High Mortality in HIV-Associated Cryptococcal Meningitis Patients Treated With Amphotericin B-Based Therapy Under Routine Care Conditions in Africa.

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Author list: Patel RKK, Leeme T, Azzo C, Tlhako N, Tsholo K, Tawanana EO, Molefi M, Mosepele M, Lawrence DS, Mokomane M, Tenforde MW, Jarvis JN

Publication year: 2018

Journal: Open forum infectious diseases (2328-8957)

Journal acronym: Open Forum Infect Dis

Volume number: 5

Issue number: 11

ISSN: 2328-8957

Languages: English-Great Britain (EN-GB)

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Abstract

Background\nMethods\nResults\nConclusions\nCryptococcal meningitis (CM) causes 10%-20% of HIV-related deaths in Africa. Due to limited access to liposomal amphotericin and flucytosine, most African treatment guidelines recommend amphotericin B deoxycholate (AmB-d) plus high-dose fluconazole; outcomes with this treatment regimen in routine care settings have not been well described.\nElectronic national death registry data and computerized medical records were used to retrospectively collect demographic, laboratory, and 1-year outcome data from all patients with CM between 2012 and 2014 at Botswana's main referral hospital, when recommended treatment for CM was AmB-d 1 mg/kg/d plus fluconazole 800 mg/d for 14 days. Cumulative survival was estimated at 2 weeks, 10 weeks, and 1 year.\nThere were 283 episodes of CM among 236 individuals; 69% (163/236) were male, and the median age was 36 years. All patients were HIV-infected, with a median CD4 count of 39 cells/mm³. Two hundred fifteen person-years of follow-up data were captured for the 236 CM patients. Complete outcome data were available for 233 patients (99%) at 2 weeks, 224 patients (95%) at 10 weeks, and 219 patients (93%) at 1 year. Cumulative mortality was 26% (95% confidence interval [CI], 20%-32%) at 2 weeks, 50% (95% CI, 43%-57%) at 10 weeks, and 65% (95% CI, 58%-71%) at 1 year.\nMortality rates following HIV-associated CM treated with AmB-d and fluconazole in a routine health care setting in Botswana were very high. The findings highlight the inadequacies of current antifungal treatments for HIV-associated CM and underscore the difficulties of administering and monitoring intravenous amphotericin B deoxycholate therapy in resource-poor settings.

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