title: Treatment of cryptococcal meningitis in KwaZulu-Natal, South Africa.
abstract: BACKGROUND
  Cryptococcal meningitis (CM) remains a leading cause of death for HIV-infected individuals in sub-Saharan Africa. Improved treatment strategies are needed if individuals are to benefit from the increasing availability of antiretroviral therapy. We investigated the factors associated with mortality in routine care in KwaZulu-Natal, South Africa.
  
  
  RESULTS
  A prospective year long, single-center, consecutive case series of individuals diagnosed with cryptococcal meningitis 190 patients were diagnosed with culture positive cryptococcal meningitis, of whom 186 were included in the study. 52/186 (28.0%) patients died within 14 days of diagnosis and 60/186 (32.3%) had died by day 28. In multivariable cox regression analysis, focal neurology (aHR 11 95%C.I. 3.08-39.3, P<0.001), diastolic blood pressure<60 mmHg (aHR 2.37 95%C.I. 1.11-5.04, P=0.025), concurrent treatment for tuberculosis (aHR 2.11 95%C.I. 1.02-4.35, P=0.044) and use of fluconazole monotherapy (aHR 3.69 95% C.I. 1.74-7.85, P<0.001) were associated with increased mortality at 14 and 28 days.
  
  
  CONCLUSIONS
  Even in a setting where amphotericin B is available, mortality from cryptococcal meningitis in this setting is high, particularly in the immediate period after diagnosis. This highlights the still unmet need not only for earlier diagnosis of HIV and timely access to treatment of opportunistic infections, but for better treatment strategies of cryptococcal meningitis.
authors.affiliation: Ngwelezane Hospital, Empangeni, KwaZulu-Natal, South Africa.
authors.forename: Josephine V J
authors.initials: JV
authors.lastname: Lightowler
authors.forename: Graham S
authors.initials: GS
authors.lastname: Cooke
authors.forename: Portia
authors.initials: P
authors.lastname: Mutevedzi
authors.forename: Richard J
authors.initials: RJ
authors.lastname: Lessells
authors.forename: Marie-Louise
authors.initials: ML
authors.lastname: Newell
authors.forename: Martin
authors.initials: M
authors.lastname: Dedicoat
mesh_terms: D000328:Adult; D000666:Amphotericin B / Q000627:therapeutic use*; D000935:Antifungal Agents / Q000627:therapeutic use*; D005260:Female; D015725:Fluconazole / Q000627:therapeutic use*; D006801:Humans; D008297:Male; D016919:Meningitis, Cryptococcal / Q000188:drug therapy*; D011446:Prospective Studies; D013019:South Africa; D016019:Survival Analysis
chemical_list: D000935:Antifungal Agents; D000666:Amphotericin B; D015725:Fluconazole