Abstract
BackgroundCryptococcal meningitis (CM) remains a leading cause of death for HIV-infected individuals in sub-Saharan Africa. Improved treatment strategies are needed if individuals are to benefit from the increasing availability of antiretroviral therapy. We investigated the factors associated with mortality in routine care in KwaZulu-Natal, South Africa.Methodology/Principal FindingsA prospective year long, single-center, consecutive case series of individuals diagnosed with cryptococcal meningitis 190 patients were diagnosed with culture positive cryptococcal meningitis, of whom 186 were included in the study. 52/186 (28.0%) patients died within 14 days of diagnosis and 60/186 (32.3%) had died by day 28. In multivariable cox regression analysis, focal neurology (aHR 11 95%C.I. 3.08–39.3, P<0.001), diastolic blood pressure <60 mmHg (aHR 2.37 95%C.I. 1.11–5.04, P = 0.025), concurrent treatment for tuberculosis (aHR 2.11 95%C.I. 1.02–4.35, P = 0.044) and use of fluconazole monotherapy (aHR 3.69 95% C.I. 1.74–7.85, P<0.001) were associated with increased mortality at 14 and 28 days.ConclusionsEven in a setting where amphotericin B is available, mortality from cryptococcal meningitis in this setting is high, particularly in the immediate period after diagnosis. This highlights the still unmet need not only for earlier diagnosis of HIV and timely access to treatment of opportunistic infections, but for better treatment strategies of cryptococcal meningitis.
Highlights
[1] Prior to the availability of antiretrovirals, cryptococcal meningitis (CM) accounted for a significant proportion of deaths in HIV infected individuals [2,3,4] and even with increasing availability of highly active antiretroviral therapy (HAART), recent data suggests that Cryptococcal meningitis (CM) may account for more deaths amongst HIV positive individuals in sub-Saharan Africa than tuberculosis [5]
In 16 cases initially treated with amphotericin, patients were changed to fluconazole because of the development of renal failure
We describe a prospective series of individuals within a single health care setting operating within the public health sector of South Africa
Summary
For many individuals with HIV, their first presentation to health services is with a major opportunistic infection such as CM and optimal management in these individuals is crucial if they are to benefit fully from antiretroviral therapy. Data from different healthcare settings is valuable for the identification of factors associated with treatment outcome and understanding which interventions are necessary to improve survival. We set out to understand the factors associated with outcome for patients with CM in a public sector hospital setting within northern KwaZulu-Natal, South Africa, where the prevalence of HIV infection reaches 20% or more among the general adult population. Improved treatment strategies are needed if individuals are to benefit from the increasing availability of antiretroviral therapy. We investigated the factors associated with mortality in routine care in KwaZulu-Natal, South Africa
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