Mortality After Peritonitis in Sub-Saharan Africa: An Issue of Access to Care

There is a lack of access to emergency surgical care in developing countries despite a burden of surgical disease.¹ Health care systems are overwhelmed by the high volume of patients who need acute care and by insufficient capacity because of a lack of appropriate prehospital care, surgery-capable clinicians, and basic health care delivery infrastructures.² Compared with high-income countries where mortality from peritonitis is less than 5%, mortality in this resource-poor setting is nearly 20%.^1,3 These patients are particularly susceptible because of a lack of the prerequisite surgical infrastructure, which includes prompt triage and diagnosis, early transfer to a higher level of care, timely surgical intervention, and critical care services.⁴ This study identifies outcomes of patients with peritonitis and factors that contribute to mortality.

This is a prospective observational study of patients at Kamuzu Central Hospital in Lilongwe, Malawi, presenting with acute abdominal complaints from September 2013 through March 2016. The University of North Carolina institutional review board and the Malawi National Health Services review committee approved this study and waived consent because this study was not changing the standard of surgical care. We compared patients with and without peritonitis using the Pearson correlation for categorical variables and 2-sample t tests for continuous variables. We fit a modified Poisson model⁵ to estimate the risk ratio for in-hospital mortality among patients with peritonitis and adjusted for confounders. Clinically relevant confounders were initially included and removed using a change-in-effect method. A multivariate modified Poisson model was used to examine predictors of mortality from peritonitis. All clinically relevant variables were initially included and reduced models were compared with a complete model using a likelihood ratio test. Adjusted risk ratios and adjusted predicted probabilities with 95% CIs are reported. The statistical significance of all P values was set at less than .05.

A total of 1492 patients were enrolled in the study (mean [SD] age of 35.7 [19.5] years; 68% male). On presentation, 374 patients (25.1%) had peritonitis. There were differences in demographics, disease etiology, and surgical management between those with and those without peritonitis (Table).

Patients with peritonitis experienced a significant increase in crude in-hospital mortality compared with patients without peritonitis (18.2% vs 11.8%, respectively; P = .002). Characteristics associated with mortality included older patient age; being female; living in a rural environment; transferring from another facility; a poor Alert, Voice, Pain, Unresponsive score; and nonsurgical management. The risk ratio of in-hospital death for those with peritonitis compared with those without was 1.6 (95% CI, 1.1-2.1), adjusted for age, sex, surgical intervention, and a poor Alert, Voice, Pain, Unresponsive score.

Among those with peritonitis, time to operation from presentation (each day: risk ratio, 1.08 [95% CI, 1.05-1.10]; each 10-year increase in age: risk ratio, 1.29 [95% CI, 1.14-1.47]; a poor Alert, Voice, Pain, Unresponsive score: risk ratio, 2.03 [95% CI, 1.16-3.54]; and a postoperative diagnosis of gastrointestinal perforation: risk ratio, 2.26 [95% CI, 1.35-3.77]) significantly increased the risk of in-hospital death. The adjusted predicted probability of death increased significantly based on time to operation when controlling for these factors (Figure).

Our study highlights critical points related to surgical access. First, patients with access to timely triage, such as those living in an urban environment, had a survival benefit. Second, not only is transfer from an outside facility associated with increased mortality, but for patients with peritonitis, each day from the time of initial presentation to their first operation increased the adjusted risk of death approximately 10%. Finally, at our tertiary center, a third of patients with peritonitis did not have access to surgical management because of limitations in surgery- and anesthesia-capable clinicians and operating room support staff.

The improvement of emergency surgical care should parallel efforts to expand national trauma systems in areas such as prehospital care, triage, and management. Increasing the surgical workforce at the secondary level of the health care system can lower transfer rates and increase the number of district-performed emergent procedures.⁶ These system improvements, along with a prioritization of national expenditures in surgical care, would likely result in improved mortality.

Corresponding Author: Anthony G. Charles, MD, MPH, University of North Carolina School of Medicine, 4008 Burnett Womack Bldg, CB 7228, Chapel Hill, NC 27599 (anthchar@med.unc.edu).

Published Online: December 28, 2016. doi:10.1001/jamasurg.2016.4638

Author Contributions: Drs Gallaher and Charles had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: All authors.

Acquisition, analysis, or interpretation of data: Gallaher, Charles.

Drafting of the manuscript: Gallaher, Charles.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Gallaher, Cairns, Charles.

Obtained funding: Charles.

Study supervision: Varela, Charles.

Conflict of Interest Disclosures: None reported.

Funding/Support: This work was supported by the North Carolina Jaycee Burn Centre in the Department of Surgery at the University of North Carolina.

Role of the Funder/Sponsor: The North Carolina Jaycee Burn Centre had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Previous Presentation: This study was presented at the American College of Surgeons Annual Scientific Forum; October 5, 2015; Chicago, Illinois.