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Giri A, Karkey A, Dangol S, Arjyal A, Pokharel S, Rijal S, Gajurel D, Sharma R, Lamsal K, Shrestha P, Prajapati G, Pathak S, Shrestha SR, K C RK, Pandey S, Thapa A, Shrestha N, Thapa RK, Poudyal B, Phuong DNT, Baker S, Kestelyn E, Geskus R, Thwaites G, Basnyat B. Trimethoprim-sulfamethoxazole Versus Azithromycin for the Treatment of Undifferentiated Febrile Illness in Nepal: A Double-blind, Randomized, Placebo-controlled Trial. Clin Infect Dis 2020; 73:e1478-e1486. [PMID: 32991678 PMCID: PMC8492158 DOI: 10.1093/cid/ciaa1489] [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] [Received: 08/12/2020] [Indexed: 11/12/2022] Open
Abstract
Background Azithromycin and trimethoprim-sulfamethoxazole (SXT) are widely used to treat undifferentiated febrile illness (UFI). We hypothesized that azithromycin is superior to SXT for UFI treatment, but the drugs are noninferior to each other for culture-confirmed enteric fever treatment. Methods We conducted a double-blind, randomized, placebo-controlled trial of azithromycin (20 mg/kg/day) or SXT (trimethoprim 10 mg/kg/day plus sulfamethoxazole 50 mg/kg/day) orally for 7 days for UFI treatment in Nepal. We enrolled patients >2 years and <65 years of age presenting to 2 Kathmandu hospitals with temperature ≥38.0°C for ≥4 days without localizing signs. The primary endpoint was fever clearance time (FCT); secondary endpoints were treatment failure and adverse events. Results From June 2016 to May 2019, we randomized 326 participants (163 in each arm); 87 (26.7%) had blood culture–confirmed enteric fever. In all participants, the median FCT was 2.7 days (95% confidence interval [CI], 2.6–3.3 days) in the SXT arm and 2.1 days (95% CI, 1.6–3.2 days) in the azithromycin arm (hazard ratio [HR], 1.25 [95% CI, .99–1.58]; P = .059). The HR of treatment failures by 28 days between azithromycin and SXT was 0.62 (95% CI, .37–1.05; P = .073). Planned subgroup analysis showed that azithromycin resulted in faster FCT in those with sterile blood cultures and fewer relapses in culture-confirmed enteric fever. Nausea, vomiting, constipation, and headache were more common in the SXT arm. Conclusions Despite similar FCT and treatment failure in the 2 arms, significantly fewer complications and relapses make azithromycin a better choice for empirical treatment of UFI in Nepal. Clinical Trials Registration NCT02773407.
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Affiliation(s)
- Abhishek Giri
- Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Abhilasha Karkey
- Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Lalitpur, Nepal.,Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Sabina Dangol
- Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Lalitpur, Nepal.,Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Amit Arjyal
- Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Sunil Pokharel
- Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Samita Rijal
- Patan Academy of Health Sciences, Lalitpur, Nepal
| | | | - Rabi Sharma
- Civil Service Hospital, Minbhawan Kathmandu, Nepal
| | - Kamal Lamsal
- Civil Service Hospital, Minbhawan Kathmandu, Nepal
| | | | | | - Saruna Pathak
- Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Lalitpur, Nepal
| | | | - Raj Kumar K C
- Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Sujata Pandey
- Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Abishkar Thapa
- Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Nistha Shrestha
- Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Lalitpur, Nepal
| | | | | | | | - Stephen Baker
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.,University of Cambridge, Cambridge, United Kingdom
| | - Evelyne Kestelyn
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
| | - Ronald Geskus
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
| | - Guy Thwaites
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
| | - Buddha Basnyat
- Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Lalitpur, Nepal.,Patan Academy of Health Sciences, Lalitpur, Nepal.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
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Pokharel S, Basnyat B, Arjyal A, Mahat SP, Kc RK, Bhuju A, Poudyal B, Kestelyn E, Shrestha R, Phuong DNT, Thapa R, Karki M, Dongol S, Karkey A, Wolbers M, Baker S, Thwaites G. Co-trimoxazole versus azithromycin for the treatment of undifferentiated febrile illness in Nepal: study protocol for a randomized controlled trial. Trials 2017; 18:450. [PMID: 28969659 PMCID: PMC5625657 DOI: 10.1186/s13063-017-2199-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 09/19/2017] [Indexed: 11/18/2022] Open
Abstract
Background Undifferentiated febrile illness (UFI) includes typhoid and typhus fevers and generally designates fever without any localizing signs. UFI is a great therapeutic challenge in countries like Nepal because of the lack of available point-of-care, rapid diagnostic tests. Often patients are empirically treated as presumed enteric fever. Due to the development of high-level resistance to traditionally used fluoroquinolones against enteric fever, azithromycin is now commonly used to treat enteric fever/UFI. The re-emergence of susceptibility of Salmonella typhi to co-trimoxazole makes it a promising oral treatment for UFIs in general. We present a protocol of a randomized controlled trial of azithromycin versus co-trimoxazole for the treatment of UFI. Methods/design This is a parallel-group, double-blind, 1:1, randomized controlled trial of co-trimoxazole versus azithromycin for the treatment of UFI in Nepal. Participants will be patients aged 2 to 65 years, presenting with fever without clear focus for at least 4 days, complying with other study criteria and willing to provide written informed consent. Patients will be randomized either to azithromycin 20 mg/kg/day (maximum 1000 mg/day) in a single daily dose and an identical placebo or co-trimoxazole 60 mg/kg/day (maximum 3000 mg/day) in two divided doses for 7 days. Patients will be followed up with twice-daily telephone calls for 7 days or for at least 48 h after they become afebrile, whichever is later; by home visits on days 2 and 4 of treatment; and by hospital visits on days 7, 14, 28 and 63. The endpoints will be fever clearance time, treatment failure, time to treatment failure, and adverse events. The estimated sample size is 330. The primary analysis population will be all the randomized population and subanalysis will be repeated on patients with blood culture-confirmed enteric fever and culture-negative patients. Discussion Both azithromycin and co-trimoxazole are available in Nepal and are extensively used in the treatment of UFI. Therefore, it is important to know the better orally administered antimicrobial to treat enteric fever and other UFIs especially against the background of fluoroquinolone-resistant enteric fever. Trial registration ClinicalTrials.gov, ID: NCT02773407. Registered on 5 May 2016. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-2199-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sunil Pokharel
- Oxford University Clinical Research Unit Nepal, Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Buddha Basnyat
- Oxford University Clinical Research Unit Nepal, Patan Academy of Health Sciences, Lalitpur, Nepal. .,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK.
| | - Amit Arjyal
- Oxford University Clinical Research Unit Nepal, Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Saruna Pathak Mahat
- Oxford University Clinical Research Unit Nepal, Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Raj Kumar Kc
- Oxford University Clinical Research Unit Nepal, Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Abhusani Bhuju
- Oxford University Clinical Research Unit Nepal, Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Buddhi Poudyal
- Patan Hospital, Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Evelyne Kestelyn
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK.,Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Ritu Shrestha
- Oxford University Clinical Research Unit Nepal, Patan Academy of Health Sciences, Lalitpur, Nepal
| | | | - Rajkumar Thapa
- Patan Hospital, Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Manan Karki
- Oxford University Clinical Research Unit Nepal, Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Sabina Dongol
- Oxford University Clinical Research Unit Nepal, Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Abhilasha Karkey
- Oxford University Clinical Research Unit Nepal, Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Marcel Wolbers
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK.,Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Stephen Baker
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK.,Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Guy Thwaites
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK.,Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
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Kurosu M, Siricilla S, Mitachi K. Advances in MRSA drug discovery: where are we and where do we need to be? Expert Opin Drug Discov 2013; 8:1095-116. [PMID: 23829425 DOI: 10.1517/17460441.2013.807246] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Methicillin-resistant Staphylococcus aureus (MRSA) have been on the increase during the past decade, due to the steady growth of the elderly and immunocompromised patients, and the emergence of multidrug-resistant (MDR) bacterial strains. Although there are a limited number of anti-MRSA drugs available, a number of different combination antimicrobial drug regimens have been used to treat serious MRSA infections. Thus, the addition of several new antistaphylococcal drugs into clinical practice should broaden clinician's therapeutic options. As MRSA is one of the most common and problematic bacteria associated with increasing antimicrobial resistance, continuous efforts for the discovery of lead compounds as well as development of alternative therapies and faster diagnostics are required. AREAS COVERED This article summarizes the FDA-approved drugs to treat MRSA infections, the drugs in clinical trials, and the drug leads for MRSA and related Gram-positive bacterial infections. In addition, the article discusses the mode of action of antistaphylococcal molecules and the resistant mechanisms of some molecules. EXPERT OPINION The number of pipeline drugs presently undergoing clinical trials is not particularly encouraging. There are limited and rather expensive therapeutic options for MRSA infections in the critically ill. Further research efforts are required for effective phage therapy on MRSA infections in clinical use, which seem to be attractive therapeutic options for the future.
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Affiliation(s)
- Michio Kurosu
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Tennessee, 881 Madison Avenue, Memphis, TN 38163, USA.
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Cunha BA. New uses for older antibiotics. The 'rediscovery' of four beneficial and cost-effective antimicrobials. Postgrad Med 1997; 101:68-70, 73-4, 79-80 passim. [PMID: 9126205 DOI: 10.3810/pgm.1997.04.197] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Because of its intracellular mechanism of activity, excellent safety profile, and low cost, doxycycline is one of the most extensively used antibiotics in the world, and its use will increase as new applications are found. One of its most important uses is in treatment of bacterial community-acquired pneumonias, but it is also useful against atypical pneumonias and sexually transmitted disease. As zoonotic infections continue to increase around the world, doxycycline will occupy an increasingly prominent place. Minocycline shares doxycycline's favorable attributes and also has tissue-penetration characteristics that are important when therapeutic alternatives are few, as in MRSA. TMP-SMX is widely used to treat urinary and respiratory tract infections and for prophylaxis and treatment of P carinii infection. As the AIDS epidemic continues, its use will continue to grow, because it is also effective against other pathogens associated with AIDS. TMP-SMX is relatively underused for treating gram-negative bacteremias, especially nosocomial infections caused by nonaeruginosa pseudomonads. Metronidazole is a cost-effective antianaerobic component in treatment of intra-abdominal and pelvic infections, especially when it is combined with a once-a-day antibiotic.
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Affiliation(s)
- B A Cunha
- Infectious disease division, Winthrop-University Hospital, Mineola, New York 11501, USA
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