Infectious Diseases Unit, GF Jooste Hospital, Cape Town, South Africa.
S Afr Med J. 2010 Jun;100(6):378-82. doi: 10.7196/samj.3515.
Cryptococcal meningitis is the commonest cause of adult meningitis in Southern Africa. A sizeable proportion of this disease burden is thought to be due to symptomatic relapse of previously treated infection. We carried out a study to examine the contribution of inadequate secondary fluconazole prophylaxis to symptomatic relapses of cryptococcal meningitis.
A prospective observational study of patients presenting with laboratory-confirmed symptomatic relapse of HIV-associated cryptococcal meningitis between January 2007 and December 2008 at GF Jooste Hospital, a public sector adult referral hospital in Cape Town.
Relapse episodes were categorized into 1) patients not taking fluconazole prophylaxis, 2) immune reconstitution inflammatory syndrome (IRIS) and 3) relapses occurring prior to ART in patients taking fluconazole. In-hospital mortality was recorded.
There were 69 relapse episodes, accounting for 23% of all cases of cryptococcal meningitis. 43%(n=30) of relapse episodes were in patients not taking fluconazole prophylaxis, 45%(31) were due to IRIS and 12%(8) were in patients pre-ART taking fluconazole. Patients developing relapse due to inadequate secondary prophylaxis had severe disease and high in-hospital mortality (33%). Of the 30 patients not taking fluconazole, 47% (14) had not been prescribed secondary prophylaxis by their healthcare providers. Importantly, we documented no relapses due to fluconazole resistance in this cohort of patients who has received amphotericin B as initial therapy.
Large numbers of relapses of cryptococcal meningitis are due to failed prescription, dispensing, referral for or adherence to secondary fluconazole prophylaxis. Interventions to improve the use of secondary fluconazole prophylaxis are essential.
隐球菌性脑膜炎是南部非洲成人脑膜炎的最常见病因。据认为，这种疾病负担的相当一部分是由于以前治疗过的感染出现症状性复发。我们进行了一项研究，以检查氟康唑二级预防不足对隐球菌性脑膜炎症状性复发的贡献。
对 2007 年 1 月至 2008 年 12 月在开普敦 GF Jooste 医院就诊的实验室确诊的 HIV 相关性隐球菌性脑膜炎症状性复发的患者进行前瞻性观察性研究。
复发发作分为 1）未服用氟康唑预防的患者，2）免疫重建炎症综合征（IRIS）和 3）服用氟康唑的患者在开始 ART 之前发生的复发。记录院内死亡率。
有 69 例复发发作，占隐球菌性脑膜炎总病例的 23%。43%（n=30）的复发发作发生在未服用氟康唑预防的患者中，45%（31）是由于 IRIS，12%（8）是在开始 ART 前服用氟康唑的患者中。由于二级预防不足导致复发的患者病情严重，院内死亡率高（33%）。在未服用氟康唑的 30 名患者中，47%（14）的患者未按其医疗保健提供者的建议开具二级预防处方。重要的是，我们在接受两性霉素 B 作为初始治疗的这组患者中没有记录到因氟康唑耐药而导致的复发。
大量的隐球菌性脑膜炎复发是由于预防、配药、转诊或二级氟康唑预防的坚持使用失败所致。改善二级氟康唑预防使用的干预措施至关重要。
