Management of cryptococcal meningitis in adults at Mthatha Hospital Complex, Eastern Cape, South Africa

Abstract

Background. Cryptoccocal meningitis (CM) remains prevalent in HIV-infected individuals across South Africa (SA). Early diagnosis and management, aided by the existing Southern African HIV Clinicians Society (SAHIVSoc) 2007 guidelines on management of CM, could reduce the mortality associated with this condition. 

Objective. To review the management of adult patients with CM and adherence to the SAHIVSoc 2007 guidelines in a district hospital.

Methods. A retrospective chart review of patients admitted with CM from December 2011 to May 2012 was performed. The following key recommendations of the guidelines were evaluated: measurement of cerebrospinal fluid (CSF) opening pressure at the first lumbar puncture (LP), prescription of amphotericin B (AMB)/fluconazole therapy, intravenous prehydration preceding administration of AMB, monitoring of renal function and performance of serial LPs to manage raised intracranial pressure (ICP).

Results. A total of 57 patient charts were reviewed, of which 40 (70%) were of females. The mean age (range) of the cohort was 36 (21 - 60) years. Fifty-two (91%) patients presented with headache. Confusion was recorded in 30 (53%) and vomiting in 26 (46%). The major signs observed were fever (n=29 (51%)) and neck stiffness (n=34 (60%)). Fifty-five (96%) patients were HIV-infected at presentation, with a median (range) CD4⁺ count of 77 (13 - 90) cells/µl. None of the patients had a CSF opening pressure measured at first LP. AMB was used as an induction agent in 51 (89%) patients, of whom 47 (92%) completed 2 weeks of AMB. Of these 51, only 20 (40%) were prehydrated and 10 (18%) had two repeat LPs performed 1 week apart. Renal function was monitored in only 27 (53%) of the patients receiving AMB. This was done at baseline and twice weekly, and was consistent with the guidelines. No abnormality in renal function was recorded in these cases during the study. The mortality rate was 30% in the first 10 days of admission.

Conclusion. This chart review showed inadequate adherence to the recommendations of the 2007 SAHIVSoc guidelines in the majority of cases except for the use of AMB as a first-line antifungal agent. Control of ICP and monitoring for drug toxicity were not done as per guidelines and may impact on clinical care and outcome. Despite this, the early 30% mortality is comparable with published reports from other regions in SA, but is higher than in developed health systems.