HIV Infection Is an Independent Predictor of Mortality Among Adults with Reduced Level of Consciousness in Uganda.

Amir A Mbonde,Lydia Mbatidde,Richard Butterfield,Bart M Demaerschalk,Rose Muhindo,Abdirahim A Aden,Cumara B O’Carroll,Adrian Kayanja,Nan Zhang

doi:10.4269/ajtmh.21-0813

Abstract

ABSTRACT.The clinical epidemiology of adults admitted with reduced level of consciousness (LOC) in sub-Saharan Africa (SSA) and the impact of HIV infection on the risk of mortality in this population is unknown. We secondarily analyzed data from a cohort study that enrolled 359 consecutive adults with reduced LOC presenting to Mbarara Regional Hospital in Uganda with the aim of comparing the prognostic utility of the Full Outline of Unresponsiveness (FOUR) score to the Glasgow Coma Scale (GCS) Score. For this analysis, we included 336 individuals with known HIV serostatus, obtaining clinical, laboratory, and follow-up data. We recorded investigations and treatments deemed critical by clinicians for patient care but were unavailable. We computed mortality rates and used logistic regression to determine predictors of 30-day mortality. The median GCS was 10. Persons living with HIV infection (PLWH) accounted for 97 of 336 (29%) of the cohort. The 30-day mortality rate in the total cohort was 148 of 329 (45%), and this was significantly higher in PLWH (57% versus 40%, adjusted odds ratio [aOR] 2.39: 95% confidence interval [CI]: 1.31–4.35, P = 0.0046). Other predictors of mortality were presence of any unmet clinical need (aOR 1.72; 95% CIL 1.04–2.84, P = 0.0346), anemia (aOR 1.68; 95% CI: 1.01–2.81, P = 0.047), and admission FOUR score < 12 [aOR 4.26; 95% CI: 2.36–7.7, P < 0.0001). Presentation with reduced LOC in Uganda is associated with high mortality rates, with worse outcomes in PLWH. Improvement of existing acute care services is likely to improve outcomes.

Highlights

The spectrum of underlying diseases associated with reduced LOC in Uganda and sub-Saharan Africa (SSA) is broad and distinctly different when compared with that of patients seen in other parts of the world
This was a secondary analysis of data derived from a cohort study that enrolled 359 consecutive adults with reduced LOC of any cause, admitted to the medical ward of Mbarara Regional Referral Hospital (MRRH) in southwestern Uganda between April 2017 and April 2018.13 The main aim of the primary study was to compare the prognostic utility of the Full Outline of Unresponsiveness (FOUR) score to the Glasgow Coma Scale (GCS) score.[13]
Our study offers the first comprehensive real-world description of the clinical epidemiology, treatment challenges, and outcomes of individuals with reduced LOC admitted to a public academic hospital in a high HIV endemic setting in SSA

Summary

Introduction

The spectrum of underlying diseases associated with reduced LOC in Uganda and sub-Saharan Africa (SSA) is broad and distinctly different when compared with that of patients seen in other parts of the world. Central nervous system (CNS) infections, severe sepsis from a non-CNS infection, and metabolic encephalopathy are the leading causes of reduced LOC in SSA.[1,2,3,4] Outcomes in this population are generally poor, with estimated mortality rates of approximately 40% to 60%.1,2. Most hospitals in SSA are faced with the challenge of a dire lack of adequate

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