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High Mortality in HIV-Associated Cryptococcal Meningitis Patients Treated With Amphotericin B–Based Therapy Under Routine Care Conditions in Africa
BACKGROUND: Cryptococcal 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 i...
Autores principales: | , , , , , , , , , , , |
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Formato: | Online Artículo Texto |
Lenguaje: | English |
Publicado: |
Oxford University Press
2018
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Materias: | |
Acceso en línea: | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6251350/ https://www.ncbi.nlm.nih.gov/pubmed/30488038 http://dx.doi.org/10.1093/ofid/ofy267 |
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author | Patel, Raju K K Leeme, Tshepo Azzo, Caitlin Tlhako, Nametso Tsholo, Katlego Tawanana, Ephraim O Molefi, Mooketsi Mosepele, Mosepele Lawrence, David S Mokomane, Margaret Tenforde, Mark W Jarvis, Joseph N |
author_facet | Patel, Raju K K Leeme, Tshepo Azzo, Caitlin Tlhako, Nametso Tsholo, Katlego Tawanana, Ephraim O Molefi, Mooketsi Mosepele, Mosepele Lawrence, David S Mokomane, Margaret Tenforde, Mark W Jarvis, Joseph N |
author_sort | Patel, Raju K K |
collection | PubMed |
description | BACKGROUND: Cryptococcal 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. METHODS: Electronic 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. RESULTS: There 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/mm(3). 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. CONCLUSIONS: Mortality 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. |
format | Online Article Text |
id | pubmed-6251350 |
institution | National Center for Biotechnology Information |
language | English |
publishDate | 2018 |
publisher | Oxford University Press |
record_format | MEDLINE/PubMed |
spelling | pubmed-62513502018-11-28 High Mortality in HIV-Associated Cryptococcal Meningitis Patients Treated With Amphotericin B–Based Therapy Under Routine Care Conditions in Africa Patel, Raju K K Leeme, Tshepo Azzo, Caitlin Tlhako, Nametso Tsholo, Katlego Tawanana, Ephraim O Molefi, Mooketsi Mosepele, Mosepele Lawrence, David S Mokomane, Margaret Tenforde, Mark W Jarvis, Joseph N Open Forum Infect Dis Major Articles BACKGROUND: Cryptococcal 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. METHODS: Electronic 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. RESULTS: There 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/mm(3). 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. CONCLUSIONS: Mortality 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. Oxford University Press 2018-10-23 /pmc/articles/PMC6251350/ /pubmed/30488038 http://dx.doi.org/10.1093/ofid/ofy267 Text en © The Author(s) 2018. Published by Oxford University Press on behalf of Infectious Diseases Society of America. http://creativecommons.org/licenses/by/4.0/ This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited. |
spellingShingle | Major Articles Patel, Raju K K Leeme, Tshepo Azzo, Caitlin Tlhako, Nametso Tsholo, Katlego Tawanana, Ephraim O Molefi, Mooketsi Mosepele, Mosepele Lawrence, David S Mokomane, Margaret Tenforde, Mark W Jarvis, Joseph N High Mortality in HIV-Associated Cryptococcal Meningitis Patients Treated With Amphotericin B–Based Therapy Under Routine Care Conditions in Africa |
title | High Mortality in HIV-Associated Cryptococcal Meningitis Patients Treated With Amphotericin B–Based Therapy Under Routine Care Conditions in Africa |
title_full | High Mortality in HIV-Associated Cryptococcal Meningitis Patients Treated With Amphotericin B–Based Therapy Under Routine Care Conditions in Africa |
title_fullStr | High Mortality in HIV-Associated Cryptococcal Meningitis Patients Treated With Amphotericin B–Based Therapy Under Routine Care Conditions in Africa |
title_full_unstemmed | High Mortality in HIV-Associated Cryptococcal Meningitis Patients Treated With Amphotericin B–Based Therapy Under Routine Care Conditions in Africa |
title_short | High Mortality in HIV-Associated Cryptococcal Meningitis Patients Treated With Amphotericin B–Based Therapy Under Routine Care Conditions in Africa |
title_sort | high mortality in hiv-associated cryptococcal meningitis patients treated with amphotericin b–based therapy under routine care conditions in africa |
topic | Major Articles |
url | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6251350/ https://www.ncbi.nlm.nih.gov/pubmed/30488038 http://dx.doi.org/10.1093/ofid/ofy267 |
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