1439. The Effect of Therapeutic Lumbar Punctures on Acute Mortality from Cryptococcal Meningitis
Session: Poster Abstract Session: Fungal Infections
Saturday, October 5, 2013
Room: The Moscone Center: Poster Hall C
  • Rolfes_Rhein IDSA Poster_Final.pdf (535.4 kB)
  • Background: Individuals with cryptococcal meningitis (CM) typically have elevated intracranial pressure (ICP). Prior studies suggest an association between uncontrolled ICP and mortality, yet few studies of interventions have been conducted. We evaluated the effect of therapeutic lumbar punctures (LPs) on acute mortality after CM diagnosis.

    Methods: 246 individuals in Uganda and South Africa diagnosed with CM and screened for entry into the Cryptococcal Optimal ART Timing (COAT) trial were included. All individuals received: diagnostic LP, two weeks of amphotericin B (0.7-1.0mg/kg/day) plus 800mg/day fluconazole, and therapeutic LPs as needed. Observation began one day after CM diagnosis. Therapeutic LPs were any LP occurring after diagnostic LP. A marginal structural model, pooled Poisson regression with inverse-probability weights, was used to assess the effect of therapeutic LPs on 11-day mortality. Multiple imputation accounted for missing baseline parameters.

    Results: 75 individuals (30%) had at least one therapeutic LP. Those who received therapeutic LPs were more likely to have lower heart rates and mental status, and higher ICP and fungal burden at baseline. Death occurred among 5 of 75 (7%) with a therapeutic LP and among 28 of 171 (16%) without a therapeutic LP. Mortality was associated with greater age, heart rate, and respiratory rate; but not fungal burden or raised ICP. With adjustment for heart rate, weight, mental status, ICP, and fungal burden, the relative risk of mortality was 0.50 (95% CI: 0.17-1.51) in those with compared to without therapeutic LP. This effect did not differ by baseline ICP.

    Conclusion: Current CM treatment guidelines support therapeutic LPs to reduce ICP. Though the effect was non-significant, this analysis suggests a possible survival benefit to undergoing at least one therapeutic LP, regardless of baseline ICP. Further investigation is warranted to evaluate the benefits of therapeutic LPs and optimal ICP control in larger groups of patients.

    Melissa Rolfes, MPH1, Joshua Rhein, MD2, Katherine Huppler Hullsiek, PhD3, Henry Nabeta, MBChB4, Kabanda Taseera5, Charlotte Schutz6, Radha Rajasingham7, Darlisha Williams, MPH8, David Meya4, Conrad Muzoora, MD9, Graeme Meintjes, MD6 and David Boulware, MD, MPH1, (1)University of Minnesota, Minneapolis, MN, (2)Division of Infectious Disease and International Medicine, Department of Medicine, Univ of Minnesota, Minneapolis, MN, (3)Univ. of Minnesota, Minneapolis, MN, (4)Infectious Diseases Institute, Makerere University, Kampala, Uganda, (5)Mbarara University of Science & Technology (MUST), Mbarara, Uganda, (6)University of Cape Town, Cape Town, South Africa, (7)Beth Israel Deaconess Medical Center, Boston, MA, (8)Univ of Minnesota, Minneapolis, MN, (9)Mbarara University of Science and Technology, Mbarara, Uganda


    M. Rolfes, None

    J. Rhein, None

    K. Huppler Hullsiek, None

    H. Nabeta, None

    K. Taseera, None

    C. Schutz, None

    R. Rajasingham, None

    D. Williams, None

    D. Meya, None

    C. Muzoora, None

    G. Meintjes, None

    D. Boulware, None

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