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Using amphotericin B for the management of cryptococcal meningitis in a resource-limited setting: the role of a printed daily assessment form
D. Namarika1,2, A. Jackson1,2, J. Phulusa1,2, M. Chikasema1,2, C. Kenyemba2, D. Henke2, R. Hogenschurz1, M. Hosseinipour2
1Kamuzu Central Hospital, Department of Medicine, Lilongwe, Malawi, 2UNC Project, Lilongwe, Malawi
Background: Cryptococcal meningitis (CCM) is a major cause of HIV-related mortality in Malawi, accounting for almost 40% of meningitis cases seen. It carries a mortality approaching 50% at 10 weeks. Until recently oral fluconazole has been the main pharmacotherapy for CCM. Amphotericin B (AMB) is available but has been underused due to perceived difficulties with toxicity and administration. To address this we developed a CCM treatment protocol involving AMB usage in the first week of therapy.
Methods: Our protocol involves 1-week AMB (1mg/kg/day) followed by 1200 mg/day oral fluconazole. We use a printed CCM Management Form which is attached to the notes of patients diagnosed with CCM. The form is filled in daily and serves as a reminder to the clinician for daily assessment of 1) AMB administration, 2) intravenous fluid/potassium administration, 3) LP requirement, 4) blood monitoring requirement. CSF pressures and blood results are recorded on the form.
Ward files and laboratory records were analysed retrospectively for outcomes and adverse events.
Results: The CCM management form was made available from Jan 29th, 2009. To date (February 25th) 18 CCM cases (44% male) have been treated in Kamuzu Central Hospital. No adverse events resulted in early discontinuation of AMB. Significant hypokalaemia was seen in 3 cases (17%). There have been 3 in-hospital deaths (17%). Outcome data for 1 patient was missing.
Initial implementation difficulties involved low staff awareness of the forms, missing of scheduled blood draws and omission of supplemental potassium doses. This has improved with ongoing staff education.
Conclusions: Administration of AMB for 1 week is feasible at central hospital level in Malawi with the aid of a printed management form. This simple measure may improve the delivery of medical care to a vulnerable group. An ongoing register will assess the overall effect that this will have on mortality and morbidity.
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