In this study, the proportion of patient with secondary peritonitis was elevated (45.2%). Compared to the proportion found in this study, Seni et al.(12) in Tanzania found a higher proportion of secondary peritonitis (57.7%). In Ethiopia, two studies reported lower proportions of secondary peritonitis (19.3%(21) and 24%(22). A recent study in Tanzania also reported a lower proportion (21.5%) (23). Contrary to our findings, Nyundo et al.(24) in Rwanda reported a proportion of 41.5% related to poor knowledge of mid and a lower level health professionals on the diagnosis and early decision for management of acute abdomen. The high proportion in our study could be explained by the late presentation related to some behaviour such as self-treatment, used of herbal treatment and financial constrains typical of low resource settings and low income- countries.
In this study, gram-negative bacteria represented (66.7%) of isolated bacteria which was comparable to the findings in a study conducted in Ethiopia by Alelign, (10) where gram negative organisms accounted (76.6%). Escherichia coli (35.8%) and Klebsiella spp (17.0%) were identified as the commonest bacteria cultured from infected peritoneal fluid. These findings are similar to the study done in Ethiopia by Alelign, (10) which reported E. coli (36.67%) and Klebsiella (20%) to be the commonest isolates. Furthermore, other studies conducted in Tanzania by Seni et al. (12); in Nigeria by Akujobi et al. (25) and in India by Kumar-m et al. (5) confirmed the predominance of E. coli followed by Klebsiella spp as the most frequent bacteria growth from peritoneal infected fluid associated with secondary peritonitis. In contrast, a study done In Mbarara by Mutiibwa & Tumusiime, (16) found the most common bacteria to be Klebiella spp (37.9%) followed by E. coli (26.4%) in small bowel perforation as the cause of secondary peritonitis. The predominance of these bacteria species in the infected peritoneal fluid of patient with secondary peritonitis might be due to their presence as normal flora in the gastrointestinal tract.
All the nine bacteria isolated from infected peritoneal fluid due to secondary peritonitis had resistance to Cloxacillin, methicillin, ceftriaxone, amoxiclav, cefixime, penicillin, ampicillin, and metronidazole. This implies that these commonly prescribed antibiotics will not be encouraged to be used as first line empirical therapy for secondary peritonitis, particularly in the study area. The practice of prescribing broad spectrum antibiotics with no clear indication and over the counter use of antibiotics might have contributed to resistance of these bacteria to these antibiotics which are normally readily available and affordable for the management of these strains of bacterial isolates. The Antibiotics that demonstrated effectiveness at varying degrees to the different organisms isolated were Imipenem, Amikacin, Ciprofloxacin, and Gentamicin which is slightly close to the result found by Alelign in Ethiopia and Mutiibwa at Mbarara regional referral hospital in Uganda (10, 16)
E. coli was highly sensitive to Imipenem (94.7%) and Amikacin (78.9%), with low sensitivity to Gentamycin (31.6%) and Ciprofloxacin (5.3%). This result is similar to a study done in Indian by Kumar-m et al. (26) and Sheikhbahaei et al. (27) in Iran where Imipenem and Amikacin (̱≥95.6%), Gentamycin and Ciprofloxacin (≥ 60%) had high sensitivities to E.coli. In this study, the difference could be explained by irrational prescription of Gentamycin and ciprofloxacin in our medical setting and also the fact that these drugs are cheap and readily available than Imipenem and Amikacin.
Klebsiella spp were sensitive to Imipenem (100%), Amikacin (55.6%) but slight sensitivity to Gentamycin (22.2%) and Ciprofloxacin (22.2%). Kumar-m et al. (5) in India reported similar result as Dwihantoro & Rochadi, (28) in Indonesia but with some differences in antibiotic susceptibilities which included cephalosporin. These differences could be explained by the fact that the practices of antibacterial use have been shown to vary which can result in different patterns of resistance.
Literature shows that many factors are known to be associated with secondary peritonitis such as demographic, social behavior, medical and even environmental factors; (8, 9). In this study, two factors male gender and time to presentation were the significant risk factors associated with secondary peritonitis.
Being a male patient with acute abdomen was 3.658 (CI = 1.570–8.519, p = 0.003) times more likely to have secondary peritonitis compared to being female. This finding is similar to the research done in Uganda by Ojuka & Ekwaro,(30) in Nsambya Hospital where the male to female ratio was 3:1 for peritonitis. Other studies conducted in Tanzania by Mabewa et al.(2) and Mukherjee & Sarkar,(31) in Indian found similar results of male to female ratios 1.8:1 and 8.4:1.6 respectively. This could also be explained by the poor health seeking behavior of males patients (2, 31) resulting in late presentation to the health facilities and the associated complications. Men are known to be unworried than women about their health, which means they might spend more time with a medical condition before they decide to search for appropriate management. A research done by Fillingim et al.(32) at Alabama University showed that women were more likely to worry about pain and feel more helpless about it, and are more likely than men to have depression and anxiety, all of which can lead to higher pain levels and health care seeking (32).
A patient who took 3 days or more to come to hospital after onset of symptoms was also found to be 2.957(CI = 1.232–7.099, p = 0.015) times more likely to have secondary peritonitis compared to the one who presented in less than 3 days which is in agreement with a study done in Mbarara regional referral hospital (16). Others studies by Nansubuga et al. (32) at Mulago national referral hospital, Mabewa et al. (2) in Tanzania and Ndayizeye et al. (34) in Rwanda also had similar findings suggesting that late presentation could reflect delay in seeking health care, attempted treatment through a traditional healer, lack of resources for transport to the health center and late referral by the peripheral health facilities. In Africa, late presentation (beyond 24 hours of the onset of the symptom) has been the norm especially in the rural areas.
5.5 Conclusion
Secondary Peritonitis is a common surgical emergency among patients with acute abdomen at Hoima regional referral hospital and its management needs urgent surgical attention. Escherichia coli and Klebsiella spp were the most common bacteria found in the infected peritoneal fluid of patients with secondary peritonitis after culture and sensitivity. These bacteria showed multiple resistances to the most commonly used antibiotics but were sensitive to Imipenem, Amikacin, Gentamicin and Ciprofloxacin at varying degrees. Male sex and time to presentation to the Hospital were the two main factors found to be independently associated with secondary peritonitis among patients having acute abdomen.
5.6 Study Limitations
This as a cross-sectional study was not able to follow up the outcome related to antibiotics found effective after culture and sensitivity. Depending on the culture media used, we were able to isolate aerobics and facultative anaerobes. Therefore, strict anaerobes and fungi were not captured which might explain why some samples did not yield any growth.
5.8 Recommendations
Imipenem, Amikacin, Ciprofloxacin and Gentamicin should be considered for empirical therapy in cases of secondary peritonitis. Patients, more especially males with abdominal pain should be encouraged to present early to hospital in order to minimise progression to secondary peritonitis. All health workers should participate in antibiotic stewardship to prevent the emergence, spread and persistence of antibiotic resistance and do further studies to determine resistant genes of the isolates. There should be periodic monitoring of antimicrobial resistance patterns to helps physicians to choose antimicrobial agents for empiric treatment of secondary peritonitis.