Title:
Prehospital Delay and the Care Cascade in Intracranial Suppurative Infections: An Exploratory Mediation Analysis of In-Hospital Prognosis in a Resource-Limited Ivorian Cohort

Authors:
Serge Konan Yao*, Faozo Stéphane Landry Teti, Koffi Jean-Jacques Kouassi, Djoko Traoré, Adama Kouadio, Aderehime Haidara, Cote d'Ivoire

Abstract:

Background. In our cohort of intracranial suppurative infections (ISI), the median delay between symptom onset and admission was 19 days. We hypothesised that a longer prehospital delay is associated with higher in-hospital mortality, partly through impaired consciousness on admission, measured by the Glasgow Coma Scale (GCS).

Methods. Single-centre secondary analysis of 150 admissions (148 patients; 16 deaths; mortality 10.7%) at Bouaké University Hospital, Côte d'Ivoire, 2016–2026. The care cascade distinguished the prehospital phase (symptom onset to admission; n = 150) from the in-hospital phase (admission to surgery; n = 125 operated patients). Associations between delay, severity and lesion characteristics were estimated with Spearman's coefficient and models adjusted for age and sex. A counterfactual mediation analysis (natural direct and indirect effects expressed as odds ratios; non-parametric percentile bootstrap, 2000 resamples) followed a causal framework defined before model estimation (directed acyclic graph). Firth penalised regression, sensitivity analyses (adjustment for rurality and referral, exclusion of scalp involvement and of postoperative forms, one admission per patient, risk-scale g-formula) and the E-value assessed robustness. Given 16 deaths, all analyses are exploratory.

Results. The median prehospital delay (19 days; IQR 15–25) was about nine to ten times the admission-to-surgery delay (2 days; IQR 1–3). A prolonged delay (>19 days) was associated with rural residence (aOR 2.27; 95% CI 1.16–4.43) and, borderline, with referral from another facility (aOR 1.88; 95% CI 0.96–3.67). A longer delay was associated with a lower admission GCS (ρ = −0.25; p = 0.002; −0.67 point per 10 days after adjustment). The total effect of delay on death was imprecise and compatible with no effect (OR 1.79 per +10 days; 95% CI 0.85–4.52). The proportion mediated through the GCS was about 19% (95% CI −48 to 105%); the indirect effect (OR 1.11; 95% CI 0.99–1.39) did not reach significance. Adjustment for rurality and referral modestly attenuated the direct effect (OR 1.49; 95% CI 0.73–3.19).

Conclusion. Delay was mainly prehospital and associated with structural access factors and with a lower GCS on admission; its effect on mortality remained imprecise. Prehospital delay is a potential target for organisational interventions, whose effectiveness must be evaluated prospectively.

DOI: http://dx.doi.org/10.51505/ijmshr.2026.10510