Simple but effective management of raised intracranial pressure in cryptococcal meningitis

Cryptococcal meningitis management in Tanzania with strict schedule of serial lumbar punctures using intravenous tubing sets: an operational research study.

Meda J, Kalluvya S, Downs JA, Chofle AA, Seni J, Kidenya B, Fitzgerald DW, Peck RN. J Acquir Immune Defic Syndr. 2014 Jun 1;66(2):e31-6. doi: 10.1097/QAI.0000000000000147.

Background: Cryptococcal meningitis (CM) has a mortality rate of approximately 70% among HIV-infected adults in low-income countries. Controlling intracranial pressure (ICP) is essential in CM, but it is difficult in low-income countries because manometers and practical ICP management protocols are lacking.

Methods: As part of a continuous quality improvement project, our Tanzanian hospital initiated a new protocol for ICP management for CM. All adult inpatients with CM are included in a prospective patient registry. At the time of analysis, this registry included data from 2 years before the initiation of this new ICP management protocol and for a 9-month period after. ICP was measured at baseline and at days 3, 7, and 14 by both manometer and intravenous (IV) tubing set. All patients were given IV fluconazole according to Tanzanian treatment guidelines and were followed until 30 days after admission.

Results: Among adult inpatients with CM, 32 of 35 patients (91%) had elevated ICP on admission. Cerebrospinal fluid pressure measurements using the improvised IV tubing set demonstrated excellent agreement (r = 0.96) with manometer measurements. Compared with historical controls, the new ICP management protocol was associated with a significant reduction in 30-day mortality (16/35 [46%] vs. 48/64 [75%] in historical controls; hazard ratio = 2.1 [95% CI: 1.1 to 3.8]; P = 0.018].

Conclusions: Increased ICP is almost universal among HIV-infected adults admitted with CM in Tanzania. Intensive ICP management with a strict schedule of serial lumbar punctures reduced in-hospital mortality compared with historical controls. ICP measurement with IV tubing sets may be a good alternative in resource-limited health facilities where manometers are not available.

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Editor’s notes: Cryptococcal meningitis remains an important cause of morbidity and mortality among people with advanced HIV disease. Management is difficult in resource-limited settings. This is in part because optimal drug treatments are often not accessible, but also because of increased intracranial pressure, which may require repeated lumbar puncture. This should be done ideally using specialist equipment to measure intracranial pressure. This operational research study from United Republic of Tanzania illustrates the effectiveness of a standardised management protocol to manage intracranial pressure, using equipment which is widely available in resource-constrained settings. The simplified equipment produced pressure measurements which agreed well with measures from the “gold standard” manometer, and people managed according to this protocol experienced lower mortality than historical controls. However, mortality was still higher than would be expected in industrialised countries, illustrating the need for improved access to more effective antifungal drugs. 

Avoid TB deaths
Comorbidity, HIV Treatment
Africa
United Republic of Tanzania
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