649. Assessment of Adherence to IDSA Guidelines for Management of Cryptococcal Meningitis (CM): Does It Affect Outcome?
Session: Abstracts: Mycology
Friday, October 22, 2010
Background:

Performance measures and adherence to guidelines is increasingly emphasized but impact on clinical outcomes has not been extensively evaluated.  In 2000 and 2010, IDSA guidelines for management of CM emphasized use of polyenes for induction therapy and management of elevated intracranial pressure (ICP). We assessed correlation of adherence to management guidelines with clinical outcome. 

Methods:

We reviewed records of patients at a University hospital with AIDS and CM from 2000-2009. Demographics including length of stay, mortality, and clinical outcomes were reviewed. Major criteria for adherence (A) to guideline management included pre-treatment LP with opening pressure (OP), measures to reduce OP >25 cm water and induction therapy with a polyene. Minor deviations from guidelines were considered a lack of an initial head CT and repeat LP at 2 weeks.  Any major deviation was considered non-adherence (NA) to guidelines. Outcome measures were CNS complications and mortality.

Results:

Records of 44 patients with AIDS and CSF culture proven CM were reviewed.  Twenty-one (47%) were managed with adherence (A) to guidelines.  Of the 23 with NA management, 8/23 (35%) did not have an OP measured on initial LP, 5/23 (22%) had no serial LP to reduce OP, 11/23 (48%) did not receive polyene induction therapy.  Notably, 7/8  patients with no initial OP obtained underwent LP in the ED.  Minor deviations from guidelines included failure to obtain a repeat LP at 2 weeks for microbiologic cure in 31/44 (70%).  Significantly more CNS complications were seen in the NA vs A group (65% vs 29%, p=0.0139).  Elevated OPs (>25 cm) were seen in 21/44 patients and serial lumbar punctures to reduce pressures occurred in 18/21 (78%).  There were no differences in LOS (p=0.45) and no patient died at 2 weeks.  At 6 month follow-up, only 1(4.8%) patient in the adherent group relapsed and 3(13%) in the NA group. Two patients in NA group developed IRIS vs 1 in A group at 6 months followup.

Conclusion:

Outcomes in our patients with CM were good with no mortality at 2 weeks, likely relating to aggressive management of increased ICP. Adherence to performance guidelines including management of ICP and induction with a polyene regimen significantly reduced central nervous system complications.


Subject Category: M. Mycology including clinical and basic studies of fungal infections

Speakers:
Mariejane Braza, MD , Medicine/Infectious Diseases, University of Texas Health Science Center at San Antonio and South Texas Veterans Health Care System, San Antonio, TX
John R. Graybill, MD , Medicine/Infectious Diseases, University of Texas Health Science Center at San Antonio, San Antonio, TX
Thomas F. Patterson, MD , Medicine/Infectious Diseases, University of Texas Health Science Center at San Antonio and South Texas Veterans Health Care System, San Antonio, TX
Elizabeth Walter, MD , Medicine/Infectious Diseases, University of Texas Health Science Center at San Antonio and South Texas Veterans Health Care System, San Antonio, TX

Disclosures:

M. Braza, None

J. R. Graybill, Yes
Merck, Shering: Speaker's Bureau,

T. F. Patterson, Yes
Pfizer: Grant Investigator and Scientific Advisor,
Merck: Grant Investigator,
Basilea: Consultant, Grant Investigator and Scientific Advisor,

E. Walter, None

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