Profile and mortality outcome of patients admitted with cryptococcal meningitis to an urban district hospital in KwaZulu-Natal, South Africa.

INTRODUCTION: Cryptococcal meningitis (CCM) is one of the leading causes of early mortality among HIV-infected patients. This study was a part of clinical audit (1) aimed at improving care for patients with CCM at an urban district hospital in South Africa. METHODS: Clinical records of all patients (age>13 years) admitted to the hospital with a diagnosis of CCM (based on a positive India ink, positive cryptococcal latex agglutination test (CLAT) or a positive culture of Cryptococcus neoformans) between June 2011 and December 2012 were retrospectively reviewed. Descriptive statistics and Chi-square analysis were generated with Epi Info 7.1.2.0. 95% confidence intervals were reported where appropriate. RESULTS: Of the 127 patients admitted with CCM, only 97 (76.4%) knew their HIV status. Only 44.8% (43/96) of those who knew they were HIV positive were on antiretroviral therapy (ART). Seventeen out of 25 patients (68%) previously treated for CCM had defaulted fluconazole and only 60% (15/25) were on ART. Acute mortality (death within 14 days of CCM diagnosis) was 55.9% (71/127). The median time to death from diagnosis was four days (IQR 2-9). The association between CSF WBC count<20cells/mL and increased risk of death within 14 days was statistically significant (OR 2.2; 95% CI 1.1-4.6, p=0.03). Patients with heavy cryptococcal burden (reported as numerous yeasts seen on microscopy) at diagnosis were three times more likely to die within 14 days of diagnosis of CCM (OR 3.2; 95% CI 0.9-10.7, p=0.06). Even though a CD4 count<100cells/mm(3) was associated with a 1.6 times increased acute mortality risk, the association was not statistically significant (OR 1.6; 95% CI 0.6-4.6, p=0.3). The role of elevated CSF opening pressure at diagnosis was not assessed because only two (1.6%) patients had their baseline opening pressure measured. CONCLUSIONS: Acute CCM-related mortality remains high. The number of patients who do not know their HIV status, the number of HIV positive patients not on ART, the high level of non-adherence to fluconazole and the proportion of patients not on ART after at least one previous CCM episode all point to the need of developing comprehensive strategies aimed at encouraging HIV testing and improving patient's retention in HIV care and support.

Management of cryptococcal meningitis in a district hospital in KwaZulu-Natal: a clinical audit.

BACKGROUND: Despite the development of context-specific guidelines, cryptococcal meningitis (CCM) remains a leading cause of death amongst HIV-infected patients. Results from clinical audits in routine practice have shown critical gaps in clinicians' adherence to recommendations regarding the management of CCM. AIM: The aim of this study was to review the acute management of CCM at an urban district hospital in KwaZulu-Natal, South Africa with a view to making recommendations for improving care. SETTING: An urban district hospital in KwaZulu-Natal, South Africa. METHODS: A retrospective audit was performed on clinical records of all patients (age > 13 years) admitted to the hospital with a diagnosis of CCM between June 2011 and December 2012. RESULTS: Measurement of cerebrospinal fluid opening pressure at initial lumbar puncture (LP) was done rarely and only 23.4% of patients had therapeutic LPs. The majority of patients (117/127; 92.1%) received amphotericin B, however, only 19 of the 117 patients (16.2%) completed the 14-day treatment target. Amphotericin B-toxicity monitoring and prevention was suboptimal; however, in-patient referral for HIV counselling and testing was excellent. CONCLUSIONS: The quality of care of CCM based on selected process criteria showed gaps in routine care at the hospital despite the availability of context-specific guidelines. An action plan for improving care was developed based on stakeholders' feedback. A repeat audit should be conducted in the future in order to evaluate the impact of this plan and to ensure that improvements are sustained.

Diagnosis of left-ventricular non-compaction in patients with left-ventricular systolic dysfunction: time for a reappraisal of diagnostic criteria?

AIMS: Left-ventricular non-compaction (LVNC) is characterized by excessive and prominent left-ventricular (LV) trabeculations and may be associated with systolic dysfunction in advanced disease. We sought to determine the proportion of patients fulfilling LVNC criteria in an adult population referred to a heart failure clinic using current diagnostic criteria. METHODS AND RESULTS: One hundred and ninety-nine patients [age 63.5 +/- 15.9 years, 124 (62.3%) males] with LV systolic impairment were studied. All underwent clinical examination, electrocardiography, and 2-D echocardiography. The number of patients fulfilling diagnostic criteria for LVNC was retrospectively determined using three published definitions. Results were compared with 60 prospectively evaluated normal controls (age 35.7 +/- 13.5 years; 31 males, 30 blacks). Forty-seven patients (23.6%) fulfilled one or more echocardiographic definitions for LVNC. Patients fulfilling LVNC criteria were younger (P = 0.002), had larger LV end-diastolic dimension (P < 0.001), and smaller left atrial size (P = 0.01). LVNC was more common in black individuals (35.5 vs. 16.2%, P = 0.003). Five controls (four blacks) fulfilled one or more LVNC criteria. CONCLUSIONS: This study demonstrates an unexpectedly high percentage of patients with heart failure fulfilling current echocardiographic criteria for LVNC. This might be explained by a hitherto underestimated cause of heart failure, but the comparison with controls suggests that current diagnostic criteria are too sensitive, particularly in black individuals.