Ambulatory induction phase treatment of cryptococcal meningitis in HIV integrated primary care clinics, Yangon, Myanmar

Clare E Warrell,Elizabeth A Ashley,Frank Smithuis,Edmund Wilkins,Alistair R D Mclean,Catriona Macrae,Ni Ni Tun

doi:10.1186/s12879-021-06049-z

Abstract

BackgroundCryptococcal meningitis (CM) is a common HIV-associated opportunistic-infection worldwide. Existing literature focusses on hospital-based outcomes of induction treatment. This paper reviews outpatient management in integrated primary care clinics in Yangon.MethodThis retrospective case note review analyses a Myanmar HIV-positive patient cohort managed using ambulatory induction-phase treatment with intravenous amphotericin-B-deoxycholate (0.7–1.0 mg/kg) and oral fluconazole (800 mg orally/day).ResultsSeventy-six patients were diagnosed between 2010 and 2017. The median age of patients diagnosed was 35 years, 63% were male and 33 (45%) were on concurrent treatment for tuberculosis. The median CD4 count was 60 at the time of diagnosis. Amphotericin-B-deoxycholate infusions precipitated 56 episodes of toxicity, namely hypokalaemia, nephrotoxicity, anaemia, febrile reactions, phlebitis, observed in 44 patients (58%). One-year survival (86%) was higher than existing hospital-based treatment studies.ConclusionAmbulation of patients in this cohort saved 1029 hospital bed days and had better survival outcomes when compared to hospital-based studies in other resource constrained settings.

Highlights

Cryptococcal meningitis (CM) is a common HIV-associated opportunistic-infection worldwide
A retrospective case note review was carried out of all cryptococcal meningitis patients presenting to four outpatient clinics (9 am-5 pm, 7 days per week) from 2010 to 2017 in Yangon’s most deprived townships
Demographic factors In total, 76 HIV positive patients diagnosed with cryptococcal meningitis were treated at MAM clinics from January 2010 to December 2017

Summary

Introduction

Cryptococcal meningitis (CM) is a common HIV-associated opportunistic-infection worldwide. In Myanmar, HIV prevalence in adults is 0.57% [2]. It is an epidemic concentrated in key affected populations (KAPs), including female sex workers, men who have sex with men and people who inject drugs, who are generally reluctant to utilize hospital care, for fear of prejudice. Until recently the World Health Organization (WHO) treatment guidelines advised a 14-day course of Warrell et al BMC Infectious Diseases (2021) 21:375 amphotericin-B-deoxycholate and high dose fluconazole are still used in these settings. Complications associated with amphotericin-B-deoxycholate include nephrotoxicity, hypokalaemia, anaemia, phlebitis and febrile reactions, close monitoring is required [5–7]

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Discussion

Conclusion