Management of amphotericin-induced phlebitis among HIV patients with cryptococcal meningitis in a resource-limited setting: a prospective cohort study

Abstract

Background Amphotericin-induced phlebitis is a common infusion-related reaction in patients managed for cryptococcal meningitis. High-quality nursing care is critical component to successful cryptococcosis treatment. We highlight the magnitude and main approaches in the management of amphotericin-induced phlebitis and the challenges faced in resource-limited settings. Methods We prospectively determined the incidence of amphotericin-induced phlebitis during clinical trials in Kampala, Uganda from 2013 to 2018. We relate practical strategies and challenges faced in clinical management of phlebitis. Results Overall, 696 participants were diagnosed with HIV-related cryptococcal meningitis. Participants received 7–14 doses of intravenous (IV) amphotericin B deoxycholate 0.7–1.0 mg/kg/day for induction therapy through peripheral IV lines at a concentration of 0.1 mg/mL in 5% dextrose. Overall, 18% (125/696) developed amphotericin-induced phlebitis. We used four strategies to minimize/prevent the occurrence of phlebitis. First, after every dose of amphotericin, we gave one liter of intravenous normal saline. Second, we rotated IV catheters every three days. Third, we infused IV amphotericin over 4 h. Finally, early ambulation was encouraged to minimize phlebitis. To alleviate phlebitis symptoms, warm compresses were used. In severe cases, treatment included topical diclofenac gel and oral anti-inflammatory medicines. Antibiotics were used only when definite signs of infection developed. Patient/caregivers’ education was vital in implementing these management strategies. Major challenges included implementing these interventions in participants with altered mental status and limited access to topical and oral anti-inflammatory medicines in resource-limited settings. Conclusions Amphotericin-induced phlebitis is common with amphotericin, yet phlebitis is a preventable complication even in resource-limited settings. Trial registration The ASTRO-CM trial was registered prospectively. ClincalTrials.gov : NCT01802385 ; Registration date: March 1, 2013; Last verified: February 14, 2018.

Rates of refusal of clinical autopsies among HIV-positive decedents and an overview of autopsies in Uganda

“…Clinical trials currently provide a platform for improving outcomes for individuals with HIV in Uganda 17,18 . Therefore, combining post-mortems with clinical studies is one way to increase uptake of autopsies.…”

The acceptability of the AMBITION-cm treatment regimen for HIV-associated cryptococcal meningitis: Findings from a qualitative methods study of participants and researchers in Botswana and Uganda

“…Cryptococcal meningitis has historically been treated with highdose oral fluconazole monotherapy which is widely available but associated with high mortality: over 50% at ten weeks and over 70% within a year [6][7][8][9]. Ten week mortality outcomes can be improved to roughly 40% in clinical trial settings when combining fluconazole with 14 daily doses of intravenous amphotericin B deoxycholate (amphotericin B) [10,11] but this regimen is notoriously toxic and prolonged courses often lead to renal impairment, electrolyte disturbances, anaemia and thrombophlebitis [12,13]. An alternative antifungal, flucytosine, which is given for seven to fourteen days in four daily oral doses has been proven to be superior to fluconazole as a partner drug for amphotericin B [10].…”

Impact of community engagement and social support on the outcomes of HIV-related meningitis clinical trials in a resource-limited setting

“…However, there remains a low index of clinical suspicion for all fungal infections in Uganda [8,9]. Clinical trials provide a platform for improving outcomes for HIV-infected individuals with cryptococcal meningitis [10][11][12][13][14].…”