SURGERY Postoperative Sepsis Among HIV-Positive Patients with Acute Abdomen at Tertiary Hospital in Sub-Saharan Africa: a Prospective Study Mohamed Abdullahi Awale1,2 & Timothy Makumbi2 & Gideon Rukundo2 & Gideon K. Kurigamba2 & Geoffrey Kisuze2 & Daniel Semakula2 & Moses Galukande2 Accepted: 8 March 2019 /Published online: 16 April 2019 # The Author(s) 2019 Abstract The incidence of HIVin Uganda as reported by UNAIDS (2012) was increased from 6.7% in 2004 to 7.6% to 2012. Themain threat to HIV-infected patients following surgery is the development of sepsis. Inadequacy of surgical supplies and human resources further hastens and complicates the postoperative sepsis in HIV patients. The objective of the study was to determine incidence and risk factors associated with postoperative sepsis, among HIV seropositive with acute abdomen. A prospective study ran for a period of 11months fromOctober 2015 to April 2016 inMulago Hospital in Kampala. Eligible patients were recruited and included. Study variables included postoperative wound sepsis, type of surgery, and CD4 counts. Thirty-eight data were collected using a question- naire then entered in the Epidata software 3.1 and analyzed by Stata software version. Sixty-two patients were recruited; of these, 42 were male, 37 were HIV-negative and 25 were HIV-positive. The proportion of patients with postoperative sepsis in the HIV- positive groupwas 7 (28%) and in the HIV-negative groupwas 8 (21.6%). The number of patients discharged in HIV-positive group was 24 (96%) and in HIV-negative group was 35 (94.6%). Among the HIV-positive group was 1 out of 25 (4) % and HIV-negative was 2 out of 37 (5.4%). The overall postoperative sepsis incidence rate was 3 per 100 person days for under observation (95% CI 0.02–0.1), and the incidence rate ratio of HIV-positive patients and HIV-negative was 1.04 (95%CI 0.32–3.3; P = 0.47. The limited health resource was associated with developing postoperative sepsis. There was a higher risk of positive operative sepsis among HIV-positive compared to HIV-negative patients undergoing surgery for acute abdominal conditions. Keywords Postoperative sepsis . Acute abdomen . HIV Background Globally, an estimated 35.3 million people were living with HIV in 2012. HIV infection was first recognized in Uganda in 1982 [1]. It has been a global pandemic and major cause of morbidity and mortality for over the last three decades. Sub- Saharan Africa bears the greatest burden of this disease with 68% of the global burden [2]. A study showed that HIV- infected patients with preoperative CD4 count ≤ 200 cells/ μL had overall higher postoperative sepsis morbidity. Preoperative CD4 count was used as a useful indicator for postoperative sepsis in HIV-infected patients undergoing ab- dominal operations. Postoperative sepsis was onlymajor post- operative event associated with long-term mortality. Postoperative sepsis may reflect a deep impairment of im- mune response, which is potentially associated with mortality [3]. An increase in ARTusage from previous years is observed as more people are receiving the life-saving antiretroviral This article is part of the Topical Collection on Surgery Previous presentation: this study was presented at the GPAS annual meeting Kampala Uganda, August 2016. Electronic supplementary material The online version of this article (https://doi.org/10.1007/s42399-019-00061-w) contains supplementary material, which is available to authorized users. * Mohamed Abdullahi Awale drawaale@gmail.com 1 International Hospital Mogadishu, Mogadishu, Banadir, Somalia 2 Department of Surgery, Makerere University College of Health Sciences, Makerere University and Mulago National Referral Hospital, Kampala, Uganda SN Comprehensive Clinical Medicine (2019) 1:465–472 https://doi.org/10.1007/s42399-019-00061-w http://orcid.org/0000-0003-0114-3022 https://doi.org/10.1007/s42399-019-00061-w mailto:drawaale@gmail.com http://crossmark.crossref.org/dialog/?doi=10.1007/s42399-019-00061-w&domain=pdf therapy. There were 2.3 (1.9–2.7) million new HIV infections globally, showing a 33% decline in the number of new infec- tions from 3.4 (3.1–3.7) million in 2001. At the same time, the number of AIDS deaths is also declining with 1.6 (1.4–1.9) million AIDS deaths in 2012, dropping from 2.3 (2.1–2.6) million in 2005 [4]. The development of sepsis creates a sub- stantial health care burden and limited epidemiologic informa- tion exists with regard to postoperative sepsis. Patients who undergo major surgery are at a high risk of postoperative sep- sis. HIV-infected patients are more likely to develop postop- erative infectious complications [5]. Severe sepsis in two Ugandan hospitals was found to have a mortality rate of up to 43%. In-hospital mortality was increased and the average length of stay was 6 days for those who survived to be discharged. Lack of surgical materials and human resources contributes to the inability to achieve improved management of sepsis in resource-constrained setting [6]. To a greater or lesser extent, the HIV disease now influences the performance and outcome of surgery in every country of the world. Surgical studies show that this impairment has not resulted in an increased incidence of postoperative infections or failure of wound healing in the asymptomatic HIV-positive patient. Current surgical management seems adequate to prevent in- creased risk of early postoperative infection in the symptom- atic HIV-positive patient undergoing surgical procedures [7]. HIV-seropositive patients had more complications, including more perioperative infections, impaired wound healing, and greater mortality and these results were used as justification to withhold surgery in certain circumstances [8]. In this study, we estimated the incidence of postoperative sepsis and the asso- ciated risk factors among HIV-seropositive and HIV-negative patients presenting with acute abdomen. Methods Study Design A prospective cohort study was carried out be- tween 1st of October 2015 and 30th of April 2016 for a period of 7 months. The research was carried out in MNRH general sur- gical wards. MNRH is a teaching Hospital for Makerere University College of Health Sciences and also a National Referral Hospital located in Kampala, the capital city of Uganda. It is a 1500-bed capacity hospital and runs a specialized HIVunit. MulagoHospital provides specialized inpatient care to patients referred from district and regional hospitals around the country and from various outpatient HIV care centers. Presentation of acute abdomen is one to three patients per day who undergo surgery inMulagoHospital. HIV prevalence in the general adult population in Uganda is 7.3%, and approximately 64% of patients hospitalized in Mulago Hospital are infected with HIV. Participants were recruited from the surgical emer- gency ward as well as the general surgical wards of the hospital. Patients on A&E and the general surgical wards were suspected of having acute abdominal surgical manifestation; HIV- seropositive and HIV-negative patients at MNRH were interviewed and enrolled in the study after the patient signed a written consent form (Fig. 1). So all HIV-positive and HIV- negative patients with acute abdominal surgical manifestation taking ART or not were recruited in the study at MNRH and they were part of the target population. All patients (women, men, and > 15 years of age) who were present at MNRH were directly or referred with surgical manifestation. All acute abdo- men patients above 15 years of age received at MNRH between 1st of October 2015 and 30th of April 2016 gave informed consent (for adults 18 years and above) and assent plus guardian consent (for patients younger than 18 years) to participate in the study. Unconscious surgical patients, whose attendants refused to participate in the study. Mentally ill, and unstable patients. Sampling Procedure Patients admitted to the surgical unit of the Accidents and Emergency department and general wards with acute abdomen were recruited to this study according to the eligibility criteria. An HIV test was performed using the Determine method which is rapid test. Any positive test was confirmed using Statpak and Unigold. CD + 4 counts and CBC were obtained before surgery for all HIV-positive pa- tients. The participants were grouped as HIV-positive or HIV-negative and henceforth analyzed in those groups. The initial diagnosis at first assessment was recorded. The final diagnosis after investigations and/or surgery were also record- ed. In this study, we used consecutive selection. Sample Size The sample size was determined using the Kish and Leslie formula (1965), n = 63 patients. Our dependent variables were sociodemographic data: age, sex, address, level of education, occupation, HIV status, acute abdomen diagno- sis, CD4 level, ART drugs, duration of surgery, duration of antibiotic use, type of surgery, and health system challenges. Our dependent variable was postoperative sepsis. Data Management We pre-coded and pre-tested data collec- tion tool. The raw data then was entered using Epidata Entry Version 3.1. We collected data by using an administered ques- tionnaire. We tested HIV patients with acute abdomen using the Determine test, and confirmed using Statpak. Any discrep- ancies were resolved with a third tie-breaker test—Unigold. We have done CD4 count, CBC, consent was obtained, and their contacts taken. At this stage, the questionnaire was par- tially filled and fully completed after surgery and follow-up. The informed consent process as well as questionnaire inter- views were conducted in the local language (Luganda) for the majority of patients and in English for a few patients. We collected data over a specified period of time and interviewed at the arrival time, except patients who were unstable such as those in coma or shock. We summarized data and presented it in tables for easy interpretation. Epidata version 3.1 was used 466 SN Compr. Clin. Med. (2019) 1:465–472 for the entry, validation, and consistency of data; double data entry to check for errors was done. We analyzed data by STATA version 12 computer program and was presented in tabulation form and frequency graphs. It was summarized as tables, pie charts, and bar graphs. In the analysis described, patients are characterized and presented as percentage (%) and mean (SD). The incidence of HIV patients calculated as the proportion of all patients with acute abdomen who are HIVpositive were presented as number (percentage) or mean (SD). The incidence of postoperative sepsis used 95% CI. We divided the participants into two groups, HIV-positive and HIV-negative. The proportions of the various identified etiol- ogies of acute abdomen were calculated for each group. The chi-square statistic was used to test for significance of the difference in the proportions. Similarly, the postoperative risk factors associated with acute HIV accompanying acute abdo- men were compared between the two groups. The incidence of postoperative sepsis was estimated as the proportion of patients who had HIV presenting with acute abdomen among the study participants. Logistic regression was used to identify factors associated with HIV presenting with acute abdomen by deriving the odds ratio (CI) and p value of the respective relationships. In all analyses, a p value < 0.05 was considered statistically significant. The postoperative sepsis and associat- ed risk factors used Poisson regression methods to estimate the incidence rate of occurrence of postoperative sepsis among HIV patients as compared to HIV-negative and used incidence relative risk (IRR) (95%CI). Analytics were used to assess the confounders using the same regression method. We pretested the questionnaire and cross-checked for completeness and in- ternal consistency. Research assistant was trained. Inconsistent data evaluated and necessary adjustments were made. Approval was obtained from Makerere University College Board (IRB); the nature of study, its potential risks, and benefits to the patients on the community were explained to the patients. The consent forms were in both Luganda and English. Written informed consent was obtained by signature or thumbprint using a consent form. Patients at A&E and surgical wards:3360 patients in 7 months 380 screened pa�ents in 7 months 352 HIV negative 3 HIV positive refused to consent. 4 lost ques. form 32 patients were HIV positive 25 recruited HIV positive 272 HIV negative 30 lost ques�onnaire forms 13 Un able to consent 37 recruited for HIV negative HIV + patients (25) 7 Sepsis cases Age/gender Type of surgery CD4count ART duration 18 Non sepsis cases Age/gender Type of surgery CD4count ART duration HIV – patients (N37) 8 Sepsis cases Age/gender Type of surgery 29 Non sepsis cases Age/gender Type of surgery Fig. 1 Patient flowchart SN Compr. Clin. Med. (2019) 1:465–472 467 Results A total of 62 patients were recruited and followed-up to dis- charge or death from 1st of October 2015 to April 2016. The median age and inter quartile of HIV-negative patients was 35 (IQR, 25) while the HIV-positive group was 37 (IQR, 8). The urban residents were 22 out of 37 (59.46%) in HIV-negative and 15 out of 25 (59.68%) in HIV-positive while rural was 15 out of 37 (40.54%) in HIV-negative and 10 out of 25 (40) in HIV-positive. Most of the patients were married, 26 out of 37 (70.26%) in HIV-negative group and 20 out of 25 (74.19%) for HIV-positive followed by the single status which presented 11 out of 37 (29.73%) and 4 out of 25 (16%) respectively. The educational level for most of study participants were Secondary School level both HIV-negative and HIV-positive 56.76% and 52% respectively. Occupation was professional with 16 (43%) in HIV-negative and 8 (32%) in HIV-positive; businessmen, HIV-negative 5 out of 37 (13.51%), HIV-positive 8 out 25 (32%); and peasant, HIV-negative 7 out of 37 (18.92%) and HIV-positive 8 out of 25 (32%) respectively. Themost common presentation was abdominal pain. The HIV-negative group with 33 out 37 (89.19%), and HIV-positive with 24 out of 25 (96%). Within the HIV-positive group, the most common condition was intestinal obstruction at 12 out of 25 (48%) followed by acute appendicitis which presented in 5 out of 25 (20%). In the HIV-negative participants, obstructed hernia wasmost common condition in 14 out of 37 (37%) followed by intestinal obstruc- tion in 10 out of 37 (27%). Anemia was the most common co- morbid association condition for HIV-positive and HIV- negative patients with 7 out 37 (18%) and 5 out 25 (20%) respectively. Exploratory laparotomy was the most frequently performed procedure in HIV-negative representing 22 out of 37 (59.56%) and HIV-positive with 15 out of 25 (56%) respective- ly. Baseline demographic characteristics of the study partici- pants are shown in Table 1. Finding at Laparotomy The most common finding at surgery was gut perforation ob- served 19 out of 62 (30.64%) operations. Most of the perfo- rations were observed in the small intestine in 14 cases and the stomach in 4 cases. Incarcerated or strangulated hernia, is the second most common finding observed in 16 out of 62 (25.8%) patients. Small intestine obstruction was the third most common finding observed in 11 out of 62 (17.7%) and was caused by bands, adhesions, or pyoperitoneum. Inflamed appendix in 6 out of 62 (9.7%) and sigmoid volvulus in 5 out of 62 (8.1%) ranked 4th and 5th respectively. Postoperative Outcomes Fifteen out of 62 patients (24.2%) in the study developed postoperative sepsis, whom 7 out of 25 (28%) were HIV- positive and 8 out of 37 (21.62%) were HIV-negative. Twenty-four out of 25 (96%) of the HIV-positive patients were discharged compared to the 35 out of 37 (94.59) of the HIV- negative patients. Patients died following surgery were 1 out of 7 (4%) of whom was HIV-positive and 2 out of 37 (5.4%) were HIV-negative. Incidence of Postoperative Sepsis The total person time of the study participants was 489 and patients who developed postoperative sepsis were 15 cases. The overall incidence rate was 3 per 100 person days under observation (95% CI 0.02–0.051). The incidence rate of post- operative HIV-positive patients was 3.1 per 100 person days under observation while that in HIV-negative was 3.0 per 100 person days under observation; the person time in HIV- negative group was 265 while in the HIV-positive was 224. The incidence rate ratio for HIV-positive and HIV-negative was 1.035 (95% CI 0.319–3.29; P = 0.47). Study Variables Most emergency cases were operated by surgical residents, i.e., 54 out 62 (87%) cases with 3 years mean experience followed by those done by the Registrar (junior consultants) with 6 out of 62 (8.1%). Antiseptic solution was used in all cases except in one case where normal saline was used as an antiseptic solution. Most HIV-positive patients in this study were in stage І, 23 out of 25 (92%). Most of the HIV patients were on HARRT, 18 out of 25 (68%) followed none, and 8 out of 25 (32%) used Septrin. All patients who developed postop- erative sepsis during this study presented in 1 out of 15 (6.7%). Most surgeons who operated patients in this study were experienced but faced a problem of limited health re- sources like unavailability or shortage of surgical instruments, gowns, antiseptic solution, and anesthesiologist. Most of the patients operated in this study had been given preoperative antibiotics for an average of 1.7 ± 2.13 days, the minimum was 1 day and the maximum was 22 days. The mean duration of surgery was 1.7 ± 0.6 h, with a minimum of 1 h and max- imum of 3 h. Surgical experience ranged from 1 to 30 years with a mean of 4.7 ± 5.3 years. SHO were the least experi- enced surgeons. The mean duration of symptoms was 5.4 ± 3.73 dayswith aminimum of 2 days andmaximum of 14 days. Mean length of hospital stay was 7.88 ± 8.4 days with a min- imum of 1 day and maximum of 37 days. Sixteen out of 25 (64%) HIV-positive patients who had CD4 count, ranged from 200 to 500 uL. These were protected from getting postopera- tive sepsis (IRR 0.678; 95% CI 0.152—0.03; P = 0.611). Patients who had CD4 > 200 uL were 7 out of 25 (28%) and more protected CD4 > 500 uL were 2 out of 25 (8%). 468 SN Compr. Clin. Med. (2019) 1:465–472 Risk Factors for Postoperative Sepsis in HIV+ Participants We assessed for factors associated with postoperative sepsis using Poisson regression model. Bivariate analysis factors which had P value of 0.2 were considered statistically signifi- cant and included in the multivariate Poisson regression model. At multivariate analysis, factors were considered to be statisti- cally significant if they had aP value of 0.05. The health system challenges were found to have an association with postopera- tive sepsis WBC, platelets, duration of surgery were included. The risk of postoperative sepsis increased by 3.17 times for every additional hour spent in surgery (95% CI 10.66–15.15; P = 0.14). Patients who had leukocytosis were 1.11 times (95% CI 0.951–1.31; P = 0.17) more likely to develop sepsis. Bivariate Analysis of Risk Factors for Postoperative Sepsis HIV− Participants Married patients were less likely to develop postoperative sep- sis (IRR 0.39; 95% CI 0.138–1.14; P = 0.08). Duration of sur- gery increased (IRR 3.34; 95% CI 1.04–11.5; P = 0.043) folds of getting postoperative sepsis. Patients who had anemia had increased incident-related risk (IRR 23.4; 1.25; P = 0.18) of developing sepsis. The status of being married, duration of surgery, and limited health resources were associated with post- operative sepsis and were presented with a P value less than 0.2 which were taken for multivariate analysis. Multivariate Analysis of Risk Factors for Postoperative Sepsis among HIV-Positive and HIV-Negative Participants After controlling for CD4 < 200,WBC, and platelets, the risk of having postoperative sepsis among HIV-positive patients was 2.1 times higher among patients whose health care worker experienced limited health resource (IRR 3.6; 95% CI − 0.2– 4.4; P = 0.072). The risk factors for postoperative sepsis among HIV-negative. The controlling factors were absence of core staff and unavailability; these were not statistically and significantly associated with postoperative sepsis (IRR 3.5; 95% CI 0.61–207; P = 0.500) as shown in Table 2. Discussion We set out to find the incidence and risk factors of postoper- ative sepsis among HIV patients presenting with acute Table 1 Demographic characteristics, clinical presentations, and surgical management of 62 study participants Characteristic HIV-negative 9 (n = 37) HIV-positive (n = 25) Age yrs.: median(IQR) 35 (25) 37 (8) Sex Male 31 (83.78) 11 (44) Female 6 (16.67) 14 (56.52) Rural or urban Rural 15 (40.54) 10 (40) Urban 22 (59.46) 15 (59.68) Marital status Single 11 (29.73) 4 (16.00) Married 26 (70.27) 20 (74.19) Divorced 0 1 (1.69) Educational level None 1 (2.70) 1 (4) Primary 13 (35.14) 11 (44) Secondary 21 (56.76) 13 (52) Tertiary 2 (5.41) 0 Occupation Un employed 2 (5.41) 0 Peasant 7 (18.92) 8 (32) Professional 16 (43.24) 8 (32) Business/trader 5 (13.51) 8 (32) Student 7 (18.92) 1 (4) Clinical presentation of participants Abdominal pain 33 (89.19) 24 (96) Abdominal distention 30 (81.08) 17 (68) Intestinal obstruction 10 (27.03) 12 (48) peritonitis 10 (29.73) 2 (8) Obstructed hernia 10 (29.73) 2 (8) Acute appendicitis 3 (8.11) 5 (20) Pre-existing medical condition Diabetes mellitus 1 (2.70) 0 (00) Anemia 7 (18.92) 5 (20) Surgical management of participants Explorative laparotomy 22 (59.56) 15 (56) Appendectomy 4 (10.1) 6 (24) Herniorrhaphy 14 (37.84) 4 (16) SN Compr. Clin. Med. (2019) 1:465–472 469 abdomen at Mulago Hospital. We found that the overall inci- dence rate of postoperative sepsis was 0.03 per person days under observation (IR 0.03; 95% CI 0.02–0.051). This is equivalent to three cases of postoperative sepsis per 100 per- son days under observation. The incidence rate ratio for post- operative sepsis in HIV-positive versus HIV-negative partici- pants was 1.035 (95% CI 0.319–3.29; P = 0.47). King et al. in a similar study done in a veterans’ hospital in the USA found an incidence rate ratio of 2.11 (95% CI 1.41–3.17; P < 001) [9]. This rate was higher than that in our study possibly be- cause they followed-up patients for a longer period. It is pos- sible that some patients developed postoperative sepsis in the days after being discharged from hospital. Such patients would be missed by our study which followed-up participants up to discharge or death. Some studies presented data as inci- dence and percentages of patients with postoperative sepsis. In the discussion below, we discuss our findings using statistics presented by other studies in order to aid the comparison. Nandyala et al. [10], in a study done in India, found the post- operative sepsis was 30%. From our study, the incidence of postoperative sepsis was 28% (7 out of 25). Zhang et al. [11], in a study done in China, found an incidence of postoperative sepsis of 2.6% in HIV-infected patients versus HIV-negative patients. Mafana et al. [12] collected data from six different hospitals in South Africa and found an incidence of postoper- ative sepsis of 3.6% among the HIV-negative patients and 3.7% among HIV-postoperative sepsis. These were lower than what we found in our study probably because of differences in study setting and study patients. Risk Factors for Postoperative Sepsis In all study participants irrespective of HIV status, longer duration of surgery increased the risk of postoperative sepsis. The risk of postoperative sepsis increased threefold for every extra hour spent under operation (IRR 3.4; 95% CI 0.66–15.5; P = 0.14) but this finding was not statistically significant. In a similar study done by Berthus et al. in the Netherlands, re- searchers also found that longer duration of surgery increased risk of developing postoperative sepsis [13]. This finding was statistically significant with P value as 0.01. It is possible that surgery deplete patients’ energy levels and affects the hemo- dynamics required to fend off infection. It is also possible that longer duration of surgery exposes patients to the risk of con- tamination and infection especially if the conditions under which surgery is performed have reduced sterility. In this study, we found that HIV patients were 2.1 times more likely to develop postoperative sepsis, where health workers report- ed limited health resources such as lack of sundries, drapes, antiseptic solution, gowns, and other materials necessary to care for patients in the postoperative period (IRR 13.9; 95% CI 1.5–130) and this finding was statistically significant (p = 0.021) after controlling all other possible confounders. Indeed, other studies have found results similar to ours. Kizza et al. found that lack of material and human resources contributes to the inability to achieve improved management of sepsis in Mulago Hospital. The high mortality associated with sepsis syndromes resulted from the lack of materials and human resources necessary for optimal care [14]. Having anemia in which we used WHO guideline < 9 mg/dl have increased the risk of postoperative sepsis 4.5 times (IRR, 95% CI 1.5–13.1; P = 0.006) at bivariate analysis although this finding was not statistically significant after controlling other factors (IRR 1.66; 95% CI 0.99–27.8, p = 0.72). It is possible that there are other factors confounding the relationship between anemia and postoperative sepsis that have to be explored further to tease out the actual effect of anemia on the development of postoperative sepsis. We found that having a higher CD4 cell count reduced the risk of developing postoperative sepsis among patients who were HIV-positive (IRR − 0.31; 95% CI Table 2 Multivariate analysis of risk factors of postoperative sepsis among HIV-positive and HIV-negative participants Characteristics IRR (95% CI) P value* HIV-positive participants CD < 200 0.31 (1.96–1.35) 0.717 CD 200–500 13.7 (5225.9–5198.5) 0.900 WBC 0.935 (0.1–0.29) 0.400 Platelets 0.0017 (0.01–0.12) 0.740, 0.072 Limited health resources 2.1 (− 0.2–4.4) 0.072 HIV-negative patients Age 0.95 (0.7–1.3) 0.770 Duration of surgery 1.76 (0.21–14.86) 0.600 WBC 1.2 (0.88–1.8) 0.200 Anemia 3 (0.99–27.8) 0.720 Absence core staffing availability 3.5 (0.61–207) 0.530 IRR incidence rate ratio, WBC white blood count, CD cluster differentiation *Poisson regression 470 SN Compr. Clin. Med. (2019) 1:465–472 − 1.96–1.3; P = 0.7), for HIV-positive patients with CD4 count between 200 and 500 versus patients with CD4 count < 200/μl. This finding is in close agreement with a similar study done in China by Xia et al. who found incidence of postoperative sepsis in patients with preoperative CD4 count < 200cells/μl marked higher than those with CD4 counts > 200/μl (83.3% versus 17.65%) [15]. Clinical Findings and Findings at Surgery Among Study Patients Almost all patients had abdominal pain (96%) and abdominal distention (81%). Similar to a Tanzanian study by Chalya et al., it was found that abdominal pain was the main clinical presen- tation; hospital stay in Chalya et al. study was 26 days, which was greater than the median duration of hospital stay in our study of 7.8 (IQR, 8.4 days) [16]. In our study, the most com- mon finding at surgery was gut perforation 30.64% and this consistently agreed with findings from studies done by Clark et al. in South Africa [17], Weledji et al. from Nigeria [18], and Nandyala et al. from India (10) where themost common finding was gut perforation presenting in 30% of patients. Galukande et al. found appendectomy followed by hernia, and there was similarity to this study whereby the second most operation was herniorrhaphy [19]. In our study, strangulated hernia was found in 17.7% of patients; a finding similar to that was found by Doumgba et al. in Central Africa in which he found 16% of cases had strangulated hernia [20]. The mean hemoglobin of our study was 12.3 mg/dl and it was similar to the study done by Ischie et al. in Nigeria [21] and Okuma et al. [19] in Uganda which they found 12.3mg/dl and 12.1mg/dl respectively. CD4 < 200/μl in our study was associated with postoperative sepsis which Misauno et al. found the same in Nigeria [21]. In our study, the proportion of postoperative sepsis in HIV-positive patients was 28% similar to what Montoya et al. found in Peru in 2014 which was 28.1% [22]. Comparison of Incidence of Postoperative Sepsis Among HIV-Positive and HIV-Negative Patients The incidence rate of postoperative sepsis in this study for HIV- positive patients was 3.1/100 person days under observation while that of the HIV-negative patients was 3.0/100 person days under observation. This gave an incidence rate ratio of 1.1 for HIV-positive versus HIV-negative patients (IRR 1.035; 95%CI 0.32–3.30; p = 0.47) but this finding was not statistically signif- icant. Other studies presented data as incidence instead of inci- dence rates. Our study showed higher incidence of 7 out of 25 (28%) in the HIV-positive group compared to similar studies done elsewhere. A study done by Zhang et al. showed an inci- dence of postoperative sepsis of 2.6% in HIV patients [11]. Hadnott et al. [23] and Yiiet et al. [24] found incidence of sepsis of 13% (17 out of 51 patients). The proportion of patients with postoperative sepsis in HIV-positive patients was 28% (7 out of 25) and 21.62% (8 out of 37) in HIV-negative patients. In comparison, a study done by out of 2 (20%) and in the HIV-negative group was 7 out of 76 (9.2%) [19]. Kakande et al. found postoperative sepsis in 7 cases out 76 (9.9%) [25]. Study Limitations Most patients were from Kampala metropolitan so generaliza- tion of results to the country is limited. The study was subject- ed to the potential of recall bias, e.g., age and duration of symptoms. Some of the patients were not able to remember, we minimized this by asking patients’ ages, and duration of symptoms, and cross-checking with the admission file. Duration of operation, antibiotic usage, and antiseptic solution were obtained from admission files. In case they were not written or reported, information was obtained from the sur- geon. This did not have any net effect on the internal validity of the results. Conclusion The incidence rate ratio for HIV-positive and HIV-negative patients was 1.035 (95% CI 0.319–3.29; P = 0.47). Incidence rate of HIV-positive patients was 3.1 per 100 person time under observation compared to HIV-negative patients 3.0 per 100 person time under observation. Risks of postoperative sepsis among both HIV-positive and HIV-negative patients increased by longer duration of surgery, anemia, and limited health resources. Author Contribution AMA collected data and took responsibility for integrity of the data and the accuracy of data analysis, acquisition analy- sis, and drafting of manuscript. MG is DELTA/THRIVE fellow under DEL15-011/07742/Z/15/Z, TM, and GR participated in study design data analysis and manuscript writing. Funding This work was supported byMaryam Ali and Abdullahi Awale. The funders has no role in the design and conduct of the study, collection, management, analysis and interpretation of the data. Availability of Data and Materials The datasets generated and analyzed during the current study are available from the corresponding author on reasonable request. Compliance with Ethical Standards Conflict of Interest The authors declared that they have no conflict of interest. Ethics Approval and Consent to Participate This study was approved by institute research board (2016-03-03REC REF 2016–033). The written informed consent was obtained from all individual participants included in the study. SN Compr. Clin. Med. (2019) 1:465–472 471 Consent for Publication Written consent for publication was obtained from all individual participants included in the study. 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(2019) 1:465–472 Postoperative... Abstract Background Methods Results Finding at Laparotomy Postoperative Outcomes Incidence of Postoperative Sepsis Study Variables Risk Factors for Postoperative Sepsis in HIV+ Participants Bivariate Analysis of Risk Factors for Postoperative Sepsis HIV− Participants Multivariate Analysis of Risk Factors for Postoperative Sepsis among HIV-Positive and HIV-Negative Participants Discussion Risk Factors for Postoperative Sepsis Clinical Findings and Findings at Surgery Among Study Patients Comparison of Incidence of Postoperative Sepsis Among HIV-Positive and HIV-Negative Patients Study Limitations Conclusion References