title: Predictors of outcome in routine care for Cryptococcal meningitis in Western Kenya: lessons for HIV outpatient care in resource-limited settings.
abstract: OBJECTIVE
  Cryptococcal meningitis is a leading cause of mortality among HIV-infected individuals in sub-Saharan Africa but little is known about its treatment and outcomes in decentralised HIV outpatient settings. We assessed adherence to treatment guidelines and determined predictors of survival.
  
  
  METHODS
  A computerised laboratory database identified HIV-infected adults with cryptococcal meningitis at Family AIDS Care and Education Services in Nyanza Province, Kenya, between 2005-2009. Medical records were reviewed. Kaplan-Meier survival curves were generated. Bivariate and multivariate Cox proportional hazards models were used to determine associations between key clinical characteristics and survival.
  
  
  RESULTS
  Medical records were located for 79% (71/90). Mortality was 38% (27/71) over a median follow-up period of 201 days (IQR: 10-705 days). Adherence to local guidelines for treatment of cryptococcal meningitis was 48% (34/71). Higher body mass index was associated with improved survival (HR: 0.82, 95% CI (0.68 to 0.99)) even after controlling for factors such as age, CD4 cell count, receipt of highly active anti-retroviral therapy, and treatment with any anti-fungal therapy.
  
  
  CONCLUSIONS
  Cryptococcal meningitis diagnosed in routine HIV outpatient settings is largely treated as an outpatient and adherence to treatment guidelines is poor. Body mass index is a critical independent predictor of outcome. Additional research to determine the most effective strategies to reduce premature mortality is urgently needed.
authors.affiliation: Department of Neurology, University of California, San Francisco, Visiting Scientist, Research, Care and Training Program, Center for Microbiology Research, Kenya Medical Research Institute, Box 614-40100, Kisumu, Kenya.
authors.forename: Caroline
authors.initials: C
authors.lastname: Kendi
authors.forename: Jeremy
authors.initials: J
authors.lastname: Penner
authors.forename: Julius
authors.initials: J
authors.lastname: Koech
authors.forename: Mary
authors.initials: M
authors.lastname: Nyonda
authors.forename: Craig R
authors.initials: CR
authors.lastname: Cohen
authors.forename: Elizabeth A
authors.initials: EA
authors.lastname: Bukusi
authors.forename: Evelyn
authors.initials: E
authors.lastname: Ngugi
authors.forename: Ana-Claire Lew
authors.initials: AC
authors.lastname: Meyer
mesh_terms: D017088:AIDS-Related Opportunistic Infections / Q000150:complications* / Q000188:drug therapy / Q000401:mortality; D000328:Adult; D000367:Age Factors; D000553:Ambulatory Care; D000935:Antifungal Agents / Q000627:therapeutic use*; D023241:Antiretroviral Therapy, Highly Active / Q000379:methods*; D015992:Body Mass Index; D018791:CD4 Lymphocyte Count; D019983:Guideline Adherence; D015658:HIV Infections / Q000150:complications* / Q000188:drug therapy / Q000401:mortality; D006801:Humans; D007630:Kenya; D016919:Meningitis, Cryptococcal / Q000188:drug therapy* / Q000209:etiology / Q000401:mortality; D017410:Practice Guidelines as Topic; D016016:Proportional Hazards Models; D016896:Treatment Outcome
chemical_list: D000935:Antifungal Agents