Cryptococcus neoformans Meningitis at 2 Hospitals in Washington, D.C.: Adherence of Health Care Providers to Published Practice Guidelines for the Management of Cryptococcal Disease

Shoham, Shmuel; Cover, Cameron; Donegan, Nancy; Fulnecky, Eric J.; Kumar, Princy

doi:10.1086/427213

Cited by 67 publications

(57 citation statements)

References 13 publications

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“…9,10 Deviations in the management of raised ICP were observed in 88% of patients with poor neurological outcome. Aggressive management of raised ICP was associated with an improved outcome.…”

Section: Introductionmentioning

confidence: 99%

A medical audit of the management of cryptococcal meningitis in HIV-positive patients in the Cape Winelands (East) district, Western Cape

Pressentin¹,

Conradie

Mash

2012

South African Family Practice

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. 8 The key concerns were management of CMassociated raised intracranial pressure (ICP), general CM management uncertainties, and follow-up challenges regarding ART and long-term fluconazole adherence. The key recommendations included addressing resource needs (manometers), paying attention to the diagnosis and management of raised ICP, and addressing the need to develop a local CM treatment guideline. AbstractBackground: Cryptococcal meningitis (CM) has become the most common type of community-acquired meningitis. CM has a poor outcome if the initial in-hospital treatment does not adhere to standard guidelines. The aim of this audit was to improve the quality of the care of human immunodeficiency virus (HIV) positive patients with CM in the Cape Winelands District.Method: Following an initial audit in 2008, the researchers and a new audit team introduced interventions, and planned a second audit cycle. The folders of 25 HIV-positive adults (admitted to three district hospitals, one regional hospital, and one tuberculosis hospital) were audited.Results: Spinal manometry was performed more consistently in the regional hospital, than in the district hospitals. Reasons for failing to reach the 14-day amphotericin B target were in-patient deaths, drug stock problems, and renal impairment. The renal monitoring of amphotericin B treatment was suboptimal. The quality of care at district hospitals appeared to be comparable to that found at the regional hospital. The in-patient referral for antiretroviral treatment (ART) counselling was better in the district hospital setting. However, both levels of care had difficulty in achieving the four-week target between the onset of amphotericin B and onset of ART. Conclusion:Deficiencies in the quality of care remained. Between the prior and current audit cycles, there was no consistent improvement in care at the regional hospital. An integrated care pathway document has been developed, and adopted as policy in the Cape Winelands district. Its impact on the quality of care will be evaluated by a dedicated audit team in the future.Peer reviewed.

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Section: Introductionmentioning

confidence: 99%

A medical audit of the management of cryptococcal meningitis in HIV-positive patients in the Cape Winelands (East) district, Western Cape

Pressentin¹,

Conradie

Mash

2012

South African Family Practice

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“…Significant neurological decline can occur if elevated CSF pressures are inadequately managed. 28,29,33,39 Various treatment strategies to address intracranial hypertension in this setting have been described, including medical management, serial lumbar punctures, external lumbar and ventricular drain placement, and either ventricular or lumbar shunting. 26 The literature remains unclear as to when each approach is indicated and how often patients require neurosurgical intervention.…”

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confidence: 99%

Shunting in cryptococcal meningitis

Cherian¹,

Atmar

Gopinath³

2016

JNS

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obJective Patients with cryptococcal meningitis often develop symptomatic intracranial hypertension. The need for permanent CSF diversion in these cases remains unclear. Methods Cases of cryptococcal meningitis over a 5-year period were reviewed from a single, large teaching hospital. Sources of identification included ICD-9 codes, operative logs, and microscopy laboratory records. results Fifty cases of cryptococcal meningitis were identified. Ninety-eight percent (49/50) of patients were HIV positive. Opening pressure on initial lumbar puncture diagnosing cryptococcal meningitis was elevated (> 25 cm H 2 O) in 33 cases and normal (≤ 25 cm H 2 O) in 17 cases. Thirty-eight patients ultimately developed elevated opening pressure over a follow-up period ranging from weeks to years. Serial lumbar punctures for relief of intracranial hypertension were performed in 29 cases. Thirteen of these patients ultimately had shunting procedures performed after failing to improve clinically. Two factors were significantly associated with the need for shunting: patients undergoing shunt placement were more likely to be women (5/13 vs 0/16; p = 0.01) and to have a pattern of increasing CSF cryptococcal antigen (10/13 vs 3/16 cases; p = 0.003). All patients re-presenting with mycological relapse either underwent or were offered shunt placement. coNclusioNs Neurosurgeons are often asked to consider CSF diversion in cases of cryptococcal meningitis complicated by intracranial hypertension. Most patients do well with serial lumbar punctures combined with antifungal therapy. When required, shunting generally provided sustained relief from intracranial hypertension symptoms. Ventriculoperitoneal shunts are the favored method of diversion. To the authors' knowledge, the present study is the largest series on diversionary shunts in primarily HIV-positive patients with this problem.

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“…C. neoformans capsule is considered as the major virulence factor of this intracellular pathogen. The polysaccharide capsule antigen contributes to the virulence by being antiphagocytic among other features that affect the host immune response 1,2 . Cryptococcal meningitis treatment has been primarily focused on optimizing antifungal therapy based on amphotericin B plus fl ucytosine or fl uconazole.…”

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confidence: 99%

Ventriculoperitoneal shunts for treating increased intracranial pressure in cryptococcal meningitis with or without ventriculomegaly

Corti

Priarone

Negroni

et al. 2014

Rev. Soc. Bras. Med. Trop.

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Introduction:Cryptococcosis is an opportunistic mycosis, especially in patients that are human immunodefi ciency virus (HIV)-positive, and frequently involves the central nervous system. Methods: We assessed the potential of ventriculoperitoneal shunting (VPS) in preventing mortality due to uncontrollable intracranial hypertension (ICH) in 15 patients with acquired immunodefi ciency syndrome (AIDS)-related cryptococcal meningitis. Results: After 2 weeks of antifungal therapy consisting of amphotericin B deoxycholate with or without fl uconazole, patients with persistent ICH underwent VPS, despite having persistent Cryptococcus neoformans infection. In 12 patients, the uncontrollable ICH was resolved by VPS. Conclusions: Patients with cryptococcal meningoencephalitis who have ICH must be considered for VPS even with positive cerebrospinal fl uid cultures.

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Cryptococcus neoformans Meningitis at 2 Hospitals in Washington, D.C.: Adherence of Health Care Providers to Published Practice Guidelines for the Management of Cryptococcal Disease

Cited by 67 publications

References 13 publications

A medical audit of the management of cryptococcal meningitis in HIV-positive patients in the Cape Winelands (East) district, Western Cape

A medical audit of the management of cryptococcal meningitis in HIV-positive patients in the Cape Winelands (East) district, Western Cape

Shunting in cryptococcal meningitis

Ventriculoperitoneal shunts for treating increased intracranial pressure in cryptococcal meningitis with or without ventriculomegaly

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