The role of treatment delays in surgical site infection after appendicectomy in a South African rural regional hospital

Abstract

Background. Delays to surgery for acute appendicitis in low- and middle-income countries lead to significant morbidity. Objectives. To investigate the role of time to surgery in the development of complicated appendicitis and surgical site infection (SSI) in a rural referral hospital in South Africa (SA). Methods. A prospective cohort study was conducted of all patients presenting to a regional hospital in SA with acute appendicitis during 2017. Inpatient interview and data collection were followed by 30-day post-surgical follow-up to assess time periods to surgery and operative outcomes. Results. A total of 188 patients underwent surgery for acute appendicitis. The median (interquartile range (IQR)) age was 19 (3 - 73) years, and 62% were male. The median (IQR) time from symptoms to surgery was 60 (42 - 86) hours and from hospital admission to surgery 8 (4 - 16) hours. Forty-one percent were managed laparoscopically, 62% had complicated appendicitis, and 25% developed SSI. Time from symptoms to surgery >72 hours was associated with an increased risk of complicated appendicitis (odds ratio (OR) 4.32; 95% confidence interval (CI) 1.36 - 13.75; p =0.013). Patients with SSI had an increased median delay of 15 hours ( p =0.05) compared with those without SSI. Multivariable analysis showed that the risk of SSI increased with complicated appendicitis (OR 8.96; 95% CI 2.73 - 29.41; p <0,001) and decreased with laparoscopic surgery (OR 0.21; 95% CI 0.07 - 0.59; p =0.003). Time to surgery had no effect on the risk of SSI in adjusted analyses. Conclusions. Delays to surgery beyond 72 hours significantly increased complicated appendicitis, an important risk factor for SSI. Access to facilities with surgical capability and the use of laparoscopic surgery are modifiable risk factors for SSI.