The spectrum and outcome of surgical sepsis in Pietermaritzburg, South Africa

Background. Sepsis is a leading cause of morbidity and mortality worldwide, and the incidence appears to be increasing. In the resource-limited environment in low- and middle-income countries, the management of surgical sepsis (SS) continues to represent a significant portion of the workload for most general surgeons. Objective. To describe the spectrum of SS seen at a busy emergency department, and categorise the outcomes. Methods. The Pietermaritzburg Metropolitan Trauma Service (PMTS) and Pietermaritzburg Metropolitan Surgical Service (PMSS) in KwaZulu-Natal Province, South Africa (SA), maintain a prospective electronic registry. All patients with features of sepsis among emergency general surgical patients >15 years of age admitted to the PMSS over the period January 2012 - January 2015 were identified. From this cohort, all patients with sepsis that required surgical source control or who had a documented surgical source of sepsis (i.e. had SS) were selected for analysis. Results. Of a total of 6 020 adult surgical patients on the database, a cohort of 1 240 acute surgical patients with features of sepsis were identified, and 675 with SS were then analysed further. Of the 675 patients, 49.2% were male, and the mean age was 46 years (standard deviation (SD) 19); 47.0% presented to the PMSS directly from within the metropolitan area, while the remaining 53.0% were referred from hospitals outside the area. Physiological parameters (mean values) on presentation were as follows: systolic blood pressure 123 mmHg (standard deviation (SD) 23), respiratory rate 22 breaths/min (SD 5.2), heart rate 107 bpm (SD 19), temperature 37 degrees C (SD 2) and white cell count 20 x 10(9) /L (SD 8). Of the patients, 21.6% were known to be HIV-positive, 13.5% (91/675) were negative and 64.9% were of unknown status; 57.6% had intra-abdominal sepsis, 26.1% diabetes-related limb sepsis and the remaining 16.3% soft-tissue infections; 17.5% required intensive care unit admission, with a mean length of stay of 4 days (SD 4), and 30.7% developed complications. In this last group (n=207), a total of 313 morbidities were identified. The overall mortality rate was 12.7% (86/675). The mortality rate for intra-abdominal sepsis was 13.1%, for diabetic foot sepsis 14.2% and for necrotising fasciitis 27.3%. Conclusions. The spectrum of SS in SA is different to that seen in the developed world. Intra-abdominal sepsis is the most common SS and is overwhelmingly caused by acute appendicitis. Diabetic foot infection is a major cause of SS, reflecting the increasing burden of non-communicable chronic diseases in SA.