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Mertiri L, Freiling JT, Desai NK, Kralik SF, Huisman TAGM. Pediatric and adult meningeal, parenchymal, and spinal tuberculosis: A neuroimaging review. J Neuroimaging 2024; 34:179-194. [PMID: 38073450 DOI: 10.1111/jon.13177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 11/24/2023] [Accepted: 11/28/2023] [Indexed: 03/12/2024] Open
Abstract
Neurotuberculosis is defined as a tuberculous infection of the meninges, brain parenchyma, vessels, cranial and spinal nerves, spinal cord, skull, and spine that can occur either in a localized or in a diffuse form. It is a heterogeneous disease characterized by many imaging appearances and it has been defined as "the great mimicker" due to similarities with many other conditions. The diagnosis of central nervous system (CNS) tuberculosis (TB) is based on clinical presentation, neuroimaging findings, laboratory and microbiological findings, and comprehensive evaluation of the response to anti-TB drug treatment. However, the absence of specific symptoms, the wide spectrum of neurological manifestations, the myriad of imaging findings, possible inconclusive laboratory results, and the paradoxical reaction to treatment make the diagnosis often challenging and difficult, potentially delaying adequate treatment with possible devastating short-term and long-term neurologic sequelae. Familiarity with the imaging characteristics helps in accurate diagnosis and may prevent or limit significantly morbidity and mortality. The goal of this review is to provide a comprehensive up-to-date overview of the conventional and advanced imaging features of CNS TB for radiologists, neuroradiologists, and pediatric radiologists. We discuss the most typical neurotuberculosis imaging findings and their differential diagnosis in children and adults with the goal to provide a global overview of this entity.
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Affiliation(s)
- Livja Mertiri
- Edward B. Singleton Department of Radiology, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas, USA
| | - John T Freiling
- Edward B. Singleton Department of Radiology, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas, USA
| | - Nilesh K Desai
- Edward B. Singleton Department of Radiology, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas, USA
| | - Stephen F Kralik
- Edward B. Singleton Department of Radiology, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas, USA
| | - Thierry A G M Huisman
- Edward B. Singleton Department of Radiology, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas, USA
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Pace D, Corvaglia F, Lisi C, Galli L, Chiappini E. Extrapulmonary and Drug-Resistant Childhood Tuberculosis: Unveiling the Disease to Adopt the Optimal Treatment Strategy. Pathogens 2023; 12:1439. [PMID: 38133322 PMCID: PMC10745899 DOI: 10.3390/pathogens12121439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 12/01/2023] [Accepted: 12/08/2023] [Indexed: 12/23/2023] Open
Abstract
Paediatric tuberculosis (TB) is a substantial threat among infectious diseases, particularly considering the high risk of extrapulmonary tuberculosis (EPTB), severe forms of the disease, and the spreading of drug-resistant strains. Describing the characteristics of children with EPTB and those with drug-resistant tuberculosis (DR-TB) and analysing the role of second-line drugs could facilitate the management of these cases. This retrospective study was conducted on 271 children diagnosed with active TB disease (44 EPTB cases, 9 DR-TB cases), originating from diverse geographic areas, who were referred to the infectious disease unit at Meyer Children's Hospital, Florence, Italy, from 2006 to 2022. In most patients, the management of therapies was complicated by the impossibility to obtain drug susceptibility testing (DST) results, which improved over the years: 17/154 (11.04%) children had DST results between 2006 and 2013, and 50/117 (42.73%, p < 0.001) between 2014 and 2022. Second-line drugs were not exclusively administered to DR-TB cases, but also to EPTB cases (20/44, 45.45%). Drugs were generally well tolerated; adverse events occurred in 13 children (13/271, 4.80%) and were generally mild and reversable. Therapies were successful in 267 children (98.52%) considered cured, while 4 (1.48%) presented sequelae. Both univariate and multivariate logistic regression analyses were conducted to investigate factors associated with EPTB, DR-TB, and second-line drugs administration. Originating from Asia emerged as a risk factor associated with both EPTB and DR-TB (p = 0.013 and p = 0.045, respectively). The introduction of GeneXpert tests has significantly improved TB diagnosis and the obtaining of DST results. The administration of second-line therapies should be limited primarily to DR-TB cases, but it is possible that these drugs may also be beneficial in selected EPTB cases.
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Affiliation(s)
| | | | | | | | - Elena Chiappini
- Infectious Disease Unit, Department of Health Sciences, Meyer Children’s Hospital IRCCS, University of Florence, 50121 Florence, Italy; (D.P.)
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3
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Manesh A, Gautam P, Kumar D SS, Mannam P, Jasper A, Gunasekaran K, Thomas NC, Benjamin RN, Inbaraj LR, Devasagayam E, George MM, Karthik R, Abraham OC, Vanjare HA, Sivadasan A, Appaswamy PT, Jonathan E, Michael JS, Samuel P, Varghese GM. Effectiveness of Adjunctive High-Dose Infliximab Therapy to Improve Disability-Free Survival Among Patients With Severe Central Nervous System Tuberculosis: A Matched Retrospective Cohort Study. Clin Infect Dis 2023; 77:1460-1467. [PMID: 37405816 DOI: 10.1093/cid/ciad401] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 06/10/2023] [Accepted: 06/27/2023] [Indexed: 07/06/2023] Open
Abstract
BACKGROUND Few treatment options exist for patients with severe central nervous system (CNS) tuberculosis (TB) worsening due to inflammatory lesions, despite optimal antitubercular therapy (ATT) and steroids. Data regarding the efficacy and safety of infliximab in these patients are sparse. METHODS We performed a matched retrospective cohort study based on Medical Research Council (MRC) grading system and modified Rankin Scale (mRS) scores comparing 2 groups of adults with CNS TB. Cohort A received at least 1 dose of infliximab after optimal ATT and steroids between March 2019 and July 2022. Cohort B received only ATT and steroids. Disability-free survival (mRS score ≤2) at 6 months was the primary outcome. RESULTS Baseline MRC grades and mRS scores were similar between the cohorts. Median duration before initiation of infliximab therapy from start of ATT and steroids was 6 (IQR: 3.7-13) months and for neurological deficits was 4 (IQR: 2-6.2) months. Indications for infliximab were symptomatic tuberculomas (20/30; 66.7%), spinal cord involvement with paraparesis (8/30; 26.7%), and optochiasmatic arachnoiditis (3/30; 10%), worsening despite adequate ATT and steroids. Severe disability (5/30 [16.7%] and 21/60 [35%]) and all-cause mortality (2/30 [6.7%] and 13/60 [21.7%]) at 6 months were lower in cohort A versus cohort B, respectively. In the combined study population, only exposure to infliximab was positively associated (aRR: 6.2; 95% CI: 2.18-17.83; P = .001) with disability-free survival at 6 months. There were no clear infliximab-related side effects noted. CONCLUSIONS Infliximab may be an effective and safe adjunctive strategy among severely disabled patients with CNS TB not improving despite optimal ATT and steroids. Adequately powered phase 3 clinical trials are required to confirm these early findings.
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Affiliation(s)
- Abi Manesh
- Department of Infectious Diseases, Christian Medical College, Vellore, Tamil Nadu, India
| | - Priyanka Gautam
- Department of Infectious Diseases, Christian Medical College, Vellore, Tamil Nadu, India
| | - Selwyn Selva Kumar D
- Department of Infectious Diseases, Christian Medical College, Vellore, Tamil Nadu, India
| | - Pavithra Mannam
- Department of Radiology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Anitha Jasper
- Department of Radiology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Karthik Gunasekaran
- Department of Internal Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | - Naveen Cherian Thomas
- Department of Physical Medicine and Rehabilitation, Christian Medical College, Vellore, Tamil Nadu, India
| | | | - Leeberk Raja Inbaraj
- Department of Clinical Research, ICMR-National Institute for Research in Tuberculosis, Chennai, Tamil Nadu, India
| | - Emily Devasagayam
- Department of Infectious Diseases, Christian Medical College, Vellore, Tamil Nadu, India
| | - Mithun Mohan George
- Department of Infectious Diseases, Christian Medical College, Vellore, Tamil Nadu, India
| | - Rajiv Karthik
- Department of Infectious Diseases, Christian Medical College, Vellore, Tamil Nadu, India
| | | | - Harshad A Vanjare
- Department of Radiology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Ajith Sivadasan
- Department of Neurology, Christian Medical College, Vellore, Tamil Nadu, India
| | | | - Edmond Jonathan
- Department of Neurosurgery, Christian Medical College, Vellore, Tamil Nadu, India
| | - Joy S Michael
- Department of Clinical Microbiology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Prasanna Samuel
- Department of Biostatistics, Christian Medical College, Vellore, Tamil Nadu, India
| | - George M Varghese
- Department of Infectious Diseases, Christian Medical College, Vellore, Tamil Nadu, India
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4
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Litjens CHC, Verscheijden LFM, Svensson EM, van den Broek PHH, van Hove H, Koenderink JB, Russel FGM, Aarnoutse RE, te Brake LHM. Physiologically-Based Pharmacokinetic Modelling to Predict the Pharmacokinetics and Pharmacodynamics of Linezolid in Adults and Children with Tuberculous Meningitis. Antibiotics (Basel) 2023; 12:antibiotics12040702. [PMID: 37107064 PMCID: PMC10135070 DOI: 10.3390/antibiotics12040702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 03/23/2023] [Accepted: 03/30/2023] [Indexed: 04/07/2023] Open
Abstract
Linezolid is used off-label for treatment of central nervous system infections. However, its pharmacokinetics and target attainment in cranial cerebrospinal fluid (CSF) in tuberculous meningitis patients is unknown. This study aimed to predict linezolid cranial CSF concentrations and assess attainment of pharmacodynamic (PD) thresholds (AUC:MIC of >119) in plasma and cranial CSF of adults and children with tuberculous meningitis. A physiologically based pharmacokinetic (PBPK) model was developed to predict linezolid cranial CSF profiles based on reported plasma concentrations. Simulated steady-state PK curves in plasma and cranial CSF after linezolid doses of 300 mg BID, 600 mg BID, and 1200 mg QD in adults resulted in geometric mean AUC:MIC ratios in plasma of 118, 281, and 262 and mean cranial CSF AUC:MIC ratios of 74, 181, and 166, respectively. In children using ~10 mg/kg BID linezolid, AUC:MIC values at steady-state in plasma and cranial CSF were 202 and 135, respectively. Our model predicts that 1200 mg per day in adults, either 600 mg BID or 1200 mg QD, results in reasonable (87%) target attainment in cranial CSF. Target attainment in our simulated paediatric population was moderate (56% in cranial CSF). Our PBPK model can support linezolid dose optimization efforts by simulating target attainment close to the site of TBM disease.
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Affiliation(s)
- Carlijn H. C. Litjens
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
- Department of Pharmacology and Toxicology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Laurens F. M. Verscheijden
- Department of Pharmacology and Toxicology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Elin M. Svensson
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
- Department of Pharmacy, Uppsala University, 75123 Uppsala, Sweden
| | - Petra H. H. van den Broek
- Department of Pharmacology and Toxicology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Hedwig van Hove
- Department of Pharmacology and Toxicology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Jan B. Koenderink
- Department of Pharmacology and Toxicology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Frans G. M. Russel
- Department of Pharmacology and Toxicology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Rob E. Aarnoutse
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Lindsey H. M. te Brake
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
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Mehta K, Narayanan N, Heysell SK, Bisson GP, Subbian S, Kurepina N, Kreiswirth BN, Vinnard C. Pharmacogenetic variability and the probability of site of action target attainment during tuberculosis meningitis treatment: A physiologically based pharmacokinetic modeling and simulations study. Tuberculosis (Edinb) 2022; 137:102271. [PMID: 36375279 DOI: 10.1016/j.tube.2022.102271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 09/01/2022] [Accepted: 10/12/2022] [Indexed: 11/22/2022]
Abstract
OBJECTIVE AND METHODS Our objective was to investigate the role of patient pharmacogenetic variability in determining site of action target attainment during tuberculous meningitis (TBM) treatment. Rifampin and isoniazid PBPK model that included SLCO1B1 and NAT2 effects on exposures respectively were obtained from literature, modified, and validated using available cerebrospinal-fluid (CSF) concentrations. Population simulations of isoniazid and rifampin concentrations in brain interstitial fluid and probability of target attainment according to genotypes and M. tuberculosis MIC levels, under standard and intensified dosing, were conducted. RESULTS The rifampin and isoniazid model predicted steady-state drug concentration within brain interstitial fluid matched with the observed CSF concentrations. At MIC level of 0.25 mg/L, 57% and 23% of the patients with wild type and heterozygous SLCO1B1 genotype respectively attained the target in CNS with rifampin standard dosing, improving to 98% and 91% respectively with 35 mg/kg dosing. At MIC level of 0.25 mg/L, 33% of fast acetylators attained the target in CNS with isoniazid standard dosing, improving to 90% with 7.5 mg/kg dosing. CONCLUSION In this study, the combined effects of pharmacogenetic and M. tuberculosis MIC variability were potent determinants of target attainment in CNS. The potential for genotype-guided dosing during TBM treatment should be further explored in prospective clinical studies.
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Affiliation(s)
| | | | - Scott K Heysell
- University of Virginia, Division of Infectious Diseases and International Health, Charlottesville, VA, USA
| | - Gregory P Bisson
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Selvakumar Subbian
- Public Health Research Institute, New Jersey Medical School, Newark, NJ, USA
| | - Natalia Kurepina
- Center for Discovery & Innovation, Hackensack Meridian Health, Nutley, NJ, USA
| | - Barry N Kreiswirth
- Center for Discovery & Innovation, Hackensack Meridian Health, Nutley, NJ, USA
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Evans EE, Avaliani T, Gujabidze M, Bakuradze T, Kipiani M, Sabanadze S, Smith AGC, Avaliani Z, Collins JM, Kempker RR. Long term outcomes of patients with tuberculous meningitis: The impact of drug resistance. PLoS One 2022; 17:e0270201. [PMID: 35749509 PMCID: PMC9232145 DOI: 10.1371/journal.pone.0270201] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 06/06/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Little is known about the impact of drug-resistance on clinical outcomes among patients with tuberculosis meningitis (TBM). METHODS A retrospective cohort study among patients treated for TBM in Tbilisi, Georgia. We performed medical chart abstraction to collect patient data. Long-term vital status was assessed using the Georgia National Death Registry. We utilized a Cox proportional-hazards model to evaluate the association of drug-resistance and mortality. RESULTS Among 343 TBM suspects, 237 had a presentation consistent with TBM. Drug resistance was suspected (n = 5) or confirmed (n = 31) in 36 patients including 30 with multidrug- or rifampin-resistance and 6 with isoniazid-resistance. Thirty-four patients had HIV. The median follow-up time was 1331 days (IQR, 852-1767). Overall, 73 of 237 (30%) people died with 50 deaths occurring during and 23 after treatment. The proportion of death was higher among patients with drug-resistant vs. drug-susceptible disease (67% vs. 24%, p<0.001) and with HIV versus no HIV (59% vs 27%, p<0.001). Mortality was significantly higher in patients with drug-resistant TBM after 90 days of treatment (aHR = 7.2, CI95% [3.6-14.3], p < 0.001). CONCLUSIONS Mortality was high among patients with drug-resistant TBM with many deaths occurring post treatment. More effective treatment options are urgently needed for drug-resistant TBM.
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Affiliation(s)
- Emily E. Evans
- Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Teona Avaliani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Mariam Gujabidze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Tinatin Bakuradze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Maia Kipiani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Shorena Sabanadze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Alison G. C. Smith
- Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Zaza Avaliani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Jeffrey M. Collins
- Department of Medicine, Division of Infectious Diseases, Emory University, Atlanta, Georgia, United States of America
| | - Russell R. Kempker
- Emory University School of Medicine, Atlanta, Georgia, United States of America
- Department of Medicine, Division of Infectious Diseases, Emory University, Atlanta, Georgia, United States of America
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Sullivan A, Nathavitharana RR. Addressing TB-related mortality in adults living with HIV: a review of the challenges and potential solutions. Ther Adv Infect Dis 2022; 9:20499361221084163. [PMID: 35321342 PMCID: PMC8935406 DOI: 10.1177/20499361221084163] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 02/12/2022] [Indexed: 11/17/2022] Open
Abstract
Tuberculosis (TB) is the leading cause of death in people living with HIV (PLHIV) globally, causing 208,000 deaths in PLHIV in 2019. PLHIV have an 18-fold higher risk of TB, and HIV/TB mortality is highest in inpatient facilities, compared with primary care and community settings. Here we discuss challenges and potential mitigating solutions to address TB-related mortality in adults with HIV. Key factors that affect healthcare engagement are stigma, knowledge, and socioeconomic constraints, which are compounded in people with HIV/TB co-infection. Innovative approaches to improve healthcare engagement include optimizing HIV/TB care integration and interventions to reduce stigma. While early diagnosis of both HIV and TB can reduce mortality, barriers to early diagnosis of TB in PLHIV include difficulty producing sputum specimens, lower sensitivity of TB diagnostic tests in PLHIV, and higher rates of extra pulmonary TB. There is an urgent need to develop higher sensitivity biomarker-based tests that can be used for point-of-care diagnosis. Nonetheless, the implementation and scale-up of existing tests including molecular World Health Organization (WHO)-recommended diagnostic tests and urine lipoarabinomannan (LAM) should be optimized along with expanded TB screening with tools such as C-reactive protein and digital chest radiography. Decreased survival of PLHIV with TB disease is more likely with late HIV diagnosis and delayed start of antiretroviral (ART) treatment. The WHO now recommends starting ART within 2 weeks of initiating TB treatment in the majority of PLHIV, aside from those with TB meningitis. Dedicated TB treatment trials focused on PLHIV are needed, including interventions to improve TB meningitis outcomes given its high mortality, such as the use of intensified regimens using high-dose rifampin, new and repurposed drugs such as linezolid, and immunomodulatory therapy. Ultimately holistic, high-quality, person-centered care is needed for PLHIV with TB throughout the cascade of care, which should address biomedical, socioeconomic, and psychological barriers.
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Affiliation(s)
- Amanda Sullivan
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Ruvandhi R. Nathavitharana
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA 02215, USA
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Abstract
Tuberculosis (TB) is one of the leading causes of mortality in children worldwide, but there remain significant challenges in diagnosing and treating TB infection and disease. Treatment of TB infection in children and adolescents is critical to prevent progression to TB disease and to prevent them from becoming the future reservoir for TB transmission. This article reviews the clinical approach to diagnosing and treating latent TB infection and pulmonary and extrapulmonary TB disease in children. Also discussed are emerging diagnostics and therapeutic regimens that aim to improve pediatric TB detection and outcomes.
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Affiliation(s)
- Devan Jaganath
- Division of Pediatric Infectious Diseases, University of California, San Francisco
| | - Jeanette Beaudry
- Division of Pediatric Infectious Diseases, Johns Hopkins University Baltimore, USA
| | - Nicole Salazar-Austin
- Division of Pediatric Infectious Diseases, Johns Hopkins University School of Medicine, 200 N Wolfe Street, Room 3147, Baltimore, MD 21287, USA.
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9
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Nataprawira HM, Gafar F, Risan NA, Wulandari DA, Sudarwati S, Marais BJ, Stevens J, Alffenaar JWC, Ruslami R. Treatment Outcomes of Childhood Tuberculous Meningitis in a Real-World Retrospective Cohort, Bandung, Indonesia. Emerg Infect Dis 2022; 28:660-671. [PMID: 35202524 PMCID: PMC8888221 DOI: 10.3201/eid2803.212230] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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10
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Joseph SK, M A A, Thomas S, Nair SC. Nanomedicine as a future therapeutic approach for treating meningitis. J Drug Deliv Sci Technol 2022. [DOI: 10.1016/j.jddst.2021.102968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Li K, Wang L, Wen L, Wang J, Li M. Intrathecal therapy for tuberculous meningitis: propensity-matched cohort study. Neurol Sci 2021; 43:2693-2698. [PMID: 34708262 DOI: 10.1007/s10072-021-05690-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 07/12/2021] [Indexed: 02/05/2023]
Abstract
OBJECTIVE The study aimed to determine the safety and efficacy of intrathecally administered isoniazid (INH) and prednisolone in addition to systemic anti-TB therapy and compare it with systemic anti-TB therapy alone in adult patients with tuberculous meningitis (TBM). METHODS In this retrospective study, patients were categorized into two groups: Group A patients received systematic anti-TB therapy alone, Group B patients received IT INH (50 mg) and prednisolone (25 mg) twice a week together with the same standard systemic anti-TB therapy as Group A, in addition to the standard systemic anti-TB therapy. Functional outcomes were compared between the two groups in a prosperity-matched cohort using propensity score matching (PSM) method. RESULTS A total of 198 patients with TBM were enrolled. After PSM, 30 patients from each group were analyzed, so that there was no significant difference in the characteristics of the two groups. Mortality at follow-up was significantly lower among patients receiving additional IT therapy (4/30, 13.3%) compared with matched patients receiving systemic anti-TB therapy alone (11/30, 36.7%, P value = 0.037). CONCLUSIONS In this propensity score-matched cohort, the addition of IT INH and prednisolone to systemic anti-TB therapy could be effective for the better outcome among adult TBM patients. Further large-scale, prospective, and randomized controlled trials are warranted to the best timing and indication of IT therapy.
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Affiliation(s)
- Kunyi Li
- Department of Neurology, the Second People's Hospital of Chengdu, Chengdu, 610000, China
| | - Lijun Wang
- Department of Neurology, Institute of Neurology, Ruijin Hospital Affiliated to School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Lan Wen
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Jian Wang
- Department of Neurology, the Second People's Hospital of Chengdu, Chengdu, 610000, China
| | - Maolin Li
- Department of Neurology, People's Hospital of Deyang City, No. 173, North Taishan, Road, Deyang, Sichuan, China.
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Abstract
Introduction: Tuberculosis (TB) is a major cause of morbidity and mortality globally. Extrapulmonary TB (EPTB) constitutes about 15%-20% of all TB patients, but accounts for 50% among HIV-coinfected. Confirmation of microbial diagnosis of EPTB is usually challenging.Areas covered: Availability of newer imaging modalities like 18FDG-PET-CT and PET-MRI has facilitated precise anatomical localization of the lesions and mapping the extent of EPTB. The use of image- and endoscopy-guided invasive diagnostic methods has made procurement of tissue/body fluids for diagnostic testing possible. With the advent of universal drug-susceptibility testing, a rapid diagnosis of drug-resistance is now possible in EPTB. Drug-susceptible EPTB usually responds well to first-line anti-TB treatment; TB meningitis, bone and joint TB and lymph node TB requires longer durations of treatment.Expert opinion: Adjunctive use of corticosteroids in the initial period is recommended in the central nervous system and pericardial TB. Surgical intervention is helpful to obtain tissue samples for diagnosis. Adjunctive surgical treatment along with medical treatment is useful in treating complications like hydrocephalus, Pott's spine. Follow-up of EPTB patients is crucial as treatment period is usually prolonged, requires recognition of development of immune reconstitution and inflammatory syndrome (IRIS), monitoring of adverse events, serious adverse events like anti-TB drug-induced hepatotoxicity, organ-related complications, and treatment adherence.
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Affiliation(s)
- Surendra K Sharma
- Department of Molecular Medicine, Jamia Hamdard Institute of Molecular Medicine, New Delhi, India.,Departments of General Medicine & Pulmonary Medicine, JNMC, Datta Meghe Institute of Medical Sciences (DMIMS), Wardha, India.,Department of Internal Medicine (WHO Collaborating Centre for Research & Training in Tuberculosis, Centre of Excellence for EPTB, MoH & FW, GoI), All India Institute of Medical Sciences, New Delhi, India
| | - Alladi Mohan
- Department of Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati, India
| | - Mikashmi Kohli
- Department of Epidemiology and Biostatistics and Occupational Health, McGill International TB Centre, McGill University, Canada
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van Crevel R. Improving host-directed therapy for tuberculous meningitis by linking clinical and multi-omics data. Tuberculosis (Edinb) 2021; 128:102085. [PMID: 34022506 DOI: 10.1016/j.tube.2021.102085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 04/17/2021] [Accepted: 04/26/2021] [Indexed: 11/19/2022]
Abstract
There is a clear need to improve host-directed therapy for tuberculous meningitis (TBM), the most severe and deadly manifestation of tuberculosis. Corticosteroids represent the only host-directed therapy of proven benefit in TBM, yet their effect is modest, the mechanism by which they reduce mortality is unknown, and there is evidence for heterogeneity in their effect. Novel therapeutic approaches are therefore urgently needed. Cellular metabolism is critical for the function of immune cells; through unbiased metabolomics we recently found that high concentrations of cerebrospinal fluid (CSF) tryptophan are associated with increased mortality in Indonesian TBM patients, and that CSF tryptophan concentrations are under strong genetic regulation. Many questions remain. How exactly is tryptophan metabolism altered during TBM? How does it correlate with inflammation, immunopathology, and response to corticosteroids? How is tryptophan metabolism genetically regulated? What is the effect of HIV co-infection on tryptophan metabolism before and during TBM treatment? The ULTIMATE project addresses these questions by integrating data and specimens from large patient studies and clinical trials evaluating the effects of corticosteroids in Vietnam and Indonesia. Through its powerful and unbiased approach, ULTIMATE aims to identify which TBM patients benefit from corticosteroids and if novel therapeutic targets, such as the tryptophan pathway, could be targeted.
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Affiliation(s)
- Reinout van Crevel
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, the Netherlands; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
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14
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Abstract
PURPOSE OF REVIEW Central nervous system (CNS) infections associated with HIV remain significant contributors to morbidity and mortality, particularly among people living with HIV (PLWH) in resource-limited settings worldwide. In this review, we discuss several recent important scientific discoveries in the prevention, diagnosis, and management around two of the major causes of CNS opportunistic infections-tuberculous meningitis (TBM) and cryptococcal meningitis including immune reconstitution syndrome (IRIS) associated with cryptococcal meningitis. We also discuss the CNS as a possible viral reservoir, highlighting Cerebrospinal fluid viral escape. RECENT FINDINGS CNS infections in HIV-positive people in sub-Saharan Africa contribute to 15-25% of AIDS-related deaths. Morbidity and mortality in those is associated with delays in HIV diagnosis, lack of availability for antimicrobial treatment, and risk of CNS IRIS. The CNS may serve as a reservoir for replication, though it is unclear whether this can impact peripheral immunosuppression. SUMMARY Significant diagnostic and treatment advances for TBM and cryptococcal meningitis have yet to impact overall morbidity and mortality according to recent data. Lack of early diagnosis and treatment initiation, and also maintenance on combined antiretroviral treatment are the main drivers of the ongoing burden of CNS opportunistic infections. The CNS as a viral reservoir has major potential implications for HIV eradication strategies, and also control of CNS opportunistic infections.
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15
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Hammami F, Koubaa M, Chakroun A, Rekik K, Feki W, Marrakchi C, Smaoui F, Jemaa MB. Comparative analysis between tuberculous meningitis and other forms of extrapulmonary tuberculosis. Germs 2021; 11:23-31. [PMID: 33898338 DOI: 10.18683/germs.2021.1237] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 11/17/2020] [Accepted: 12/30/2020] [Indexed: 11/08/2022]
Abstract
Introduction Tuberculosis is a multisystem disease that may affect any organ or tissue. Tuberculous meningitis (TBM) is the most severe form of tuberculosis and commonly affects the brain. We aimed to study the epidemiological, clinical, therapeutic and evolutionary features of TBM among adults and to compare them with other forms of extrapulmonary tuberculosis. Methods We conducted a retrospective study including all patients hospitalized for extrapulmonary tuberculosis in the infectious disease department in Sfax, Tunisia between 1993 and 2018. We specified the particularities of TBM cases, and we compared them with other extrapulmonary tuberculosis cases. Results We encountered 78 patients diagnosed with TBM, among 519 patients with extrapulmonary tuberculosis (15%). The median age was 36 years (23-50) years. There were 44 females (56.4%). In comparison with other forms of extrapulmonary tuberculosis, fever [odds ratio (OR)=4.4; p<0.001], asthenia (OR=3.4; p<0.001) and anorexia (OR=2.3; p=0.001) were significantly more frequent in TBM patients. Adverse effects of antitubercular therapy were more frequent among TBM patients (OR=3.1; p<0.001). The mean duration of antitubercular therapy was 15 (12-20) months. Recovery occurred in 66 cases (84.6%), complications in 44 cases (56.4%) and death in 7 cases (9%). Comparison of the disease evolution showed that complications (OR=7.4; p<0.001) and mortality rates (OR=10.7; p<0.001) were significantly more frequent in TBM patients, while recovery was significantly more frequent in other sites of extrapulmonary tuberculosis patients (OR=0.5; p=0.02). Conclusions In our country, TBM remains a disabling disease. Despite antitubercular therapy, the prognosis was more severe with the occurrence of not only complications but also a high mortality rate in comparison with other forms of extrapulmonary tuberculosis. When clinical and laboratory features suggest the diagnosis of TBM, clinicians should look for tuberculosis elsewhere in the body.
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Affiliation(s)
- Fatma Hammami
- MD, Infectious Diseases Department and Extra-pulmonary Research Unity, Hedi Chaker University Hospital, University of Sfax, 3029, Tunisia
| | - Makram Koubaa
- MD, Infectious Diseases Department and Extra-pulmonary Research Unity, Hedi Chaker University Hospital, University of Sfax, 3029, Tunisia
| | - Amal Chakroun
- MD, Infectious Diseases Department and Extra-pulmonary Research Unity, Hedi Chaker University Hospital, University of Sfax, 3029, Tunisia
| | - Khaoula Rekik
- MD, Infectious Diseases Department and Extra-pulmonary Research Unity, Hedi Chaker University Hospital, University of Sfax, 3029, Tunisia
| | - Wiem Feki
- MD, Radiology Department, Hedi Chaker University Hospital, University of Sfax, 3029, Tunisia
| | - Chakib Marrakchi
- MD, Infectious Diseases Department and Extra-pulmonary Research Unity, Hedi Chaker University Hospital, University of Sfax, 3029, Tunisia
| | - Fatma Smaoui
- MD, Infectious Diseases Department and Extra-pulmonary Research Unity, Hedi Chaker University Hospital, University of Sfax, 3029, Tunisia
| | - Mounir Ben Jemaa
- MD, Infectious Diseases Department and Extra-pulmonary Research Unity, Hedi Chaker University Hospital, University of Sfax, 3029, Tunisia
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16
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Cresswell FV, Meya DB, Kagimu E, Grint D, te Brake L, Kasibante J, Martyn E, Rutakingirwa M, Quinn CM, Okirwoth M, Tugume L, Ssembambulidde K, Musubire AK, Bangdiwala AS, Buzibye A, Muzoora C, Svensson EM, Aarnoutse R, Boulware DR, Elliott AM. High-Dose Oral and Intravenous Rifampicin for the Treatment of Tuberculous Meningitis in Predominantly Human Immunodeficiency Virus (HIV)-Positive Ugandan Adults: A Phase II Open-Label Randomized Controlled Trial. Clin Infect Dis 2021; 73:876-884. [PMID: 33693537 PMCID: PMC8423465 DOI: 10.1093/cid/ciab162] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND High-dose rifampicin may improve outcomes of tuberculous meningitis (TBM). Little safety or pharmacokinetic (PK) data exist on high-dose rifampicin in human immunodeficiency virus (HIV) coinfection, and no cerebrospinal fluid (CSF) PK data exist from Africa. We hypothesized that high-dose rifampicin would increase serum and CSF concentrations without excess toxicity. METHODS In this phase II open-label trial, Ugandan adults with suspected TBM were randomized to standard-of-care control (PO-10, rifampicin 10 mg/kg/day), intravenous rifampicin (IV-20, 20 mg/kg/day), or high-dose oral rifampicin (PO-35, 35 mg/kg/day). We performed PK sampling on days 2 and 14. The primary outcomes were total exposure (AUC0-24), maximum concentration (Cmax), CSF concentration, and grade 3-5 adverse events. RESULTS We enrolled 61 adults, 92% were living with HIV, median CD4 count was 50 cells/µL (interquartile range [IQR] 46-56). On day 2, geometric mean plasma AUC0-24hr was 42.9·h mg/L with standard-of-care 10 mg/kg dosing, 249·h mg/L for IV-20 and 327·h mg/L for PO-35 (P < .001). In CSF, standard of care achieved undetectable rifampicin concentration in 56% of participants and geometric mean AUC0-24hr 0.27 mg/L, compared with 1.74 mg/L (95% confidence interval [CI] 1.2-2.5) for IV-20 and 2.17 mg/L (1.6-2.9) for PO-35 regimens (P < .001). Achieving CSF concentrations above rifampicin minimal inhibitory concentration (MIC) occurred in 11% (2/18) of standard-of-care, 93% (14/15) of IV-20, and 95% (18/19) of PO-35 participants. Higher serum and CSF levels were sustained at day 14. Adverse events did not differ by dose (P = .34). CONCLUSIONS Current international guidelines result in sub-therapeutic CSF rifampicin concentration for 89% of Ugandan TBM patients. High-dose intravenous and oral rifampicin were safe and respectively resulted in exposures ~6- and ~8-fold higher than standard of care, and CSF levels above the MIC.
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Affiliation(s)
- Fiona V Cresswell
- Clinical Research Department, London School of Hygiene and Tropical Medicine, Keppel Street, London, United Kingdom,Infectious Diseases Institute, Makerere University, Kampala, Uganda,Medical Research Council - Uganda Virus Research Institute – LSHTM Uganda Research Unit, Entebbe, Uganda,Correspondence: F. Cresswell, Clinical Research Department, London School of Hygiene and Tropical Medicine, Keppel St, London, WC1E 7HT, UK ()
| | - David B Meya
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Enock Kagimu
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Daniel Grint
- Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine, Keppel Street, London, United Kingdom
| | - Lindsey te Brake
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Centre, The Netherlands
| | - John Kasibante
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Emily Martyn
- Clinical Research Department, London School of Hygiene and Tropical Medicine, Keppel Street, London, United Kingdom
| | | | - Carson M Quinn
- University of California, San Francisco, San Francisco, California, USA
| | - Micheal Okirwoth
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Lillian Tugume
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | - Abdu K Musubire
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Ananta S Bangdiwala
- Division of Biostatistics, University of Minnesota, Minneapolis, Minneapolis, Minnesota, USA
| | - Allan Buzibye
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Conrad Muzoora
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Elin M Svensson
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Centre, The Netherlands,Department of Pharmacy, Uppsala University, Sweden
| | - Rob Aarnoutse
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Centre, The Netherlands
| | - David R Boulware
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, Minneapolis, Minnesota, USA
| | - Alison M Elliott
- Clinical Research Department, London School of Hygiene and Tropical Medicine, Keppel Street, London, United Kingdom,Medical Research Council - Uganda Virus Research Institute – LSHTM Uganda Research Unit, Entebbe, Uganda
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17
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Presentations and outcomes of central nervous system TB in a UK cohort: The high burden of neurological morbidity. J Infect 2020; 82:90-97. [PMID: 33137354 DOI: 10.1016/j.jinf.2020.10.028] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 10/02/2020] [Accepted: 10/06/2020] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Most data for Central Nervous System Tuberculosis (CNS-TB) derive from high-incidence, resource-limited countries. We sought to determine the presentation, management and outcomes of CNS-TB in a low-incidence setting with accessible healthcare. METHODS We undertook a retrospective, observational study of CNS-TB in adults at a single tertiary-referral London hospital (2001-2017). Cases were categorised as either TB meningitis (TBM) or TB mass lesions without meningitis (TBML), applying novel criteria for definite, probable, and possible TBML. RESULTS We identified sixty-two cases of TBM (37% definite; 31% probable; 32% possible) alongside 14 TBML cases (36% definite; 29% probable; and 36% possible). Clinical presentation was highly variable. Among CSF parameters, hypoglycorrhachia proved most discriminatory for "definite" TBM. Neurosurgical intervention was required for mass-effect or hydrocephalus in 16%. Mortality was higher in TBM versus TBML (16% vs. 0%) but overall morbidity was significant; 33% of TBM and 29% of TBML survivors suffered persisting neurological disability at 12-months. In TBM, hydrocephalus, infarct, basal enhancement and low CSF white cell count were independently associated with worse neurological outcomes. CONCLUSION Although mortality was lower than previously reported in other settings, morbidity was significant, highlighting the need for improved CNS-TB diagnostics, therapeutics and interventions to mitigate neurological sequelae.
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18
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Clifford KM, Szumowski JD. Disseminated Mycobacterium bovis Infection Complicated by Meningitis and Stroke: A Case Report. Open Forum Infect Dis 2020; 7:ofaa475. [PMID: 33134425 PMCID: PMC7588105 DOI: 10.1093/ofid/ofaa475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Accepted: 09/30/2020] [Indexed: 11/29/2022] Open
Abstract
We describe a case of a 19-year-old female presenting with Mycobacterium bovis meningitis, a rarely encountered infection. We discuss the use of pyrosequencing to aid in prompt diagnosis of M. bovis infection, as well as treatment strategies and challenges given the organism’s intrinsic resistance to pyrazinamide.
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Affiliation(s)
- Katherine M Clifford
- Department of Neurology, Stanford University School of Medicine, Stanford, California, USA
| | - John D Szumowski
- Division of HIV, ID and Global Medicine, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
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19
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Marais S, Cresswell FV, Hamers RL, Te Brake LHM, Ganiem AR, Imran D, Bangdiwala A, Martyn E, Kasibante J, Kagimu E, Musubire A, Maharani K, Estiasari R, Kusumaningrum A, Kusumadjayanti N, Yunivita V, Naidoo K, Lessells R, Moosa Y, Svensson EM, Huppler Hullsiek K, Aarnoutse RE, Boulware DR, van Crevel R, Ruslami R, Meya DB. High dose oral rifampicin to improve survival from adult tuberculous meningitis: A randomised placebo-controlled double-blinded phase III trial (the HARVEST study). Wellcome Open Res 2020; 4:190. [PMID: 33083560 PMCID: PMC7542255 DOI: 10.12688/wellcomeopenres.15565.2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/06/2020] [Indexed: 12/18/2022] Open
Abstract
Background: Tuberculous meningitis (TBM), the most severe form of tuberculosis (TB), results in death or neurological disability in >50%, despite World Health Organisation recommended therapy. Current TBM regimen dosages are based on data from pulmonary TB alone. Evidence from recent phase II pharmacokinetic studies suggests that high dose rifampicin (R) administered intravenously or orally enhances central nervous system penetration and may reduce TBM associated mortality. We hypothesize that, among persons with TBM, high dose oral rifampicin (35 mg/kg) for 8 weeks will improve survival compared to standard of care (10 mg/kg), without excess adverse events. Protocol: We will perform a parallel group, randomised, placebo-controlled, double blind, phase III multicentre clinical trial comparing high dose oral rifampicin to standard of care. The trial will be conducted across five clinical sites in Uganda, South Africa and Indonesia. Participants are HIV-positive or negative adults with clinically suspected TBM, who will be randomised (1:1) to one of two arms: 35 mg/kg oral rifampicin daily for 8 weeks (in combination with standard dose isoniazid [H], pyrazinamide [Z] and ethambutol [E]) or standard of care (oral HRZE, containing 10 mg/kg/day rifampicin). The primary end-point is 6-month survival. Secondary end points are: i) 12-month survival ii) functional and neurocognitive outcomes and iii) safety and tolerability. Tertiary outcomes are: i) pharmacokinetic outcomes and ii) cost-effectiveness of the intervention. We will enrol 500 participants over 2.5 years, with follow-up continuing until 12 months post-enrolment. Discussion: Our best TBM treatment still results in unacceptably high mortality and morbidity. Strong evidence supports the increased cerebrospinal fluid penetration of high dose rifampicin, however conclusive evidence regarding survival benefit is lacking. This study will answer the important question of whether high dose oral rifampicin conveys a survival benefit in TBM in HIV-positive and -negative individuals from Africa and Asia. Trial registration: ISRCTN15668391 (17/06/2019)
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Affiliation(s)
- Suzaan Marais
- Department of Neurology, Inkosi Albert Luthuli Central Hospital, Durban, 4091, South Africa
| | - Fiona V Cresswell
- Infectious Diseases Institute, Mulago College of Health Sciences, Kampala, PO Box 22418, Uganda.,Clinical Research Department, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK.,MRC-UVRI, London School of Hygiene & Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Raph L Hamers
- Eijkman-Oxford Clinical Research Unit, Jakarta, Indonesia.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Lindsey H M Te Brake
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Ahmad R Ganiem
- Department of Neurology, Faculty of Medicine, Universitas Padjadjaran/ Hasan Sadikin Hospital, Bandung, 40161, Indonesia.,Infectious Disease Research Centre, Faculty of Medicine, Universitas Padjadaran, Bandung, 40161, Indonesia
| | - Darma Imran
- Department of Neurology, Faculty of Medicine, Universitas Indonesia, Dr Cipto Mangukusumo Hospital, Jakarta, 10430, Indonesia
| | - Ananta Bangdiwala
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, 55455, USA
| | - Emily Martyn
- Infectious Diseases Institute, Mulago College of Health Sciences, Kampala, PO Box 22418, Uganda
| | - John Kasibante
- Infectious Diseases Institute, Mulago College of Health Sciences, Kampala, PO Box 22418, Uganda
| | - Enock Kagimu
- Infectious Diseases Institute, Mulago College of Health Sciences, Kampala, PO Box 22418, Uganda
| | - Abdu Musubire
- Infectious Diseases Institute, Mulago College of Health Sciences, Kampala, PO Box 22418, Uganda
| | - Kartika Maharani
- Department of Neurology, Faculty of Medicine, Universitas Indonesia, Dr Cipto Mangukusumo Hospital, Jakarta, 10430, Indonesia
| | - Riwanti Estiasari
- Department of Neurology, Faculty of Medicine, Universitas Indonesia, Dr Cipto Mangukusumo Hospital, Jakarta, 10430, Indonesia
| | - Ardiana Kusumaningrum
- Department of Microbiology, Faculty of Medicine, Universitas Indonesia, Dr Cipto Mangukusumo Hospital, Jakarta, 10430, Indonesia
| | - Nadytia Kusumadjayanti
- Infectious Disease Research Centre, Faculty of Medicine, Universitas Padjadaran, Bandung, 40161, Indonesia
| | - Vycke Yunivita
- Department of Neurology, Faculty of Medicine, Universitas Padjadjaran/ Hasan Sadikin Hospital, Bandung, 40161, Indonesia.,Infectious Disease Research Centre, Faculty of Medicine, Universitas Padjadaran, Bandung, 40161, Indonesia
| | - Kogieleum Naidoo
- Centre for the AIDS programme of research in South Africa (CAPRISA), Doris Duke Medical Research Institute, Durban, 4041, South Africa.,CAPRISA-MRC HIV-TB Pathogenesis and Treatment Research Unit, Doris Duke Medical Research Institute, University of KwaZulu Natal, Durban, South Africa
| | - Richard Lessells
- Centre for the AIDS programme of research in South Africa (CAPRISA), Doris Duke Medical Research Institute, Durban, 4041, South Africa.,KwaZulu-Natal Research Innovation and Sequencing Platform, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, 4001, South Africa
| | - Yunus Moosa
- Department of Infectious Diseases, Division of Internal Medicine, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, 4013, South Africa
| | - Elin M Svensson
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands.,Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | - Katherine Huppler Hullsiek
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, 55455, USA
| | - Rob E Aarnoutse
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - David R Boulware
- Division of Medicine, University of Minnesota, Minneapolis, MN, 55455, USA
| | - Reinout van Crevel
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.,Department of Internal Medicine, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Rovina Ruslami
- Infectious Disease Research Centre, Faculty of Medicine, Universitas Padjadaran, Bandung, 40161, Indonesia.,Department of Biomedical Sciences, Division of Pharmacology and Therapy, Faculty of Medicine, Universitas Padjadjaran, Bandung, 40161, Indonesia
| | - David B Meya
- Infectious Diseases Institute, Mulago College of Health Sciences, Kampala, PO Box 22418, Uganda
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20
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Marais S, Cresswell FV, Hamers RL, te Brake LH, Ganiem AR, Imran D, Bangdiwala A, Martyn E, Kasibante J, Kagimu E, Musubire A, Maharani K, Estiasari R, Kusumaningrum A, Kusumadjayanti N, Yunivita V, Naidoo K, Lessells R, Moosa Y, Svensson EM, Huppler Hullsiek K, Aarnoutse RE, Boulware DR, van Crevel R, Ruslami R, Meya DB. High dose oral rifampicin to improve survival from adult tuberculous meningitis: A randomised placebo-controlled double-blinded phase III trial (the HARVEST study). Wellcome Open Res 2020; 4:190. [PMID: 33083560 PMCID: PMC7542255 DOI: 10.12688/wellcomeopenres.15565.1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/06/2020] [Indexed: 11/12/2023] Open
Abstract
Background: Tuberculous meningitis (TBM), the most severe form of tuberculosis (TB), results in death or neurological disability in >50%, despite World Health Organisation recommended therapy. Current TBM regimen dosages are based on data from pulmonary TB alone. Evidence from recent phase II pharmacokinetic studies suggests that high dose rifampicin (R) administered intravenously or orally enhances central nervous system penetration and may reduce TBM associated mortality. We hypothesize that, among persons with TBM, high dose oral rifampicin (35 mg/kg) for 8 weeks will improve survival compared to standard of care (10 mg/kg), without excess adverse events. Protocol: We will perform a parallel group, randomised, placebo-controlled, double blind, phase III multicentre clinical trial comparing high dose oral rifampicin to standard of care. The trial will be conducted across five clinical sites in Uganda, South Africa and Indonesia. Participants are HIV-positive or negative adults with clinically suspected TBM, who will be randomised (1:1) to one of two arms: 35 mg/kg oral rifampicin daily for 8 weeks (in combination with standard dose isoniazid [H], pyrazinamide [Z] and ethambutol [E]) or standard of care (oral HRZE, containing 10 mg/kg/day rifampicin). The primary end-point is 6-month survival. Secondary end points are: i) 12-month survival ii) functional and neurocognitive outcomes and iii) safety and tolerability. Tertiary outcomes are: i) pharmacokinetic outcomes and ii) cost-effectiveness of the intervention. We will enrol 500 participants over 2.5 years, with follow-up continuing until 12 months post-enrolment. Discussion: Our best TBM treatment still results in unacceptably high mortality and morbidity. Strong evidence supports the increased cerebrospinal fluid penetration of high dose rifampicin, however conclusive evidence regarding survival benefit is lacking. This study will answer the important question of whether high dose oral rifampicin conveys a survival benefit in TBM in HIV-positive and -negative individuals from Africa and Asia. Trial registration: ISRCTN15668391 (17/06/2019).
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Affiliation(s)
- Suzaan Marais
- Department of Neurology, Inkosi Albert Luthuli Central Hospital, Durban, 4091, South Africa
| | - Fiona V Cresswell
- Infectious Diseases Institute, Mulago College of Health Sciences, Kampala, PO Box 22418, Uganda
- Clinical Research Department, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
- MRC-UVRI, London School of Hygiene & Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Raph L. Hamers
- Eijkman-Oxford Clinical Research Unit, Jakarta, Indonesia
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Lindsey H.M. te Brake
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Ahmad R. Ganiem
- Department of Neurology, Faculty of Medicine, Universitas Padjadjaran/ Hasan Sadikin Hospital, Bandung, 40161, Indonesia
- Infectious Disease Research Centre, Faculty of Medicine, Universitas Padjadaran, Bandung, 40161, Indonesia
| | - Darma Imran
- Department of Neurology, Faculty of Medicine, Universitas Indonesia, Dr Cipto Mangukusumo Hospital, Jakarta, 10430, Indonesia
| | - Ananta Bangdiwala
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, 55455, USA
| | - Emily Martyn
- Infectious Diseases Institute, Mulago College of Health Sciences, Kampala, PO Box 22418, Uganda
| | - John Kasibante
- Infectious Diseases Institute, Mulago College of Health Sciences, Kampala, PO Box 22418, Uganda
| | - Enock Kagimu
- Infectious Diseases Institute, Mulago College of Health Sciences, Kampala, PO Box 22418, Uganda
| | - Abdu Musubire
- Infectious Diseases Institute, Mulago College of Health Sciences, Kampala, PO Box 22418, Uganda
| | - Kartika Maharani
- Department of Neurology, Faculty of Medicine, Universitas Indonesia, Dr Cipto Mangukusumo Hospital, Jakarta, 10430, Indonesia
| | - Riwanti Estiasari
- Department of Neurology, Faculty of Medicine, Universitas Indonesia, Dr Cipto Mangukusumo Hospital, Jakarta, 10430, Indonesia
| | - Ardiana Kusumaningrum
- Department of Microbiology, Faculty of Medicine, Universitas Indonesia, Dr Cipto Mangukusumo Hospital, Jakarta, 10430, Indonesia
| | - Nadytia Kusumadjayanti
- Infectious Disease Research Centre, Faculty of Medicine, Universitas Padjadaran, Bandung, 40161, Indonesia
| | - Vycke Yunivita
- Department of Neurology, Faculty of Medicine, Universitas Padjadjaran/ Hasan Sadikin Hospital, Bandung, 40161, Indonesia
- Infectious Disease Research Centre, Faculty of Medicine, Universitas Padjadaran, Bandung, 40161, Indonesia
| | - Kogieleum Naidoo
- Centre for the AIDS programme of research in South Africa (CAPRISA), Doris Duke Medical Research Institute, Durban, 4041, South Africa
- CAPRISA-MRC HIV-TB Pathogenesis and Treatment Research Unit, Doris Duke Medical Research Institute, University of KwaZulu Natal, Durban, South Africa
| | - Richard Lessells
- Centre for the AIDS programme of research in South Africa (CAPRISA), Doris Duke Medical Research Institute, Durban, 4041, South Africa
- KwaZulu-Natal Research Innovation and Sequencing Platform, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, 4001, South Africa
| | - Yunus Moosa
- Department of Infectious Diseases, Division of Internal Medicine, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, 4013, South Africa
| | - Elin M. Svensson
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | - Katherine Huppler Hullsiek
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, 55455, USA
| | - Rob E. Aarnoutse
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - David R. Boulware
- Division of Medicine, University of Minnesota, Minneapolis, MN, 55455, USA
| | - Reinout van Crevel
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Department of Internal Medicine, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Rovina Ruslami
- Infectious Disease Research Centre, Faculty of Medicine, Universitas Padjadaran, Bandung, 40161, Indonesia
- Department of Biomedical Sciences, Division of Pharmacology and Therapy, Faculty of Medicine, Universitas Padjadjaran, Bandung, 40161, Indonesia
| | - David B. Meya
- Infectious Diseases Institute, Mulago College of Health Sciences, Kampala, PO Box 22418, Uganda
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21
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Schutz C, Chirehwa M, Barr D, Ward A, Janssen S, Burton R, Wilkinson RJ, Shey M, Wiesner L, Denti P, McIlleron H, Maartens G, Meintjes G. Early antituberculosis drug exposure in hospitalized patients with human immunodeficiency virus-associated tuberculosis. Br J Clin Pharmacol 2020; 86:966-978. [PMID: 31912537 PMCID: PMC7163385 DOI: 10.1111/bcp.14207] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 11/28/2019] [Accepted: 12/16/2019] [Indexed: 12/30/2022] Open
Abstract
AIMS Patients hospitalized at the time of human immunodeficiency virus-associated tuberculosis (HIV-TB) diagnosis have high early mortality. We hypothesized that compared to outpatients, there would be lower anti-TB drug exposure in hospitalized HIV-TB patients, and amongst hospitalized patients exposure would be lower in patients who die or have high lactate (a sepsis marker). METHODS We performed pharmacokinetic sampling in hospitalized HIV-TB patients and outpatients. Plasma rifampicin, isoniazid and pyrazinamide concentrations were measured in samples collected predose and at 1, 2.5, 4, 6 and 8 hours on the third day of standard anti-TB therapy. Twelve-week mortality was ascertained for inpatients. Noncompartmental pharmacokinetic analysis was performed. RESULTS Pharmacokinetic data were collected in 59 hospitalized HIV-TB patients and 48 outpatients. Inpatient 12-week mortality was 11/59 (19%). Rifampicin, isoniazid and pyrazinamide exposure was similar between hospitalized and outpatients (maximum concentration [Cmax ]: 7.4 vs 8.3 μg mL-1 , P = .223; 3.6 vs 3.5 μg mL-1 , P = .569; 50.1 vs 46.8 μg mL-1 , P = .081; area under the concentration-time curve from 0 to 8 hours: 41.0 vs 43.8 mg h L-1 , P = 0.290; 13.5 vs 12.4 mg h L-1 , P = .630; 316.5 vs 292.2 mg h L-1 , P = .164, respectively) and not lower in inpatients who died. Rifampicin and isoniazid Cmax were below recommended ranges in 61% and 39% of inpatients and 44% and 35% of outpatients. Rifampicin exposure was higher in patients with lactate >2.2 mmol L-1 . CONCLUSION Mortality in hospitalized HIV-TB patients was high. Early anti-TB drug exposure was similar to outpatients and not lower in inpatients who died. Rifampicin and isoniazid Cmax were suboptimal in 61% and 39% of inpatients and rifampicin exposure was higher in patients with high lactate. Treatment strategies need to be optimized to improve survival.
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Affiliation(s)
- Charlotte Schutz
- Wellcome Centre for Infectious Diseases Research in AfricaInstitute of Infectious Disease and Molecular Medicine, University of Cape TownObservatorySouth Africa,Department of MedicineUniversity of Cape TownObservatorySouth Africa
| | - Maxwell Chirehwa
- Division of Clinical Pharmacology, Department of MedicineUniversity of Cape TownCape TownSouth Africa
| | - David Barr
- Wellcome Trust Liverpool Glasgow Centre for Global Health ResearchUniversity of LiverpoolLiverpoolUK
| | - Amy Ward
- Wellcome Centre for Infectious Diseases Research in AfricaInstitute of Infectious Disease and Molecular Medicine, University of Cape TownObservatorySouth Africa,Department of MedicineUniversity of Cape TownObservatorySouth Africa
| | - Saskia Janssen
- Amsterdam University Medical CentreUniversity of AmsterdamAmsterdamNetherlands
| | - Rosie Burton
- Department of MedicineUniversity of Cape TownObservatorySouth Africa,Khayelitsha Hospital, Department of MedicineCape TownSouth Africa
| | - Robert J. Wilkinson
- Wellcome Centre for Infectious Diseases Research in AfricaInstitute of Infectious Disease and Molecular Medicine, University of Cape TownObservatorySouth Africa,Department of MedicineUniversity of Cape TownObservatorySouth Africa,Department of Infectious DiseasesImperial CollegeLondonUK,The Francis Crick InstituteLondonUK
| | - Muki Shey
- Wellcome Centre for Infectious Diseases Research in AfricaInstitute of Infectious Disease and Molecular Medicine, University of Cape TownObservatorySouth Africa
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of MedicineUniversity of Cape TownCape TownSouth Africa
| | - Paolo Denti
- Division of Clinical Pharmacology, Department of MedicineUniversity of Cape TownCape TownSouth Africa
| | - Helen McIlleron
- Wellcome Centre for Infectious Diseases Research in AfricaInstitute of Infectious Disease and Molecular Medicine, University of Cape TownObservatorySouth Africa,Division of Clinical Pharmacology, Department of MedicineUniversity of Cape TownCape TownSouth Africa
| | - Gary Maartens
- Wellcome Centre for Infectious Diseases Research in AfricaInstitute of Infectious Disease and Molecular Medicine, University of Cape TownObservatorySouth Africa,Division of Clinical Pharmacology, Department of MedicineUniversity of Cape TownCape TownSouth Africa
| | - Graeme Meintjes
- Wellcome Centre for Infectious Diseases Research in AfricaInstitute of Infectious Disease and Molecular Medicine, University of Cape TownObservatorySouth Africa,Department of MedicineUniversity of Cape TownObservatorySouth Africa
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22
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Preclinical models to optimize treatment of tuberculous meningitis - A systematic review. Tuberculosis (Edinb) 2020; 122:101924. [PMID: 32501258 DOI: 10.1016/j.tube.2020.101924] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 02/19/2020] [Accepted: 03/20/2020] [Indexed: 01/04/2023]
Abstract
Tuberculous meningitis (TBM) is the most devastating form of TB, resulting in death or neurological disability in up to 50% of patients affected. Treatment is similar to that of pulmonary TB, despite poor cerebrospinal fluid (CSF) penetration of the cornerstone anti-TB drug rifampicin. Considering TBM pathology, it is critical that optimal drug concentrations are reached in the meninges, brain and/or the surrounding CSF. These type of data are difficult to collect in TBM patients. This review aims to identify and describe a preclinical model representative for human TBM which can provide the indispensable data needed for future pharmacological characterization and prioritization of new TBM regimens in the clinical setting. We reviewed existing literature on treatment of TBM in preclinical models: only eight articles, all animal studies, could be identified. None of the animal models completely recapitulated human disease and in most of the animal studies key pharmacokinetic data were missing, making the comparison with human exposure and CNS distribution, and the study of pharmacokinetic-pharmacodynamic relationships impossible. Another 18 articles were identified using other bacteria to induce meningitis with treatment including anti-TB drugs (predominantly rifampicin, moxifloxacin and levofloxacin). Of these articles the pharmacokinetics, i.e. plasma exposure and CSF:plasma ratios, of TB drugs in meningitis could be evaluated. Exposures (except for levofloxacin) agreed with human exposures and also most CSF:plasma ratios agreed with ratios in humans. Considering the lack of an ideal preclinical pharmacological TBM model, we suggest a combination of 1. basic physicochemical drug data combined with 2. in vitro pharmacokinetic and efficacy data, 3. an animal model with adequate pharmacokinetic sampling, microdialysis or imaging of drug distribution, all as a base for 4. physiologically based pharmacokinetic (PBPK) modelling to predict response to TB drugs in treatment of TBM.
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23
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Ding J, Thuy Thuong Thuong N, Pham TV, Heemskerk D, Pouplin T, Tran CTH, Nguyen MTH, Nguyen PH, Phan LP, Nguyen CVV, Thwaites G, Tarning J. Pharmacokinetics and Pharmacodynamics of Intensive Antituberculosis Treatment of Tuberculous Meningitis. Clin Pharmacol Ther 2020; 107:1023-1033. [PMID: 31956998 PMCID: PMC7158205 DOI: 10.1002/cpt.1783] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 01/13/2020] [Indexed: 12/24/2022]
Abstract
The most effective antituberculosis drug treatment regimen for tuberculous meningitis is uncertain. We conducted a randomized controlled trial comparing standard treatment with a regimen intensified by rifampin 15 mg/kg and levofloxacin for the first 60 days. The intensified regimen did not improve survival or any other outcome. We therefore conducted a nested pharmacokinetic/pharmacodynamic study in 237 trial participants to define exposure-response relationships that might explain the trial results and improve future therapy. Rifampin 15 mg/kg increased plasma and cerebrospinal fluid (CSF) exposures compared with 10 mg/kg: day 14 exposure increased from 48.2 hour·mg/L (range 18.2-93.8) to 82.5 hour·mg/L (range 8.7-161.0) in plasma and from 3.5 hour·mg/L (range 1.2-9.6) to 6.0 hour·mg/L (range 0.7-15.1) in CSF. However, there was no relationship between rifampin exposure and survival. In contrast, we found that isoniazid exposure was associated with survival, with low exposure predictive of death, and was linked to a fast metabolizer phenotype. Higher doses of isoniazid should be investigated, especially in fast metabolizers.
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Affiliation(s)
- Junjie Ding
- Nuffield Department of Clinical Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK.,The WorldWide Antimalarial Resistance Network, Oxford, UK.,Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | | | - Toi Van Pham
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam
| | - Dorothee Heemskerk
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam
| | - Thomas Pouplin
- Nuffield Department of Clinical Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK.,Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | | | | | - Phu Hoan Nguyen
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam.,Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Loc Phu Phan
- Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | | | - Guy Thwaites
- Nuffield Department of Clinical Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK.,Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam
| | - Joel Tarning
- Nuffield Department of Clinical Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK.,The WorldWide Antimalarial Resistance Network, Oxford, UK.,Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
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24
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Seddon JA, Wilkinson R, van Crevel R, Figaji A, Thwaites GE. Knowledge gaps and research priorities in tuberculous meningitis. Wellcome Open Res 2019; 4:188. [PMID: 32118120 PMCID: PMC7014926 DOI: 10.12688/wellcomeopenres.15573.1] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/14/2019] [Indexed: 12/15/2022] Open
Abstract
Tuberculous meningitis (TBM) is the most severe and disabling form of tuberculosis (TB), accounting for around 1-5% of the global TB caseload, with mortality of approximately 20% in children and up to 60% in persons co-infected with human immunodeficiency virus even in those treated. Relatively few centres of excellence in TBM research exist and the field would therefore benefit from greater co-ordination, advocacy, collaboration and early data sharing. To this end, in 2009, 2015 and 2019 we convened the TBM International Research Consortium, bringing together approximately 50 researchers from five continents. The most recent meeting took place on 1 st and 2 nd March 2019 in Lucknow, India. During the meeting, researchers and clinicians presented updates in their areas of expertise, and additionally presented on the knowledge gaps and research priorities in that field. Discussion during the meeting was followed by the development, by a core writing group, of a synthesis of knowledge gaps and research priorities within seven domains, namely epidemiology, pathogenesis, diagnosis, antimicrobial therapy, host-directed therapy, critical care and implementation science. These were circulated to the whole consortium for written input and feedback. Further cycles of discussion between the writing group took place to arrive at a consensus series of priorities. This article summarises the consensus reached by the consortium concerning the unmet needs and priorities for future research for this neglected and often fatal disease.
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Affiliation(s)
- James A Seddon
- Infectious Diseases, Imperial College London, London, W2 1PG, UK
- Paediatric Infectious Diseases, Imperial College Healthcare NHS Trust, St. Mary's Campus, London, W2 1PG, UK
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, Western Cape, 8005, South Africa
| | - Robert Wilkinson
- Infectious Diseases, Imperial College London, London, W2 1PG, UK
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, Observatory, 7925, South Africa
- Francis Crick Institute, London, NW1 1AT, UK
| | - Reinout van Crevel
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Anthony Figaji
- Neuroscience Institute, Division of Neurosurgery, University of Cape Town, Cape Town, South Africa
| | - Guy E Thwaites
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Oxford University Clinical Research Unit, University of Oxford, Ho Chi Minh City, Vietnam
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25
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Imran D, Hill PC, McKnight J, van Crevel R. Establishing the cascade of care for patients with tuberculous meningitis. Wellcome Open Res 2019; 4:177. [PMID: 32118119 PMCID: PMC7008603 DOI: 10.12688/wellcomeopenres.15515.1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/29/2019] [Indexed: 10/13/2023] Open
Abstract
Meningitis is a relatively rare form of tuberculosis, but it carries a high mortality rate, reaching 50% in some settings, with higher rates among patients with HIV co-infection and those with drug-resistant disease. Most studies of tuberculosis meningitis (TBM) tend to focus on better diagnosis, drug treatment and supportive care for patients in hospital. However, there is significant variability in mortality between settings, which may be due to specific variation in the availability and quality of health care services, both prior to, during, and after hospitalization. Such variations have not been studied thoroughly, and we therefore present a theoretical framework that may help to identify where efforts should be focused in providing optimal services for TBM patients. As a first step, we propose an adjusted cascade of care for TBM and patient pathway studies that might help identify factors that account for losses and delays across the cascade. Many of the possible gaps in the TBM cascade are related to health systems factors; we have selected nine domains and provide relevant examples of systems factors for TBM for each of these domains that could be the basis for a health needs assessment to address such gaps. Finally, we suggest some immediate action that could be taken to help make improvements in services. Our theoretical framework will hopefully lead to more health system research and improved care for patients suffering from this most dangerous form of tuberculosis.
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Affiliation(s)
- Darma Imran
- Department of Neurology, Cipto Mangunkusumo Hospital, Faculty of Medicine University of Indonesia, Jakarta, Indonesia
| | - Philip C. Hill
- Center for International Health, University of Otago, Dunedin, New Zealand
| | - Jacob McKnight
- Oxford Health System Collaboration, Oxford University, Oxford, UK
| | - Reinout van Crevel
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
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26
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Imran D, Hill PC, McKnight J, van Crevel R. Establishing the cascade of care for patients with tuberculous meningitis. Wellcome Open Res 2019; 4:177. [PMID: 32118119 PMCID: PMC7008603 DOI: 10.12688/wellcomeopenres.15515.2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/29/2019] [Indexed: 12/03/2022] Open
Abstract
Meningitis is a relatively rare form of tuberculosis, but it carries a high mortality rate, reaching 50% in some settings, with higher rates among patients with HIV co-infection and those with drug-resistant disease. Most studies of tuberculosis meningitis (TBM) tend to focus on better diagnosis, drug treatment and supportive care for patients in hospital. However, there is significant variability in mortality between settings, which may be due to specific variation in the availability and quality of health care services, both prior to, during, and after hospitalization. Such variations have not been studied thoroughly, and we therefore present a theoretical framework that may help to identify where efforts should be focused in providing optimal services for TBM patients. As a first step, we propose an adjusted cascade of care for TBM and patient pathway studies that might help identify factors that account for losses and delays across the cascade. Many of the possible gaps in the TBM cascade are related to health systems factors; we have selected nine domains and provide relevant examples of systems factors for TBM for each of these domains that could be the basis for a health needs assessment to address such gaps. Finally, we suggest some immediate action that could be taken to help make improvements in services. Our theoretical framework will hopefully lead to more health system research and improved care for patients suffering from this most dangerous form of tuberculosis.
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Affiliation(s)
- Darma Imran
- Department of Neurology, Cipto Mangunkusumo Hospital, Faculty of Medicine University of Indonesia, Jakarta, Indonesia
| | - Philip C Hill
- Center for International Health, University of Otago, Dunedin, New Zealand
| | - Jacob McKnight
- Oxford Health System Collaboration, Oxford University, Oxford, UK
| | - Reinout van Crevel
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.,Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
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27
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Cresswell F, Lange C, van Crevel R. Improving the diagnosis of tuberculous meningitis: good, but not good enough. Clin Microbiol Infect 2019; 26:134-136. [PMID: 31639473 DOI: 10.1016/j.cmi.2019.10.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 10/06/2019] [Accepted: 10/09/2019] [Indexed: 11/29/2022]
Affiliation(s)
- F Cresswell
- Clinical Research Department, London School of Hygiene and Tropical Medicine, Keppel Street, London, UK; Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda; Medical Research Council/Uganda Virus Research Institute and London School of Hygiene & Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - C Lange
- Research Center Borstel, Clinical Infectious Diseases, Borstel, Germany; German Center for Infection Research (DZIF) Clinical Tuberculosis Unit, Germany; Department of Internal Medicine, Karolinska Institute, Stockholm, Sweden.
| | - R van Crevel
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, the Netherlands; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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28
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Stemkens R, Litjens C, Dian S, Ganiem A, Yunivita V, van Crevel R, te Brake L, Ruslami R, Aarnoutse R. Pharmacokinetics of pyrazinamide during the initial phase of tuberculous meningitis treatment. Int J Antimicrob Agents 2019; 54:371-374. [DOI: 10.1016/j.ijantimicag.2019.06.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 05/29/2019] [Accepted: 06/10/2019] [Indexed: 11/27/2022]
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29
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Mezochow A, Thakur KT, Zentner I, Subbian S, Kagan L, Vinnard C. Attainment of target rifampicin concentrations in cerebrospinal fluid during treatment of tuberculous meningitis. Int J Infect Dis 2019; 84:15-21. [PMID: 31051278 PMCID: PMC6666413 DOI: 10.1016/j.ijid.2019.04.026] [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: 01/09/2019] [Revised: 03/21/2019] [Accepted: 04/24/2019] [Indexed: 11/29/2022] Open
Abstract
Objective: There is considerable uncertainty regarding the optimal use of rifampicin for the treatment of tuberculous (TB) meningitis. A pharmacokinetic modeling and simulation study of rifampicin concentrations in cerebrospinal fluid (CSF) during TB meningitis treatment was performed in this study. Methods: Parameters for rifampicin pharmacokinetics in CSF were estimated using individual-level rifampicin pharmacokinetic data, and the model was externally validated in three separate patient cohorts. Monte Carlo simulations of rifampicin serum and CSF concentrations were performed. The area under the rifampicin CSF concentration-versus-time curve during 24 h (AUC0–24) relative to the minimum inhibitory concentration (MIC) served as the pharmacodynamic target. Results: Across all simulated patients on the first treatment day, 85% attained the target AUC0–24/MIC ratio of 30 under a weight-based dosing scheme approximating 10 mg/kg. At the rifampicin MIC of 0.5 mg/l, the probability of AUC0–24/MIC target attainment was 26%. With an intensified dosing strategy corresponding to 20 mg/kg, target attainment increased to 99%, including 93% with a MIC of 0.5 mg/l. Conclusions: Under standard dosing guidelines, few TB meningitis patients would be expected to attain therapeutic rifampicin exposures in CSF when the MIC is ≤0.5 mg/l. Either downward adjustment of the rifampicin MIC breakpoint in the context of TB meningitis, or intensified rifampicin dosing upwards of 20 mg/kg/day, would reflect the likelihood of pharmacodynamic target attainment in CSF.
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Affiliation(s)
- Alyssa Mezochow
- Department of Medicine, University of Pennsylvania, 3400 Spruce, Philadelphia, PA, USA
| | - Kiran T Thakur
- Department of Neurology, Columbia University Irving Medical Center, 650 West 168th Street, New York, USA
| | - Isaac Zentner
- Public Health Research Institute, New Jersey Medical School, Rutgers University, 225 Warren St, Newark, NJ, USA
| | - Selvakumar Subbian
- Public Health Research Institute, New Jersey Medical School, Rutgers University, 225 Warren St, Newark, NJ, USA
| | - Leonid Kagan
- Department of Pharmaceutics, Ernest Mario School of Pharmacy, Rutgers University, 160 Frelinghuysen Road, Piscataway, NJ, USA
| | - Christopher Vinnard
- Public Health Research Institute, New Jersey Medical School, Rutgers University, 225 Warren St, Newark, NJ, USA.
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