Predictors of outcome in routine care for Cryptococcal meningitis in Western Kenya: lessons for HIV outpatient care in resource-limited settings
- Caroline Kendi1,
- Jeremy Penner1,2,
- Julius Koech1,
- Mary Nyonda1,
- Craig R Cohen3,
- Elizabeth A Bukusi1,
- Evelyn Ngugi4,
- Ana-Claire Lew Meyer1,5
- 1Family AIDS Care and Education Services, Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
- 2Department of Family Practice, University of British Columbia, Vancouver, British Columbia, Canada
- 3Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco, San Francisco, California, USA
- 4Division of Global HIV/AIDS Care and Treatment (USA), Centers for Disease Control and Prevention, Nairobi, Kenya
- 5Department of Neurology, San Francisco General Hospital, University of California San Francisco, San Francisco, California, USA
- Correspondence to Dr Ana-Claire Lew Meyer, Department of Neurology, University of California, San Francisco, Visiting Scientist, Research, Care and Training Program, Center for Microbiology Research, Kenya Medical Research Institute, Box 614-40100, Kisumu, Kenya;
- Received 5 February 2012
- Revised 24 September 2012
- Accepted 27 September 2012
- Published Online First 30 October 2012
Purpose Cryptococcal meningitis is a leading cause of mortality among HIV-infected individuals in sub-Saharan Africa but little is known about its treatment and outcomes in decentralised HIV outpatient settings. We assessed adherence to treatment guidelines and determined predictors of survival.
Design A computerised laboratory database identified HIV-infected adults with cryptococcal meningitis at Family AIDS Care and Education Services in Nyanza Province, Kenya, between 2005–2009. Medical records were reviewed. Kaplan-Meier survival curves were generated. Bivariate and multivariate Cox proportional hazards models were used to determine associations between key clinical characteristics and survival.
Results Medical records were located for 79% (71/90). Mortality was 38% (27/71) over a median follow-up period of 201 days (IQR: 10–705 days). Adherence to local guidelines for treatment of cryptococcal meningitis was 48% (34/71). Higher body mass index was associated with improved survival (HR: 0.82, 95% CI (0.68 to 0.99)) even after controlling for factors such as age, CD4 cell count, receipt of highly active anti-retroviral therapy, and treatment with any anti-fungal therapy.
Conclusions Cryptococcal meningitis diagnosed in routine HIV outpatient settings is largely treated as an outpatient and adherence to treatment guidelines is poor. Body mass index is a critical independent predictor of outcome. Additional research to determine the most effective strategies to reduce premature mortality is urgently needed.