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.

• Authors: Cynthia Ahimbisibwe, Richard Kwizera, Jane Frances Ndyetukira, Florence Kugonza, Alisat Sadiq, Kathy Huppler Hullsiek, Darlisha A Williams, Joshua Rhein, David R Boulware, David B Meya
• Journal: BMC infectious diseases (BMC Infect Dis) Vol. 19 Issue 1 Pg. 558 (Jun 26 2019) ISSN: 1471-2334 [Electronic] England
• PMID: 31242860 (Publication Type: Clinical Trial, Clinical Trial, Phase II, Clinical Trial, Phase III, Journal Article, Multicenter Study, Observational Study, Randomized Controlled Trial)

Chemical References

• Antifungal Agents
• Drug Combinations
• Deoxycholic Acid
• Amphotericin B
• amphotericin B, deoxycholate drug combination

Topics

• AIDS-Related Opportunistic Infections (drug therapy, epidemiology)
• Adult
• Amphotericin B (administration & dosage, adverse effects)
• Antifungal Agents (administration & dosage, adverse effects)
• Deoxycholic Acid (administration & dosage, adverse effects)
• Drug Combinations
• Female
• HIV Infections (complications, drug therapy, epidemiology)
• Health Resources (economics)
• Humans
• Incidence
• Infusions, Intravenous
• Male
• Meningitis, Cryptococcal (complications, drug therapy, epidemiology)
• Phlebitis (chemically induced, epidemiology, therapy)
• Poverty Areas
• Uganda (epidemiology)