Seasonal Variations and Influence of the Weather on the Appearance of Peritoneal Infection
Variaciones estacionales e influencia del clima en la aparición de la infección peritoneal
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Emilio Sánchez-Álvarez, Isabel González-Díaz, Beatriz Peláez-Requejo, Aurora Quintana-Fernández, Carmen Rodríguez-Suárez" "autores" => array:6 [ 0 => array:4 [ "nombre" => "Miguel" "apellidos" => "Núñez-Moral" "email" => array:1 [ 0 => "jesastur@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 1 => array:3 [ "nombre" => "J. Emilio" "apellidos" => "Sánchez-Álvarez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 2 => array:3 [ "nombre" => "Isabel" "apellidos" => "González-Díaz" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 3 => array:3 [ "nombre" => "Beatriz" "apellidos" => "Peláez-Requejo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 4 => array:3 [ "nombre" => "Aurora" "apellidos" => "Quintana-Fernández" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 5 => array:3 [ "nombre" => "Carmen" "apellidos" => "Rodríguez-Suárez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] ] "afiliaciones" => array:1 [ 0 => array:3 [ "entidad" => "Servicio de Nefrología, Hospital Universitario Central de Asturias, Oviedo, " "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Variaciones estacionales e influencia del clima en la aparición de la infección peritoneal" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig1" "etiqueta" => "Tab. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "12420_16025_64100_en_t112420_03.jpg" "Alto" => 503 "Ancho" => 1063 "Tamanyo" => 187657 ] ] "descripcion" => array:1 [ "en" => "Characteristics of the population" ] ] ] "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">INTRODUCTION</span><span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara"><span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara">A historical concern, common to all units of peritoneal dialysis (PD), is the reduction of peritonitis incidence. The continuous technique evolution, with changes in connections, catheters or dialysate has allowed some units to achieve rates of 1 peritonitis/patient/53 months<span class="elsevierStyleSup">1</span>. Even so, peritoneal infection (PI) is the most important complication of PD, not due to its fatality rate, which is 4%, but due to its influence on patient survival and long-term failure of PD<span class="elsevierStyleSup">1,2</span>.</p><p class="elsevierStylePara">There are multiple factors related to PI<span class="elsevierStyleSup">3</span> from socio-cultural level, or distance to the PD centre, to “coach” experience<span class="elsevierStyleSup">4</span>, patients’ moods (depression versus euphoria<span class="elsevierStyleSup">1,5</span>), exit site infection<span class="elsevierStyleSup">6</span> or days of the week<span class="elsevierStyleSup">7</span>.</p><p class="elsevierStylePara">Chan<span class="elsevierStyleSup">8</span> analysed the relationship between the seasons and the onset of peritonitis, and saw an increase in the number of cases of peritonitis caused by Gram-negative bacteria and <span class="elsevierStyleItalic">Staphylococcus epidermidis</span> in the warmer months of the year. Subsequently, other Asian and Oceania authors established a relationship between humidity and environmental temperature and increase of peritonitis<span class="elsevierStyleSup">9-11</span>. We are unaware of any European study relating increases in PI with the season of the year. Nor has the influence of climatic factors such as temperature and humidity been studied.</p><p class="elsevierStylePara">The aim of this study is to analyse the influence of climate on the occurrence of peritonitis in our region, in order to develop the best strategies for prevention.</p><p class="elsevierStylePara"><span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">MATERIAL AND METHOD</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara">Retrospective observational study of all PI diagnosed in our PD unit over a five-year period (2007-2011). We included all prevalent patients on PD due to stage 5 chronic kidney disease within the study period.</p><p class="elsevierStylePara">All patients had a Swan-Neck high flux (Fresenius Medical Care ®) peritoneal catheter, implanted by the Department of Surgery. Antibiotic prophylaxis with cefazolin, or vancomycin if allergic, was administered preoperatively. All patients used biocompatible solutions (Bicavera®/Phisoneal®). The study was approved by the ethics committee of our hospital.</p><p class="elsevierStylePara">Exposure time was the period between the start of the technique at home until the end of the study period or until the patient left the PD programme.</p><p class="elsevierStylePara">The following variables were considered: age, sex, diabetes (yes/no), place of residence, mean environmental temperature and mean environmental humidity on the day when the infection occurred, nasal carriage of Staphylococcus aureus, modality (continuous ambulatory peritoneal dialysis or automated peritoneal dialysis [CAPD/APD]), use of icodextrin, outlet site infection and/or subcutaneous tunnel and/or peritonitis from the time of catheter implantation to beginning procedure at home, episodes of peritonitis and germs responsible for these.</p><p class="elsevierStylePara">The Spanish Meteorological Agency (AEMET) in Asturias has three weather stations located in Gijón, Oviedo and Mieres. For this study, we divided the region into three areas longitudinally, so that the different municipalities where patients lived could be assigned to a weather station. Consequently, we believe that the climatic conditions in Gijón may reflect those of the coastal towns of the region. The data recorded by the Oviedo Station reflect conditions in the nearby countryside (altitude between 100 and 500m above sea level) and finally data recorded at Mieres reflect the situation of the municipalities closest to the Cantabrian Mountains (above 500m of altitude).</p><p class="elsevierStylePara">We considered PI to be any episode of unclear peritoneal effluent with a pathological cell count (more than 100 cells/mm<span class="elsevierStyleSup">3</span> with a percentage of polymorphonuclear cells higher than 50%<span class="elsevierStyleSup">12</span>) we counted re-infections and excluded relapses, refractory peritonitis and polymicrobial infections<span class="elsevierStyleSup">13</span>. We also excluded infections that occurred during periods of hospitalisation outside our region and/or secondary community interventions that could cause them (alpha manoeuvre, colonoscopy, etc.).</p><p class="elsevierStylePara"><span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Statistical analysis</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara">Categorical variables were expressed in terms of absolute and relative frequencies. Continuous variables were expressed as mean and standard deviations. We calculated annual incidences and confidence intervals (CI) at 95% based on the bootstrap method, which take into account inter-patient variability. Relative risks were calculated by dividing annual incidences. P-values were approximated using a general bootstrap algorithm<span class="elsevierStyleSup">14</span>, considering values lower than 0.05 statistically significant. All analyses were performed using the free software R2.15 (www.r-project.org).</p><p class="elsevierStylePara"><span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">RESULTS</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Population characteristics</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara">Of the 201 patients studied, with a follow-up of a total of 4123 patients-month. The sample characteristics are displayed in Table 1.</p><p class="elsevierStylePara"><span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Relationship between incidence of peritonitis and seasons of the year</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">There were 171 infections in 81 patients (40.3%). The mean of infections per patient was 0.851±1.47, with a global incidence of peritonitis of 0.498 episodes/patients/year at risk (95 % IC: 0.395-0.611). We found no age or sex-related differences. There were no differences due to diabetes, initial nasal carriage of <span class="elsevierStyleItalic">Staphylococcus aureus</span> or form of treatment.</p><p class="elsevierStylePara">For each season, mean follow-up in days was: Spring 150.1±148.3, Summer 163.9±151.6, Autumn 164.6±148.5 and Winter 140.2±139.2. The seasonal variation of peritonitis can be seen in Table 2. In general, there was a lower relative risk of PI in Summer and Winter, which was not significant. Of the total number of infections analysed, 117 (68.4%) were caused by Gram-positive and 25 (14.6°%) by Gram-negative organisms; no growth was observed in other cultures (16.99°%) (Table 2). The rate per patient/year of Gram-positive infections was 0.340 (0.257 to 0.433) and in the case of Gram-negative ones was 0.072 (0.043 to 0.106) (<span class="elsevierStyleItalic">P</span><.001). If we use risk in Spring as a reference (value 1), the observed relative risk of developing Gram-positive peritonitis was 0.611 (0.315 to 1.082) in Summer, 1.078 (0.717 to 1.688) in Autumn and 0.747 (0.439 to 1.232) in Winter No significant seasonal variation was seen (P 0.122). However,  in the case of Gram-negative peritonitis, using Spring as reference, the relative risk for Summer, Autumn and Winter was 0.666 (0.211 to 1.832), 0.248 (0.000 to 0.912) and 0.292 (0.000 to 0.833), respectively. We thus proved that the risk of infection in Spring is four times greater than in Autumn and three times greater than in winter (<span class="elsevierStyleItalic">P</span><.001) (Figure 1).</p><p class="elsevierStylePara"><span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Association between peritonitis, temperature and humidity</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara">We found that the average daily temperature on the days when peritoneal Gram-negative infections occurred (15.46±3.71° C) was higher than in the case of Gram-positive ones (13.61±3.89° C) (<span class="elsevierStyleItalic">P</span>.022) Mean humidity was also slightly higher (78.76±4.40 vs. 77.5±3.69%), without being significant (Figure 2)</p><p class="elsevierStylePara"><span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">DISCUSSION</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara">In Asturias peritonitis undergoes seasonal variation, with less risk of occurrence in Summer, very marked in the case of Gram-negative peritonitis, with a relative risk of suffering infections up to four times greater than in Spring.</p><p class="elsevierStylePara">Until now there have been no published data analysing the influence of seasonal factors on the occurrence of peritonitis in Spain. Different authors have published experiences in other parts of the world. A study carried out in Australia and New Zealand<span class="elsevierStyleSup">9</span>, with 6610 patients, found no seasonal variation in the overall number of PI, but did find an increase in Gram-negative peritonitis during Summer (December, January and February) and Autumn (March, April and May). In this study, furthermore, they saw seasonal variations in the occurrence of PI due to coagulase negative Staff, <span class="elsevierStyleItalic">Corynebacterium</span> and fungi. These correlations could be due to simple size, the large areas of these countries and climate variations between seasons. Similarly, Szeto<span class="elsevierStyleSup">11</span> found an increase of Gram-negative peritonitis in the hottest and most humid months. A Korean<span class="elsevierStyleSup">11</span> group noted that in the warmer months there was greater incidence of peritonitis, caused by Gram-positive organisms. These differences with previous studies could be due to small sample size (80 patients) and a high percentage of cultures with no growth (41.5%), far from the quality standards that recommend that cultures without growth should be below 20%<span class="elsevierStyleSup">15</span>. Finally, Yeoungjee<span class="elsevierStyleSup">16</span> compared the rates of PI between temperate and tropical areas, and found that in these last there is less time to the first PI episode and there are more cases of peritonitis. The authors considered the differences were due to low socio-cultural level of the aborigines that live in tropical areas.</p><p class="elsevierStylePara">We were surprised by the fact that the total distribution of peritonitis during summer had a lower RR.</p><p class="elsevierStylePara">We thought that this difference could be due to the fact that many patients are on vacation during this season and therefore leave their homes and suffer infections outside the territories we studied. In addition, we know that patients with PI are treated with antibiotics for 2 to 3 weeks, thus reducing the time at risk, which would explain why after a season with a high incidence there follows another season with lower incidence.</p><p class="elsevierStylePara">The incidence of Gram-negative PI, throughout the year, is heterogeneous, risk appears to increase in Spring by up to four times (compared with Autumn) and three times (compared to Winter).</p><p class="elsevierStylePara">We agree with other authors that during Spring and Summer, patients enjoy more leisure and could be less “rigorous” when applying the technique<span class="elsevierStyleSup">5</span>. During these periods there is usually an increase in diarrhoeal episodes, which are clearly in line with PI due to Gram-negative organisms<span class="elsevierStyleSup">17</span>.</p><p class="elsevierStylePara">We also found that mean temperatures on the days when Gram-negative PI occurred were significantly higher than on the days when Gram-positive infections occurred. This leads us to suppose that temperature, together with humidity, affect bacterial populations, facilitating and increasing their proliferation<span class="elsevierStyleSup">16 </span>and patients’ sweating<span class="elsevierStyleSup">18</span>, which contributes to bacterial transport. The coincidence of these two factors could explain the greater incidence of PI due to Gram-negative organisms during the hottest most humid months in our region.</p><p class="elsevierStylePara">Based on our data, we consider that quality standards<span class="elsevierStyleSup">15</span> should be adjusted according to the climate. The group working in the Levant<span class="elsevierStyleSup">2</span>, in a study on 1515 patients with characteristics similar to ours, saw an overall peritonitis rate of one episode/patient every 24 months, similar to ours, but with a rate of Gram-negative peritonitis (21%) clearly superior to ours (14.6%). This difference could be explained by the different climates in each region.</p><p class="elsevierStylePara">It is obvious that retraining is necessary to decrease episodes of IP<span class="elsevierStyleSup">19</span>. Some authors consider retraining should be performed once a year or every six months<span class="elsevierStyleSup">20</span>. Considering the forgetting curve of patients and our data, retraining should be carried out in the months prior to Spring (in our geographic location), to decrease the partial rate of Gram-negative peritoneal infections and thus lower the overall rate.</p><p class="elsevierStylePara">We did not include variables such as outlet site infections, episodes of diarrhoea<span class="elsevierStyleSup">17</span>, or patients’ socio-cultural level, and consider this limits our results, since we cannot rule out that they may be confounding variables. A multicentre and multigeographic observational study would be able to include a larger sample and greater climate variability, and may further narrow down possible seasonal and climate influence on the development of peritonitis.</p><p class="elsevierStylePara">We conclude that Gram-negative peritonitis is caused heterogeneously year long, with a greater risk during the warm seasons, especially Spring.</p><p class="elsevierStylePara"><span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Acknowledgements</span></p><p class="elsevierStylePara">Dr. Pablo Martínez Camblor, for his invaluable statistical work.</p><p class="elsevierStylePara">Dr.Gustavo Fernández Bayón, for his computer knowledge and personal friendship.</p><p class="elsevierStylePara">AEMET, for all the data.</p><p class="elsevierStylePara"><span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflicts of interest</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara">The authors declare that they have no conflicts of interest related to the contents of this article.</p><p class="elsevierStylePara"><a href="grande/12420_16025_64100_en_t112420_03.jpg" class="elsevierStyleCrossRefs"><img src="12420_16025_64100_en_t112420_03.jpg" alt="Characteristics of the population"></img></a></p><p class="elsevierStylePara">Table 1. Characteristics of the population</p><p class="elsevierStylePara"><a href="grande/12420_16025_64101_en_t212420_032.jpg" class="elsevierStyleCrossRefs"><img src="12420_16025_64101_en_t212420_032.jpg" alt="Incidence and relative risk of peritonitis globally and depending on causal Gram germ, according to days at risk for each season "></img></a></p><p class="elsevierStylePara">Table 2. Incidence and relative risk of peritonitis globally and depending on causal Gram germ, according to days at risk for each season </p><p class="elsevierStylePara"><a href="grande/12420_16025_64102_en_f112420_032.jpg" class="elsevierStyleCrossRefs"><img src="12420_16025_64102_en_f112420_032.jpg" alt="Incidence of peritonitis by season and type of germ"></img></a></p><p class="elsevierStylePara">Figure 1. Incidence of peritonitis by season and type of germ</p><p class="elsevierStylePara"><a href="grande/12420_16025_64103_en_f212420_032.jpg" class="elsevierStyleCrossRefs"><img src="12420_16025_64103_en_f212420_032.jpg" alt="Relationship between onset of peritonitis and climatic variables such as temperature and humidity"></img></a></p><p class="elsevierStylePara">Figure 2. Relationship between onset of peritonitis and climatic variables such as temperature and humidity</p>" "pdfFichero" => "P1-E577-S4785-A12420-EN.pdf" "tienePdf" => true "PalabrasClave" => array:2 [ "es" => array:3 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec436959" "palabras" => array:1 [ 0 => "Clima" ] ] 1 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec436961" "palabras" => array:1 [ 0 => "Peritonitis" ] ] 2 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec436963" "palabras" => array:1 [ 0 => "Diálisis peritoneal" ] ] ] "en" => array:3 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec436960" "palabras" => array:1 [ 0 => "Climate" ] ] 1 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec436962" "palabras" => array:1 [ 0 => "Peritonitis" ] ] 2 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec436964" "palabras" => array:1 [ 0 => "Peritoneal dialisis" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:1 [ "resumen" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">Introduction:</span><span class="elsevierStyleBold"> </span>Peritoneal infections are a common complication in patients undergoing peritoneal dialysis (PD) and are frequently the cause of the failure of the technique. Knowing the factors that can lead to their appearance helps to establish preventative measures. <span class="elsevierStyleBold">Aim:</span> To understand the influence of climatic variables in the appearance of peritonitis, such as seasonal variation, the temperature and humidity in Asturias. <span class="elsevierStyleBold">Method: </span>A retrospective, observational study of all peritoneal infections that occurred in our PD department over a period of 5 years (2007-2011). The region was divided lengthways into three areas: the coast, central area and mountains, each of which has a climatological season for reference, which is defined by the State Meteorology Agency (AEMET) (in Gijón, Oviedo and Mieres, respectively). The AEMET provided us with data on the humidity and average temperature of the months in which all the cases of peritonitis appeared. <span class="elsevierStyleBold">Results: </span>There were 171 cases of peritonitis (0.498 episodes/patient/year) in 201 patients (58±16 years, 59% males, 33% diabetics, 20±19 months on technique). We did not find any differences according to age, sex, having diabetes, nasal carrier status for <span class="elsevierStyleItalic">Staphylococcus aureus </span>or therapeutic modality. Overall, there were no differences among seasons. However, using spring as a reference (value 1), the incidence rate of gram-negative peritonitis (95% confidence interval) in summer, autumn and winter was 0.666 (0.211-1.832), 0.248 (0.000-0.912) and 0.292 (0.000-0.833), respectively (<span class="elsevierStyleItalic">P</span><.001). We do not see this variation upon analysing the incidence rates of peritonitis caused by gram-positive bacteria. The average temperature of the days on which peritoneal infections were caused by gram-negative bacteria (15.46±3.71°C) was significantly higher than on those days when it was caused by gram-positive bacteria (13.61±3.89 °C) (<span class="elsevierStyleItalic">P</span>.022). There are no significant differences in relation to humidity (78.76 ± 4.40 vs. 77.5±3.69 %) (<span class="elsevierStyleItalic">P</span>.227). <span class="elsevierStyleBold">Conclusions: </span>Overall, the rates of peritoneal infection are similar in all four seasons of the year, although in the case of gram-negative bacteria there is an increase in its incidence in spring and summer. The higher the temperature, the higher the risk that a peritoneal infection will be the result of a gram-negative bacterium.</p>" ] "es" => array:1 [ "resumen" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">Introducción: </span>La infección peritoneal es una complicación común en los pacientes en diálisis peritoneal (DP) y una causa frecuente de fallo de la técnica. Conocer los factores que predisponen a su aparición ayuda a establecer medidas preventivas. <span class="elsevierStyleBold">Objetivos</span><span class="elsevierStyleBold">:</span> Conocer la influencia de variables climáticas en la aparición de peritonitis, como son las variaciones estacionales, la temperatura y la humedad en Asturias. <span class="elsevierStyleBold">Métodos</span><span class="elsevierStyleBold">:</span> Estudio retrospectivo, observacional, de todas las infecciones peritoneales acaecidas en nuestra unidad de DP a lo largo de un período de 5 años (2007-2011). La región fue divida longitudinalmente en tres áreas: costa, medianías y cordillera, cada una de las cuales dispone de una estación climatológica de la Agencia Estatal de Meteorología (AEMET) de referencia (en Gijón, Oviedo y Mieres, respectivamente). La AEMET nos proporcionó los datos de humedad y temperatura media de los meses en los que se produjeron todas las peritonitis. <span class="elsevierStyleBold">Resultados</span><span class="elsevierStyleBold">:</span> Se produjeron 171 peritonitis (0,498 episodios/paciente/año) en 201 pacientes (58 ± 16 años, 59 % varones, 33 % diabéticos, tiempo en técnica 20 ± 19 meses). No encontramos diferencias en función de la edad, el sexo, la condición de diabético, el ser portador nasal inicial de <span class="elsevierStyleItalic">Staphylococcus aureus</span> ni la modalidad terapéutica. Globalmente, no hubo diferencias en las distintas estaciones. Sin embargo, usando la primavera como referencia (valor 1), la tasa de incidencia de peritonitis por gramnegativos (95 % intervalo de confianza) en verano, otoño e invierno fue 0,666 (0,211-1,832), 0,248 (0,000-0,912) y 0,292 (0,000-0,833), respectivamente (P < 0,001). No constatamos dicha variación al analizar las tasas de incidencia de las peritonitis causadas por gérmenes grampositivos. La temperatura media los días en los que se produjeron infecciones peritoneales por gérmenes gramnegativos (15,46 ± 3,71 °C) es significativamente mayor que en los grampositivos (13,61 ± 3,89 °C) (P 0,022). No hay diferencias significativas en cuanto a la humedad (78,76 ± 4,40 frente a 77,5 ± 3,69 %) (P 0,227). <span class="elsevierStyleBold">Conclusiones</span><span class="elsevierStyleBold">:</span> Globalmente, las tasas de infección peritoneal son semejantes en las cuatro estaciones del año, aunque en el caso de los gérmenes gramnegativos en primavera y verano se produce un aumento en su aparición. A mayor temperatura, mayor riesgo de que la infección peritoneal esté causada por un germen gramnegativo.</p>" ] ] "multimedia" => array:4 [ 0 => array:8 [ "identificador" => "fig1" "etiqueta" => "Tab. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "12420_16025_64100_en_t112420_03.jpg" "Alto" => 503 "Ancho" => 1063 "Tamanyo" => 187657 ] ] "descripcion" => array:1 [ "en" => "Characteristics of the population" ] ] 1 => array:8 [ "identificador" => "fig2" "etiqueta" => "Tab. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "12420_16025_64101_en_t212420_032.jpg" "Alto" => 478 "Ancho" => 2133 "Tamanyo" => 403031 ] ] "descripcion" => array:1 [ "en" => "Incidence and relative risk of peritonitis globally and depending on causal Gram germ, according to days at risk for each season" ] ] 2 => array:8 [ "identificador" => "fig3" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "12420_16025_64102_en_f112420_032.jpg" "Alto" => 973 "Ancho" => 2101 "Tamanyo" => 281873 ] ] "descripcion" => array:1 [ "en" => "Incidence of peritonitis by season and type of germ" ] ] 3 => array:8 [ "identificador" => "fig4" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "12420_16025_64103_en_f212420_032.jpg" "Alto" => 892 "Ancho" => 2107 "Tamanyo" => 255333 ] ] "descripcion" => array:1 [ "en" => "Relationship between onset of peritonitis and climatic variables such as temperature and humidity" ] ] ] "bibliografia" => array:2 [ "titulo" => "Bibliography" "seccion" => array:1 [ 0 => array:1 [ "bibliografiaReferencia" => array:20 [ 0 => array:3 [ "identificador" => "bib1" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Wiggins KJ, Craig JC, Johnson DW, Strippoli GF. 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"contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/20132514/0000003400000006/v0_201502091558/X2013251414054824/v0_201502091558/en/main.assets" "Apartado" => array:4 [ "identificador" => "35444" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Short Originals" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/20132514/0000003400000006/v0_201502091558/X2013251414054824/v0_201502091558/en/P1-E577-S4785-A12420-EN.pdf?idApp=UINPBA000064&text.app=https://revistanefrologia.com/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X2013251414054824?idApp=UINPBA000064" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 9 | 5 | 14 |
| 2024 October | 62 | 52 | 114 |
| 2024 September | 63 | 41 | 104 |
| 2024 August | 66 | 70 | 136 |
| 2024 July | 58 | 26 | 84 |
| 2024 June | 73 | 34 | 107 |
| 2024 May | 92 | 40 | 132 |
| 2024 April | 69 | 37 | 106 |
| 2024 March | 45 | 21 | 66 |
| 2024 February | 54 | 28 | 82 |
| 2024 January | 48 | 26 | 74 |
| 2023 December | 34 | 21 | 55 |
| 2023 November | 52 | 31 | 83 |
| 2023 October | 55 | 29 | 84 |
| 2023 September | 29 | 39 | 68 |
| 2023 August | 32 | 24 | 56 |
| 2023 July | 37 | 32 | 69 |
| 2023 June | 37 | 28 | 65 |
| 2023 May | 57 | 43 | 100 |
| 2023 April | 33 | 15 | 48 |
| 2023 March | 29 | 27 | 56 |
| 2023 February | 41 | 21 | 62 |
| 2023 January | 41 | 21 | 62 |
| 2022 December | 66 | 40 | 106 |
| 2022 November | 51 | 30 | 81 |
| 2022 October | 53 | 34 | 87 |
| 2022 September | 85 | 30 | 115 |
| 2022 August | 50 | 49 | 99 |
| 2022 July | 35 | 44 | 79 |
| 2022 June | 39 | 44 | 83 |
| 2022 May | 44 | 37 | 81 |
| 2022 April | 45 | 56 | 101 |
| 2022 March | 49 | 56 | 105 |
| 2022 February | 36 | 43 | 79 |
| 2022 January | 56 | 35 | 91 |
| 2021 December | 52 | 47 | 99 |
| 2021 November | 29 | 36 | 65 |
| 2021 October | 62 | 48 | 110 |
| 2021 September | 43 | 46 | 89 |
| 2021 August | 35 | 56 | 91 |
| 2021 July | 41 | 39 | 80 |
| 2021 June | 38 | 41 | 79 |
| 2021 May | 67 | 47 | 114 |
| 2021 April | 131 | 96 | 227 |
| 2021 March | 82 | 52 | 134 |
| 2021 February | 57 | 22 | 79 |
| 2021 January | 70 | 31 | 101 |
| 2020 December | 52 | 20 | 72 |
| 2020 November | 51 | 14 | 65 |
| 2020 October | 30 | 28 | 58 |
| 2020 September | 30 | 9 | 39 |
| 2020 August | 47 | 21 | 68 |
| 2020 July | 44 | 21 | 65 |
| 2020 June | 48 | 27 | 75 |
| 2020 May | 81 | 32 | 113 |
| 2020 April | 44 | 20 | 64 |
| 2020 March | 63 | 51 | 114 |
| 2020 February | 64 | 24 | 88 |
| 2020 January | 85 | 25 | 110 |
| 2019 December | 101 | 24 | 125 |
| 2019 November | 104 | 27 | 131 |
| 2019 October | 70 | 24 | 94 |
| 2019 September | 93 | 19 | 112 |
| 2019 August | 63 | 19 | 82 |
| 2019 July | 56 | 37 | 93 |
| 2019 June | 38 | 27 | 65 |
| 2019 May | 57 | 28 | 85 |
| 2019 April | 110 | 50 | 160 |
| 2019 March | 80 | 24 | 104 |
| 2019 February | 48 | 31 | 79 |
| 2019 January | 44 | 36 | 80 |
| 2018 December | 83 | 47 | 130 |
| 2018 November | 86 | 23 | 109 |
| 2018 October | 63 | 24 | 87 |
| 2018 September | 78 | 15 | 93 |
| 2018 August | 60 | 20 | 80 |
| 2018 July | 60 | 15 | 75 |
| 2018 June | 67 | 20 | 87 |
| 2018 May | 60 | 19 | 79 |
| 2018 April | 71 | 11 | 82 |
| 2018 March | 59 | 15 | 74 |
| 2018 February | 54 | 13 | 67 |
| 2018 January | 50 | 11 | 61 |
| 2017 December | 71 | 12 | 83 |
| 2017 November | 64 | 11 | 75 |
| 2017 October | 57 | 18 | 75 |
| 2017 September | 64 | 19 | 83 |
| 2017 August | 70 | 16 | 86 |
| 2017 July | 67 | 12 | 79 |
| 2017 June | 74 | 9 | 83 |
| 2017 May | 89 | 17 | 106 |
| 2017 April | 69 | 15 | 84 |
| 2017 March | 61 | 26 | 87 |
| 2017 February | 63 | 17 | 80 |
| 2017 January | 26 | 8 | 34 |
| 2016 December | 84 | 9 | 93 |
| 2016 November | 83 | 9 | 92 |
| 2016 October | 118 | 17 | 135 |
| 2016 September | 141 | 5 | 146 |
| 2016 August | 231 | 8 | 239 |
| 2016 July | 232 | 10 | 242 |
| 2016 June | 128 | 0 | 128 |
| 2016 May | 134 | 0 | 134 |
| 2016 April | 127 | 0 | 127 |
| 2016 March | 92 | 0 | 92 |
| 2016 February | 123 | 0 | 123 |
| 2016 January | 131 | 0 | 131 |
| 2015 December | 185 | 0 | 185 |
| 2015 November | 115 | 0 | 115 |
| 2015 October | 136 | 0 | 136 |
| 2015 September | 90 | 0 | 90 |
| 2015 August | 93 | 0 | 93 |
| 2015 July | 110 | 0 | 110 |
| 2015 June | 56 | 0 | 56 |
| 2015 May | 68 | 0 | 68 |
| 2015 April | 17 | 0 | 17 |
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