Images in Clinical Rheumatology
Osteoarticular Infections Caused by Streptococcus pneumoniae Since Authorization of Conjugate Vaccines
Afectación osteoarticular por Streptococcus pneumoniae tras la autorización de las vacunas conjugadas
María Arrizabalagaa,
, Yolanda Borjasa, María Peñarandab, Margarita Garauc, Enrique Ruíz de Gopeguid, Antoni Payerasa
Corresponding author
a Servicio de Medicina Interna, Hospital Son Llàtzer, Palma de Mallorca, Spain
b Servicio de Medicina Interna, Hospital Universitario Son Espases, Palma de Mallorca, Spain
c Servicio de Microbiología, Hospital Son Llàtzer, Palma de Mallorca, Spain
d Servicio de Microbiología, Hospital Universitario Son Espases, Palma de Mallorca, Spain
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Osteoarticular involvement is much less common; the incidence of septic arthritis is approximately 3%,<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">1</span></a> and it is less frequently involved in individuals over the age of 50 years.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">However, in one of the largest series in the literature—4 hospitals in the United States, the authors reported 13 cases, stressing that joint involvement by <span class="elsevierStyleItalic">S. pneumoniae</span> is the third cause of septic arthritis.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">In Spain, in a study on arthritis due to pneumococcal bacteremia, the authors described 4 cases, pointing out the rareness of the condition.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">In 2010, the 13-valent pneumococcal conjugate vaccine (PCV-13) was authorized by the Food and Drug Administration of the United States for the prevention of invasive pneumococcal disease. This vaccine contains the polysaccharides of serotypes 1, 3, 5, 6A, 7F and 19A, which were added to the 7 serotypes contained in the 7-valent conjugate vaccine.</p><p id="par0025" class="elsevierStylePara elsevierViewall">In 2002, the Spanish Association of Pediatrics recommended the use of the 7-valent conjugate vaccine and, in June 2010, authorized the use in children of PVC-13. Nevertheless, on the Spanish island of Mallorca, as in other Spanish provinces, these vaccines were not financed by the national health care system. The use is recommended but is funded privately, and it is not incorporated into the universal vaccine coverage.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The 23-valent polysaccharide vaccine was included in the Spanish vaccination schedule for adults in 2003, for patients with comorbidities and those over 60 years of age. However, PCV-13 was recommended in 2012 for immunocompromised adults and patients with comorbidities, but is not financed in the last group.</p><p id="par0035" class="elsevierStylePara elsevierViewall">According to data provided by the Health Department in the regional parliament of the Balearic Islands, which includes Mallorca, based on reports from public and private pediatricians, the rates of childhood vaccination are around 24%–26%. In terms of the data provided by Pfizer, the rates are about 50% (according to the number of vaccines sold).</p><p id="par0040" class="elsevierStylePara elsevierViewall">In adults, these rates are lower; individuals over the age of 65 years have a coverage of 2.6% (all with the 23-valent polysaccharide vaccine).<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">5</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Given the scarcity of data on osteoarticular involvement due to <span class="elsevierStyleItalic">S. pneumoniae</span> over the past decade, our objective was to describe the epidemiological and clinical characteristics of the patients with osteoarticular involvement produced by pneumococci treated in our setting.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Methods</span><p id="par0050" class="elsevierStylePara elsevierViewall">The cases were recorded from January 2006 until January 2016 among the patients attended to in 2 hospitals in Mallorca, Spain: teaching hospital Son Espases and hospital Son Llàtzer. The two centers attend a population sector of 500,000 inhabitants.</p><p id="par0055" class="elsevierStylePara elsevierViewall">We retrospectively reviewed the medical records of patients with blood cultures that were positive for pneumococci and the results of the cultures and antigens of pneumococci in joint fluid, according to the microbiological registry of both centers.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Pneumococcal osteoarticular involvement was considered to be any septic arthritis or osteomyelitis.</p><p id="par0065" class="elsevierStylePara elsevierViewall">The study was approved by the research commissions of both centers.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Results</span><p id="par0070" class="elsevierStylePara elsevierViewall">During the study period, we registered 10 individuals with osteoarticular involvement (9 cases of arthritis and 1 of vertebral osteomyelitis), respectively, 1.8% of the septic arthritis and 0.8% of the cases of spondylodiscitis diagnosed in the two centers. Of a total of 523 pneumococcal bacteremias, only 10 had osteoarticular involvement (1.9%).</p><p id="par0075" class="elsevierStylePara elsevierViewall">The demographic, clinical and microbiological characteristics of the 10 patients are summarized in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. All but 2 patients had at least 1 comorbidity, with a mean Charlson Comorbidity index of 3.55 (standard deviation [SD] 2.46).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">Only 1 of the patients was of pediatric age (2 years) and the mean age for the 9 adult patients was 62 years (range: 32–79). Osteoarticular involvement was much more frequent among women: 8 cases (80%). Previous presence of a condition involving the upper airway was encountered in 1 patient, and another 3 had pneumonic infiltrates.</p><p id="par0085" class="elsevierStylePara elsevierViewall">In 3 patients (30%), the arthritis was over a prosthesis (2 knees and a shoulder). None of our study group had had a previous injury in the affected joint and there was no history of arthropathy.</p><p id="par0090" class="elsevierStylePara elsevierViewall">Among the laboratory findings, we observed leukocytosis in all of the patients, with a mean of 16.7<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span><span class="elsevierStyleHsp" style=""></span>cells/L (SD 5.37<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span><span class="elsevierStyleHsp" style=""></span>cell/L).</p><p id="par0095" class="elsevierStylePara elsevierViewall">Arthrocentesis was performed in the 9 cases of arthritis and the culture was positive in 8.</p><p id="par0100" class="elsevierStylePara elsevierViewall">Only 5 patients had fluid samples that could be processed by biochemical means; in the other 3 cases, the analysis was not carried out because the fluid was very purulent. <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the biochemical characteristics of the fluid.</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">Among the viable strains of <span class="elsevierStyleItalic">S. pneumoniae</span> (8/10), all were sensitive to penicillin and to cephalosporins.</p><p id="par0110" class="elsevierStylePara elsevierViewall">In 4 patients, we obtained the following serotypes (11D, 19A, 23F and 24F). Only 2 patients had been vaccinated against pneumococcus; 1 had received PCV-13 and was infected by a nonvaccine serotype (24F), and the other who had been vaccinated with the 7-valent conjugate vaccine, was infected by a strain of 19A.</p><p id="par0115" class="elsevierStylePara elsevierViewall">Of the 10 patients, 8 survived and 2 died from complications associated with the infection: one had pneumonia and the other developed endocarditis.</p><p id="par0120" class="elsevierStylePara elsevierViewall">The survivors received intravenous antibiotic therapy for an average of 19.3 days (SD 12.1 days), followed by oral antibiotic therapy during an average of 32.1 days (SD 22.83 days).</p><p id="par0125" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the types of surgical approach, the duration of treatment and the outcome.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Discussion</span><p id="par0130" class="elsevierStylePara elsevierViewall">In our setting, osteoarticular infection caused by pneumococcus is not very common, taking into account that the rate of bacteremia was only 1.9%, data that are similar to others reported previously. In a review of invasive pneumococcal disease, only 1.3% of the episodes of pneumococcal bacteremia resulted in septic arthritis.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">6</span></a> Moreover, in a series by Frankel et al.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">7</span></a> involving 147 patients with pneumococcal bacteremia, there were only 2 cases of arthritis (1%).<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">8</span></a> In a number of Spanish series on septic arthritis in different locations, the rarity of this condition is also stressed,<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">9,10</span></a> with arthritis caused by pneumococcus representing less than 5% of the cases of septic arthritis.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">8</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">In our series, we observed a clear predominance of involvement among women, a finding that varied depending on the authors of the different reports.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">3,11</span></a> We should point out the fact that the majority of our patients were adults with an age of 60 years or more and that there was only one child. This contrasts with the article by Ross et al. who, in a review of the literature, compiled 190 cases of pneumococcal septic arthritis in which 43% of the patients were of pediatric age.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">3</span></a> The data from that study correspond to a period prior to the introduction of conjugate vaccines. The reduction in the number of pediatric patients is probably influenced by the massive vaccination of the pediatric population that began in 2002, which prevented invasive pneumococcal infections.</p><p id="par0140" class="elsevierStylePara elsevierViewall">Half of the patients reviewed had some comorbidity, with a high Charlson Comorbidity Index, and another 3 patients had conditions closely related to invasive pneumococcal disease, immunosuppressive therapy, splenectomy or were smokers.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">11</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">It is not uncommon that another extraarticular infection precedes or coexists in patients with osteoarticular infection produced by <span class="elsevierStyleItalic">S. pneumoniae</span>; in fact, it seems to occur more frequently than septic arthritis caused by other microorganisms.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">6</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">In our series, pneumonia was observed to be the most common extraarticular focus.</p><p id="par0155" class="elsevierStylePara elsevierViewall">As was expected, the joint most frequently affected was the knee, since it is the structure that is related in up to 50% of cases of bacterial septic arthritis.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">1,2</span></a> In our series, we include a case of pneumococcal vertebral osteomyelitis, considered a rarity.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">12</span></a> The lumbar site and absence of side effects after appropriate antibiotic therapy are common factors in this type of involvement.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">13</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">It has been reported that <span class="elsevierStyleItalic">S. pneumoniae</span> most frequently causes polyarticular involvement in comparison with other microorganisms related to septic arthritis, attributed to high rates of bacteremia in those patients with pneumococcal septic arthritis.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">3</span></a> We encountered no cases of polyarticular involvement in our registry.</p><p id="par0165" class="elsevierStylePara elsevierViewall">Given that this was a retrospective study, the data on the vaccination status of our patients cannot be corroborated. However, it is striking that the 2 patients vaccinated with a known serotype did not get infected with a vaccine strain, although one of them did get infected due to a related serotype (19A).</p><p id="par0170" class="elsevierStylePara elsevierViewall">The standard management of septic arthritis consists of adequate draining of the affected joint, together with appropriate antibiotic therapy, in a reduced period of time, to favor functional recovery.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">14</span></a> The majority of the patients received a combination of intravenous antibiotic therapy, followed by oral treatment and surgical drainage of the joint.</p><p id="par0175" class="elsevierStylePara elsevierViewall">The outcome of this infection is usually good, although it is determined by the severity of the underlying diseases.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">4</span></a> The mortality rate in septic arthritis varies depending on the different studies, but is normally around 11% in those cases of monoarticular septic arthritis<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">14</span></a>; this percentage is similar in cases of pneumococcal arthritis, although it ranges depending on the series from 11% to 32%.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">1,6</span></a> In the population we studied, the mortality was 20%, 2 patients out of 10, both of whom were over 65 years of age and had significant comorbidities. One of them did not even receive surgical treatment; due to the comorbidity and the seriousness of the case, palliative measures were implemented.</p><p id="par0180" class="elsevierStylePara elsevierViewall">The limitations of this study are the retrospective nature, as well as the small sample size. However, it is the largest series reported in the last decade. Although only 4 patients had positive blood cultures, we can assume that all of them presented bacteremia at some time during the course of the disease, given that hematogenous spread is key in these cases.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="par0185" class="elsevierStylePara elsevierViewall">As was the case before the use of conjugate vaccines, pneumococcal osteoarticular involvement in our setting is very uncommon. It is observed above all in women and elderly patients with associated comorbidities, predominantly in the form of monoarticular septic arthritis affecting the knee. The course is usually favorable and deaths were related to the presence of other synchronic foci, such as pneumonia or endocarditis. We cannot conclude that vaccination in adults is effective in the prevention of osteoarticular complications, given the low prevalence; however, massive vaccination of the pediatric population seems to have an impact on the prevention of this infection.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Ethical Disclosures</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Protection of human and animal subjects</span><p id="par0190" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Confidentiality of data</span><p id="par0195" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Right to privacy and informed consent</span><p id="par0200" class="elsevierStylePara elsevierViewall">The authors have obtained the written informed consent of the patients or subjects mentioned in the article. The corresponding author is in possession of this document.</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conflicts of Interest</span><p id="par0205" class="elsevierStylePara elsevierViewall">The authors declare they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:8 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 4 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusions" ] 5 => array:3 [ "identificador" => "sec0030" "titulo" => "Ethical Disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0035" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0040" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0045" "titulo" => "Right to privacy and informed consent" ] ] ] 6 => array:2 [ "identificador" => "sec0050" "titulo" => "Conflicts of Interest" ] 7 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-03-29" "fechaAceptado" => "2017-05-08" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Arrizabalaga M, Borjas Y, Peñaranda M, Garau M, Ruíz de Gopegui E, Payeras A. Afectación osteoarticular por <span class="elsevierStyleItalic">Streptococcus pneumoniae</span> tras la autorización de las vacunas conjugadas. Reumatol Clin. 2019;15:e62–e65.</p>" ] ] "multimedia" => array:2 [ 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="spar0010" class="elsevierStyleSimplePara elsevierViewall">BA, bronchial aspirate; F, female; HIV, human immunodeficiency virus; M, male; NP, not performed.</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">Case \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">Sex/age (years) \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">Comorbidity \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">Site \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">Blood cultures \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 positive microbiological tests \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" 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">1 \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">F/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">Heart 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">Knee \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">Synovial fluid culture \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \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">M/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">AlcoholismPrevious surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Elbow \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">NP \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">Synovial fluid culture \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \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">M/75 \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">DiabetesHeart diseaseNeoplasmRenal insufficiency \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">Knee \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">Synovial fluid culture \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \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">F/79 \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">Smoking \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">Knee (prosthesis) \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">SputumPleural fluid Gram stainSynovial fluid Gram stainAntigens in synovial fluid \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="char" 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">F/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">Heart transplantationTacrolimus and everolimus therapy \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">Shoulder (prosthesis) \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">Positive \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">Synovial fluid cultureBAAntigens in urine \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="char" 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">F/32 \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">HIV infection \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">Spondylodiscitis \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">Positive \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">NP \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="char" 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">F/72 \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">Smoking \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">Knee \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">Synovial fluid culture \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="char" 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">F/2 \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 comorbidity \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">Hip \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">Synovial fluid culture \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="char" 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">F/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">LymphomaNeoplasmSplenectomy \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">Wrist \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">Positive \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">NP \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="char" 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">F/77 \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 comorbidity \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">Knee (prosthesis) \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">Positive \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">Synovial fluid culture \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2151627.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Demographic, Clinical and Microbiological Characteristics of the Patients.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">iv: intravenous.</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">Case \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">Surgical approach \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">Duration of antibiotic therapy (days) \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">Outcome \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" 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">1 \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">Drainage by arthroscopy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14 iv, 30 oral \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">Slight functional limitation \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Intraoperative lavage \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 iv, 7 oral \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">Complete recovery \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \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">8 iv \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">Death \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \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">Synovectomy, change of polyethylene and intraoperative lavage \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 iv, 60 oral \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">Minimal limitation \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="char" 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">Debridement, intraoperative lavage and removal of osteosynthesis material \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">18 iv, 23 oral \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">Moderate limitation \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="char" 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">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">42 iv, 60 oral \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">Complete recovery \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="char" 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">Intraoperative lavage \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">28 iv \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">Complete recovery \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="char" 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">Intraoperative lavage \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15 iv, 15 oral \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">Complete recovery \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="char" 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">Intraoperative lavage \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">28 iv \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">Complete recovery \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="char" 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">Intraoperative lavage \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">30 iv \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">Death \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2151626.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Surgical Approach, Duration of Antibiotic Therapy and Outcome.</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" => "Pneumococcal septic arthritis in adults: clinical analysis and review" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "L. Belkhir" 1 => "H. Rodriguez-Villalobos" 2 => "B. Vandercam" 3 => "J.C. Marot" 4 => "O. Cornu" 5 => "M. Lambert" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1179/0001551213Z.00000000015" "Revista" => array:6 [ "tituloSerie" => "Acta Clin Belg" "fecha" => "2014" "volumen" => "69" "paginaInicial" => "40" "paginaFinal" => "46" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24635398" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0080" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Septic arthritis due to <span class="elsevierStyleItalic">Streptococcus pneumoniae</span> in Nottingham, United Kingdom, 1985–1998" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "P. Ispahani" 1 => "V.C. Weston" 2 => "D.P. Turner" 3 => "F.E. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 2 | 2 | 4 |
| 2024 October | 53 | 34 | 87 |
| 2024 September | 66 | 27 | 93 |
| 2024 August | 65 | 45 | 110 |
| 2024 July | 51 | 26 | 77 |
| 2024 June | 59 | 46 | 105 |
| 2024 May | 48 | 38 | 86 |
| 2024 April | 53 | 23 | 76 |
| 2024 March | 47 | 28 | 75 |
| 2024 February | 34 | 26 | 60 |
| 2024 January | 43 | 17 | 60 |
| 2023 December | 33 | 31 | 64 |
| 2023 November | 43 | 30 | 73 |
| 2023 October | 35 | 28 | 63 |
| 2023 September | 97 | 45 | 142 |
| 2023 August | 53 | 13 | 66 |
| 2023 July | 25 | 24 | 49 |
| 2023 June | 31 | 22 | 53 |
| 2023 May | 35 | 23 | 58 |
| 2023 April | 21 | 7 | 28 |
| 2023 March | 38 | 22 | 60 |
| 2023 February | 41 | 21 | 62 |
| 2023 January | 31 | 11 | 42 |
| 2022 December | 63 | 32 | 95 |
| 2022 November | 50 | 26 | 76 |
| 2022 October | 56 | 24 | 80 |
| 2022 September | 34 | 27 | 61 |
| 2022 August | 25 | 47 | 72 |
| 2022 July | 30 | 31 | 61 |
| 2022 June | 30 | 26 | 56 |
| 2022 May | 28 | 42 | 70 |
| 2022 April | 38 | 33 | 71 |
| 2022 March | 53 | 42 | 95 |
| 2022 February | 39 | 30 | 69 |
| 2022 January | 50 | 37 | 87 |
| 2021 December | 30 | 41 | 71 |
| 2021 November | 29 | 41 | 70 |
| 2021 October | 45 | 43 | 88 |
| 2021 September | 32 | 40 | 72 |
| 2021 August | 29 | 40 | 69 |
| 2021 July | 23 | 20 | 43 |
| 2021 June | 20 | 36 | 56 |
| 2021 May | 46 | 28 | 74 |
| 2021 April | 77 | 72 | 149 |
| 2021 March | 62 | 41 | 103 |
| 2021 February | 68 | 17 | 85 |
| 2021 January | 60 | 20 | 80 |
| 2020 December | 53 | 28 | 81 |
| 2020 November | 31 | 22 | 53 |
| 2020 October | 24 | 19 | 43 |
| 2020 September | 43 | 29 | 72 |
| 2020 August | 30 | 27 | 57 |
| 2020 July | 22 | 30 | 52 |
| 2020 June | 37 | 22 | 59 |
| 2020 May | 35 | 14 | 49 |
| 2020 April | 23 | 15 | 38 |
| 2020 March | 3 | 4 | 7 |
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