Impact of Infectious Diseases Consultation on Mortality of Cryptococcal infection in Patients without HIV.

Abstract

An infectious disease (ID) consultation is often obtained to treat patients with cryptococcosis due to the complex nature of the disease, but has never been demonstrated to impact outcomes. We assembled a retrospective cohort of 147 consecutive cases of cryptococcosis in patients without HIV. Patients who were diagnosed less than 24 hours prior to death were excluded. Survival analysis was performed with Cox regression with survival censored past 90 days. The patients with an ID consult had a higher fungal burden but a lower 90-day mortality compared to patients without ID involvement (27% vs 45%, p<0.001), with an adjusted hazard ratio of not receiving an ID consult of 4.1 (95% CI: 2.2, 7.6). The ID consult group was more likely to receive an indicated lumbar puncture (86% vs 32%, p<0.001), and more likely to be treated with amphotericin B (AmB) (87% vs 24%, p<0.001) and flucytosine (5-FC) (57% vs 16%, p<0.001) when indicated. The duration of therapy with AmB (14 vs 11 days, p=0.05) and 5-FC (7.5 vs 1 days, p<0.001) was longer in the ID consult group. Patients that received an ID consult were significantly less likely to die in the 90 days following diagnosis. Patients seen by ID physicians were more likely to be managed according to evidence based practice established by randomized controlled trials and published in IDSA guidelines. These data suggest that an ID consult should be an integral part of clinical care of patients with cryptococcosis.