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Cryptococcal Meningitis Management in Tanzania With Strict Schedule of Serial Lumber Punctures Using Intravenous Tubing Sets: An Operational Research Study

Meda, John MD*; Kalluvya, Samuel MD†,‡; Downs, Jennifer A. MD†,‡,§; Chofle, Awilly A. MD; Seni, Jeremiah MD; Kidenya, Benson MD#; Fitzgerald, Daniel W. MD§; Peck, Robert N. MD†,‡,§

JAIDS Journal of Acquired Immune Deficiency Syndromes: June 1st, 2014 - Volume 66 - Issue 2 - p e31–e36
doi: 10.1097/QAI.0000000000000147
Implementation and Operational Research: Clinical Science
IOR articles

Background: Cryptococcal meningitis (CM) has a mortality rate of ∼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 (r2 = 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.

*Department of Internal Medicine, Dodoma University, Dodoma, Tanzania;

Department of Internal Medicine, Bugando Medical Centre, Mwanza, Tanzania;

Department of Internal Medicine, Weill Bugando School of Medicine, Mwanza, Tanzania;

§Department of Medicine, Center for Global Health, Weill Cornell Medical College, New York, NY;

Department of Internal Medicine, Muhimbili National Hospital, Dar-es-Salaam, Tanzania; and

Departments of Microbiology;

#Biochemistry, Catholic University of Health and Allied Sciences—Bugando, Mwanza, Tanzania.

Correspondence to: Robert N. Peck, MD, Department of Medicine, Weill Bugando School of Medicine, PO Box 5034, Mwanza, Tanzania (e-mail: rnp2002@gmail.com).

Supported by a research grant from the University of Dodoma College of Health Sciences to J.M. and by grants from the National Institutes of Health Fogarty Foundation (TW000018) and the National Institute of Allergy and Infectious Diseases (K24 AI098627).

The authors have no conflicts of interest to disclose.

Received November 26, 2013

Accepted January 31, 2014

© 2014 by Lippincott Williams & Wilkins