Typhoid intestinal perforation in Francophone Africa, a scoping review

Typhoid intestinal perforation (TIP) is a leading cause of peritonitis and indication for emergency surgery in Africa, with reported mortality rates up to 30% in pediatric patients. Currently, data on TIP in Western databases are primarily from countries that speak English, likely due to non-English publication and citation biases. Despite the high burden of infectious diseases in Francophone Africa, data from these countries regarding TIP remain limited. This study aims to highlight the incidence and morbidity of TIP in Francophone African countries using an extended search algorithm. We conducted a scoping review using the PubMed, EMBASE, and SCOPUS databases with the keywords "peritonitis", "non-traumatic ileal perforation", and "typhoid" in Francophone African countries. Additionally, we contacted surgeons in Africa and concurrently used citation chasing to obtain data not found in western databases. In total, 32 studies from 12 countries were identified and included in this review. A total of 22 publications were in French. Patient median age was 20 years and TIP caused a median of 35% of acute peritonitis cases. Mortality rates ranged from 6-37% (median: 16%). Rate of complications ranged from 15-92% (median: 46%). Ileostomy creation as a treatment for TIP varied between hospitals (0-79%), with the highest rates reported in Niger. In Francophone Africa, TIP is associated with high morbidity and mortality, most commonly in children and young adults. Interventions, including improved sanitation and the introduction of typhoid conjugate vaccines into routine vaccination programs, have the potential to significantly decrease typhoid fever and its complications.

Characterization of Typhoid Intestinal Perforation in Africa: Results From the Severe Typhoid Fever Surveillance in Africa Program

Background

Typhoid intestinal perforation (TIP) remains the most serious complication of typhoid fever. In many countries, the diagnosis of TIP relies on intraoperative identification, as blood culture and pathology capacity remain limited. As a result, many cases of TIP may not be reported as typhoid. This study demonstrates the burden of TIP in sites in Burkina Faso, Democratic Republic of Congo (DRC), Ethiopia, Ghana, Madagascar, and Nigeria.

Methods

Patients with clinical suspicion of nontraumatic intestinal perforation were enrolled and demographic details, clinical findings, surgical records, blood cultures, tissue biopsies, and peritoneal fluid were collected. Participants were then classified as having confirmed TIP, probable TIP, possible TIP, or clinical intestinal perforation based on surgical descriptions and cultures.

Results

A total of 608 participants were investigated for nontraumatic intestinal perforation; 214 (35%) participants had surgically-confirmed TIP and 33 participants (5%) had culture-confirmed typhoid. The overall proportion of blood or surgical site Salmonella enterica subspecies enterica serovar Typhi positivity in surgically verified TIP cases was 10.3%. TIP was high in children aged 5-14 years in DRC, Ghana, and Nigeria. We provide evidence for correlation between monthly case counts of S. Typhi and the occurrence of intestinal perforation.

Conclusions

Low S. Typhi culture positivity rates, as well as a lack of blood and tissue culture capability in many regions where typhoid remains endemic, significantly underestimate the true burden of typhoid fever. The occurrence of TIP may indicate underlying typhoid burden, particularly in countries with limited culture capability.

Small bowel necrosis and perforation due to sodium polystyrene sulfonate in the setting of graft versus host disease and fulminant Clostridium difficile infection

Gastrointestinal injury is a common adverse event associated with use of sodium polystyrene sulfonate (SPS), tradename Kayexalate. Risk factors for SPS-mediated gastrointestinal necrosis include chronic kidney disease, solid organ transplant recipiency and recent surgery. This report presents a patient with past medical history significant for acute myeloid leukemia (AML) complicated by graft versus host disease (GvHD) and Clostridium difficile colitis who initially presented with small bowel obstruction. She was taken to the operating room and her small bowel pathology was significant for transmural necrosis with SPS crystals in the granulation tissue, despite last receiving SPS over a year ago. Previous mucosal damage should be considered as a risk factor for SPS-mediated injury and the effects of this medication may occur longer than previously thought.

Is Opioid Prescribing Driving Trauma Recidivism or is Trauma Driving Opioid Use?

In the past 30 years, opioid prescription rates have quadrupled and hospital admissions for overdose are rising. Previous studies have focused on alcohol use and trauma recidivism, however rarely evaluating recidivism and opioid use. We hypothesized there is an association between opioid use and trauma recidivism. This is a retrospective review of patients with multiple admissions for traumatic injury. Demographics, opioid toxicology screen (TS) results, and injury characteristics were collected. Statistical analysis was performed with chi-squared and Poisson regression models. One thousand six hundred forty-nine patients (age ≥18 years) had multiple trauma admissions. Seven hundred nine patients had TS data for both admissions. Thirty-one per cent (218) were TS positive on the 1st admission compared with 34 per cent (244) on their 2nd admission. Fifty-five per cent of patients who were TS positive on the 1st admission were positive on their 2nd admission, whereas 25 per cent who were TS negative on the 1st admission were subsequently positive on their 2nd admission ( P < 0.0001). Patients who were TS positive on the subsequent admission were less severely injured than TS negative patients (Injury Severity Score > 15, 26.3% vs 22.3%, P = 0.04). The only significant risk factor for being TS positive on the 2nd admission was being TS positive on the 1st admission (relative risk = 2.18, P < 0.001). A previous history of opioid use is the strongest predictor of recurrent use in recidivists.

Is Opioid Prescribing Driving Trauma Recidivism or Is Trauma Driving Opioid Use?

In the past 30 years, opioid prescription rates have quadrupled and hospital admissions for overdose are rising. Previous studies have focused on alcohol use and trauma recidivism, however rarely evaluating recidivism and opioid use. We hypothesized there is an association between opioid use and trauma recidivism. This is a retrospective review of patients with multiple admissions for traumatic injury. Demographics, opioid toxicology screen (TS) results, and injury characteristics were collected. Statistical analysis was performed with chi-squared and Poisson regression models. One thousand six hundred forty-nine patients (age ≥18 years) had multiple trauma admissions. Seven hundred nine patients had TS data for both admissions. Thirty-one per cent (218) were TS positive on the 1st admission compared with 34 per cent (244) on their 2nd admission. Fifty-five per cent of patients who were TS positive on the 1st admission were positive on their 2nd admission, whereas 25 per cent who were TS negative on the 1st admission were subsequently positive on their 2nd admission (P < 0.0001). Patients who were TS positive on the subsequent admission were less severely injured than TS negative patients (Injury Severity Score > 15, 26.3% vs 22.3%, P = 0.04). The only significant risk factor for being TS positive on the 2nd admission was being TS positive on the 1st admission (relative risk = 2.18, P < 0.001). A previous history of opioid use is the strongest predictor of recurrent use in recidivists.