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Ponatshego PL, Lawrence DS, Youssouf N, Molloy SF, Alufandika M, Bango F, Boulware DR, Chawinga C, Dziwani E, Gondwe E, Hlupeni A, Hosseinipour MC, Kanyama C, Meya DB, Mosepele M, Muthoga C, Muzoora CK, Mwandumba H, Ndhlovu CE, Rajasingham R, Sayed S, Shamu S, Tsholo K, Tugume L, Williams D, Maheswaran H, Shiri T, Boyer-Chammard T, Loyse A, Chen T, Wang D, Lortholary O, Lalloo DG, Meintjes G, Jaffar S, Harrison TS, Jarvis JN, Niessen LW. AMBIsome Therapy Induction OptimisatioN (AMBITION): High dose AmBisome for cryptococcal meningitis induction therapy in sub-Saharan Africa: economic evaluation protocol for a randomised controlled trial-based equivalence study. BMJ Open 2019; 9:e026288. [PMID: 30940760 PMCID: PMC6500286 DOI: 10.1136/bmjopen-2018-026288] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Cryptococcal meningitis is responsible for around 15% of all HIV-related deaths globally. Conventional treatment courses with amphotericin B require prolonged hospitalisation and are associated with multiple toxicities and poor outcomes. A phase II study has shown that a single high dose of liposomal amphotericin may be comparable to standard treatment. We propose a phase III clinical endpoint trial comparing single, high-dose liposomal amphotericin with the WHO recommended first-line treatment at six sites across five counties. An economic analysis is essential to support wide-scale implementation. METHODS AND ANALYSIS Country-specific economic evaluation tools will be developed across the five country settings. Details of patient and household out-of-pocket expenses and any catastrophic healthcare expenditure incurred will be collected via interviews from trial patients. Health service patient costs and related household expenditure in both arms will be compared over the trial period in a probabilistic approach, using Monte Carlo bootstrapping methods. Costing information and number of life-years survived will be used as the input to a decision-analytic model to assess the cost-effectiveness of a single, high-dose liposomal amphotericin to the standard treatment. In addition, these results will be compared with a historical cohort from another clinical trial. ETHICS AND DISSEMINATION The AMBIsome Therapy Induction OptimisatioN (AMBITION) trial has been evaluated and approved by the London School of Hygiene and Tropical Medicine, University of Botswana, Malawi National Health Sciences, University of Cape Town, Mulago Hospital and Zimbabwe Medical Research Council research ethics committees. All participants will provide written informed consent or if lacking capacity will have consent provided by a proxy. The findings of this economic analysis, part of the AMBITION trial, will be disseminated through peer-reviewed publications and at international and country-level policy meetings. TRIAL REGISTRATION ISRCTN 7250 9687; Pre-results.
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Affiliation(s)
| | - David Stephen Lawrence
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
| | - Nabila Youssouf
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
| | - Sile F Molloy
- Research Centre for Infection and Immunity, St. George's University of London, London, UK
| | - Melanie Alufandika
- Malawi-Liverpool-Wellcome Trust Clinical Research Centre, Blantyre, Malawi
| | - Funeka Bango
- Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - David R Boulware
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
- Department of Medicine, University of Minnesota, Minnesota, USA
| | | | - Eltas Dziwani
- Malawi-Liverpool-Wellcome Trust Clinical Research Centre, Blantyre, Malawi
| | - Ebbie Gondwe
- Malawi-Liverpool-Wellcome Trust Clinical Research Centre, Blantyre, Malawi
| | - Admire Hlupeni
- Department of Medicine, University of Zimbabwe, Harare, Zimbabwe
| | | | - Cecilia Kanyama
- Lilongwe Medical Relief Trust (UNC Project), Lilongwe, Malawi
| | - David B Meya
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Mosepele Mosepele
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
- Department of Internal Medicine, University of Botswana, Gaborone, Botswana
| | - Charles Muthoga
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Conrad K Muzoora
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Henry Mwandumba
- Malawi-Liverpool-Wellcome Trust Clinical Research Centre, Blantyre, Malawi
- Department of Clinical Sciences and International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | | | | | - Sumaya Sayed
- Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Shepherd Shamu
- Department of Medicine, University of Zimbabwe, Harare, Zimbabwe
| | - Katlego Tsholo
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Lillian Tugume
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Darlisha Williams
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
- Department of Medicine, University of Minnesota, Minnesota, USA
| | - Hendramoorthy Maheswaran
- Malawi-Liverpool-Wellcome Trust Clinical Research Centre, Blantyre, Malawi
- Population Evidence and Technologies, University of Warwick, Coventry, UK
| | - Tinevimbo Shiri
- Department of Clinical Sciences and International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Timothée Boyer-Chammard
- Molecular Mycology Unit and National Reference Centre for Invasive Mycoses, Institut Pasteur, Paris, France
| | - Angela Loyse
- Research Centre for Infection and Immunity, St. George's University of London, London, UK
| | - Tao Chen
- Department of Clinical Sciences and International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Duolao Wang
- Department of Clinical Sciences and International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Olivier Lortholary
- Molecular Mycology Unit and National Reference Centre for Invasive Mycoses, Institut Pasteur, Paris, France
| | - David G Lalloo
- Malawi-Liverpool-Wellcome Trust Clinical Research Centre, Blantyre, Malawi
- Department of Clinical Sciences and International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Graeme Meintjes
- Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Shabbar Jaffar
- Department of Clinical Sciences and International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Thomas S Harrison
- Research Centre for Infection and Immunity, St. George's University of London, London, UK
| | - Joseph N Jarvis
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
| | - Louis Wilhelmus Niessen
- Department of Clinical Sciences and International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
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Le T, Ly VT, Thu NTM, Nguyen A, Thanh NT, Chau NVV, Thwaites G, Perfect J, Kolamunnage-Dona R, Hope W. Population Pharmacodynamics of Amphotericin B Deoxycholate for Disseminated Infection Caused by Talaromyces marneffei. Antimicrob Agents Chemother 2019; 63:e01739-18. [PMID: 30420478 PMCID: PMC6355582 DOI: 10.1128/aac.01739-18] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2018] [Accepted: 11/01/2018] [Indexed: 02/07/2023] Open
Abstract
Amphotericin B deoxycholate (DAmB) is a first-line agent for the initial treatment of talaromycosis. However, little is known about the population pharmacokinetics and pharmacodynamics of DAmB for talaromycosis. Pharmacokinetic data were obtained from 78 patients; among them, 55 patients had serial fungal CFU counts in blood also available for analysis. A population pharmacokinetic-pharmacodynamic model was fitted to the data. The relationships between the area under the concentration-time curve (AUC)/MIC and the time to blood culture sterilization and the time to death were investigated. There was only modest pharmacokinetic variability in the average AUC, with a mean ± standard deviation of 11.51 ± 3.39 mg·h/liter. The maximal rate of drug-induced kill was 0.133 log10 CFU/ml/h, and the plasma concentration of the DAmB that induced the half-maximal rate of kill was 0.02 mg/liter. Fifty percent of patients sterilized their bloodstreams by 83.16 h (range, 13 to 264 h). A higher initial fungal burden was associated with a longer time to sterilization (hazard ratio [HR], 0.51; 95% confidence interval [CI], 0.36 to 0.70; P < 0.001). There was a weak relationship between AUC/MIC and the time to sterilization, although this did not reach statistical significance (HR, 1.03; 95% CI, 1.00 to 1.06, P = 0.091). Furthermore, there was no relationship between the AUC/MIC and time to death (HR, 0.97; 95% CI, 0.88 to 1.08; P = 0.607) or early fungicidal activity {slope = log[(0.500 - 0.003·(AUC/MIC)]; P = 0.319} adjusted for the initial fungal burden. The population pharmacokinetics of DAmB are surprisingly consistent. The time to sterilization of the bloodstream may be a useful pharmacodynamic endpoint for future studies. (This study has been registered at the ISRCTN registry under no. ISRCTN59144167.).
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Affiliation(s)
- Thuy Le
- Division of Infectious Diseases and International Health, Duke University School of Medicine, Durham, North Carolina, USA
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Vo Trieu Ly
- Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
- University of Medicine and Pharmacy, Ho Chi Minh City, Vietnam
| | - Nguyen Thi Mai Thu
- Division of Infectious Diseases and International Health, Duke University School of Medicine, Durham, North Carolina, USA
| | - Ashley Nguyen
- University of Houston College of Pharmacy, Houston, Texas, USA
| | - Nguyen Tat Thanh
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | | | - Guy Thwaites
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - John Perfect
- Division of Infectious Diseases and International Health, Duke University School of Medicine, Durham, North Carolina, USA
| | - Ruwanthi Kolamunnage-Dona
- Department of Biostatistics, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - William Hope
- Antimicrobial Pharmacodynamics and Therapeutics, Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
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Le T, Ly VT, Thu NTM, Nguyen A, Thanh NT, Chau NVV, Thwaites G, Perfect J, Kolamunnage-Dona R, Hope W. Population Pharmacodynamics of Amphotericin B Deoxycholate for Disseminated Infection Caused by
Talaromyces marneffei. Antimicrob Agents Chemother 2019; 63. [DOI: https:/doi.org/10.1128/aac.01739-18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2018] [Accepted: 11/01/2018] [Indexed: 05/14/2024] Open
Abstract
Amphotericin B deoxycholate (DAmB) is a first-line agent for the initial treatment of talaromycosis. However, little is known about the population pharmacokinetics and pharmacodynamics of DAmB for talaromycosis.
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Affiliation(s)
- Thuy Le
- Division of Infectious Diseases and International Health, Duke University School of Medicine, Durham, North Carolina, USA
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Vo Trieu Ly
- Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
- University of Medicine and Pharmacy, Ho Chi Minh City, Vietnam
| | - Nguyen Thi Mai Thu
- Division of Infectious Diseases and International Health, Duke University School of Medicine, Durham, North Carolina, USA
| | - Ashley Nguyen
- University of Houston College of Pharmacy, Houston, Texas, USA
| | - Nguyen Tat Thanh
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | | | - Guy Thwaites
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - John Perfect
- Division of Infectious Diseases and International Health, Duke University School of Medicine, Durham, North Carolina, USA
| | - Ruwanthi Kolamunnage-Dona
- Department of Biostatistics, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - William Hope
- Antimicrobial Pharmacodynamics and Therapeutics, Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
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Lawrence DS, Youssouf N, Molloy SLF, Alanio A, Alufandika M, Boulware DR, Boyer-Chammard T, Chen T, Dromer F, Hlupeni A, Hope W, Hosseinipour MC, Kanyama C, Lortholary O, Loyse A, Meya DB, Mosepele M, Muzoora C, Mwandumba HC, Ndhlovu CE, Niessen L, Schutz C, Stott KE, Wang D, Lalloo DG, Meintjes G, Jaffar S, Harrison TS, Jarvis JN. AMBIsome Therapy Induction OptimisatioN (AMBITION): High Dose AmBisome for Cryptococcal Meningitis Induction Therapy in sub-Saharan Africa: Study Protocol for a Phase 3 Randomised Controlled Non-Inferiority Trial. Trials 2018; 19:649. [PMID: 30470259 PMCID: PMC6251219 DOI: 10.1186/s13063-018-3026-4] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 10/29/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cryptococcal meningitis (CM) is a major cause of mortality in HIV programmes in Africa despite increasing access to antiretroviral therapy (ART). Mortality is driven in part by limited availability of amphotericin-based treatment, drug-induced toxicities of amphotericin B deoxycholate and prolonged hospital admissions. A single, high-dose of liposomal amphotericin (L-AmB, Ambisome) on a fluconazole backbone has been reported as non-inferior to 14 days of standard dose L-AmB in reducing fungal burden. This trial examines whether single, high-dose L-AmB given with high-dose fluconazole and flucytosine is non-inferior to a seven-day course of amphotericin B deoxycholate plus flucytosine (the current World Health Organization [WHO] recommended treatment regimen). METHODS An open-label phase III randomised controlled non-inferiority trial conducted in five countries in sub-Saharan Africa: Botswana, Malawi, South Africa, Uganda and Zimbabwe. The trial will compare CM induction therapy with (1) a single dose (10 mg/kg) of L-AmB given with 14 days of fluconazole (1200 mg/day) and flucytosine (100 mg/kg/day) to (2) seven days amphotericin B deoxycholate (1 mg/kg/day) given alongside seven days of flucytosine (100 mg/kg/day) followed by seven days of fluconazole (1200 mg/day). The primary endpoint is all-cause mortality at ten weeks with a non-inferiority margin of 10% and 90% power. Secondary endpoints are early fungicidal activity, proportion of grade III/IV adverse events, pharmacokinetic parameters and pharmacokinetic/pharmacodynamic associations, health service costs, all-cause mortality within the first two and four weeks, all-cause mortality within the first ten weeks (superiority analysis) and rates of CM relapse, immune reconstitution inflammatory syndrome and disability at ten weeks. A total of 850 patients aged ≥ 18 years with a first episode of HIV-associated CM will be enrolled (425 randomised to each arm). All patients will be followed for 16 weeks. All patients will receive consolidation therapy with fluconazole 800 mg/day to complete ten weeks of treatment, followed by fluconazole maintenance and ART as per local guidance. DISCUSSION A safe, sustainable and easy to administer regimen of L-AmB that is non-inferior to seven days of daily amphotericin B deoxycholate therapy may reduce the number of adverse events seen in patients treated with amphotericin B deoxycholate and shorten hospital admissions, providing a highly favourable and implementable alternative to the current WHO recommended first-line treatment. TRIAL REGISTRATION ISRCTN, ISRCTN72509687 . Registered on 13 July 2017.
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Affiliation(s)
- David S. Lawrence
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Nabila Youssouf
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Síle L. F. Molloy
- Research Centre for Infection and Immunity, St George’s University of London, London, UK
| | - Alexandre Alanio
- Molecular Mycology Unit and National Reference Centre for Invasive Mycoses, Institut Pasteur, Paris, France
| | - Melanie Alufandika
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi
| | - David R. Boulware
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
- Department of Medicine, University of Minnesota, Minneapolis, MN USA
| | - Timothée Boyer-Chammard
- Molecular Mycology Unit and National Reference Centre for Invasive Mycoses, Institut Pasteur, Paris, France
| | - Tao Chen
- Department of Clinical Sciences and International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Francoise Dromer
- Molecular Mycology Unit and National Reference Centre for Invasive Mycoses, Institut Pasteur, Paris, France
| | - Admire Hlupeni
- Department of Medicine, University of Zimbabwe College of Health Sciences, Parirenyatwa Hospital, Harare, Zimbabwe
| | - William Hope
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | | | - Cecilia Kanyama
- Lilongwe Medical Relief Trust (UNC Project), Lilongwe, Malawi
| | - Oliver Lortholary
- Molecular Mycology Unit and National Reference Centre for Invasive Mycoses, Institut Pasteur, Paris, France
| | - Angela Loyse
- Research Centre for Infection and Immunity, St George’s University of London, London, UK
| | - David B. Meya
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Mosepele Mosepele
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
- Department of Internal Medicine, University of Botswana, Gaborone, Botswana
| | - Conrad Muzoora
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Henry C. Mwandumba
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi
- Department of Clinical Sciences and International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Chiratidzo E. Ndhlovu
- Department of Medicine, University of Zimbabwe College of Health Sciences, Parirenyatwa Hospital, Harare, Zimbabwe
| | - Louis Niessen
- Department of Clinical Sciences and International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Charlotte Schutz
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, and Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Katharine E. Stott
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Duolao Wang
- Department of Clinical Sciences and International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - David G. Lalloo
- Department of Clinical Sciences and International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Graeme Meintjes
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, and Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Shabbar Jaffar
- Department of Clinical Sciences and International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Thomas S. Harrison
- Research Centre for Infection and Immunity, St George’s University of London, London, UK
| | - Joseph N. Jarvis
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
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Patel RKK, Leeme T, Azzo C, Tlhako N, Tsholo K, Tawanana EO, Molefi M, Mosepele M, Lawrence DS, Mokomane M, Tenforde MW, Jarvis JN. High Mortality in HIV-Associated Cryptococcal Meningitis Patients Treated With Amphotericin B-Based Therapy Under Routine Care Conditions in Africa. Open Forum Infect Dis 2018; 5:ofy267. [PMID: 30488038 PMCID: PMC6251350 DOI: 10.1093/ofid/ofy267] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 10/22/2018] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Cryptococcal meningitis (CM) causes 10%-20% of HIV-related deaths in Africa. Due to limited access to liposomal amphotericin and flucytosine, most African treatment guidelines recommend amphotericin B deoxycholate (AmB-d) plus high-dose fluconazole; outcomes with this treatment regimen in routine care settings have not been well described. METHODS Electronic national death registry data and computerized medical records were used to retrospectively collect demographic, laboratory, and 1-year outcome data from all patients with CM between 2012 and 2014 at Botswana's main referral hospital, when recommended treatment for CM was AmB-d 1 mg/kg/d plus fluconazole 800 mg/d for 14 days. Cumulative survival was estimated at 2 weeks, 10 weeks, and 1 year. RESULTS There were 283 episodes of CM among 236 individuals; 69% (163/236) were male, and the median age was 36 years. All patients were HIV-infected, with a median CD4 count of 39 cells/mm3. Two hundred fifteen person-years of follow-up data were captured for the 236 CM patients. Complete outcome data were available for 233 patients (99%) at 2 weeks, 224 patients (95%) at 10 weeks, and 219 patients (93%) at 1 year. Cumulative mortality was 26% (95% confidence interval [CI], 20%-32%) at 2 weeks, 50% (95% CI, 43%-57%) at 10 weeks, and 65% (95% CI, 58%-71%) at 1 year. CONCLUSIONS Mortality rates following HIV-associated CM treated with AmB-d and fluconazole in a routine health care setting in Botswana were very high. The findings highlight the inadequacies of current antifungal treatments for HIV-associated CM and underscore the difficulties of administering and monitoring intravenous amphotericin B deoxycholate therapy in resource-poor settings.
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Affiliation(s)
- Raju K K Patel
- Botswana–University of Pennsylvania Partnership, Gaborone, Botswana
| | - Tshepo Leeme
- Botswana–University of Pennsylvania Partnership, Gaborone, Botswana
| | - Caitlin Azzo
- Botswana–University of Pennsylvania Partnership, Gaborone, Botswana
| | - Nametso Tlhako
- Botswana–University of Pennsylvania Partnership, Gaborone, Botswana
| | - Katlego Tsholo
- Botswana–University of Pennsylvania Partnership, Gaborone, Botswana
| | | | | | - Mosepele Mosepele
- University of Botswana, Gaborone, Botswana
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - David S Lawrence
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Mark W Tenforde
- Botswana–University of Pennsylvania Partnership, Gaborone, Botswana
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington School of Medicine, Seattle, Washington
- Department of Epidemiology, University of Washington School of Public Health, Seattle, Washington
| | - Joseph N Jarvis
- Botswana–University of Pennsylvania Partnership, Gaborone, Botswana
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
- Division of Infectious Diseases, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Tenforde MW, Shapiro AE, Rouse B, Jarvis JN, Li T, Eshun‐Wilson I, Ford N. Treatment for HIV-associated cryptococcal meningitis. Cochrane Database Syst Rev 2018; 7:CD005647. [PMID: 30045416 PMCID: PMC6513250 DOI: 10.1002/14651858.cd005647.pub3] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Cryptococcal meningitis is a severe fungal infection that occurs primarily in the setting of advanced immunodeficiency and remains a major cause of HIV-related deaths worldwide. The best induction therapy to reduce mortality from HIV-associated cryptococcal meningitis is unclear, particularly in resource-limited settings where management of drug-related toxicities associated with more potent antifungal drugs is a challenge. OBJECTIVES To evaluate the best induction therapy to reduce mortality from HIV-associated cryptococcal meningitis; to compare side effect profiles of different therapies. SEARCH METHODS We searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL, MEDLINE (PubMed), Embase (Ovid), LILACS (BIREME), African Index Medicus, and Index Medicus for the South-East Asia Region (IMSEAR) from 1 January 1980 to 9 July 2018. We also searched the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP), ClinicalTrials.gov, and the ISRCTN registry; and abstracts of select conferences published between 1 July 2014 and 9 July 2018. SELECTION CRITERIA We included randomized controlled trials that compared antifungal induction therapies used for the first episode of HIV-associated cryptococcal meningitis. Comparisons could include different individual or combination therapies, or the same antifungal therapies with differing durations of induction (less than two weeks or two or more weeks, the latter being the current standard of care). We included data regardless of age, geographical region, or drug dosage. We specified no language restriction. DATA COLLECTION AND ANALYSIS Two review authors independently screened titles and abstracts identified by the search strategy. We obtained the full texts of potentially eligible studies to assess eligibility and extracted data using standardized forms. The main outcomes included mortality at 2 weeks, 10 weeks, and 6 months; mean rate of cerebrospinal fluid fungal clearance in the first two weeks of treatment; and Division of AIDS (DAIDS) grade three or four laboratory events. Using random-effects models we determined pooled risk ratio (RR) and 95% confidence interval (CI) for dichotomous outcomes and mean differences (MD) and 95% CI for continuous outcomes. For the direct comparison of 10-week mortality, we assessed the certainty of the evidence using the GRADE approach. We performed a network meta-analysis using multivariate meta-regression. We modelled treatment differences (RR and 95% CI) and determined treatment rankings for two-week and 10-week mortality outcomes using surface under the cumulative ranking curve (SUCRA). We assessed transitivity by comparing distribution of effect modifiers between studies, local inconsistency through a node-splitting approach, and global inconsistency using design-by-treatment interaction modelling. For the network meta-analysis, we applied a modified GRADE approach for assessing the certainty of the evidence for 10-week mortality. MAIN RESULTS We included 13 eligible studies that enrolled 2426 participants and compared 21 interventions. All studies were carried out in adults, and all but two studies were conducted in resource-limited settings, including 11 of 12 studies with 10-week mortality data.In the direct pairwise comparisons evaluating 10-week mortality, one study from four sub-Saharan African countries contributed data to several key comparisons. At 10 weeks these data showed that those on the regimen of one-week amphotericin B deoxycholate (AmBd) and flucytosine (5FC) followed by fluconazole (FLU) on days 8 to 14 had lower mortality when compared to (i) two weeks of AmBd and 5FC (RR 0.62, 95% CI 0.42 to 0.93; 228 participants, 1 study), (ii) two weeks of AmBd and FLU (RR 0.58, 95% CI 0.39 to 0.86; 227 participants, 1 study), (iii) one week of AmBd with two weeks of FLU (RR 0.49, 95% CI 0.34 to 0.72; 224 participants, 1 study), and (iv) two weeks of 5FC and FLU (RR 0.68, 95% CI 0.47 to 0.99; 338 participants, 1 study). The evidence for each of these comparisons was of moderate certainty. For other outcomes, this shortened one-week AmBd and 5FC regimen had similar fungal clearance (MD 0.05 log10 CFU/mL/day, 95% CI -0.02 to 0.12; 186 participants, 1 study) as well as lower risk of grade three or four anaemia (RR 0.31, 95% CI 0.16 to 0.60; 228 participants, 1 study) compared to the two-week regimen of AmBd and 5FC.For 10-week mortality, the comparison of two weeks of 5FC and FLU with two weeks of AmBd and 5FC (RR 0.92, 95% CI 0.69 to 1.23; 340 participants, 1 study) or two weeks of AmBd and FLU (RR 0.85, 95% CI 0.64 to 1.13; 339 participants, 1 study) did not show a difference in mortality, with moderate-certainty evidence for both comparisons.When two weeks of combination AmBd and 5FC was compared with AmBd alone, pooled data showed lower mortality at 10 weeks (RR 0.66, 95% CI 0.46 to 0.95; 231 participants, 2 studies, moderate-certainty evidence).When two weeks of AmBd and FLU was compared to AmBd alone, there was no difference in 10-week mortality in pooled data (RR 0.94, 95% CI 0.55 to 1.62; 371 participants, 3 studies, low-certainty evidence).One week of AmBd and 5FC followed by FLU on days 8 to 14 was the best induction therapy regimen after comparison with 11 other regimens for 10-week mortality in the network meta-analysis, with an overall SUCRA ranking of 88%. AUTHORS' CONCLUSIONS In resource-limited settings, one-week AmBd- and 5FC-based therapy is probably superior to other regimens for treatment of HIV-associated cryptococcal meningitis. An all-oral regimen of two weeks 5FC and FLU may be an alternative in settings where AmBd is unavailable or intravenous therapy cannot be safely administered. We found no mortality benefit of combination two weeks AmBd and FLU compared to AmBd alone. Given the absence of data from studies in children, and limited data from high-income countries, our findings provide limited guidance for treatment in these patients and settings.
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Affiliation(s)
- Mark W Tenforde
- University of Washington School of MedicineDivision of Allergy and Infectious Diseases1959 Pacific Street NESeattleUSAWA 98195
- University of Washington School of Public HealthDepartment of EpidemiologySeattleUSA
| | - Adrienne E Shapiro
- University of Washington School of MedicineDivision of Allergy and Infectious Diseases1959 Pacific Street NESeattleUSAWA 98195
| | - Benjamin Rouse
- Johns Hopkins Bloomberg School of Public HealthDepartment of Epidemiology615 N. Wolfe StreetBaltimoreMarylandUSA21205
| | - Joseph N Jarvis
- London School of Hygiene & Tropical MedicineFaculty of Infectious and Tropical DiseasesKeppel StreetLondonUKWC1E 7HT
- Botswana Harvard AIDS Institute PartnershipGaboroneBotswana
| | - Tianjing Li
- Johns Hopkins Bloomberg School of Public HealthDepartment of Epidemiology615 N. Wolfe StreetBaltimoreMarylandUSA21205
| | - Ingrid Eshun‐Wilson
- Stellenbosch UniversityCentre for Evidence Based Health Care, Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health SciencesFrancie van Zyl Drive, Tygerberg, 7505, ParowCape TownWestern CapeSouth Africa7505
| | - Nathan Ford
- World Health OrganizationDepartment of HIV & Global Hepatitis ProgrammeGenevaSwitzerland
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