolidation in 3 patients (43%). Anaerobic bacteria were isolated in 2 patients (29%): <span class="elsevierStyleItalic">Enterobacter aerogenes</span>, <span class="elsevierStyleItalic">Bacteroides capillosus</span> and <span class="elsevierStyleItalic">Prevotella intermedia</span>. In 3 cases, <span class="elsevierStyleItalic">S. milleri</span> was resistant to erythromycin, clindamycin and amoxicillin. The mean duration of antibiotic treatment was 28 days (SD: 11). Pleural drainage by chest tube was required in 6 patients (86%) and 1 patient underwent ultrasound-guided thoracocentesis for evacuation of fluid. Three patients required fibrinolytics with urokinase for a mean of 6 days (SD: 2). Clinical course was satisfactory in 5 patients (71%). One patient required surgery due to poor clinical progress, undergoing pleural decortication and pulmonary debridement without complications. One patient was admitted to the intensive care unit due to septic shock associated with empyema and sub-diaphragmatic abscess secondary to perforated gangrenous appendicitis. Length of hospitalization was 30 days (8–72; SD: 23.7). None of the patients died. They all had minimal pleural thickening and 2 individuals (29%) had restrictive ventilatory changes.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The main patient characteristics are described in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a> shows the radiological characteristics of one of the patients.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Discussion</span><p id="par0030" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">S. milleri</span> is the most common causative agent in pyogenic infections, and most of which are located in the abdomen, the central nervous system and the chest.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">3</span></a> These infections usually occur in adults over 50 years of age and more often in patients with predisposing pathological factors. In our series, 86% of the patients had predisposing factors which could cause a certain degree of immunosuppression and their mean hospital stay was prolonged due to the need for pleural procedures and prolonged antimicrobial regimens.</p><p id="par0035" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">S. milleri</span> bacteremia is uncommon and generally associated with a septic intraabdominal focus,<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> as was the case in one of our patients. The chest is involved in one fifth of <span class="elsevierStyleItalic">S. milleri</span> infections, the most common manifestations being empyema and less frequently mediastinitis and lung abscess.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,3–5</span></a> In our series, empyema was associated with lung abscess in 2 cases (29%), and 3 cases (43%) were primary empyema.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The pathogenic role of the co-existence of anaerobic bacteria and <span class="elsevierStyleItalic">Streptococcus</span> has been established. This concomitancy leads to synergy that increases virulence, lung tissue damage and the dissemination of the infection<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">4</span></a>: this was the case in 2 of our patients (29%).</p><p id="par0045" class="elsevierStylePara elsevierViewall">Earlier studies in patients with <span class="elsevierStyleItalic">S. milleri</span> pleuropulmonary infection found that between 67% and 87% of cases required invasive procedures and antimicrobial treatment.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Pleural fluid drainage may suffice in early stages, but advanced stages require video-assisted thoracic surgery (VATS) that according to most studies should be carried out between 3 and 7 days after failed drainage.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">This group of bacteria are very sensitive to ureidopenicillins, carbapenem and cephalosporins,<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">3–5</span></a> although resistance has been reported in up to 33% of cases of <span class="elsevierStyleItalic">S. intermedius</span>.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">3</span></a> In our series, the mean antibiotic treatment time was 28 days, but this varies in other published series (10–65 days).<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Our conclusion is that <span class="elsevierStyleItalic">S. milleri</span> must be considered in community-acquired empyemas, and should be appropriately treated with antibiotics and early pleural drainage in order to avoid major surgical procedures and long periods of hospitalization and to improve prognosis.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:2 [ "identificador" => "xres364408" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec344011" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres364407" "titulo" => "Resumen" ] 3 => array:2 [ "identificador" => "xpalclavsec344012" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Patients and Methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2013-08-01" "fechaAceptado" => "2013-11-27" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec344011" "palabras" => array:4 [ 0 => "Pleural effusion" 1 => "Empyema" 2 => "<span class="elsevierStyleItalic">Streptococcus milleri</span>" 3 => "Associated factors" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec344012" "palabras" => array:4 [ 0 => "Derrame pleural" 1 => "Empiema" 2 => "<span class="elsevierStyleItalic">Streptococcus milleri</span>" 3 => "Factores asociados" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">In this study we analyzed the characteristics of patients with pleural effusion secondary to <span class="elsevierStyleItalic">Streptococcus milleri</span> studied retrospectively between January and March 2013 and found seven patients with a mean age of 60 years; 43% of them were smokers and 57% with a drinking habit. The most common associated factors were alcoholism, previous pneumonia and diabetes. Other bacteria were identified as <span class="elsevierStyleItalic">Enterobacter aerogenes</span>, <span class="elsevierStyleItalic">Bacteroides</span> and <span class="elsevierStyleItalic">Prevotella intermedia capillosus</span> in two patients. The mean duration of antibiotic therapy was 28 days; six patients underwent pleural drainage by chest tube and one patient needed surgery due to poor clinical progress. The mean duration of hospitalization was 30<span class="elsevierStyleHsp" style=""></span>days with satisfactory outcome in all cases, despite some changes in residual function.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Se realiza un análisis retrospectivo de las características de los pacientes con derrame pleural secundario a <span class="elsevierStyleItalic">Streptococcus milleri</span> diagnosticados en nuestro hospital entre enero de 2011 y marzo 2013. Se diagnosticaron 7<span class="elsevierStyleHsp" style=""></span>pacientes con una edad media de 60<span class="elsevierStyleHsp" style=""></span>años, el 57% con hábito enólico importante y el 43% fumadores. Los factores asociados más frecuentemente fueron el alcoholismo, la existencia de neumonía previa y diabetes mellitus. En 2<span class="elsevierStyleHsp" style=""></span>pacientes se identificaron otros gérmenes, como <span class="elsevierStyleItalic">Enterobacter aerogenes</span>, <span class="elsevierStyleItalic">Bacteroides capillosus</span> y <span class="elsevierStyleItalic">Prevotella intermedia</span>. La duración media del tratamiento antibiótico fue de 28<span class="elsevierStyleHsp" style=""></span>días. En 6<span class="elsevierStyleHsp" style=""></span>casos (86%) se realizó drenaje pleural con tubo de tórax, y un paciente precisó cirugía por evolución tórpida. La duración media de la hospitalización fue de 30<span class="elsevierStyleHsp" style=""></span>días, con evolución satisfactoria en todos los casos, aunque con alteración funcional restrictiva residual.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Madrid-Carbajal CJ, Molinos L, García-Clemente M, Pando-Sandoval A, Fleites A, Casan-Clarà P. Descripción de casos de derrame pleural secundario a <span class="elsevierStyleItalic">Streptococcus milleri</span>. Arch Bronconeumol. 2014;50:404–406.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 786 "Ancho" => 1025 "Tamanyo" => 118183 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Radiological features. Right submassive pleural effusion in the posteroinferior region of the right pleural cavity, 17<span class="elsevierStyleHsp" style=""></span>cm×7<span class="elsevierStyleHsp" style=""></span>cm in diameter.</p>" ] ] 1 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">PE: pleural effusion; DILD: diffuse interstitial lung disease; COPD: chronic obstructive pulmonary disease; F: female; M: male.</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"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Sex \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Age (years) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Associated factors \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Radiological features \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Antibiotic used \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Duration of antibiotic (days) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Drainage with chest tube \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">67 \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">COPD. Diabetes. Alcoholism. Septic mouth. \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">Left massive multiloculated PE \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 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">40 \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></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">58 \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">Asthma. Crohn's disease. Immunosuppression. \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">Submassive non-loculated PE with abscess \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">Piperacillin–tazobactam \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">29 \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></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">59 \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">Previous pneumonia due to bronchoaspiration secondary to drug overdose \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">Submassive loculated PE with abscess. Consolidation. \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">Piperacillin–tazobactam \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">16 \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></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">62 \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">Previous pneumonia due to bronchoaspiration. Alcoholism. \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">Submassive loculated PE. Consolidation. \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">Piperacillin–tazobactam \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14 \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></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">61 \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">Chronic liver disease. Alcoholism. Diabetes. \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">Submassive loculated PE. Lesion with residual inflammatory appearance in lateral segment of middle lobe. \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 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">29 \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></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">55 \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">DILD \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">Submassive loculated PE. Anterior hydropneumothorax \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">Piperacillin–tazobactam \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">40 \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></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">60 \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">Perforated appendix with subdiaphragmatic abscess. \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">Bilateral submassive loculated PE. Consolidation. \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">Imipenem. Amikacin. Linezolid \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">40 \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></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab546874.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Clinical, Radiological and Therapeutic Characteristics.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "<span class="elsevierStyleItalic">Streptococcus constellatus:</span> agente etiológico asociado en empiema pleural" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "J. 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Echávarri Razquín" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Arch Bronconeumol" "fecha" => "1995" "volumen" => "31" "paginaInicial" => "252" "paginaFinal" => "254" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7788089" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0015" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clinical analysis of cases of empyema due to <span class="elsevierStyleItalic">Streptococcus milleri</span> group" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "Y. Kobashi" 1 => "K. Mouri" 2 => "S. Yagi" 3 => "Y. Obase" 4 => "M. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 2 | 1 | 3 |
| 2024 October | 63 | 16 | 79 |
| 2024 September | 64 | 15 | 79 |
| 2024 August | 98 | 32 | 130 |
| 2024 July | 63 | 22 | 85 |
| 2024 June | 86 | 30 | 116 |
| 2024 May | 111 | 34 | 145 |
| 2024 April | 51 | 28 | 79 |
| 2024 March | 64 | 21 | 85 |
| 2024 February | 42 | 16 | 58 |
| 2023 March | 14 | 2 | 16 |
| 2023 February | 87 | 20 | 107 |
| 2023 January | 79 | 36 | 115 |
| 2022 December | 87 | 46 | 133 |
| 2022 November | 77 | 25 | 102 |
| 2022 October | 58 | 32 | 90 |
| 2022 September | 61 | 30 | 91 |
| 2022 August | 61 | 37 | 98 |
| 2022 July | 44 | 31 | 75 |
| 2022 June | 80 | 29 | 109 |
| 2022 May | 91 | 36 | 127 |
| 2022 April | 59 | 32 | 91 |
| 2022 March | 74 | 43 | 117 |
| 2022 February | 80 | 36 | 116 |
| 2022 January | 97 | 29 | 126 |
| 2021 December | 77 | 47 | 124 |
| 2021 November | 69 | 44 | 113 |
| 2021 October | 98 | 40 | 138 |
| 2021 September | 59 | 51 | 110 |
| 2021 August | 69 | 30 | 99 |
| 2021 July | 44 | 27 | 71 |
| 2021 June | 49 | 50 | 99 |
| 2021 May | 88 | 27 | 115 |
| 2021 April | 149 | 67 | 216 |
| 2021 March | 87 | 26 | 113 |
| 2021 February | 75 | 18 | 93 |
| 2021 January | 60 | 11 | 71 |
| 2020 December | 41 | 14 | 55 |
| 2020 November | 81 | 11 | 92 |
| 2020 October | 100 | 15 | 115 |
| 2020 September | 139 | 11 | 150 |
| 2020 August | 136 | 16 | 152 |
| 2020 July | 91 | 29 | 120 |
| 2020 June | 72 | 5 | 77 |
| 2020 May | 100 | 9 | 109 |
| 2020 April | 79 | 24 | 103 |
| 2020 March | 66 | 12 | 78 |
| 2020 February | 70 | 14 | 84 |
| 2020 January | 70 | 18 | 88 |
| 2019 December | 68 | 23 | 91 |
| 2019 November | 67 | 17 | 84 |
| 2019 October | 54 | 7 | 61 |
| 2019 September | 53 | 9 | 62 |
| 2019 August | 60 | 14 | 74 |
| 2019 July | 73 | 24 | 97 |
| 2019 June | 84 | 5 | 89 |
| 2019 May | 102 | 12 | 114 |
| 2019 April | 86 | 32 | 118 |
| 2019 March | 83 | 21 | 104 |
| 2019 February | 48 | 20 | 68 |
| 2019 January | 70 | 26 | 96 |
| 2018 December | 56 | 20 | 76 |
| 2018 November | 83 | 23 | 106 |
| 2018 October | 92 | 17 | 109 |
| 2018 September | 33 | 10 | 43 |
| 2018 May | 28 | 0 | 28 |
| 2018 April | 73 | 6 | 79 |
| 2018 March | 66 | 8 | 74 |
| 2018 February | 72 | 14 | 86 |
| 2018 January | 90 | 8 | 98 |
| 2017 December | 60 | 6 | 66 |
| 2017 November | 58 | 4 | 62 |
| 2017 October | 42 | 6 | 48 |
| 2017 September | 66 | 15 | 81 |
| 2017 August | 103 | 8 | 111 |
| 2017 July | 113 | 5 | 118 |
| 2017 June | 111 | 10 | 121 |
| 2017 May | 97 | 12 | 109 |
| 2017 April | 88 | 24 | 112 |
| 2017 March | 71 | 50 | 121 |
| 2017 February | 77 | 6 | 83 |
| 2017 January | 67 | 6 | 73 |
| 2016 December | 83 | 8 | 91 |
| 2016 November | 100 | 6 | 106 |
| 2016 October | 91 | 17 | 108 |
| 2016 September | 96 | 12 | 108 |
| 2016 August | 74 | 11 | 85 |
| 2016 July | 51 | 9 | 60 |
| 2016 March | 3 | 0 | 3 |
| 2016 February | 1 | 0 | 1 |
| 2015 December | 3 | 0 | 3 |
| 2015 October | 45 | 3 | 48 |
| 2015 September | 48 | 10 | 58 |
| 2015 August | 47 | 6 | 53 |
| 2015 July | 60 | 15 | 75 |
| 2015 June | 29 | 5 | 34 |
| 2015 May | 54 | 18 | 72 |
| 2015 April | 40 | 12 | 52 |
| 2015 March | 29 | 11 | 40 |
| 2015 February | 23 | 7 | 30 |
| 2015 January | 28 | 10 | 38 |
| 2014 December | 25 | 12 | 37 |
| 2014 October | 0 | 2 | 2 |
| 2014 September | 1 | 0 | 1 |
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