*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.
J Acquir Immune Defic Syndr. 2014 Jun 1;66(2):e31-6. doi: 10.1097/QAI.0000000000000147.
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.
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.
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].
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.
在低收入国家，艾滋病毒感染者中隐球菌性脑膜炎（CM）的死亡率约为 70%。控制颅内压（ICP）在 CM 中至关重要，但在低收入国家这很困难，因为缺乏压力计和实用的 ICP 管理方案。
作为持续质量改进项目的一部分，我们的坦桑尼亚医院为 CM 的 ICP 管理启动了一个新方案。所有成人 CM 住院患者都被纳入前瞻性患者登记册。在分析时，该登记册包括该新 ICP 管理方案启动前 2 年和启动后 9 个月的数据。通过压力计和静脉（IV）管套件在基线和第 3、7 和 14 天测量 ICP。所有患者均根据坦桑尼亚治疗指南给予 IV 氟康唑，并随访至入院后 30 天。
在成人 CM 住院患者中，35 例患者中有 32 例（91%）入院时 ICP 升高。使用改良 IV 管套件进行的脑脊液压力测量与压力计测量具有极好的一致性（r = 0.96）。与历史对照相比，新的 ICP 管理方案与 30 天死亡率的显著降低相关（新方案组：16/35 [46%] vs. 历史对照组：48/64 [75%]；危险比=2.1 [95%CI：1.1 至 3.8]；P = 0.018）。
在坦桑尼亚，艾滋病毒感染者因 CM 入院时几乎普遍存在 ICP 升高。与历史对照相比，采用严格的多次腰椎穿刺方案进行强化 ICP 管理可降低住院死亡率。在没有压力计的资源有限的卫生设施中，IV 管套件的 ICP 测量可能是一种很好的替代方法。
