Symptomatic relapse of HIV-associated cryptococcal meningitis in South Africa: the role of inadequate secondary prophylaxis
Symptomatic relapse of HIV-associated cryptococcal meningitis in South Africa: the role of inadequate secondary prophylaxis
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DOI：
10.7196/samj.3515
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发表时间：
2010-06-01
期刊：
影响因子：
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通讯作者：
Harrison, Thomas S
中科院分区：
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作者：
Jarvis, Joseph N;Meintjes, Graeme;Harrison, Thomas S
目标。隐球菌性脑膜炎是南部非洲成人脑膜炎的最常见原因。这种疾病负担被认为大部分是由于以前治疗过的感染的症状性复发。我们研究了二次氟康唑预防不充分对隐球菌性脑膜炎症状复发的影响。一项前瞻性观察研究对2007年1月至2008年12月在开普敦一家公立成人转诊医院GF Jooste医院出现的经实验室证实的hiv相关隐球菌性脑膜炎症状复发患者进行了研究。结果的措施。复发发作分为：(i)未使用氟康唑预防的患者；（ii）免疫重建炎症综合征（IRIS）；（iii）服用氟康唑的患者在ART前发生的复发。记录住院死亡率。69例复发，占所有隐球菌性脑膜炎病例的23%；43% （N=30）的复发发生在未接受氟康唑预防治疗的患者中，45% （N=31）是由于IRIS， 12% （N=8）发生在art前服用氟康唑的患者中。由于二级预防不充分而复发的患者病情严重，住院死亡率高（33%）。在未服用氟康唑的30例患者中，47% （N=14）未由其卫生保健提供者开二级预防处方。我们没有记录到在这些接受两性霉素B作为初始治疗的患者中由于氟康唑耐药而复发。大量隐球菌性脑膜炎的复发是由于处方、配药和转诊失败或坚持二次氟康唑预防。改善二次氟康唑预防使用的干预措施至关重要。
Objectives. Cryptococcal meningitis is the most common cause of adult meningitis in southern Africa. Much of this disease burden is thought to be due to symptomatic relapse of previously treated infection. We studied the contribution of inadequate secondary fluconazole prophylaxis to symptomatic relapses of cryptococcal meningitis.Design. A prospective observational study of patients presenting with laboratory-confirmed symptomatic relapse of HIV-associated cryptococcal meningitis between January 2007 and December 2008 at GF Jooste Hospital, a public sector adult referral hospital in Cape Town.Outcome measures. Relapse episodes were categorised into: (i) patients not taking fluconazole prophylaxis; (ii) immune reconstitution inflammatory syndrome (IRIS); and (iii) relapses occurring prior to ART in patients taking fluconazole. In-hospital mortality was recorded.Results. There were 69 relapse episodes, accounting for 23% of all cases of cryptococcal meningitis; 43% (N=30) of relapse episodes were in patients not receiving fluconazole prophylaxis, 45% (N=31) were due to IRIS, and 12% (N=8) were in patients pre-ART taking fluconazole. Patients developing relapse due to inadequate secondary prophylaxis had severe disease and high in-hospital mortality (33%). Of the 30 patients not taking fluconazole, 47% (N=14) had not been prescribed secondary prophylaxis by their health care providers. We documented no relapses due to fluconazole resistance in these patients who received amphotericin B as initial therapy.Conclusions. A large number of relapses of cryptococcal meningitis are due to failed prescription, dispensing and referral for or adherence to secondary fluconazole prophylaxis. Interventions to improve the use of secondary fluconazole prophylaxis are essential.