Análise clínica e de custos do tratamento de pacientes coinfectados com meningite criptocócica e HIV em um Hospital do Nordeste do Brasil

Abstract

Immunocompromised individuals are more susceptible to be infected by fungal infections. Mycoses are not officially notified diseases in Brazil, but data from the Sistema de Infecções Hospitalares do SUS (SIH/SUS) show that 20367 individuals were hospitalized for hospital infections in Brazil. The disease disseminated form occurs when there is a cryptococcal antigen in the serum and fungal blood culture in people with CD4 ≤ 100 cells / µL. Cryptococcal meningitis/HIV co-infection affects 223,000 individuals with 180,000 deaths worldwide. Highly Active Antiretroviral Therapy improves the people living HIV/aids clinical condition, in addition to reducing the cases of cryptococcosis that presented 6,800 cases in the Brazilian population (98.5% CM/HIV.) Chinese link and cerebrospinal fluid culture are the main ones laboratory tests. International guidelines recommend the polyenic schemes associated with 5-FC for seven days. In Health Economics, financial resources are generally scarce and needs are limitless. Costs are classified as direct, indirect and intangible. The aim of this study was to determine direct hospital costs in patients coinfected with CM / HIV treated during the phase of induction of CM in a referral hospital for infectious diseases, at Fortaleza, Ceará, Brazil between 2014 to 2018. Retrospective study of the economic cohort type with evaluation of individuals who were hospitalized with CM/HIV, approved by the HSJ Research Ethics Committee, according to CNS Resolution 466/2012. Patients were divided into two groups. Research composed of 60 individuals. Male gender was predominant in 81.6%, of which 69.9% between 35-44 years old with 55% coming from the capital or metropolitan region. These data reflect a common Public Health scenario among people living HIV/aids, in which the male population is vulnerable to HIV infection. There was growth of C.neoformans in 41 CSF samples. The median T-CD4 + lymphocytes was 44 cells / mm3 (IIQ = 18-112) and the median HIV viral load was 35,319 copies / uL (IIQ = 1,413 - 246,155). Hospitalizations occurred in those who develop the severe form of the disease and have poor CD4 parameters and high viral load. 65% were using ART with an average HIV infection time of 31.9 months. The mean creatinine in males was 1.41mg / dL (0.6-5.4 mg / dL), and in females it was 1.55 mg / dL (0.7-2.3 mg / dL ). In 33.3% of patients, d-AmB was replaced by lipid formulations. 62.9% continued treatment for the next stages of treatment, 34.3% died. There was a higher proportion alive and dead among patients in group 1, than in those in group 2, but no statistical significance. The most revalent total time was 18 days with d-AmB, 6.5 days with l-AmB and 11 days with ABCL. The unavailability of flucytosine in Brazilian market causes treatments more than 14 days in induction phase. Group 1 (d-AmB + fluconazole) had 66.7% of patients and group 2 (1-AmB / ABLC + fluconazole) in 33.3%. Survival was similar between individuals in group 1 and those in group 2 (118.6 days and 74.5 days), respectively for 30 days. Elevated creatinines indicated 52% more chance of dying during hospitalization. Group 1 cost, on average, R$ 86.9 thousand and group 2, R$ 111.4 thousand, as some individuals needed intensive care and 11.86% underwent hemodialysis. The price / milligram of ABLC is cheaper than that of l-AmB, although it requires administration of pre-infusion drugs. The main global health agencies confirm that fungal diseases are a world Public Health problem. Cryptococcosis is the main fungal infection with high mortality rates worldwide, especially in CM/HIV co-infections. The national protocol for cryptococcosis should be reviewed by Public Health Policies based on international scientific article and guidelines. Health decision makers need to review the allocation of available resources to optimize the treatment of systemic mycoses.