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Wang R, Oliveira LVN, Hester MM, Carlson D, Christensen D, Specht CA, Levitz SM. Protection against experimental cryptococcosis elicited by Cationic Adjuvant Formulation 01-adjuvanted subunit vaccines. bioRxiv 2024:2024.04.24.591045. [PMID: 38712080 PMCID: PMC11071535 DOI: 10.1101/2024.04.24.591045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2024]
Abstract
The fungal infection, cryptococcosis, is responsible for >100,000 deaths annually. No licensed vaccines are available. We explored the efficacy and immune responses of subunit cryptococcal vaccines adjuvanted with Cationic Adjuvant Formulation 01 (CAF01). CAF01 promotes humoral and T helper (Th) 1 and Th17 immune responses and has been safely used in human vaccine trials. Four subcutaneous vaccines, each containing single recombinant Cryptococcus neoformans protein antigens, partially protected mice from experimental cryptococcosis. Protection increased, up to 100%, in mice that received bivalent and quadrivalent vaccine formulations. Vaccinated mice that received a pulmonary challenge with C. neoformans had an influx of leukocytes into the lung including robust numbers of polyfunctional CD4+ T cells which produced Interferon gamma (IFNγ), tumor necrosis factor alpha (TNFα), and interleukin (IL)-17 upon ex vivo antigenic stimulation. Cytokine-producing lung CD8+ T cells were also found, albeit in lesser numbers. A significant, durable IFNγ response was observed in the lungs, spleen, and blood. Moreover, IFNγ secretion following ex vivo stimulation directly correlated with fungal clearance in the lungs. Thus, we have developed multivalent cryptococcal vaccines which protect mice from experimental cryptococcosis using an adjuvant which has been safely tested in humans. These preclinical studies suggest a path towards human cryptococcal vaccine trials.
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Affiliation(s)
- Ruiying Wang
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Lorena V. N. Oliveira
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Maureen M. Hester
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Diana Carlson
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Dennis Christensen
- Statens Serum Institut, Copenhagen, Denmark
- Present address: Croda Pharma, Diplomvej 381, Lyngby 2800, Denmark
| | - Charles A. Specht
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Stuart M. Levitz
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, USA
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Sapra A, Hm H, Amin SM, Syahrani, Kelsi FA, Nur S, Permana AD. Development of mucoadhesive microspheres for intranasal delivery of fluconazole as an alternative treatment of cryptococcal meningitis infection in patients with acquired immunodeficiency. Ann Pharm Fr 2024:S0003-4509(24)00046-4. [PMID: 38604290 DOI: 10.1016/j.pharma.2024.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 01/23/2024] [Accepted: 04/03/2024] [Indexed: 04/13/2024]
Abstract
INTRODUCTION Cryptococcal meningitis is a deadly disease with few treatment options. Its incidence is still high and closely linked to the HIV/AIDS epidemic. This study aimed to develop a mucoadhesive microsphere delivery system for fluconazole for the intranasal route. METHOD Microspheres of mucoadhesive fluconazole formulation variables such as different amounts of drug concentration and polymer concentration were prepared by a simple emulsion-crosslinking method. The prepared microspheres' surface was characterised by SEM (Scanning electron microscopy) and evaluated for particle size, entrapment efficiency, production yield, infrared spectroscopic study, in-vitro muco-adhesion, and in-vitro drug release. RESULTS The results showed that formula 1 is the optimal mucoadhesive microsphere preparation, with a particle size of 56.375m, a spherical surface shape, an entrapment efficiency of 99.96%, and a greater mucoadhesive capability during 6-hour evaluation. Furthermore, wash-off examination revealed that the mucoadhesive ability of this delivery system has a long duration and may release the active material at the right time. CONCLUSION The result of the researches suggesting that the formulation of mucoadhesive microspheres of fluconazole could be used to treat cryptococcal meningitis infection in HIV/AIDS patients.
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Affiliation(s)
- Amriani Sapra
- Department of Pharmaceutical Technology, Almarisah Madani University, 90242 Makassar, Indonesia.
| | - Hendrawan Hm
- Department of Pharmaceutical Technology, Almarisah Madani University, 90242 Makassar, Indonesia
| | - Sayyid M Amin
- Department of Pharmaceutical Technology, Almarisah Madani University, 90242 Makassar, Indonesia
| | - Syahrani
- Department of Pharmaceutical Technology, Almarisah Madani University, 90242 Makassar, Indonesia
| | - Filia Ananda Kelsi
- Department of Pharmaceutical Technology, Almarisah Madani University, 90242 Makassar, Indonesia
| | - Syamsu Nur
- Department of Pharmaceutical Chemistry, Almarisah Madani University, 90242 Makassar, Indonesia
| | - Andi Dian Permana
- Department of Pharmaceutical Technology, Hasanuddin University, 90242 Makassar, Indonesia
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Ye X, Zhang L, Yang Q, Pan W, Zeng X. Rapid duplex flap probe-based isothermal assay to identify the Cryptococcus neoformans and Cryptococcus gattii. Front Cell Infect Microbiol 2024; 14:1321886. [PMID: 38558853 PMCID: PMC10981274 DOI: 10.3389/fcimb.2024.1321886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Accepted: 02/19/2024] [Indexed: 04/04/2024] Open
Abstract
Cryptococcosis is a life-threatening invasive fungal infection with significantly increasing mortality worldwide, which is mainly caused by Cryptococcus neoformans and Cryptococcus gattii. These two species complexes have different epidemiological and clinical characteristics, indicating the importance of accurate differential diagnosis. However, the clinically used culture method and cryptococcal capsular antigen detection couldn't achieve the above goals. Herein, we established a novel duplex flap probe-based isothermal assay to identify the Cryptococcus neoformans and Cryptococcus gattii within 1 hour. This assay combined the highly sensitive nucleic acid isothermal amplification and highly specific fluorescence probe method, which could effectively distinguish the sequence differences of the two species complexes using two different fluorescence flap probes in a single reaction system. This novel method showed excellent detection performance with sensitivity (10 copies/μL each) and specificity (100%) compared to traditional culture and sequencing methods. Furthermore, we applied this method to spiked clinical samples, 30 cerebrospinal fluids and 30 bronchoalveolar lavage fluids, which kept good detection performance. This novel rapid duplex flap probe-based isothermal assay is a promising and robust tool for applications in differential diagnosis of the Cryptococcus neoformans and Cryptococcus gattii in clinical settings, especially when clinical suspicion for cryptococcal disease is high and epidemiological studies.
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Affiliation(s)
- Xin Ye
- Department of Laboratory Medicine, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi, China
| | - Lei Zhang
- Department of Dermatology, The third affiliated hospital of Xi’an Jiaotong University, Shaanxi Provincial People’s Hospital, Xi’an, Shaanxi, China
| | - Qingqing Yang
- Department of Laboratory Medicine, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi, China
| | - Weihua Pan
- Department of Dermatology, Shanghai Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Xiaoyan Zeng
- Department of Laboratory Medicine, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi, China
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Duarte I, Rodrigues ML. Funding for research on cryptococcal disease: an analysis based on the G-finder report. IMA Fungus 2024; 15:4. [PMID: 38429837 PMCID: PMC10908028 DOI: 10.1186/s43008-023-00133-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 11/13/2023] [Indexed: 03/03/2024] Open
Abstract
Members of the genus Cryptococcus are the causative agents of cryptococcal meningitis, a disease mainly associated with HIV-induced immunosuppression. Patients with cryptococcal meningitis are at a serious risk of death. Most patients suffering from cryptococcosis belong to neglected populations. With reduced support for research, new therapies are unlikely to emerge. In this essay, we used the Policy Cures/G-finder platform as a reference database for funding research on cryptococcal disease. Funding for cryptococcal research started being tracked by G-finder in 2013 and has continued to appear in the annual reports ever since. In total, 15 institutions were reported as major funders for research on cryptococcal disease over the years. The US National Institutes of Health (NIH) was the main funder, followed by the UK's Wellcome Trust. The annual analysis suggested slow yearly growth in funding from 2013 to 2021. The development of new tools to prevent and fight cryptococcal disease is urgent but requires improved funding.
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Affiliation(s)
- Iraine Duarte
- Instituto Carlos Chagas, Fundação Oswaldo Cruz (Fiocruz), Rua Professor Algacyr Munhoz Mader 3775- CIC, Curitiba, PR, 81350-010, Brazil
| | - Marcio L Rodrigues
- Instituto Carlos Chagas, Fundação Oswaldo Cruz (Fiocruz), Rua Professor Algacyr Munhoz Mader 3775- CIC, Curitiba, PR, 81350-010, Brazil.
- Instituto de Microbiologia Paulo de Góes (IMPG), Universidade Federal do Rio de Janeiro. Cidade Universitária, Centro de Ciências da Saúde., Rio de Janeiro, RJ, 21941-902, Brazil.
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Liu R, Li X, Liu Y, Du L, Zhu Y, Wu L, Hu B. A high-speed microscopy system based on deep learning to detect yeast-like fungi cells in blood. Bioanalysis 2024; 16:289-303. [PMID: 38334080 DOI: 10.4155/bio-2023-0193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2024] Open
Abstract
Background: Blood-invasive fungal infections can cause the death of patients, while diagnosis of fungal infections is challenging. Methods: A high-speed microscopy detection system was constructed that included a microfluidic system, a microscope connected to a high-speed camera and a deep learning analysis section. Results: For training data, the sensitivity and specificity of the convolutional neural network model were 93.5% (92.7-94.2%) and 99.5% (99.1-99.5%), respectively. For validating data, the sensitivity and specificity were 81.3% (80.0-82.5%) and 99.4% (99.2-99.6%), respectively. Cryptococcal cells were found in 22.07% of blood samples. Conclusion: This high-speed microscopy system can analyze fungal pathogens in blood samples rapidly with high sensitivity and specificity and can help dramatically accelerate the diagnosis of fungal infectious diseases.
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Affiliation(s)
- Ruiqi Liu
- Guangxi Key Laboratory of Special Biomedicine, School of Medicine, Guangxi University, Nanning, Guangxi, P.R. China
| | - Xiaojie Li
- Department of Laboratory Medicine, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, P.R. China
| | - Yingyi Liu
- Guangxi Key Laboratory of Special Biomedicine, School of Medicine, Guangxi University, Nanning, Guangxi, P.R. China
| | - Lijun Du
- Department of Clinical Laboratory, Huadu District People's Hospital of Guangzhou, Guangdong, China
| | - Yingzhu Zhu
- Guangzhou Waterrock Gene Technology, Guangdong, China
| | - Lichuan Wu
- Guangxi Key Laboratory of Special Biomedicine, School of Medicine, Guangxi University, Nanning, Guangxi, P.R. China
| | - Bo Hu
- Department of Laboratory Medicine, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, P.R. China
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Minja M, Mbilinyi T, Mkinga B, Philipo EG, Owenya J, Kilonzi M. Prevalence, treatment, and factors associated with cryptococcal meningitis post introduction of integrase inhibitors antiretroviral based regimens among People Living with HIV in Tanzania. PLoS One 2024; 19:e0294940. [PMID: 38412200 PMCID: PMC10898767 DOI: 10.1371/journal.pone.0294940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 01/12/2024] [Indexed: 02/29/2024] Open
Abstract
OBJECTIVE This study aimed to assess the prevalence of Cryptococcal Meningitis (CM), treatment practice, and the associated factors post-introduction of Tenofovir Lamivudine and Dolutegravir (TLD) regimen among People Living with HIV (PLHIV) in Tanzania. METHODS This was an analytical cross-sectional study, and the data was collected retrospectively in three public regional referral hospitals (RRHs) in Dar es Salaam, Tanzania. A total of 405 files of the PLHIV admitted in the medical wards on the TLD regimen from January 2019 to December 2022 were reviewed. The collected information includes the patient's demographic characteristics, Cryptococcal status, CD4 level at the time of CM diagnosis, status of using ART, CM treatment approach, and outcome. Data was analyzed using SPSS software version 23. RESULTS Out of 405 patients, the majority 267(65.9%) were female, 224(55.3%) were aged between 36-55 years, and 293(72.3%) were married. ART defaulters were found to be 37(9.1%). The prevalence of CM was found to be 48(11.9%), out of which 42(87.5%) received fluconazole alone. ART defaulter and marital status significantly (p-value < 0.05) were associated with those who tested CM positive. CONCLUSION The study found the prevalence of CM among PLHIV to be significantly high and the majority were treated with fluconazole alone. ART defaulters and marital status were significantly associated with one being CM positive. Responsible authorities and stakeholders should enforce guideline adherence and PLHIV should be encouraged on medication adherence.
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Affiliation(s)
- Makyao Minja
- Department of Clinical Pharmacy and Pharmacology, School of Pharmacy, The Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Tusaligwe Mbilinyi
- Department of Pharmaceutical Microbiology, School of Pharmacy, The Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Bryceson Mkinga
- Department of Pharmacognosy, School of Pharmacy, The Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Erick G Philipo
- Department of Pharmaceutics and Pharmacy Practice, School of Pharmacy, The Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Joyce Owenya
- Department of Pharmacy, Temeke Regional Referral Hospital, Dar es Salaam, Tanzania
| | - Manase Kilonzi
- Department of Clinical Pharmacy and Pharmacology, School of Pharmacy, The Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
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Liang D, Li X. Concomitant of Cryptococcal Meningitis and COVID-19 in a Female Patient with Primary Nephrotic Syndrome and Type 2 Diabetes. Risk Manag Healthc Policy 2024; 17:279-285. [PMID: 38313397 PMCID: PMC10838511 DOI: 10.2147/rmhp.s451991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 01/26/2024] [Indexed: 02/06/2024] Open
Abstract
Background Patients with primary nephrotic syndrome (PNS) are at an increased risk of developing various infections due to the long-term use of immunosuppressive agents. Cryptococcal meningitis (CM) is an uncommon but severe complication that can occur in patients with PNS, particularly those receiving immunosuppressive medications. Case Description This case report describes a middle-aged female patient with PNS and type 2 diabetes mellitus (T2DM) who developed CM. She received a combination regimen of cyclophosphamide and prednisone, achieving partial remission of PNS. However, she later returned to the hospital with high fever and headache. At admission, her nasopharyngeal swab test was positive for severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) and she received therapy of dexamethasone and favipiravir, but her fever and headache were not improved. Following a lumbar puncture was performed for her and CM was diagnosed based on a positive Cryptococcus culture in the cerebrospinal fluid. The patient's cyclophosphamides were temporarily discontinued, and antifungal therapy with amphotericin B liposome and fluconazole was initiated. Despite a noticeable increase in her blood glucose levels due to infection during her hospitalization, she showed improvement with intensified glycemic control treatment. The anti-infection showed significant effectiveness, and the patient's proteinuria remained stable during follow-up. Conclusion The patient with PNS and T2DM was concurrently diagnosed with both CM and coronavirus disease 2019 (COVID-19), marking the first reported case of such co-infections in these patients. Prompt diagnosis and appropriate antifungal therapy are crucial for improved outcomes of PNS patients with CM and COVID-19.
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Affiliation(s)
- Dongrui Liang
- 2nd Department of Ophthalmology, Baoding No.1 Central Hospital of Hebei Medical University, Baoding, Hebei, People’s Republic of China
| | - Xiaodong Li
- Department of Nephrology, Baoding No.1 Central Hospital of Hebei Medical University, Baoding, Hebei, People’s Republic of China
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Mfinanga S, Kanyama C, Kouanfack C, Nyirenda S, Kivuyo SL, Boyer-Chammard T, Phiri S, Ngoma J, Shimwela M, Nkungu D, Fomete LN, Simbauranga R, Chawinga C, Ngakam N, Heller T, Lontsi SS, Aghakishiyeva E, Jalava K, Fuller S, Reid AM, Rajasingham R, Lawrence DS, Hosseinipour MC, Beaumont E, Bradley J, Jaffar S, Lortholary O, Harrison T, Molloy SF, Sturny-Leclère A, Loyse A. Reduction in mortality from HIV-related CNS infections in routine care in Africa (DREAMM): a before-and-after, implementation study. Lancet HIV 2023; 10:e663-e673. [PMID: 37802567 DOI: 10.1016/s2352-3018(23)00182-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 05/16/2023] [Accepted: 07/19/2023] [Indexed: 10/10/2023]
Abstract
BACKGROUND Four decades into the HIV epidemic, CNS infection remains a leading cause of preventable HIV-related deaths in routine care. The Driving Reduced AIDS-associated Meningo-encephalitis Mortality (DREAMM) project aimed to develop, implement, and evaluate pragmatic implementation interventions and strategies to reduce mortality from HIV-related CNS infection. METHODS DREAMM took place in five public hospitals in Cameroon, Malawi, and Tanzania. The main intervention was a stepwise algorithm for HIV-related CNS infections including bedside rapid diagnostic testing and implementation of WHO cryptococcal meningitis guidelines. A health system strengthening approach for hospitals was adopted to deliver quality care through a co-designed education programme, optimised clinical and laboratory pathways, and communities of practice. DREAMM was led and driven by local leadership and divided into three phases: observation (including situational analyses of routine care), training, and implementation. Consecutive adults (aged ≥18 years) living with HIV presenting with a first episode of suspected CNS infection were eligible for recruitment. The primary endpoint was the comparison of 2-week all-cause mortality between observation and implementation phases. This study completed follow-up in September, 2021. The project was registered on ClinicalTrials.gov, NCT03226379. FINDINGS From November, 2016 to April, 2019, 139 eligible participants were enrolled in the observation phase. From Jan 9, 2018, to March 25, 2021, 362 participants were enrolled into the implementation phase. 216 (76%) of 286 participants had advanced HIV disease (209 participants had missing CD4 cell count), and 340 (69%) of 494 participants had exposure to antiretroviral therapy (ART; one participant had missing ART data). In the implementation phase 269 (76%) of 356 participants had a probable CNS infection, 203 (76%) of whom received a confirmed microbiological or radiological diagnosis of CNS infection using existing diagnostic tests and medicines. 63 (49%) of 129 participants died at 2 weeks in the observation phase compared with 63 (24%) of 266 in the implementation phase; and all-cause mortality was lower in the implementation phase when adjusted for site, sex, age, ART exposure (adjusted risk difference -23%, 95% CI -33 to -13; p<0·001). At 10 weeks, 71 (55%) died in the observation phase compared with 103 (39%) in the implementation phase (-13%, -24 to -3; p=0·01). INTERPRETATION DREAMM substantially reduced mortality from HIV-associated CNS infection in resource-limited settings in Africa. DREAMM scale-up is urgently required to reduce deaths in public hospitals and help meet Sustainable Development Goals. FUNDING European and Developing Countries Clinical Trials Partnership, French Agency for Research on AIDS and Viral Hepatitis. TRANSLATIONS For the French and Portuguese translations of the abstract see Supplementary Materials section.
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Affiliation(s)
- Sayoki Mfinanga
- National Institute for Medical Research, Muhimbili Medical Research Centre, Dar es Salaam, Tanzania; Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Cecilia Kanyama
- University of North Carolina Project-Malawi, Kamuzu Central Hospital, Lilongwe, Malawi
| | | | | | - Sokoine Lesikari Kivuyo
- National Institute for Medical Research, Muhimbili Medical Research Centre, Dar es Salaam, Tanzania
| | - Timothée Boyer-Chammard
- Unité de Mycologie Moléculaire, Institut Pasteur, Université de Paris, Centre National de la Recherche Scientifique, Paris, France
| | | | | | | | | | | | - Rehema Simbauranga
- National Institute for Medical Research, Muhimbili Medical Research Centre, Dar es Salaam, Tanzania
| | - Chimwemwe Chawinga
- University of North Carolina Project-Malawi, Kamuzu Central Hospital, Lilongwe, Malawi
| | | | | | | | - Elnara Aghakishiyeva
- Institute for Infection and Immunity, St George's University of London, London, UK
| | | | - Sebastian Fuller
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Anne-Marie Reid
- Leeds Institute of Medical Education, University of Leeds, Leeds, UK
| | | | - David S Lawrence
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK; Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Mina C Hosseinipour
- University of North Carolina Project-Malawi, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Emma Beaumont
- Department of Infectious Disease Epidemiology and International Health, London School of Hygiene and Tropical Medicine, London, UK
| | - John Bradley
- Department of Infectious Disease Epidemiology and International Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Shabbar Jaffar
- UCL Institute for Global Health, University College London, London, UK
| | - Olivier Lortholary
- Unité de Mycologie Moléculaire, Institut Pasteur, Université de Paris, Centre National de la Recherche Scientifique, Paris, France; Necker-Enfants Malades Hospital, Assistance Publique - Hôpitaux de Paris, Institut Hospitalier Universitaire Imagine, Paris, France
| | - Thomas Harrison
- Institute for Infection and Immunity, St George's University of London, London, UK
| | - Síle F Molloy
- Institute for Infection and Immunity, St George's University of London, London, UK
| | - Aude Sturny-Leclère
- Institut Pasteur, Université Paris Cité, National Reference Center for Invasive Mycoses and Antifungals, Translational Mycology Research Group, Mycology Department, Paris, France
| | - Angela Loyse
- Unité de Mycologie Moléculaire, Institut Pasteur, Université de Paris, Centre National de la Recherche Scientifique, Paris, France; Institute for Infection and Immunity, St George's University of London, London, UK.
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Huang J, Lei J, Ge A, Xiao W, Xin C, Song Z, Zhang J. Antifungal Effect of Vitamin D 3 against Cryptococcus neoformans Coincides with Reduced Biofilm Formation, Compromised Cell Wall Integrity, and Increased Generation of Reactive Oxygen Species. J Fungi (Basel) 2023; 9:772. [PMID: 37504760 PMCID: PMC10381739 DOI: 10.3390/jof9070772] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 07/15/2023] [Accepted: 07/20/2023] [Indexed: 07/29/2023] Open
Abstract
Cryptococcus neoformans is an invasive fungus that causes both acute and chronic infections, especially in immunocompromised patients. Owing to the increase in the prevalence of drug-resistant pathogenic fungi and the limitations of current treatment strategies, drug repositioning has become a feasible strategy to accelerate the development of new drugs. In this study, the minimum inhibitory concentration of vitamin D3 (VD3) against C. neoformans was found to be 0.4 mg/mL by broth microdilution assay. The antifungal activities of VD3 were further verified by solid dilution assays and "time-kill" curves. The results showed that VD3 reduced fungal cell adhesion and hydrophobicity and inhibited biofilm formation at various developmental stages, as confirmed by crystal violet staining and the 2,3-bis(2-methoxy-4-nitro-5-sulfophenyl)-2H-tetrazolium-5-carboxanilide assay. Fluorescence staining of cellular components and a stress susceptibility assay indicated that VD3 compromised cell integrity. Reverse transcription quantitative PCR demonstrated that VD3 treatment upregulated the expression of fungal genes related to cell wall synthesis (i.e., CDA3, CHS3, FKS1, and AGS1). Moreover, VD3 enhanced cell membrane permeability and caused the accumulation of intracellular reactive oxygen species. Finally, VD3 significantly reduced the tissue fungal burden and prolonged the survival of Galleria mellonella larvae infected with C. neoformans. These results showed that VD3 could exert significant antifungal activities both in vitro and in vivo, demonstrating its potential application in the treatment of cryptococcal infections.
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Affiliation(s)
- Jian Huang
- Public Center of Experimental Technology, School of Basic Medical Sciences, Southwest Medical University, Luzhou 646000, China
| | - Junwen Lei
- Public Center of Experimental Technology, School of Basic Medical Sciences, Southwest Medical University, Luzhou 646000, China
| | - Anni Ge
- Public Center of Experimental Technology, School of Basic Medical Sciences, Southwest Medical University, Luzhou 646000, China
| | - Wei Xiao
- Public Center of Experimental Technology, School of Basic Medical Sciences, Southwest Medical University, Luzhou 646000, China
| | - Caiyan Xin
- Public Center of Experimental Technology, School of Basic Medical Sciences, Southwest Medical University, Luzhou 646000, China
| | - Zhangyong Song
- Public Center of Experimental Technology, School of Basic Medical Sciences, Southwest Medical University, Luzhou 646000, China
| | - Jinping Zhang
- Public Center of Experimental Technology, School of Basic Medical Sciences, Southwest Medical University, Luzhou 646000, China
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Ingle SM, Miro JM, May MT, Cain LE, Schwimmer C, Zangerle R, Sambatakou H, Cazanave C, Reiss P, Brandes V, Bucher HC, Sabin C, Vidal F, Obel N, Mocroft A, Wittkop L, d'Arminio Monforte A, Torti C, Mussini C, Furrer H, Konopnicki D, Teira R, Saag MS, Crane HM, Moore RD, Jacobson JM, Mathews WC, Geng E, Eron JJ, Althoff KN, Kroch A, Lang R, Gill MJ, Sterne JAC. Early Antiretroviral Therapy Not Associated With Higher Cryptococcal Meningitis Mortality in People With Human Immunodeficiency Virus in High-Income Countries: An International Collaborative Cohort Study. Clin Infect Dis 2023; 77:64-73. [PMID: 36883578 PMCID: PMC10320049 DOI: 10.1093/cid/ciad122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 12/13/2022] [Accepted: 03/02/2023] [Indexed: 03/09/2023] Open
Abstract
BACKGROUND Randomized controlled trials (RCTs) from low- and middle-income settings suggested that early initiation of antiretroviral therapy (ART) leads to higher mortality rates among people with HIV (PWH) who present with cryptococcal meningitis (CM). There is limited information about the impact of ART timing on mortality rates in similar people in high-income settings. METHODS Data on ART-naive PWH with CM diagnosed from 1994 to 2012 from Europe/North America were pooled from the COHERE, NA-ACCORD, and CNICS HIV cohort collaborations. Follow-up was considered to span from the date of CM diagnosis to earliest of the following: death, last follow-up, or 6 months. We used marginal structural models to mimic an RCT comparing the effects of early (within 14 days of CM) and late (14-56 days after CM) ART on all-cause mortality, adjusting for potential confounders. RESULTS Of 190 participants identified, 33 (17%) died within 6 months. At CM diagnosis, their median age (interquartile range) was 38 (33-44) years; the median CD4+ T-cell count, 19/μL (10-56/μL); and median HIV viral load, 5.3 (4.9-5.6) log10 copies/mL. Most participants (n = 157 [83%]) were male, and 145 (76%) started ART. Mimicking an RCT, with 190 people in each group, there were 13 deaths among participants with an early ART regimen and 20 deaths among those with a late ART regimen. The crude and adjusted hazard ratios comparing late with early ART were 1.28 (95% confidence interval, .64-2.56) and 1.40 (.66-2.95), respectively. CONCLUSIONS We found little evidence that early ART was associated with higher mortality rates among PWH presenting with CM in high-income settings, although confidence intervals were wide.
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Affiliation(s)
- Suzanne M Ingle
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Jose M Miro
- Infectious Diseases Service Hospital Clinic–IDIBAPS, University of Barcelona, Barcelona, Spain
- CIBERINFEC, Instituto de Salud Carlos III, Madrid, Spain
| | - Margaret T May
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Lauren E Cain
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
- Global Epidemiology, AbbVie, Chicago, Illinois, USA
| | - Christine Schwimmer
- University of Bordeaux, INSERM, Institut Bergonié, CHU de Bordeaux, CIC-EC 1401, Bordeaux, France
| | - Robert Zangerle
- Department of Dermatology, Venereology, and Allergy, Medical University Innsbruck, Innsbruck, Austria
| | - Helen Sambatakou
- 2nd Department of Internal Medicine, HIV Unit, Medical School, Hippokration General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Charles Cazanave
- Infectious and Tropical Diseases Department, CHU de Bordeaux, Bordeaux, France
| | - Peter Reiss
- Stichting HIV Monitoring, Amsterdam, The Netherlands
| | - Vanessa Brandes
- Department I of Internal Medicine, Division of Infectious Diseases, University of Cologne, Cologne, Germany
| | - Heiner C Bucher
- Basel Institute for Clinical Epidemiology & Biostatistics, Division of Infectious Diseases & Hospital Hygiene, University Hospital Basel, Basel, Switzerland
| | - Caroline Sabin
- Centre for Clinical Research, Epidemiology, Modelling and Evaluation, Institute for Global Health, University College London, London, United Kingdom
| | - Francesc Vidal
- Infectious Diseases Unit, Hospital Universitari de Tarragona Joan XXIII, IISPV, Universitat Rovira i Virgili, Tarragona, Spain
- CIBER Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
| | - Niels Obel
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Amanda Mocroft
- Centre of Excellence for Health, Immunity and Infections (CHIP) and PERSIMUNE, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Linda Wittkop
- ISPED, INSERM, Bordeaux Population Health Research Center, University of Bordeaux, Bordeaux, France
| | - Antonella d'Arminio Monforte
- Clinic of Infectious and Tropical Diseases, Department of Health Sciences, University of Milan, San Paolo Hospital, Milan, Italy
| | - Carlo Torti
- Department of Surgical and Medical Sciences, University “Magna Graecia,”, Catanzaro, Italy
| | - Cristina Mussini
- Infectious Diseases Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Hansjakob Furrer
- Department of Infectious Diseases, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Deborah Konopnicki
- Infectious Diseases Department, Saint-Pierre University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Ramon Teira
- Service of Internal Medicine, Hospital Universitario de Sierrallana, Torrelavega, Spain
| | - Michael S Saag
- Center for AIDS Research, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Heidi M Crane
- Division of Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Richard D Moore
- School of Medicine, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | - W Chris Mathews
- Department of Medicine, University of California San Diego, San Diego, California, USA
| | - Elvin Geng
- Division of Infectious Diseases, Department of Medicine and the Center for Dissemination and Implementation, Institute for Public Health, Washington University in St Louis, St Louis, Missouri, USA
| | - Joseph J Eron
- Department of Medicine, UNC School of Medicine, Chapel Hill, North Carolina, USA
| | - Keri N Althoff
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | - Raynell Lang
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - M John Gill
- Department of Medicine, University of Calgary, Southern Alberta HIV Clinic, Calgary, Alberta, Canada
| | - Jonathan A C Sterne
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
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11
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Liu S, Chen W, Cheng F, Ye X, Pan N, Lu H. Clinical characteristics and prognostic factors of 60 patients with acquired immune deficiency syndrome combined with Cryptococcus neoformans. BMC Infect Dis 2023; 23:204. [PMID: 37024795 PMCID: PMC10080839 DOI: 10.1186/s12879-023-08137-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 03/06/2023] [Indexed: 04/08/2023] Open
Abstract
OBJECTIVE Cryptococcal meningitis (CM) threatens people's health and is the main cause of opportunistic fungus-related death in acquired immune deficiency syndrome (AIDS) patients. Herein, we investigate the clinical characteristics and prognostic factors of AIDS patients with Cryptococcus neoformans in Wenzhou, Zhejiang Province, China. METHODS Our study enrolled AIDS patients diagnosed with Cryptococcus neoformans infection who were hospitalised in our hospital. They were divided into Group A (32 patients with CM) and Group B (28 patients without CM) according to their diagnosis. The differences between the two groups of patients' clinical symptoms, imaging examinations and laboratory examinations were observed. Statistical methods were used to analyse the difference in prognosis between the two groups. RESULTS Headache and fever were the most common clinical characteristics for patients with CM, while respiratory symptoms and fever were the most common clinical characteristics for patients without CM. The positive rate of cryptococcal capsular antigen, India ink staining and culture in the cerebrospinal fluid examination was higher in the CM patients than in the non-CM patients. The overall morbidity and mortality rate after systemic antifungal therapy was higher in the CM patients than in the non-CM patients. A higher incidence of headache, impaired consciousness, nuchal rigidity, first intracranial pressure > 200 mmH2O and mortality was observed in the CM patients than in the non-CM patients. Multifactorial logistic regression analysis showed that headache risk factors affecting the patient's prognosis at 12 weeks. CONCLUSION Patients with AIDS diagnosed with Cryptococcus neoformans infection have insidious clinical symptoms in the early stage, and their manifestation is often non-specific, resulting in poor prognosis and high mortality among CM patients compared to patients without CM. Therefore, early identification and timely antifungal therapy before the disease progresses to meningitis are of great value in improving the survival rate of patients.
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Affiliation(s)
- Saiduo Liu
- Departments of Infectious Disease, The Dingli Clinical College of Wenzhou Medical University, Wenzhou, Zhejiang, 325000, China
| | - Wei Chen
- Department of Radiology, The 2ed Affiliated Hospital of Wenzhou Medical University, Fuxue Lane, No. 2, Wenzhou, Zhejiang, 325000, China
| | - Fang Cheng
- Departments of Infectious Disease, The Dingli Clinical College of Wenzhou Medical University, Wenzhou, Zhejiang, 325000, China
| | - Xinchun Ye
- Departments of Infectious Disease, The Dingli Clinical College of Wenzhou Medical University, Wenzhou, Zhejiang, 325000, China
| | - Ning Pan
- Departments of Infectious Disease, The Dingli Clinical College of Wenzhou Medical University, Wenzhou, Zhejiang, 325000, China
| | - Hongzhou Lu
- Department of Infectious Disease, The 1st School of Medicine,School of Information and Engineering,The1st Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, 325000, China.
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12
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Bisso BN, Makuété AL, Tsopmene JU, Dzoyem JP. Biofilm Formation and Phospholipase and Proteinase Production in Cryptococcus neoformans Clinical Isolates and Susceptibility towards Some Bioactive Natural Products. ScientificWorldJournal 2023; 2023:6080489. [PMID: 37035538 PMCID: PMC10081907 DOI: 10.1155/2023/6080489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 03/01/2023] [Accepted: 03/15/2023] [Indexed: 04/04/2023] Open
Abstract
Background. Cryptococcosis is one of the most common fungal infections in immunocompromised patients, which is caused by Cryptococcus neoformans. However, relatively little is known about the virulence factors of C. neoformans and the incidence of antifungal drug resistance in C. neoformans is rapidly increasing. This study was undertaken to investigate the virulence factors in C. neoformans, thymol, curcumin, piperine, gallic acid, eugenol, and plumbagin for their potential antimicrobial activity against C. neoformans. Methods. The production of phospholipase and proteinase was detected using standard methods. Biofilm formation was determined using the microtiter plate method. The broth microdilution method was used to determine the antifungal activity. The antibiofilm activity was assessed using the safranin staining method. Results. All isolates of C. neoformans produced biofilms with optical density values ranging from 0.16 to 0.89. A majority of C. neoformans isolates that were tested exhibited strong phospholipase (7/8) and proteinase (5/8) production. Plumbagin (with minimum inhibitory concentration values ranging from 4 to 16 μg/mL) showed the highest antifungal activity followed by thymol (with minimum biofilm inhibitory concentration values ranging from 8 to 64 μg/mL). In addition, plumbagin showed the highest antibiofilm activity with minimum biofilm inhibitory concentration and minimum biofilm eradication concentration values ranging from 4 to 16 μg/mL and 32 to 256 μg/mL, respectively. Conclusion. Plumbagin, compared to other natural products studied, was the most efficient in terms of antifungal and antibiofilm activities. Hence, plumbagin could be used in combination with antifungals for the development of new anticryptococcal drugs.
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Affiliation(s)
- Borel Ndezo Bisso
- Department of Biochemistry, Faculty of Science, University of Dschang, Dschang, Cameroon
| | - Alvine Lonkeng Makuété
- Department of Biochemistry, Faculty of Science, University of Dschang, Dschang, Cameroon
| | - Joël Ulrich Tsopmene
- Department of Biochemistry, Faculty of Science, University of Dschang, Dschang, Cameroon
| | - Jean Paul Dzoyem
- Department of Biochemistry, Faculty of Science, University of Dschang, Dschang, Cameroon
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Andriani GM, Spoladori LFDA, Fabris M, Camargo PG, Pereira PML, Santos JP, Bartolomeu-Gonçalves G, Alonso L, Lancheros CAC, Alonso A, Nakamura CV, Macedo F, Pinge-Filho P, Yamauchi LM, Bispo MDLF, Tavares ER, Yamada-Ogatta SF. Synergistic antifungal interaction of N-(butylcarbamothioyl) benzamide and amphotericin B against Cryptococcus neoformans. Front Microbiol 2023; 14:1040671. [PMID: 36960287 PMCID: PMC10028264 DOI: 10.3389/fmicb.2023.1040671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 02/20/2023] [Indexed: 03/09/2023] Open
Abstract
Introduction Cryptococcus neoformans is one of the leading causes of invasive fungal infections worldwide. Cryptococcal meningoencephalitis is the main challenge of antifungal therapy due to high morbidity and mortality rates, especially in low- and middle-income countries. This can be partly attributed to the lack of specific diagnosis difficulty accessing treatment, antifungal resistance and antifungal toxicity. Methods In the present study, the effect of the synthetic thiourea derivative N-(butylcarbamothioyl) benzamide (BTU-01), alone and combined with amphotericin B (AmB), was evaluated in planktonic and sessile (biofilm) cells of C. neoformans. Results BTU-01 alone exhibited a fungistatic activity with minimal inhibitory concentrations (MICs) ranging from 31.25 to 62.5 μg/mL for planktonic cells; and sessile MICs ranging from 125.0 to 1000.0 μg/mL. BTU-01 caused a concentration-dependent inhibitory activity on cryptococcal urease and did not interfere with plasma membrane fluidity. Molecular docking was performed on Canavalia ensiformis urease, and BTU-01 showed relevant interactions with the enzyme. The combination of BTU-01 and AmB exhibited synergistic fungicidal activity against planktonic and sessile cells of C. neoformans. Microscopic analysis of C. neoformans treated with BTU-01, alone or combined with AmB, revealed a reduction in cell and capsule sizes, changes in the morphology of planktonic cells; a significant decrease in the number of cells within the biofilm; and absence of exopolymeric matrix surrounding the sessile cells. Neither hemolytic activity nor cytotoxicity to mammalian cells was detected for BTU-01, alone or combined with AmB, at concentrations that exhibited antifungal activity. BTU-01 also displayed drug-likeness properties. Conclusion These results indicate the potential of BTU-01, for the development of new strategies for controlling C. neoformans infections.
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Affiliation(s)
- Gabriella Maria Andriani
- Programa de Pós-graduação em Microbiologia, Departamento de Microbiologia, Centro de Ciências Biológicas, Universidade Estadual de Londrina, Londrina, Paraná, Brazil
- Laboratório de Biologia Molecular de Microrganismos, Departamento de Microbiologia, Centro de Ciências Biológicas, Universidade Estadual de Londrina, Londrina, Paraná, Brazil
| | - Lais Fernanda de Almeida Spoladori
- Programa de Pós-graduação em Microbiologia, Departamento de Microbiologia, Centro de Ciências Biológicas, Universidade Estadual de Londrina, Londrina, Paraná, Brazil
- Laboratório de Biologia Molecular de Microrganismos, Departamento de Microbiologia, Centro de Ciências Biológicas, Universidade Estadual de Londrina, Londrina, Paraná, Brazil
| | - Marciéli Fabris
- Laboratório de Síntese de Moléculas Medicinais, Departamento de Química, Centro de Ciências Exatas, Universidade Estadual de Londrina, Londrina, Paraná, Brazil
| | - Priscila Goes Camargo
- Laboratório de Síntese de Moléculas Medicinais, Departamento de Química, Centro de Ciências Exatas, Universidade Estadual de Londrina, Londrina, Paraná, Brazil
| | - Patrícia Morais Lopes Pereira
- Programa de Pós-graduação em Microbiologia, Departamento de Microbiologia, Centro de Ciências Biológicas, Universidade Estadual de Londrina, Londrina, Paraná, Brazil
| | - Jussevania Pereira Santos
- Laboratório de Biologia Molecular de Microrganismos, Departamento de Microbiologia, Centro de Ciências Biológicas, Universidade Estadual de Londrina, Londrina, Paraná, Brazil
| | - Guilherme Bartolomeu-Gonçalves
- Laboratório de Biologia Molecular de Microrganismos, Departamento de Microbiologia, Centro de Ciências Biológicas, Universidade Estadual de Londrina, Londrina, Paraná, Brazil
- Programa de Pós-graduação em Fisiopatologia Clínica e Laboratorial, Departamento de Patología, Análises Clínicas e Toxicológicas, Centro de Ciências da Saúde, Universidade Estadual de Londrina, Londrina, Paraná, Brazil
| | - Lais Alonso
- Instituto de Física, Universidade Federal de Goiás, Goiânia, Goiás, Brazil
| | - Cesar Armando Contreras Lancheros
- Laboratório de Inovação Tecnológica no Desenvolvimento de Fármacos e Cosméticos, Departamento de Ciências Básicas da Saúde, Centro de Ciências da Saúde, Universidade Estadual de Maringá, Maringá, Paraná, Brazil
| | - Antonio Alonso
- Instituto de Física, Universidade Federal de Goiás, Goiânia, Goiás, Brazil
| | - Celso Vataru Nakamura
- Programa de Pós-graduação em Microbiologia, Departamento de Microbiologia, Centro de Ciências Biológicas, Universidade Estadual de Londrina, Londrina, Paraná, Brazil
- Laboratório de Inovação Tecnológica no Desenvolvimento de Fármacos e Cosméticos, Departamento de Ciências Básicas da Saúde, Centro de Ciências da Saúde, Universidade Estadual de Maringá, Maringá, Paraná, Brazil
| | - Fernando Macedo
- Laboratório de Síntese de Moléculas Medicinais, Departamento de Química, Centro de Ciências Exatas, Universidade Estadual de Londrina, Londrina, Paraná, Brazil
| | - Phileno Pinge-Filho
- Programa de Pós-graduação em Microbiologia, Departamento de Microbiologia, Centro de Ciências Biológicas, Universidade Estadual de Londrina, Londrina, Paraná, Brazil
- Laboratório de Imunopatologia Experimental, Departamento de Ciências Patológicas, Centro de Ciências Biológicas, Universidade Estadual de Londrina, Londrina, Paraná, Brazil
| | - Lucy Megumi Yamauchi
- Programa de Pós-graduação em Microbiologia, Departamento de Microbiologia, Centro de Ciências Biológicas, Universidade Estadual de Londrina, Londrina, Paraná, Brazil
- Laboratório de Biologia Molecular de Microrganismos, Departamento de Microbiologia, Centro de Ciências Biológicas, Universidade Estadual de Londrina, Londrina, Paraná, Brazil
| | - Marcelle de Lima Ferreira Bispo
- Laboratório de Síntese de Moléculas Medicinais, Departamento de Química, Centro de Ciências Exatas, Universidade Estadual de Londrina, Londrina, Paraná, Brazil
| | - Eliandro Reis Tavares
- Programa de Pós-graduação em Microbiologia, Departamento de Microbiologia, Centro de Ciências Biológicas, Universidade Estadual de Londrina, Londrina, Paraná, Brazil
- Laboratório de Biologia Molecular de Microrganismos, Departamento de Microbiologia, Centro de Ciências Biológicas, Universidade Estadual de Londrina, Londrina, Paraná, Brazil
| | - Sueli Fumie Yamada-Ogatta
- Programa de Pós-graduação em Microbiologia, Departamento de Microbiologia, Centro de Ciências Biológicas, Universidade Estadual de Londrina, Londrina, Paraná, Brazil
- Laboratório de Biologia Molecular de Microrganismos, Departamento de Microbiologia, Centro de Ciências Biológicas, Universidade Estadual de Londrina, Londrina, Paraná, Brazil
- Programa de Pós-graduação em Fisiopatologia Clínica e Laboratorial, Departamento de Patología, Análises Clínicas e Toxicológicas, Centro de Ciências da Saúde, Universidade Estadual de Londrina, Londrina, Paraná, Brazil
- *Correspondence: Sueli Fumie Yamada-Ogatta,
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Sigera LSM, Denning DW. Flucytosine and its clinical usage. Ther Adv Infect Dis 2023; 10:20499361231161387. [PMID: 37051439 PMCID: PMC10084540 DOI: 10.1177/20499361231161387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Accepted: 02/13/2023] [Indexed: 04/14/2023] Open
Abstract
Flucytosine is an antifungal agent first licensed in the 1970's. However, its clinical value has long been overlooked and its availability across the globe is limited. This review highlights the important clinical and pharmacological aspects of flucytosine. This a narrative review of the clinical and in vitro susceptibility literature, with a focus on clinical uses for flucytosine. Detailed literature review including early literature related to primary and acquired resistance to flucytosine. Flucytosine has good antifungal activity against Cryptococcus species, Candida species, and dematiaceous fungi. Its water solubility enables good penetration into the eye, urinary tract, central nervous system (CNS), cardiac vegetations and fungal biofilms. In combination with amphotericin B, it shows early fungicidal activity against Cryptococcus species, and this translates to ~20% improved survival in cryptococcal meningitis. Combination therapy also reduces the mortality of Candida meningitis, and should be used in neonatal candidiasis because of the high frequency of CNS infection. Monotherapy for urinary candidiasis is under-studied, but is usually effective. It is probably valuable in the treatment of Candida endocarditis and endophthalmitis: there are few data. It is not effective for aspergillosis or mucormycosis. Flucytosine monotherapy of urinary candidiasis resulted in 22% developing resistance on therapy and failing therapy, and in 29% of 21 patients with cryptococcosis. Certain regions of the world still do not have access to flucytosine compromising the management of certain severe fungal infections. Flucytosine has an important role in combination therapy for yeast and dematiaceous infections and probably as monotherapy for urinary candidiasis, with a modest risk of resistance emergence. Facilitating access to flucytosine in those regions (especially low-income countries) might alleviate the mortality of invasive fungal diseases.
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Affiliation(s)
| | - David W. Denning
- Division of Infection, Immunity & Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
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15
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Wen J, Yin R, Chang J, Chen Y, Dong X, Cao W, Ma X, Li T, Wei J. Short-term and long-term outcomes in patients with cryptococcal meningitis after ventriculoperitoneal shunt placement. Front Neurol 2022; 13:773334. [PMID: 36468057 PMCID: PMC9712185 DOI: 10.3389/fneur.2022.773334] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 10/24/2022] [Indexed: 11/01/2023] Open
Abstract
OBJECTIVE The purpose of this study was to assess the short-term and long-term outcomes of ventriculoperitoneal shunt (VPS) placement in patients with cryptococcal meningitis (CM). METHODS We performed a retrospective analysis of all patients with CM admitted to the Peking Union Medical College Hospital from September 1990 to January 2021. We collected related clinical features to analyze the short- and long-term outcomes of VPS at 1 month and 1 year at least the following therapy, respectively. Overall survival (OS) was compared with all patients and a subgroup of critically ill cases by the Kaplan-Meier method with the log-rank test. Univariable and multivariable analyses were also performed using the Cox proportional hazard model to identify statistically significant prognostic factors. RESULTS We enrolled 98 patients, fifteen of whom underwent VPS. Those who received VPS had a lower cerebrospinal fluid (CSF) Cryptococcus burden (1:1 vs. 1:16; p = 0.046), lower opening pressures (173.3 mmH2 O vs. 224 mmH2O; p = 0.009) at lumbar punctures, and a lower incidence of critical cases (6.7 vs. 31.3%; p = 0.049). According to our long-term follow-up, no significant difference was shown in the Barthel Index (BI) between the two groups. Two patients in the VPS group suffered postoperative complications and had to go through another revision surgery. According to survival analysis, overall survival (OS) between the VPS and non-VPS groups was not significantly different. However, the Kaplan-Meier plots showed that critical patients with VPS had better survival in OS (p < 0.009). Multivariable analyses for critical patients showed VPS was an independent prognostic factor. CONCLUSION A VPS could reduce the intracranial pressure (ICP), decrease the counts of Cryptococcus neoformans by a faster rate and reduce the number of critical cases. The VPS used in critical patients with CM has a significant impact on survival, but it showed no improvement in the long-term Barthel Index (BI) vs. the conservative treatment and could lead to postoperative complications.
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Affiliation(s)
- Junxian Wen
- Department of Neurosurgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Rui Yin
- Department of Neurosurgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Jianbo Chang
- Department of Neurosurgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Yihao Chen
- Department of Neurosurgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Xiying Dong
- Department of Neurosurgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Wei Cao
- Department of Infectious Disease, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Xiaojun Ma
- Department of Infectious Disease, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Taisheng Li
- Department of Infectious Disease, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Junji Wei
- Department of Neurosurgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
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Li S, Yang X, Moog C, Wu H, Su B, Zhang T. Neglected mycobiome in HIV infection: Alterations, common fungal diseases and antifungal immunity. Front Immunol 2022; 13:1015775. [PMID: 36439143 PMCID: PMC9684632 DOI: 10.3389/fimmu.2022.1015775] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 10/26/2022] [Indexed: 09/16/2023] Open
Abstract
Human immunodeficiency virus (HIV) infection might have effects on both the human bacteriome and mycobiome. Although many studies have focused on alteration of the bacteriome in HIV infection, only a handful of studies have also characterized the composition of the mycobiome in HIV-infected individuals. Studies have shown that compromised immunity in HIV infection might contribute to the development of opportunistic fungal infections. Despite effective antiretroviral therapy (ART), opportunistic fungal infections continue to be a major cause of HIV-related mortality. Human immune responses are known to play a critical role in controlling fungal infections. However, the effect of HIV infection on innate and adaptive antifungal immunity remains unclear. Here, we review recent advances in understanding of the fungal microbiota composition and common fungal diseases in the setting of HIV. Moreover, we discuss innate and adaptive antifungal immunity in HIV infection.
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Affiliation(s)
- Shuang Li
- Beijing Key Laboratory for HIV/AIDS Research, Clinical and Research Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, Beijing, China
- Sino-French Joint Laboratory for Research on Humoral Immune Response to HIV Infection, Clinical and Research Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Xiaodong Yang
- Beijing Key Laboratory for HIV/AIDS Research, Clinical and Research Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, Beijing, China
- Sino-French Joint Laboratory for Research on Humoral Immune Response to HIV Infection, Clinical and Research Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Christiane Moog
- Laboratoire d’ImmunoRhumatologie Moléculaire, Institut national de la santé et de la recherche médicale (INSERM) UMR_S 1109, Institut thématique interdisciplinaire (ITI) de Médecine de Précision de Strasbourg, Transplantex NG, Faculté de Médecine, Fédération Hospitalo-Universitaire OMICARE, Fédération de Médecine Translationnelle de Strasbourg (FMTS), Université de Strasbourg, Strasbourg, France
- Vaccine Research Institute (VRI), Créteil, France
| | - Hao Wu
- Beijing Key Laboratory for HIV/AIDS Research, Clinical and Research Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, Beijing, China
- Sino-French Joint Laboratory for Research on Humoral Immune Response to HIV Infection, Clinical and Research Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Bin Su
- Beijing Key Laboratory for HIV/AIDS Research, Clinical and Research Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, Beijing, China
- Sino-French Joint Laboratory for Research on Humoral Immune Response to HIV Infection, Clinical and Research Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Tong Zhang
- Beijing Key Laboratory for HIV/AIDS Research, Clinical and Research Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, Beijing, China
- Sino-French Joint Laboratory for Research on Humoral Immune Response to HIV Infection, Clinical and Research Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, Beijing, China
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Raees M, Cheserem B, Mutiso B, Laeke T, Brotherton BJ. The Next Frontier in Neurocritical Care in Resource-Constrained Settings. Crit Care Clin 2022; 38:721-45. [PMID: 36162907 DOI: 10.1016/j.ccc.2022.06.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Neurocritical care (NCC) is an emerging field within critical care medicine, reflecting the widespread prevalence of neurologic injury in critically ill patients. Morbidity and mortality from neurocritical illness (NCI) have been reduced substantially in resource-rich settings (RRS), owing to the development of advanced technologies, neuro-specific units, and subspecialized medical training. Despite shouldering much of the burden of NCI worldwide, resource-limited settings (RLS) face immense hurdles when implementing guidelines generated in RRS. This review summarizes the current epidemiology, management, and outcomes of the most common NCIs in RLS and offers commentary on future directions in NCC practiced in RLS.
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Gow NAR, Johnson C, Berman J, Coste AT, Cuomo CA, Perlin DS, Bicanic T, Harrison TS, Wiederhold N, Bromley M, Chiller T, Edgar K. The importance of antimicrobial resistance in medical mycology. Nat Commun 2022; 13:5352. [PMID: 36097014 PMCID: PMC9466305 DOI: 10.1038/s41467-022-32249-5] [Citation(s) in RCA: 59] [Impact Index Per Article: 29.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 07/22/2022] [Indexed: 01/08/2023] Open
Abstract
Prior to the SARS-CoV-2 pandemic, antibiotic resistance was listed as the major global health care priority. Some analyses, including the O'Neill report, have predicted that deaths due to drug-resistant bacterial infections may eclipse the total number of cancer deaths by 2050. Although fungal infections remain in the shadow of public awareness, total attributable annual deaths are similar to, or exceeds, global mortalities due to malaria, tuberculosis or HIV. The impact of fungal infections has been exacerbated by the steady rise of antifungal drug resistant strains and species which reflects the widespread use of antifungals for prophylaxis and therapy, and in the case of azole resistance in Aspergillus, has been linked to the widespread agricultural use of antifungals. This review, based on a workshop hosted by the Medical Research Council and the University of Exeter, illuminates the problem of antifungal resistance and suggests how this growing threat might be mitigated.
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Affiliation(s)
- Neil A R Gow
- MRC Centre for Medical Mycology, School of Biosciences, University of Exeter, Geoffrey Pope Building, Exeter, EX4 4QD, UK.
| | - Carolyn Johnson
- Medical Research Council, Polaris House, Swindon, SN2 1FL, UK.
| | - Judith Berman
- Shmunis School of Biomedical and Cancer Research, George S. Wise Faculty of Life Sciences, Tel Aviv University, 418 Britannia Building, Ramat Aviv, 69978, Israel
| | - Alix T Coste
- Microbiology Institute, University Hospital Lausanne, rue du Bugnon 48, 1011, Lausanne, Switzerland
| | - Christina A Cuomo
- (CAC) Infectious Disease and Microbiome Program, Broad Institute of MIT and Harvard, Cambridge, MA, 02142, USA
| | - David S Perlin
- Center for Discovery and Innovation, Hackensack Meridian health, Nutley, NJ, 07110, USA
| | - Tihana Bicanic
- Institute of Infection and Immunity, St George's University of London, London, SW17 0RE, UK
- Clinical Academic Group in Infection, St George's University Hospitals NHS Foundation Trust, London, SW17 0QT, UK
| | - Thomas S Harrison
- MRC Centre for Medical Mycology, School of Biosciences, University of Exeter, Geoffrey Pope Building, Exeter, EX4 4QD, UK
- Institute of Infection and Immunity, St George's University of London, London, SW17 0RE, UK
- Clinical Academic Group in Infection, St George's University Hospitals NHS Foundation Trust, London, SW17 0QT, UK
| | - Nathan Wiederhold
- Department of Pathology and Laboratory Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, 78229, USA
| | - Mike Bromley
- Manchester Fungal Infection Group, Division of Evolution, Infection, and Genomics, Faculty of Biology, Medicine and Health, University of Manchester, CTF Building, 46 Grafton Street, Manchester, M13 9NT, UK
| | - Tom Chiller
- Center for Disease Control and Prevention Mycotic Disease Branch 1600 Clifton Rd, MSC-09, Atlanta, 30333, GA, USA
| | - Keegan Edgar
- Center for Disease Control and Prevention Mycotic Disease Branch 1600 Clifton Rd, MSC-09, Atlanta, 30333, GA, USA
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Muzazu SGY, Assefa DG, Phiri C, Getinet T, Solomon S, Yismaw G, Manyazewal T. Prevalence of cryptococcal meningitis among people living with human immuno-deficiency virus and predictors of mortality in adults on induction therapy in Africa: A systematic review and meta-analysis. Front Med (Lausanne) 2022; 9:989265. [PMID: 36160163 PMCID: PMC9494297 DOI: 10.3389/fmed.2022.989265] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 08/08/2022] [Indexed: 11/13/2022] Open
Abstract
Background Cryptococcal meningitis (CM) is a leading cause of adult meningitis in countries with a high burden of HIV. It has remained a significant cause of morbidity and mortality in Africa despite the extensive rollout of HIV antiretroviral therapy (ART). This study aimed to systematically synthesize the evidence on the prevalence of CM among people living with HIV (PLWH) and its predictors of mortality among adults who are on induction antifungal therapy in Africa. Methods PubMed/MEDLINE, Embase, and Google Scholar were searched for randomized clinical trials or observational studies published in Africa from 1995 to April 2021. Pooled prevalence of CM among PLWH was calculated using R-studio Version 1.4.1717 software and the data extracted from eligible studies were pooled as percentage with a 95% confidence interval (CI). Predictors of mortality among adults on induction antifungal therapy were synthesized narratively. Results Out of 364 studies identified, 17 eligible articles were included in the analysis. The prevalence of CM among PLWH in Africa was 5.11% (95% CI 2.71-9.43%; participants = 10,813; studies = 9; I 2 = 97%). In the subgroup analysis, the prevalence was 12.9% (95% CI 4.883-30.0; participants = 533; studies = 3; I 2 = 63%) in the years 1995-2010 and 3.18% (95% CI 1.54-6.45; participants = 10,280; studies = 6; I 2 = 98%) in the years 2011-2021, with the prevalence significantly decreased by 51% (p = 0.02). Predictors of mortality were fluconazole monotherapy, focal neurological signs, low Glasgow coma scale, and delayed diagnosis of CM at varied timepoint. Conclusion Prevalence of CM has significantly decreased from 1996-2010 to 2011-2021 among PLWH on induction therapy in Africa. Fluconazole monotherapy, focal neurological symptoms, diastolic blood pressure < 60 mmHg, and concurrent tuberculosis coinfection were significant predictors of mortality at 2- and 10-weeks timepoints. CM remains a major concern among PLWH despite increases in ART coverage. Improved access to effective antifungal therapies is needed in Africa for timely initiation of combination induction therapy and better treatment outcomes of PLWH. Systematic review registration [https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=254113], identifier [CRD42021254113].
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Affiliation(s)
- Seke G. Y. Muzazu
- Centre for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Enteric Diseases and Vaccines Research Unit, Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
| | - Dawit Getachew Assefa
- Centre for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Department of Nursing, College of Health Science and Medicine, Dilla University, Dilla, Ethiopia
| | - Christabel Phiri
- Levy Mwanawasa University Teaching Hospital, Department of Internal Medicine, Lusaka, Zambia
| | - Tewodros Getinet
- School of Public Health, Saint Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Samrawit Solomon
- School of Public Health, Saint Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Gizachew Yismaw
- Centre for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Tsegahun Manyazewal
- Centre for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
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Thomas CM, Shae W, Koestler D, DeFor T, Bahr N, Alpern JD. Antifungal drug price increases in the United States, 2000-2019. Mycoses 2022; 65:859-865. [PMID: 35722703 PMCID: PMC9378588 DOI: 10.1111/myc.13486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 06/13/2022] [Accepted: 06/15/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND Antifungal drugs treat a variety of conditions, ranging from localised dermatologic disease to life-threatening systemic infections. Some common antifungal drugs experienced large price increases in recent years, however, factors contributing to these price increases are poorly understood. We sought to examine trends in antifungal drug prices and determine underlying drivers of price changes. METHODS Antifungal drug products in the United States were identified using the Food and Drug Administration (FDA) Label database. For each product, we determined the wholesale acquisition cost per unit over time between 2000 and 2019, adjusting for inflation, and examined variables that could impact price: route of administration, number of FDA indications, the quantity of professional guideline recommendations, use for prophylaxis, number of FDA-approved manufacturers, and whether it was compounded. Price trajectories were clustered into four groups: (1) stable, 2) moderate, (3) high, and (4) extreme price increases. RESULTS Of 139 identified drug products, one outlier was removed due to exorbitant price increases. Cluster 1 (n = 31) demonstrated the most stable prices with a 25% mean price increase. Clusters 2 (n = 97), 3 (n = 7), and 4 (n = 3) demonstrated moderate, high, and extreme price increases with 52%, 318%, and 900% mean price increases, respectively. Atypical routes of administration and compounding were over-represented in clusters 3 and 4. There was no correlation between the number of manufacturers and price changes. CONCLUSIONS Antifungal drugs exhibited large, inflation-adjusted price increases. Atypical routes of administration and compounding were over-represented within clusters exhibiting extraordinary price increases. Our data support policies aiming to curb large price increases for medically important drugs.
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Affiliation(s)
- Christine M. Thomas
- Division of Infectious Diseases and International Medicine, Department of MedicineUniversity of MinnesotaMinneapolisMinnesotaUSA
| | - Whitney Shae
- Department of Biostatistics & Data ScienceUniversity of Kansas Medical CenterKansas CityKansasUSA
| | - Devin Koestler
- Department of Biostatistics & Data ScienceUniversity of Kansas Medical CenterKansas CityKansasUSA
| | | | - Nathan C. Bahr
- Division of Infectious Diseases, Department of MedicineUniversity of Kansas Medical CenterKansas CityKansasUSA
| | - Jonathan D. Alpern
- Division of Infectious Diseases and International Medicine, Department of MedicineUniversity of MinnesotaMinneapolisMinnesotaUSA
- HealthPartners InstituteBloomingtonMinnesotaUSA
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21
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Larson B, Shroufi A, Muthoga C, Oladele R, Rajasingham R, Jordan A, Jarvis JN, Chiller TM, Govender NP. Induction-phase treatment costs for cryptococcal meningitis in high HIV-burden African countries: New opportunities with lower costs. Wellcome Open Res 2022; 6:140. [PMID: 35706922 PMCID: PMC9184925 DOI: 10.12688/wellcomeopenres.16776.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/16/2022] [Indexed: 11/20/2022] Open
Abstract
Introduction: Access to and the cost of induction treatment for cryptococcal meningitis (CM) is rapidly changing. The newly-announced price for flucytosine ($0.75 per 500 mg pill) and possibly lower prices for liposomal amphotericin B (AmB-L) create opportunities to reduce CM treatment costs compared to the current standard treatment in low- and middle-income countries. Methods: We developed an Excel-based cost model to estimate health system treatment costs for CM over a two-week induction phase for multiple treatment combinations, newly feasible with improved access to flucytosine and AmB-L. CM treatment costs include medications, laboratory tests and other hospital-based costs (bed-day costs and healthcare worker time). We report results from applying the model using country-specific information for South Africa, Uganda, Nigeria, and Botswana. Results: A 14-day induction-phase of seven days of inpatient AmB-D with flucytosine, followed by seven days of high-dose fluconazole as an outpatient, will cost health systems less than a 14-day hospital stay with AmB-D and fluconazole. If daily AmB-L replaces AmB-D for those with baseline renal dysfunction, with a cost of $50 or less per 50 mg vial, incremental costs would still be less than the AmB-D with fluconazole regimen. Simple oral combinations (e.g., seven days of flucytosine with fluconazole as an inpatient) are practical when AmB-D is not available, and treatment costs would remain less than the current standard treatment. Conclusions: Improved access to and lower prices for flucytosine and AmB-L create opportunities for improving CM treatment regimens. An induction regimen of flucytosine and AmB-D for seven days is less costly than standard care in the settings studied here. As this regimen has also been shown to be more effective than current standard care, countries should prioritize scaling up flucytosine access. The cost of AmB-L based regimens is highly dependent on the price of AmB-L, which currently remains unclear.
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Affiliation(s)
- Bruce Larson
- Global Health, Boston University School of Public Health, Boston, MA, 02118, USA
- Health Economics and Epidemiology Research Office, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Charles Muthoga
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Rita Oladele
- College of Medicine, Univerity of Lagos, Lagos, Nigeria
| | - Radha Rajasingham
- Division of Infectious Diseases & International Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Alexander Jordan
- Mycotic Diseases Branch, Centers for Disease Controls and Prevention, Atlanta, Georgia, USA
| | - Joseph N. Jarvis
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Tom M. Chiller
- Mycotic Diseases Branch, Centers for Disease Controls and Prevention, Atlanta, Georgia, USA
| | - Nelesh P. Govender
- National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa
- University of Witwatersrand, Johannesburg, South Africa
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22
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Atim PB, Meya DB, Gerlach ES, Muhanguzi D, Male A, Kanamwanji B, Nielsen K. Lack of Association between Fluconazole Susceptibility and ERG11 Nucleotide Polymorphisms in Cryptococcus neoformans Clinical Isolates from Uganda. J Fungi (Basel) 2022; 8:508. [PMID: 35628763 PMCID: PMC9145384 DOI: 10.3390/jof8050508] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 05/04/2022] [Accepted: 05/10/2022] [Indexed: 11/22/2022] Open
Abstract
Fluconazole is the drug of choice for cryptococcal meningitis (CM) monoprophylaxis in resource-limited settings such as Uganda. Emerging fluconazole resistance linked to mutations in the Cryptococcus neoformansERG11 gene (CYP51) has been observed in clinical isolates. Currently, the single nucleotide polymorphisms [SNPs] in the Cryptococcus spp. ERG11 gene that could be responsible for fluconazole resistance are poorly characterized within Ugandan C. neoformans clinical isolates. If available, this information would be useful in the management of cryptococcosis among HIV patients. This cross-sectional study investigates the SNPs present in the coding region of the C. neoformansERG11 gene to determine the relationship between the SNPs identified and fluconazole susceptibility of the clinical isolates. 310 C. neoformans isolates recovered from the Cerebrospinal Fluid (CSF) of patients with HIV and cryptococcal meningitis were examined. The fluconazole half-maximal inhibitory concentrations (IC50 range: 0.25−32 μg/mL) was determined using the microbroth dilution method. A total of 56.1% of the isolates had low IC50 values of <8 μg/mL while 43.9% had high IC50 values ≥ 8 μg/mL. We amplified and sequenced 600 bp of the ERG11 coding sequence from 40 of the clinical isolates. Novel synonymous and 2 missense mutations, S460T and A457V, were identified in the ERG11 gene. The identified SNPs were not associated with differences in fluconazole IC50 values in vitro (p = 0.179).
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Affiliation(s)
| | - David B. Meya
- Infectious Diseases Institute, Kampala P.O. Box 22418, Uganda;
- Department of Microbiology and Immunology, University of Minnesota, Minneapolis, MN 55455, USA; (E.S.G.); (K.N.)
| | - Elliot S. Gerlach
- Department of Microbiology and Immunology, University of Minnesota, Minneapolis, MN 55455, USA; (E.S.G.); (K.N.)
| | - Dennis Muhanguzi
- College of Veterinary Medicine Animal Resources and Biosecurity, Makerere University, Kampala P.O. Box 7062, Uganda;
| | - Allan Male
- International Centre for Tropical Agriculture (CIAT)—Uganda, Kampala P.O. Box 6247, Uganda;
| | - Benedict Kanamwanji
- National Microbiology Reference Laboratory (NMRL), Kampala P.O. Box 7272, Uganda;
| | - Kirsten Nielsen
- Department of Microbiology and Immunology, University of Minnesota, Minneapolis, MN 55455, USA; (E.S.G.); (K.N.)
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23
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Abstract
Invasive fungal diseases cause significant morbidity and mortality, in particular affecting immunocompromised patients. Resistant organisms are of increasing importance, yet there are many notable differences in the ability to both perform and interpret antifungal susceptibility testing compared with bacteria. In this review, we will highlight the strengths and limitations of resistance data of pathogenic yeasts and moulds that may be used to guide treatment and predict clinical outcomes.
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Affiliation(s)
- Todd P McCarty
- Department of Medicine, University of Alabama at Birmingham , Birmingham, AL , USA
- Birmingham VA Medical Center , Birmingham, AL , USA
| | - Paul M Luethy
- Department of Pathology, University of Maryland , Baltimore, MD , USA
| | - John W Baddley
- Department of Medicine, University of Maryland , Baltimore, MD , USA
| | - Peter G Pappas
- Department of Medicine, University of Alabama at Birmingham , Birmingham, AL , USA
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Wang F, Wang Y, He J, Cheng Z, Wu S, Wang M, Niu T. Clinical Characteristics and Risk Factors for Mortality in Cryptococcal Meningitis: Evidence From a Cohort Study. Front Neurol 2022; 13:779435. [PMID: 35572932 PMCID: PMC9098999 DOI: 10.3389/fneur.2022.779435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Accepted: 04/07/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction Despite advances in the diagnosis and management, cryptococcal meningitis (CM) is still associated with high mortality due to insufficient knowledge about clinical characteristics and risk factors for poor outcomes. The aim of the present study is to provide additional evidence for regarding clinical characteristics, diagnosis, and factors associated with increased risk of mortality in CM patients. Methods In this cohort study, we included eligible patients consecutively admitted to West China Hospital between January 2009 and December 2018. The clinical characteristics and diagnosis method of cerebrospinal fluid culture and India ink stain were analyzed. Independent risk factors were identified by a multivariable logistic regression. Results A total of 186 CM patients were included in the analysis. After a 1-year follow-up, 63 patients had died. Headache is the most common presenting symptom (97.3%), followed by vomiting (72%), fever (71.5%), altered consciousness (45.7%), abnormal vision (32.8%), and seizure (15.1%). Older age, altered consciousness or seizures, lower white blood cell count or total protein in cerebrospinal fluid (CSF), and unidentified CSF cryptococcal antigen (CrAg) are all factors associated with increasing risk of death (P < 0.05). We also found a dose-dependent trend between the number of symptoms and risk of death (trend p < 0.001). Multivariate logistic regression revealed that age (P = 0.004, OR = 1.042, 95% CI 1.013–1.071), seizure (P = 0.025, OR = 3.105, 95% CI 1.152–8.369), altered consciousness (P < 0.001, OR=6.858, 95% CI 3.063–15.38), and unidentified CSF CrAg are the independent prognostic factors. In addition, we observed that diagnosis of 28.5% and 22.5% CM could not be established by a single testing of CSF India ink stain or culture, respectively. Use of multiple testing methods or combination of the two assays increases the detection rate. Conclusion Our data show that older age, seizures, altered consciousness, and an inability to detect CSF CrAg are the independent risk factors of death within 1 year in CM patients. Moreover, we recommend use of multiple testing methods with CSF culture and India ink stain. Combined testing with both assays should be considered for initial CM diagnosis.
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Affiliation(s)
- Fengjuan Wang
- Department of Hematology and Research Laboratory of Hematology, West China Hospital, Sichuan University, Chengdu, China
| | - Yu Wang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Jianqing He
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Zhe Cheng
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Shouquan Wu
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Minggui Wang
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Ting Niu
- Department of Hematology and Research Laboratory of Hematology, West China Hospital, Sichuan University, Chengdu, China
- *Correspondence: Ting Niu
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25
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Larson B, Shroufi A, Muthoga C, Oladele R, Rajasingham R, Jordan A, Jarvis JN, Chiller TM, Govender NP. Induction-phase treatment costs for cryptococcal meningitis in high HIV-burden African countries: New opportunities with lower costs. Wellcome Open Res 2022; 6:140. [PMID: 35706922 PMCID: PMC9184925 DOI: 10.12688/wellcomeopenres.16776.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/24/2022] [Indexed: 11/20/2022] Open
Abstract
Introduction: Access to and the cost of induction treatment for cryptococcal meningitis (CM) is rapidly changing. The newly-announced price for flucytosine ($0.75 per 500 mg pill) and possibly lower prices for liposomal amphotericin B (AmB-L) create opportunities to reduce CM treatment costs compared to the current standard treatment in low- and middle-income countries. Methods: We developed an Excel-based cost model to estimate health system treatment costs for CM over a two-week induction phase for multiple treatment combinations, newly feasible with improved access to flucytosine and AmB-L. CM treatment costs include medications, laboratory tests and other hospital-based costs (bed-day costs and healthcare worker time). We report results from applying the model using country-specific information for South Africa, Uganda, Nigeria, and Botswana. Results: A 14-day induction-phase of seven days of inpatient AmB-D with flucytosine, followed by seven days of high-dose fluconazole as an outpatient, will cost health systems less than a 14-day hospital stay with AmB-D and fluconazole. If daily AmB-L replaces AmB-D for those with baseline renal dysfunction, with a cost of $50 or less per 50 mg vial, incremental costs would still be less than the AmB-D with fluconazole regimen. Simple oral combinations (e.g., seven days of flucytosine with fluconazole as an inpatient) are practical when AmB-D is not available, and treatment costs would remain less than the current standard treatment. Conclusions: Improved access to, and lower prices for flucytosine and AmB-L create opportunities for improving CM treatment regimens. An induction regimen of flucytosine and AmB-D for seven days is less costly than standard care in the settings studied here. As this regimen has also been shown to be more effective than current standard care, countries should prioritize scaling up flucytosine access. The cost of AmB-L based regimens is highly dependent on the price of AmB-L, which currently remains unclear.
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Affiliation(s)
- Bruce Larson
- Global Health, Boston University School of Public Health, Boston, MA, 02118, USA
- Health Economics and Epidemiology Research Office, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Charles Muthoga
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Rita Oladele
- College of Medicine, Univerity of Lagos, Lagos, Nigeria
| | - Radha Rajasingham
- Division of Infectious Diseases & International Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Alexander Jordan
- Mycotic Diseases Branch, Centers for Disease Controls and Prevention, Atlanta, Georgia, USA
| | - Joseph N. Jarvis
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Tom M. Chiller
- Mycotic Diseases Branch, Centers for Disease Controls and Prevention, Atlanta, Georgia, USA
| | - Nelesh P. Govender
- National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa
- University of Witwatersrand, Johannesburg, South Africa
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Affiliation(s)
- Wang Li
- Department of Medicinal Chemistry, School of Pharmacy, Second Military Medical University, 325 Guohe Road, Shanghai 200433, China
| | - Zhaolin Yun
- Department of Medicinal Chemistry, School of Pharmacy, Second Military Medical University, 325 Guohe Road, Shanghai 200433, China
| | - Changjin Ji
- School of Pharmacy, East China University of Science & Technology, 130 Meilong Road, Shanghai 200237, People’s Republic of China
| | - Jie Tu
- Department of Medicinal Chemistry, School of Pharmacy, Second Military Medical University, 325 Guohe Road, Shanghai 200433, China
| | - Wanzhen Yang
- Department of Medicinal Chemistry, School of Pharmacy, Second Military Medical University, 325 Guohe Road, Shanghai 200433, China
| | - Jian Li
- School of Pharmacy, East China University of Science & Technology, 130 Meilong Road, Shanghai 200237, People’s Republic of China
| | - Na Liu
- Department of Medicinal Chemistry, School of Pharmacy, Second Military Medical University, 325 Guohe Road, Shanghai 200433, China
| | - Chunquan Sheng
- Department of Medicinal Chemistry, School of Pharmacy, Second Military Medical University, 325 Guohe Road, Shanghai 200433, China
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Rajasingham R, Nalintya E, Israelski DM, Meya DB, Larson BA, Boulware DR. Cost-effectiveness of single-dose AmBisome preemptive treatment for the prevention of cryptococcal meningitis in African low and middle-income countries. Med Mycol 2022; 60:6506454. [PMID: 35026017 DOI: 10.1093/mmy/myab078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 10/12/2021] [Indexed: 11/13/2022] Open
Abstract
Cryptococcal antigen (CrAg) screening is recommended for patients with advanced HIV to reduce AIDS-related mortality. For asymptomatic CrAg-positive persons, fluconazole preemptive therapy is standard, despite a ∼25% failure rate. Single-dose liposomal amphotericin B (AmBisome) is non-inferior to standard treatment for cryptococcal meningitis. We evaluate the threshold of efficacy necessary for AmBisome + fluconazole to be cost-effective as preemptive therapy for CrAg-positive persons. We created a decision analytic model to evaluate CrAg screening and treatment in HIV-infected persons with CD4 < 100 cells/µL. Costs were estimated for screening, preemptive therapy, and hospitalization for an example low-income country (Uganda) and middle-income country (South Africa). We used a discounted price range of AmBisome® at ${\$}$16.25 to ${\$}$40 per 50 mg vial for both Uganda and South Africa. We estimated AmBisome efficacy from 75% to 95%. Parameter assumptions were based on prospective CrAg screening studies and clinical trials in Africa. Disability adjusted life years (DALYs) were calculated using the age-specific life expectancy in Uganda, per WHO Global Health Observatory data. We modeled the theoretical efficacy of adjunctive AmBisome to determine cost per DALY averted. In South Africa, at ${\$}$16.25 per vial cost and a minimum efficacy of 85%, adjunctive AmBisome is cost-saving compared to fluconazole monotherapy. Compared to fluconazole preemptive therapy in Uganda, AmBisome + fluconazole would cost ${\$}$475, ${\$}$220, or ${\$}$136 per DALY averted if meningitis-free survival efficacy was 80%, 85%, or 90% at ${\$}$24 per vial cost. Investing in AmBisome may be cost-effective in low-income settings compared to using fluconazole preemptive therapy alone, if efficacy is 85% or greater. AmBisome preemptive therapy appears more cost-efficient in middle-income settings where hospitalization costs for meningitis, and GDP per capita are higher.
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Affiliation(s)
- Radha Rajasingham
- Division of Infectious Diseases & International Medicine, University of Minnesota, MN, USA
| | | | - Dennis M Israelski
- Medical Affairs, Global Patient Solutions, Gilead Sciences, Inc., CA, USA
| | - David B Meya
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Bruce A Larson
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | - David R Boulware
- Division of Infectious Diseases & International Medicine, University of Minnesota, MN, USA
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Li H, Zhang L, Zhang K, Huang Y, Liu Y, Lu X, Liao W, Liu X, Zhang Q, Pan W. Gut microbiota associated with cryptococcal meningitis and dysbiosis caused by anti-fungal treatment. Front Microbiol 2022; 13:1086239. [PMID: 36909846 PMCID: PMC9994644 DOI: 10.3389/fmicb.2022.1086239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 12/05/2022] [Indexed: 02/24/2023] Open
Abstract
The gut microbiota is a dynamic and highly diverse microbial ecosystem that affects many aspects of the host's physiology. An improved understanding of the gut microbiota could lead to better strategies for the diagnosis and therapy of cryptococcal meningitis (CM), but the impact of Cryptococcus infection and anti-fungal treatment on the gut microbiota has rarely been studied. We characterized the diversity and composition of the gut microbiota in CM patients at diagnosis and healthy controls (HCs) using metagenomic sequencing and determined the effects of anti-fungal drugs. We found that CM patients had distinct bacterial and fungal compositions compared with HCs, with eight differentially abundant fungal and 72 differentially abundant bacterial species identified between the two groups. CM patients showed an increased abundance of Enterococcus avium, Leuconostoc mesenteroides, and Weissella cibaria, and a decreased abundance of Prevotella spp. compared with HCs. However, anti-fungal treatment only led to minor changes in the intestinal microbiota. Moreover, both positive and negative correlations existed in fungal, bacterial, and clinical indicators. Our study suggests that the Cryptococcus neoformans infection caused a distinct dysbiosis of the gut microbiota and contributes valuable information implying potential links between the CM and gut microbiota.
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Affiliation(s)
- Hang Li
- Shanghai Key Laboratory of Molecular Medical Mycology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, China.,Department of Dermatology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, China.,Department of Dermatology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Lei Zhang
- Department of Dermatology, The Third Affiliated Hospital of Xi'an Jiaotong University, Shaanxi Provincial People's Hospital, Xi'an, China
| | - Keming Zhang
- Shanghai Key Laboratory of Molecular Medical Mycology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, China.,Department of Dermatology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Yue Huang
- Shanghai Key Laboratory of Molecular Medical Mycology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, China.,Department of Dermatology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, China.,Department of Dermatology, The First Naval Hospital of Southern Theater Command, Zhanjiang, China
| | - Yi Liu
- Shanghai Key Laboratory of Molecular Medical Mycology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, China.,Department of Dermatology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Xiaodi Lu
- Shanghai Key Laboratory of Molecular Medical Mycology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, China.,Department of Dermatology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Wanqing Liao
- Shanghai Key Laboratory of Molecular Medical Mycology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, China.,Department of Dermatology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Xiaogang Liu
- Shanghai Key Laboratory of Molecular Medical Mycology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, China.,Department of Dermatology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Qilong Zhang
- Department of Neurology, Jiangxi Chest Hospital, Jiangxi, China
| | - Weihua Pan
- Shanghai Key Laboratory of Molecular Medical Mycology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, China.,Department of Dermatology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, China
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29
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Hurt WJ, Harrison TS, Molloy SF, Bicanic TA. Combination Therapy for HIV-Associated Cryptococcal Meningitis-A Success Story. J Fungi (Basel) 2021; 7:1098. [PMID: 34947080 PMCID: PMC8708058 DOI: 10.3390/jof7121098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 12/16/2021] [Accepted: 12/17/2021] [Indexed: 11/17/2022] Open
Abstract
Cryptococcal meningitis is the leading cause of adult meningitis in patients with HIV, and accounts for 15% of all HIV-related deaths in sub-Saharan Africa. The mainstay of management is effective antifungal therapy, despite a limited arsenal of antifungal drugs, significant progress has been made developing effective treatment strategies by using combination regimens. The introduction of fluconazole as a safe and effective step-down therapy allowed for shorter courses of more fungicidal agents to be given as induction therapy, with higher doses achieving more rapid CSF sterilisation and improved treatment outcomes. The development of early fungicidal activity (EFA), an easily measured surrogate of treatment efficacy, has enabled rapid identification of effective combinations through dose ranging phase II studies, allowing further evaluation of clinical benefit in targeted phase III studies. Recent clinical trials have shown that shorter course induction regimens using one week of amphotericin paired with flucytosine are non-inferior to traditional two-week induction regimens and that the combination of fluconazole and flucytosine offers a viable treatment alternative when amphotericin is unavailable. Access to drugs in many low and middle-income settings remains challenging but is improving, and novel strategies based on single high dose liposomal amphotericin B promise further reduction in treatment complications and toxicities. This review aims to summarise the key findings of the principal clinical trials that have led to the success story of combination therapy thus far.
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Affiliation(s)
- William J. Hurt
- Institute of Infection & Immunity, St George’s University London, London SW17 0RE, UK; (T.S.H.); (S.F.M.); (T.A.B.)
| | - Thomas S. Harrison
- Institute of Infection & Immunity, St George’s University London, London SW17 0RE, UK; (T.S.H.); (S.F.M.); (T.A.B.)
- Clinical Academic Group in Infection & Immunity, St George’s University Hospitals NHS Trust, London SW17 0QT, UK
- The MRC Centre of Medical Mycology, University of Exeter, Stocker Road, Exeter EX4 4QD, UK
| | - Síle F. Molloy
- Institute of Infection & Immunity, St George’s University London, London SW17 0RE, UK; (T.S.H.); (S.F.M.); (T.A.B.)
| | - Tihana A. Bicanic
- Institute of Infection & Immunity, St George’s University London, London SW17 0RE, UK; (T.S.H.); (S.F.M.); (T.A.B.)
- Clinical Academic Group in Infection & Immunity, St George’s University Hospitals NHS Trust, London SW17 0QT, UK
- The MRC Centre of Medical Mycology, University of Exeter, Stocker Road, Exeter EX4 4QD, UK
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30
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Huang Y, Zou J, Zhang KM, Li H, Hu DY, Liao WQ, Zhang L, Pan WH. Prediction of hospital discharge outcome from changes in cerebrospinal fluid/serum albumin quotient and cerebrospinal fluid lactate dehydrogenase in patients with cryptococcal meningitis. Future Microbiol 2021; 17:223-233. [PMID: 34905957 DOI: 10.2217/fmb-2021-0272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: This study aims to provide reliable prognostic factors for patients with cryptococcal meningitis (CM). Patients & methods: Clinical characteristics and laboratory findings of CM patients were retrospectively reviewed. Results: Sixty-three patients with CM were enrolled and 38/63 were confirmed to be HIV serology positive. Among clinical characteristics, headache, nausea and/or vomiting, and fever were the most common symptoms. Among cerebrospinal fluid (CSF) parameters, changes in leukocyte count, lactate dehydrogenase and chloride were significantly associated with the outcome. An increased CSF/serum albumin quotient (QAlb) was indicative of an unfavorable outcome in HIV-negative patients. Conclusion: CSF lactate dehydrogenase and QAlb may improve the prediction of outcomes in patients with CM.
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Affiliation(s)
- Yue Huang
- Department of Dermatology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, 200003, PR China.,Shanghai Key Laboratory of Molecular Medical Mycology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, 200003, PR China
| | - Jun Zou
- Department of Dermatology, Nanning Forth People's Hospital, Nanning, 530002, PR China
| | - Ke-Ming Zhang
- Department of Dermatology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, 200003, PR China.,Shanghai Key Laboratory of Molecular Medical Mycology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, 200003, PR China
| | - Hang Li
- Department of Dermatology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, 200003, PR China.,Shanghai Key Laboratory of Molecular Medical Mycology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, 200003, PR China
| | - Dong-Ying Hu
- Department of Dermatology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, 200003, PR China.,Shanghai Key Laboratory of Molecular Medical Mycology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, 200003, PR China
| | - Wan-Qing Liao
- Department of Dermatology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, 200003, PR China.,Shanghai Key Laboratory of Molecular Medical Mycology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, 200003, PR China
| | - Lei Zhang
- Department of Dermatology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, 200003, PR China.,Shanghai Key Laboratory of Molecular Medical Mycology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, 200003, PR China.,Department of Dermatology, Shaanxi Provincial People's Hospital, Xi'an, 710068, PR China
| | - Wei-Hua Pan
- Department of Dermatology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, 200003, PR China.,Shanghai Key Laboratory of Molecular Medical Mycology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, 200003, PR China
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31
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Dangarembizi R. Reimagining the future of African brain health: Perspectives for basic research on the pathogenesis of cryptococcal meningitis. Brain Behav Immun Health 2021; 18:100388. [PMID: 34825235 PMCID: PMC8605210 DOI: 10.1016/j.bbih.2021.100388] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Revised: 10/28/2021] [Accepted: 11/05/2021] [Indexed: 11/24/2022] Open
Abstract
Cryptococcal meningitis is a fatal opportunistic infection of the brain and a leading cause of neurological damage and death in immunocompromised individuals. This neglected fungal disease of the brain is a huge burden on the health systems of developing countries, especially in Sub-Saharan Africa, where up to 25% of people living with HIV/AIDS succumb to it. Cryptococcal fungal cells have a predilection for the brain and they are capable of traversing the blood brain barrier and invade the brain where they cause infection, inflammation and a disruption of normal brain function. A robust host neuroimmune response is critical for pathogen clearance and survival, and a good understanding of the mechanisms underlying its development in the host is critical for the development of effective treatments. However, past basic research studies have been focussed on the characteristics of the fungus and its effect on the peripheral immune system; with little attention paid to how it interacts with brain immune cells. This mini review briefly discusses the paucity of basic research data on the neuroimmune response to cryptococcal infection, raises pertinent questions on how the brain cells respond to the fungal infection, and thereafter discusses models, techniques and advanced technologies that could be useful for carrying out high-throughput research on the pathogenesis of cryptococcal meningitis.
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Affiliation(s)
- R Dangarembizi
- Division of Physiological Sciences, Department of Human Biology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- Neuroscience Institute, Faculty of Health Sciences, University of Cape Town, Groote Schuur Hospital, Cape Town, South Africa
- CMM AFRICA Medical Mycology Research Unit, Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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32
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Chen YC, Yang Y, Zhang C, Chen HY, Chen F, Wang KJ. A Novel Antimicrobial Peptide Sparamosin 26-54 From the Mud Crab Scylla paramamosain Showing Potent Antifungal Activity Against Cryptococcus neoformans. Front Microbiol 2021; 12:746006. [PMID: 34690992 PMCID: PMC8531530 DOI: 10.3389/fmicb.2021.746006] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 09/17/2021] [Indexed: 11/20/2022] Open
Abstract
Due to the increasing prevalence of drug-resistant fungi and the limitations of current treatment strategies to fungal infections, exploration and development of new antifungal drugs or substituents are necessary. In the study, a novel antimicrobial peptide, named Sparamosin, was identified in the mud crab Scylla paramamosain, which contains a signal peptide of 22 amino acids and a mature peptide of 54 amino acids. The antimicrobial activity of its synthetic mature peptide and two truncated peptides (Sparamosin1–25 and Sparamosin26–54) were determined. The results showed that Sparamosin26–54 had the strongest activity against a variety of Gram-negative bacteria, Gram-positive bacteria and fungi, in particular had rapid fungicidal kinetics (killed 99% Cryptococcus neoformans within 10 min) and had potent anti-biofilm activity against C. neoformans, but had no cytotoxic effect on mammalian cells. The RNA-seq results showed that after Sparamosin26–54 treatment, the expression of genes involved in cell wall component biosynthesis, cell wall integrity signaling pathway, anti-oxidative stress, apoptosis and DNA repair were significantly up-regulated, indicating that Sparamosin26–54 might disrupt the cell wall of C. neoformans, causing oxidative stress, DNA damage and cell apoptosis. The underlying mechanism was further confirmed. Sparamosin26–54 could bind to several phospholipids in the cell membrane and effectively killed C. neoformans through disrupting the integrity of the cell wall and cell membrane observed by electron microscope and staining assay. In addition, it was found that the accumulation of reactive oxygen species (ROS) increased, the mitochondrial membrane potential (MMP) was disrupted, and DNA fragmentation was induced after Sparamosin26–54 treatment, which are all hallmarks of apoptosis. Taken together, Sparamosin26–54 has a good application prospect as an effective antimicrobial agent, especially for C. neoformans infections.
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Affiliation(s)
- Yan-Chao Chen
- State Key Laboratory of Marine Environmental Science, College of Ocean and Earth Sciences, Xiamen University, Xiamen, China
| | - Ying Yang
- State Key Laboratory of Marine Environmental Science, College of Ocean and Earth Sciences, Xiamen University, Xiamen, China
| | - Chang Zhang
- State Key Laboratory of Marine Environmental Science, College of Ocean and Earth Sciences, Xiamen University, Xiamen, China
| | - Hui-Yun Chen
- State Key Laboratory of Marine Environmental Science, College of Ocean and Earth Sciences, Xiamen University, Xiamen, China.,State-Province Joint Engineering Laboratory of Marine Bioproducts and Technology, College of Ocean and Earth Sciences, Xiamen University, Xiamen, China.,Fujian Innovation Research Institute for Marine Biological Antimicrobial Peptide Industrial Technology, College of Ocean and Earth Sciences, Xiamen University, Xiamen, China
| | - Fangyi Chen
- State Key Laboratory of Marine Environmental Science, College of Ocean and Earth Sciences, Xiamen University, Xiamen, China.,State-Province Joint Engineering Laboratory of Marine Bioproducts and Technology, College of Ocean and Earth Sciences, Xiamen University, Xiamen, China.,Fujian Innovation Research Institute for Marine Biological Antimicrobial Peptide Industrial Technology, College of Ocean and Earth Sciences, Xiamen University, Xiamen, China
| | - Ke-Jian Wang
- State Key Laboratory of Marine Environmental Science, College of Ocean and Earth Sciences, Xiamen University, Xiamen, China.,State-Province Joint Engineering Laboratory of Marine Bioproducts and Technology, College of Ocean and Earth Sciences, Xiamen University, Xiamen, China.,Fujian Innovation Research Institute for Marine Biological Antimicrobial Peptide Industrial Technology, College of Ocean and Earth Sciences, Xiamen University, Xiamen, China
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33
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Zhou QH, Hu CQ, Shi Y, Wu FT, Yang Q, Guan J, Li AC, Chen Z. Cryptococcosis in patients with liver cirrhosis: Death risk factors and predictive value of prognostic models. Hepatobiliary Pancreat Dis Int 2021; 20:460-468. [PMID: 34233849 DOI: 10.1016/j.hbpd.2021.06.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 06/03/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND Liver cirrhosis is associated with immune deficiency, which causes these patients to be susceptible to various infections, including cryptococcus infection. Mortality in cirrhotic patients with cryptococcosis has increased. The present study was to explore the risk factors of mortality and the predictive ability of different prognostic models. METHODS Forty-seven cirrhotic patients with cryptococcosis at a tertiary care hospital were included in this retrospective study. Data on demographics, clinical parameters, laboratory exams, diagnostic methods, medication during hospitalization, severity scores and prognosis were collected and analyzed. Student's t test and Mann-Whitney test were used to compare characteristics of survivors and non-survivors at a 90-day follow-up and cerebrospinal fluid (CSF) manifestations of cryptococcal meningitis. Multivariate Cox regression analysis was used to identify the independent risk factors for mortality. Kaplan-Meier curves were used to analyze patient survival. Receiver operating characteristic (ROC) curves were used to evaluate the different prognostic factors. RESULTS The 30- and 90-day survival rates were 93.6% and 80.9%, respectively, in cirrhotic patients with cryptococcosis. Cryptogenic liver diseases [hazard ratio (HR) = 7.567, 95% confidence interval (CI): 1.616-35.428, P = 0.010], activated partial thromboplastin time (APTT) (HR = 1.117, 95% CI: 1.016-1.229, P = 0.022) and Child-Pugh score (HR = 2.146, 95% CI: 1.314-3.504, P = 0.002) were risk factors for 90-day mortality in cirrhotic patients with cryptococcosis. Platelet count (HR = 0.965, 95% CI: 0.940-0.991, P = 0.008) was a protective factor. APTT (HR = 1.120, 95% CI: 1.044-1.202, P = 0.002) and Child-Pugh score (HR = 1.637, 95% CI: 1.086-2.469, P = 0.019) were risk factors for 90-day mortality in cirrhotic patients with cryptococcal meningitis. There was significant difference in the percentage of lymphocytes in CSF between survivors and non-survivors [60.0 (35.0-75.0) vs. 95.0 (83.8-97.2), P < 0.001]. The model of end-stage liver disease-sodium (MELD-Na) score was more accurate for predicting 30-day mortality both in patients with cryptococcosis [area under curve (AUC): 0.826, 95% CI: 0.618-1.000] and those with cryptococcal meningitis (AUC: 0.742, 95% CI: 0.560-0.924); Child-Pugh score was more useful for predicting 90-day mortality in patients with cryptococcosis (AUC: 0.823, 95% CI: 0.646-1.000) and those with cryptococcal meningitis (AUC: 0.815, 95% CI: 0.670-0.960). CONCLUSIONS These results showed that cryptogenic liver diseases, APTT and Child-Pugh score were associated with mortality in cirrhotic patients with cryptococcosis and cryptococcal meningitis. MELD-Na score was important for predicting 30-day mortality, and Child-Pugh score was critical for predicting 90-day mortality.
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Affiliation(s)
- Qi-Hui Zhou
- Department of Infectious Diseases, State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310000, China
| | - Cai-Qin Hu
- Department of Infectious Diseases, State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310000, China
| | - Yu Shi
- Department of Infectious Diseases, State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310000, China
| | - Feng-Tian Wu
- Department of Infectious Diseases, State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310000, China
| | - Qin Yang
- Department of Infectious Diseases, State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310000, China
| | - Jun Guan
- Department of Infectious Diseases, State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310000, China
| | - Ai-Chun Li
- Department of Infectious Diseases, State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310000, China
| | - Zhi Chen
- Department of Infectious Diseases, State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310000, China.
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Vitale RG. Role of Antifungal Combinations in Difficult to Treat Candida Infections. J Fungi (Basel) 2021; 7:731. [PMID: 34575770 PMCID: PMC8468556 DOI: 10.3390/jof7090731] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 08/27/2021] [Accepted: 09/02/2021] [Indexed: 01/23/2023] Open
Abstract
Candida infections are varied and, depending on the immune status of the patient, a life-threatening form may develop. C. albicans is the most prevalent species isolated, however, a significant shift towards other Candida species has been noted. Monotherapy is frequently indicated, but the patient's evolution is not always favorable. Drug combinations are a suitable option in specific situations. The aim of this review is to address this problem and to discuss the role of drug combinations in difficult to treat Candida infections. A search for eligible studies in PubMed and Google Scholar databases was performed. An analysis of the data was carried out to define in which cases a combination therapy is the most appropriate. Combination therapy may be used for refractory candidiasis, endocarditis, meningitis, eye infections and osteomyelitis, among others. The role of the drug combination would be to increase efficacy, reduce toxicity and improve the prognosis of the patient in infections that are difficult to treat. More clinical studies and reporting of cases in which drug combinations are used are needed in order to have more data that support the use of this therapeutic strategy.
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Affiliation(s)
- Roxana G. Vitale
- Consejo Nacional de Investigaciones Científicas y Tecnológicas (CONICET), Buenos Aires, Argentina;
- Unidad de Parasitología, Sector Micología, Hospital J. M. Ramos Mejía, Buenos Aires, Argentina
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35
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Stott KE, Loyse A, Jarvis JN, Alufandika M, Harrison TS, Mwandumba HC, Day JN, Lalloo DG, Bicanic T, Perfect JR, Hope W. Cryptococcal meningoencephalitis: time for action. Lancet Infect Dis 2021; 21:e259-e271. [PMID: 33872594 DOI: 10.1016/s1473-3099(20)30771-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 09/13/2020] [Accepted: 09/14/2020] [Indexed: 12/14/2022]
Abstract
Cryptococcal meningoencephalitis was first described over a century ago. This fungal infection is preventable and treatable yet continues to be associated with excessive morbidity and mortality. The largest burden of disease resides in people living with HIV in low-income and middle-income countries. In this group, mortality with the best antifungal induction regimen (7 days of amphotericin B deoxycholate [1·0 mg/kg per day] and flucytosine [100·0 mg/kg per day]) in a clinical trial setting was 24% at 10 weeks. The world is now at an inflection point in terms of recognition, research, and action to address the burden of morbidity and mortality from cryptococcal meningoencephalitis. However, the scope of interventional programmes needs to increase, with particular attention to implementation science that is specific to individual countries. This Review summarises causes of excessive mortality, interventions with proven survival benefit, and gaps in knowledge and practice that contribute to the ongoing high death toll from cryptococcal meningoencephalitis. TRANSLATIONS: For the Vietnamese and Chichewa translations of the abstract see Supplementary Materials section.
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Affiliation(s)
- Katharine Elizabeth Stott
- Antimicrobial Pharmacodynamics and Therapeutics, Institute of Translational Medicine, University of Liverpool, Liverpool Health Partners, Liverpool, UK; Malawi-Liverpool-Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi.
| | - Angela Loyse
- Institute of Infection and Immunity, St George's University and Hospital, London, UK
| | - Joe N Jarvis
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana; Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Melanie Alufandika
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi
| | | | - Henry C Mwandumba
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi; Liverpool School of Tropical Medicine, Liverpool, UK
| | - Jeremy N Day
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, UK
| | | | - Tihana Bicanic
- Institute of Infection and Immunity, St George's University and Hospital, London, UK
| | - John R Perfect
- Division of Infectious Diseases and International Health, Duke University School of Medicine, Durham, NC, USA
| | - William Hope
- Antimicrobial Pharmacodynamics and Therapeutics, Institute of Translational Medicine, University of Liverpool, Liverpool Health Partners, Liverpool, UK
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Zhao T, Xu XL, Nie JM, Chen XH, Jiang ZS, Liu SQ, Yang TT, Yang X, Sun F, Lu YQ, Harypursat V, Chen YK. Establishment of a novel scoring model for mortality risk prediction in HIV-infected patients with cryptococcal meningitis. BMC Infect Dis 2021; 21:786. [PMID: 34376147 PMCID: PMC8353436 DOI: 10.1186/s12879-021-06417-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 07/07/2021] [Indexed: 12/04/2022] Open
Abstract
Background Cryptococcal meningitis (CM) remains a leading cause of death in HIV-infected patients, despite advances in CM diagnostic and therapeutic strategies. This study was performed with the aim to develop and validate a novel scoring model to predict mortality risk in HIV-infected patients with CM (HIV/CM). Methods Data on HIV/CM inpatients were obtained from a Multicenter Cohort study in China. Independent risk factors associated with mortality were identified based on data from 2013 to 2017, and a novel scoring model for mortality risk prediction was established. The bootstrapping statistical method was used for internal validation. External validation was performed using data from 2018 to 2020. Results We found that six predictors, including age, stiff neck, impaired consciousness, intracranial pressure, CD4+ T-cell count, and urea levels, were associated with poor prognosis in HIV/CM patients. The novel scoring model could effectively identify HIV/CM patients at high risk of death on admission (area under curve 0.876; p<0.001). When the cut-off value of 5.5 points or more was applied, the sensitivity and specificity was 74.1 and 83.8%, respectively. Our scoring model showed a good discriminatory ability, with an area under the curve of 0.879 for internal validation via bootstrapping, and an area under the curve of 0.886 for external validation. Conclusions Our developed scoring model of six variables is simple, convenient, and accurate for screening high-risk patients with HIV/CM, which may be a useful tool for physicians to assess prognosis in HIV/CM inpatients.
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Affiliation(s)
- Ting Zhao
- Division of Infectious Diseases, Chongqing Public Health Medical Center, 109 Baoyu Road, Shapingba, Chongqing, 400036, China
| | - Xiao-Lei Xu
- Division of Infectious Diseases, Chongqing Public Health Medical Center, 109 Baoyu Road, Shapingba, Chongqing, 400036, China
| | - Jing-Min Nie
- Division of Infectious Diseases, Chongqing Public Health Medical Center, 109 Baoyu Road, Shapingba, Chongqing, 400036, China
| | - Xiao-Hong Chen
- Department of Infectious Diseases, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang province, China
| | - Zhong-Sheng Jiang
- Division of Infectious Diseases, Liuzhou People's Hospital, Liuzhou, Guangxi province, China
| | - Shui-Qing Liu
- Department of Infectious Diseases, Guiyang Public Health Clinical Center, Guiyang, Guizhou province, China
| | - Tong-Tong Yang
- Department of Infectious Disease, Public Health Clinical Center of Chengdu, Chengdu, Sichuan province, China
| | - Xuan Yang
- Department of Infectious Diseases, Sixth People's Hospital of Zhengzhou, Zhengzhou, Henan province, China
| | - Feng Sun
- Division of Infectious Diseases, Chongqing Public Health Medical Center, 109 Baoyu Road, Shapingba, Chongqing, 400036, China
| | - Yan-Qiu Lu
- Division of Infectious Diseases, Chongqing Public Health Medical Center, 109 Baoyu Road, Shapingba, Chongqing, 400036, China
| | - Vijay Harypursat
- Division of Infectious Diseases, Chongqing Public Health Medical Center, 109 Baoyu Road, Shapingba, Chongqing, 400036, China
| | - Yao-Kai Chen
- Division of Infectious Diseases, Chongqing Public Health Medical Center, 109 Baoyu Road, Shapingba, Chongqing, 400036, China.
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Kashima E, Nagaharu K, Ino K, Sugimoto Y, Fujieda A, Kawakami K, Tawara I. Voriconazole as a secondary prophylaxis for cryptococcal meningitis during hematopoietic stem cell transplantation. IDCases 2021; 25:e01241. [PMID: 34377674 DOI: 10.1016/j.idcr.2021.e01241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 07/24/2021] [Accepted: 07/25/2021] [Indexed: 11/25/2022] Open
Abstract
Antifungal prophylaxis is crucial for successful hematopoietic stem cell transplantation (HSCT). Maintenance therapy with fluconazole (FLCZ) is generally prescribed as secondary prophylaxis in patients with human immunodeficiency virus infection and non-immunocompromised hosts. However, previous reports have revealed that FLCZ is insufficient as a secondary prophylaxis for cryptococcal infection in HSCT cases. There is no well-established evidence of effective secondary prophylaxis against cryptococcal infection in conditions of severe immunosuppression, such as in HSCT. Herein, we report a case of atypical chronic myeloid leukemia (aCML) presenting with cryptococcal meningitis. A 58-year-old man with progressive leukocytosis and headache was referred to our hospital. Bone marrow biopsy revealed aCML. Because the estimated overall survival was limited, HSCT was indicated. Furthermore, enhanced magnetic resonance imaging and lumbar puncture aided in diagnosing cryptococcal meningitis, which was treated with a combination therapy comprising liposomal amphotericin B and 5-fluorocystine for 28 days. Given the high recurrence rate of cryptococcal meningitis, voriconazole (VRCZ) dose was calculated using the trough concentration of VRCZ in the cerebrospinal fluid. Eventually, HSCT was successfully performed at an appropriate therapeutic range of VRCZ. To the best of our knowledge, there is no case report on HSCT with secondary prophylaxis against cryptococcal meningitis. Our report thus emphasizes the efficacy of VRCZ maintenance therapy as secondary prophylaxis for cryptococcal infection.
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Larson B, Shroufi A, Muthoga C, Oladele R, Rajasingham R, Jordan A, Jarvis JN, Chiller TM, Govender NP. Induction-phase treatment costs for cryptococcal meningitis in high HIV-burden African countries: New opportunities with lower costs. Wellcome Open Res 2021; 6:140. [PMID: 35706922 PMCID: PMC9184925 DOI: 10.12688/wellcomeopenres.16776.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/25/2021] [Indexed: 11/20/2022] Open
Abstract
Introduction: Access to and the cost of induction treatment for cryptococcal meningitis (CM) is rapidly changing. The newly-announced price for flucytosine ($0.75 per 500 mg pill) and possibly lower prices for liposomal amphotericin B (AmB-L) create opportunities to reduce CM treatment costs compared to the current standard treatment in low- and middle-income countries. Methods: We developed an Excel-based cost model to estimate health system treatment costs for CM over a two-week induction phase for multiple treatment combinations, newly feasible with improved access to flucytosine and AmB-L. CM treatment costs include medications, laboratory tests and other hospital-based costs (bed-day costs and healthcare worker time). We report results from applying the model using country-specific information for South Africa, Uganda, Nigeria, and Botswana. Results: A 14-day induction-phase of seven days of inpatient AmB-D with flucytosine, followed by seven days of high-dose fluconazole as an outpatient, will cost health systems less than a 14-day hospital stay with AmB-D and fluconazole. If daily AmB-L replaces AmB-D for those with baseline renal dysfunction, with a cost of $50 or less per 50 mg vial, incremental costs would still be less than the AmB-D with fluconazole regimen. Simple oral combinations (e.g., seven days of flucytosine with fluconazole as an inpatient) are practical when AmB-D is not available, and treatment costs would remain less than the current standard treatment. Conclusions: Improved access to, and lower prices for flucytosine and AmB-L create opportunities for improving CM treatment regimens. An induction regimen of flucytosine and AmB-D for seven days is less costly than standard care in the settings studied here. As this regimen has also been shown to be more effective than current standard care, countries should prioritize scaling up flucytosine access. The cost of AmB-L based regimens is highly dependent on the price of AmB-L, which currently remains unclear.
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Affiliation(s)
- Bruce Larson
- Global Health, Boston University School of Public Health, Boston, MA, 02118, USA
- Health Economics and Epidemiology Research Office, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Charles Muthoga
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Rita Oladele
- College of Medicine, Univerity of Lagos, Lagos, Nigeria
| | - Radha Rajasingham
- Division of Infectious Diseases & International Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Alexander Jordan
- Mycotic Diseases Branch, Centers for Disease Controls and Prevention, Atlanta, Georgia, USA
| | - Joseph N. Jarvis
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Tom M. Chiller
- Mycotic Diseases Branch, Centers for Disease Controls and Prevention, Atlanta, Georgia, USA
| | - Nelesh P. Govender
- National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa
- University of Witwatersrand, Johannesburg, South Africa
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Skosana PP, Schellack N, Godman B, Kurdi A, Bennie M, Kruger D, Meyer JC. A point prevalence survey of antimicrobial utilisation patterns and quality indices amongst hospitals in South Africa; findings and implications. Expert Rev Anti Infect Ther 2021; 19:1353-1366. [PMID: 33724147 DOI: 10.1080/14787210.2021.1898946] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Objectives: Antimicrobial use is growing, driven mainly by rising demands in developing countries. Knowing how antimicrobials are prescribed is important. Consequently, we undertook a point prevalence survey (PPS) quantifying antimicrobial consumption among 18 public sector hospitals across South Africa.Method: A purpose-built web-based application was used to collect PPS data.Results: Out of 4407 adult patients surveyed, 33.6% were treated with an antimicrobial. The most frequently prescribed groups were a combination of penicillins including β-lactamase inhibitors. Amoxicillin combined with an enzyme inhibitor accounted for 21.4% total DDDs. In the medical and surgical wards, Access antimicrobials (54.1%) were mostly used, while in the ICU, Watch antimicrobials (51.5%) were mostly used. Compliance with the South African Standard Treatment Guidelines and Essential Medicines List was 90.2%; however, concerns with extended use of antimicrobials for surgical prophylaxis (73.2% of patients).Conclusion: The web-based PPS tool was easy to use and successful in capturing PPS data since the results were comparable to other PPS studies across Africa. High use of amoxicillin combined with an enzyme inhibitor, possibly because it was among the broad-spectrum antimicrobials in the Access group. The findings will assist with future targets to improve antimicrobial prescribing among public sector hospitals in South Africa.
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Affiliation(s)
- P P Skosana
- School of Pharmacy, Sefako Makgatho Health Sciences University, Ga-Rankuwa, Gauteng, South Africa
| | - N Schellack
- School of Pharmacy, Sefako Makgatho Health Sciences University, Ga-Rankuwa, Gauteng, South Africa
| | - B Godman
- School of Pharmacy, Sefako Makgatho Health Sciences University, Ga-Rankuwa, Gauteng, South Africa.,Department of Pharmacoepidemiology, Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, UK.,Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - A Kurdi
- Department of Pharmacoepidemiology, Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, UK.,Department of Pharmacology, College of Pharmacy, Hawler Medical University, Erbil, Iraq
| | - M Bennie
- Department of Pharmacoepidemiology, Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, UK
| | - D Kruger
- School of Pharmacy, Sefako Makgatho Health Sciences University, Ga-Rankuwa, Gauteng, South Africa
| | - J C Meyer
- School of Pharmacy, Sefako Makgatho Health Sciences University, Ga-Rankuwa, Gauteng, South Africa
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Deiss R, Loreti CV, Gutierrez AG, Filipe E, Tatia M, Issufo S, Ciglenecki I, Loarec A, Vivaldo H, Barra C, Siufi C, Molfino L, Tamayo Antabak N. High burden of cryptococcal antigenemia and meningitis among patients presenting at an emergency department in Maputo, Mozambique. PLoS One 2021; 16:e0250195. [PMID: 33901215 PMCID: PMC8075188 DOI: 10.1371/journal.pone.0250195] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 03/31/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Cryptococcal meningitis is a leading cause of HIV-related mortality in sub-Saharan Africa, however, screening for cryptococcal antigenemia has not been universally implemented. As a result, data concerning cryptococcal meningitis and antigenemia are sparse, and in Mozambique, the prevalence of both are unknown. METHODS We performed a retrospective analysis of routinely collected data from a point-of-care cryptococcal antigen screening program at a public hospital in Maputo, Mozambique. HIV-positive patients admitted to the emergency department underwent CD4 count testing; those with pre-defined abnormal vital signs or CD4 count ≤ 200 cells/μL received cryptococcal antigen testing and lumbar punctures if indicated. Patients with CM were admitted to the hospital and treated with liposomal amphotericin B and flucytosine; their 12-week outcomes were ascertained through review of medical records or telephone contact by program staff made in the routine course of service delivery. RESULTS Among 1,795 patients screened for cryptococcal antigenemia between March 2018-March 2019, 134 (7.5%) were positive. Of patients with cryptococcal antigenemia, 96 (71.6%) were diagnosed with CM, representing 5.4% of all screened patients. Treatment outcomes were available for 87 CM patients: 24 patients (27.6%) died during induction treatment and 63 (72.4%) survived until discharge; of these, 38 (60.3%) remained in care, 9 (14.3%) died, and 16 (25.3%) were lost-to follow-up at 12 weeks. CONCLUSIONS We found a high prevalence of cryptococcal antigenemia and meningitis among patients screened at an emergency department in Maputo, Mozambique. High mortality during and after induction therapy demonstrate missed opportunities for earlier detection of cryptococcal antigenemia, even as point-of-care screening and rapid assessment in an emergency room offer potential to improve outcomes.
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Affiliation(s)
- Robert Deiss
- Médecins Sans Frontières, Maputo, Mozambique
- Division of Infectious Diseases, Department of Medicine, University of California, San Diego, California, United States of America
| | | | | | - Eudoxia Filipe
- HIV Programme, Ministry of Health (MoH), Maputo, Mozambique
| | | | - Sheila Issufo
- HIV Programme, Ministry of Health (MoH), Maputo, Mozambique
| | | | - Anne Loarec
- Médecins Sans Frontières, Maputo, Mozambique
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41
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Miot J, Leong T, Takuva S, Parrish A, Dawood H. Cost-effectiveness analysis of flucytosine as induction therapy in the treatment of cryptococcal meningitis in HIV-infected adults in South Africa. BMC Health Serv Res 2021; 21:305. [PMID: 33823842 PMCID: PMC8025344 DOI: 10.1186/s12913-021-06268-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Accepted: 03/10/2021] [Indexed: 02/05/2023] Open
Abstract
Background Cryptococcal meningitis in HIV-infected patients in sub-Saharan Africa accounts for three-quarters of the global cases and 135,000 deaths per annum. Current treatment includes the use of fluconazole and amphotericin B. Recent evidence has shown that the synergistic use of flucytosine improves efficacy and reduces toxicity, however affordability and availability has hampered access to flucytosine in many countries. This study investigated the evidence and cost implications of introducing flucytosine as induction therapy for cryptococcal meningitis in HIV-infected adults in South Africa. Methods A decision analytic cost-effectiveness and cost impact model was developed based on survival estimates from the ACTA trial and local costs for flucytosine as induction therapy in HIV-infected adults with cryptococcal meningitis in a public sector setting in South Africa. The model considered five treatment arms: (a) standard of care; 2-week course amphotericin B/fluconazole (2wk AmBd/Flu), (b) 2-week course amphotericin B/flucytosine (2wk AmBd/5FC), (c) short course; 1-week course amphotericin B/flucytosine (1wk AmBd/5FC) (d) oral course; 2-week oral fluconazole/flucytosine (oral) and e) 1-week course amphotericin B/fluconazole (1wk AmBd/Flu). A sensitivity analysis was conducted on key variables. Results The highest total treatment costs are in the 2-week AmBd/5FC arm followed by the 2-week oral regimen, the 1-week AmBd/5FC, then standard of care with the lowest cost in the 1-week AmBd/Flu arm. Compared to the lowest cost option the 1-week flucytosine course is most cost-effective at USD119/QALY. The cost impact analysis shows that the 1-week flucytosine course has an incremental cost of just over USD293 per patient per year compared to what is currently spent on standard of care. Sensitivity analyses suggest that the model is most sensitive to life expectancy and hospital costs, particularly infusion costs and length of stay. Conclusions The addition of flucytosine as induction therapy for the treatment of cryptococcal meningitis in patients infected with HIV is cost-effective when it is used as a 1-week AmBd/5FC regimen. Savings could be achieved with early discharge of patients as well as a reduction in the price of flucytosine.
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Affiliation(s)
- Jacqui Miot
- Health Economics and Epidemiology Research Office, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
| | - Trudy Leong
- National Department of Health, Affordable Medicines Directorate, Essential Drugs Programme, Pretoria, South Africa
| | - Simbarashe Takuva
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,School of Health Systems and Public Health, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | - Andrew Parrish
- Department of Internal Medicine, Cecilia Makiwane Hospital, East London, South Africa
| | - Halima Dawood
- Department of Medicine, Greys Hospital, Pietermaritzburg, KwaZulu-Natal, South Africa.,Caprisa, University of KwaZulu-Natal, Durban, South Africa
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42
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Marcyk PT, LeBlanc EV, Kuntz DA, Xue A, Ortiz F, Trilles R, Bengtson S, Kenney TM, Huang DS, Robbins N, Williams NS, Krysan DJ, Privé GG, Whitesell L, Cowen LE, Brown LE. Fungal-Selective Resorcylate Aminopyrazole Hsp90 Inhibitors: Optimization of Whole-Cell Anticryptococcal Activity and Insights into the Structural Origins of Cryptococcal Selectivity. J Med Chem 2021; 64:1139-1169. [PMID: 33444025 PMCID: PMC8493596 DOI: 10.1021/acs.jmedchem.0c01777] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The essential eukaryotic chaperone Hsp90 regulates the form and function of diverse client proteins, many of which govern thermotolerance, virulence, and drug resistance in fungal species. However, use of Hsp90 inhibitors as antifungal therapeutics has been precluded by human host toxicities and suppression of immune responses. We recently described resorcylate aminopyrazoles (RAPs) as the first class of Hsp90 inhibitors capable of discriminating between fungal (Cryptococcus neoformans, Candida albicans) and human isoforms of Hsp90 in biochemical assays. Here, we report an iterative structure-property optimization toward RAPs capable of inhibiting C. neoformans growth in culture. In addition, we report the first X-ray crystal structures of C. neoformans Hsp90 nucleotide binding domain (NBD), as the apoprotein and in complexes with the non-species-selective Hsp90 inhibitor NVP-AUY922 and three RAPs revealing unique ligand-induced conformational rearrangements, which reaffirm the hypothesis that intrinsic differences in protein flexibility can confer selective inhibition of fungal versus human Hsp90 isoforms.
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Affiliation(s)
- Paul T. Marcyk
- Department of Chemistry and Center for Molecular Discovery (BU-CMD), Boston University, Boston, Massachusetts 02215, United States
| | - Emmanuelle V. LeBlanc
- Department of Molecular Genetics, University of Toronto, Toronto, Ontario, M5G 1M1, Canada
| | - Douglas A. Kuntz
- Princess Margaret Cancer Centre, Toronto, Ontario, M5G 1L7, Canada
| | - Alice Xue
- Department of Molecular Genetics, University of Toronto, Toronto, Ontario, M5G 1M1, Canada
| | - Francisco Ortiz
- Department of Biochemistry, UT Southwestern Medical Center, Dallas, Texas 75390-9038, United States
| | - Richard Trilles
- Department of Chemistry and Center for Molecular Discovery (BU-CMD), Boston University, Boston, Massachusetts 02215, United States
| | - Stephen Bengtson
- Department of Chemistry and Center for Molecular Discovery (BU-CMD), Boston University, Boston, Massachusetts 02215, United States
| | - Tristan M.G. Kenney
- Department of Medical Biophysics, University of Toronto, Toronto, Ontario, M5G 1L7, Canada
| | - David S. Huang
- Department of Chemistry and Center for Molecular Discovery (BU-CMD), Boston University, Boston, Massachusetts 02215, United States
| | - Nicole Robbins
- Department of Molecular Genetics, University of Toronto, Toronto, Ontario, M5G 1M1, Canada
| | - Noelle S. Williams
- Department of Biochemistry, UT Southwestern Medical Center, Dallas, Texas 75390-9038, United States
| | - Damian J. Krysan
- Departments of Pediatrics and Microbiology/Immunology, Carver College of Medicine, University of Iowa, Iowa City, Iowa, 52242, United States
| | - Gilbert G. Privé
- Princess Margaret Cancer Centre, Toronto, Ontario, M5G 1L7, Canada
- Department of Medical Biophysics, University of Toronto, Toronto, Ontario, M5G 1L7, Canada
- Department of Biochemistry, University of Toronto, Toronto, Ontario, M5S 1A8, Canada
| | - Luke Whitesell
- Department of Molecular Genetics, University of Toronto, Toronto, Ontario, M5G 1M1, Canada
| | - Leah E. Cowen
- Department of Molecular Genetics, University of Toronto, Toronto, Ontario, M5G 1M1, Canada
| | - Lauren E. Brown
- Department of Chemistry and Center for Molecular Discovery (BU-CMD), Boston University, Boston, Massachusetts 02215, United States
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Shiri T, Loyse A, Mwenge L, Chen T, Lakhi S, Chanda D, Mwaba P, Molloy SF, Heyderman RS, Kanyama C, Hosseinipour MC, Kouanfack C, Temfack E, Mfinanga S, Kivuyo S, Chan AK, Jarvis JN, Lortholary O, Jaffar S, Niessen LW, Harrison TS. Addition of Flucytosine to Fluconazole for the Treatment of Cryptococcal Meningitis in Africa: A Multicountry Cost-effectiveness Analysis. Clin Infect Dis 2021; 70:26-29. [PMID: 30816418 PMCID: PMC6912152 DOI: 10.1093/cid/ciz163] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 02/22/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Mortality from cryptococcal meningitis remains very high in Africa. In the Advancing Cryptococcal Meningitis Treatment for Africa (ACTA) trial, 2 weeks of fluconazole (FLU) plus flucytosine (5FC) was as effective and less costly than 2 weeks of amphotericin-based regimens. However, many African settings treat with FLU monotherapy, and the cost-effectiveness of adding 5FC to FLU is uncertain. METHODS The effectiveness and costs of FLU+5FC were taken from ACTA, which included a costing analysis at the Zambian site. The effectiveness of FLU was derived from cohorts of consecutively enrolled patients, managed in respects other than drug therapy, as were participants in ACTA. FLU costs were derived from costs of FLU+5FC in ACTA, by subtracting 5FC drug and monitoring costs. The cost-effectiveness of FLU+5FC vs FLU alone was measured as the incremental cost-effectiveness ratio (ICER). A probabilistic sensitivity analysis assessed uncertainties and a bivariate deterministic sensitivity analysis examined the impact of varying mortality and 5FC drug costs on the ICER. RESULTS The mean costs per patient were US $847 (95% confidence interval [CI] $776-927) for FLU+5FC, and US $628 (95% CI $557-709) for FLU. The 10-week mortality rate was 35.1% (95% CI 28.9-41.7%) with FLU+5FC and 53.8% (95% CI 43.1-64.1%) with FLU. At the current 5FC price of US $1.30 per 500 mg tablet, the ICER of 5FC+FLU versus FLU alone was US $65 (95% CI $28-208) per life-year saved. Reducing the 5FC cost to between US $0.80 and US $0.40 per 500 mg resulted in an ICER between US $44 and US $28 per life-year saved. CONCLUSIONS The addition of 5FC to FLU is cost-effective for cryptococcal meningitis treatment in Africa and, if made available widely, could substantially reduce mortality rates among human immunodeficiency virus-infected persons in Africa.
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Affiliation(s)
| | - Angela Loyse
- Centre for Global Health, Institute for Infection and Immunity, St George's University of London, United Kingdom
| | | | - Tao Chen
- Liverpool School of Tropical Medicine, United Kingdom
| | - Shabir Lakhi
- University Teaching Hospital, Lusaka, Lusaka, Zambia
| | - Duncan Chanda
- University Teaching Hospital, Lusaka, Lusaka, Zambia.,Institute for Medical Research and Training, University Teaching Hospital, Lusaka, Zambia
| | - Peter Mwaba
- Department of Internal Medicine and Directorate of Research and Post-graduate Studies, Lusaka Apex Medical University, Zambia
| | - Síle F Molloy
- Centre for Global Health, Institute for Infection and Immunity, St George's University of London, United Kingdom
| | - Robert S Heyderman
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, University of Malawi, Blantyre.,College of Medicine, University of Malawi, Blantyre.,University College London, United Kingdom
| | - Cecilia Kanyama
- University of North Carolina Project-Malawi, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Mina C Hosseinipour
- University of North Carolina Project-Malawi, Kamuzu Central Hospital, Lilongwe, Malawi.,Division of Infectious Diseases, University of North Carolina at Chapel Hill School of Medicine
| | - Charles Kouanfack
- Hôpital Central Yaoundé/Site Agence Nationale de Recherche sur le Sida Cameroun, Cameroon.,University of Dschang, Cameroon
| | - Elvis Temfack
- Douala General Hospital, Cameroon.,Institut Pasteur, Molecular Mycology Unit, National Reference Center for Invasive Mycoses & Antifungals, Centre National de la Recherche Scientifique, Paris, France
| | - Sayoki Mfinanga
- Liverpool School of Tropical Medicine, United Kingdom.,National Institute for Medical Research, Muhimbili Medical Research Centre, Dar Es Salaam, United Republic of Tanzania
| | - Sokoine Kivuyo
- National Institute for Medical Research, Muhimbili Medical Research Centre, Dar Es Salaam, United Republic of Tanzania
| | - Adrienne K Chan
- Dignitas International, Zomba Central Hospital, Malawi.,Division of Infectious Diseases, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Canada
| | - Joseph N Jarvis
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, United Kingdom.,Botswana Harvard AIDS Institute Partnership, Gabarone
| | - Olivier Lortholary
- Institut Pasteur, Molecular Mycology Unit, National Reference Center for Invasive Mycoses & Antifungals, Centre National de la Recherche Scientifique, Paris, France.,Paris Descartes University, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, Institut Hospitalo-Universitaire Imagine, Assistance Publique - Hôpitaux de Paris, France
| | | | - Louis W Niessen
- Liverpool School of Tropical Medicine, United Kingdom.,Department of International Health, Johns Hopkins School of Public Health, Baltimore, Maryland
| | - Thomas S Harrison
- Centre for Global Health, Institute for Infection and Immunity, St George's University of London, United Kingdom
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Iyer KR, Revie NM, Fu C, Robbins N, Cowen LE. Treatment strategies for cryptococcal infection: challenges, advances and future outlook. Nat Rev Microbiol 2021; 19:454-66. [PMID: 33558691 DOI: 10.1038/s41579-021-00511-0] [Citation(s) in RCA: 120] [Impact Index Per Article: 40.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/07/2021] [Indexed: 01/31/2023]
Abstract
Cryptococcus spp., in particular Cryptococcus neoformans and Cryptococcus gattii, have an enormous impact on human health worldwide. The global burden of cryptococcal meningitis is almost a quarter of a million cases and 181,000 deaths annually, with mortality rates of 100% if infections remain untreated. Despite these alarming statistics, treatment options for cryptococcosis remain limited, with only three major classes of drugs approved for clinical use. Exacerbating the public health burden is the fact that the only new class of antifungal drugs developed in decades, the echinocandins, displays negligible antifungal activity against Cryptococcus spp., and the efficacy of the remaining therapeutics is hampered by host toxicity and pathogen resistance. Here, we describe the current arsenal of antifungal agents and the treatment strategies employed to manage cryptococcal disease. We further elaborate on the recent advances in our understanding of the intrinsic and adaptive resistance mechanisms that are utilized by Cryptococcus spp. to evade therapeutic treatments. Finally, we review potential therapeutic strategies, including combination therapy, the targeting of virulence traits, impairing stress response pathways and modulating host immunity, to effectively treat infections caused by Cryptococcus spp. Overall, understanding of the mechanisms that regulate anti-cryptococcal drug resistance, coupled with advances in genomics technologies and high-throughput screening methodologies, will catalyse innovation and accelerate antifungal drug discovery.
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Moeng LR, Milburn J, Jarvis JN, Lawrence DS. HIV-associated Cryptococcal Meningitis: a Review of Novel Short-Course and Oral Therapies. Curr Treat Options Infect Dis 2020; 12:422-37. [DOI: 10.1007/s40506-020-00239-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Abstract
Purpose of review
HIV-associated cryptococcal meningitis remains a significant public health problem in parts of Africa and Asia and a major cause of AIDS-related mortality, accounting for 15% of all AIDS-related deaths worldwide. Cryptococcal meningitis is uniformly fatal if untreated, and access to antifungal therapy in regions with the highest burden is often limited. Outcomes with fluconazole monotherapy are poor, and induction treatment with amphotericin B and high-dose fluconazole for 2 weeks is associated with significant drug-related toxicities and prolonged hospital admissions. This review focuses on the potential of novel short-course and oral combination therapies for cryptococcal meningitis.
Recent findings
Recent clinical trials have shown that shorter courses of amphotericin, if paired with oral flucytosine, rather than fluconazole, can achieve non-inferior mortality outcomes. In addition, an oral combination of fluconazole and flucytosine is a potential alternative. Liposomal amphotericin B may further simplify treatment; it is associated with fewer drug-related toxicities, and a recent phase II randomised controlled trial demonstrated that a single, high dose of liposomal amphotericin is non-inferior to 14 standard daily doses at clearing Cryptococcus from cerebrospinal fluid. This has been taken forward to an ongoing phase III, clinical endpoint study.
Summary
The incidence and mortality associated with cryptococcal meningitis is still unacceptably high. There is evidence supporting the use of short-course amphotericin B and oral combination antifungal treatment regimens for cryptococcal meningitis (CM). Ongoing research into short-course, high-dose treatment with liposomal amphotericin may also help reduce the impact of this devastating disease.
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Boyd AT, Oboho I, Paulin H, Ali H, Godfrey C, Date A, Sean Cavanaugh J. Addressing advanced HIV disease and mortality in global HIV programming. AIDS Res Ther 2020; 17:40. [PMID: 32650797 PMCID: PMC7348123 DOI: 10.1186/s12981-020-00296-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 07/02/2020] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION The US President's Emergency Plan for AIDS Relief (PEPFAR) was launched to increase access to antiretroviral treatment (ART) among people living with HIV (PLHIV) and to prevent new HIV infections globally. As new infections have decreased in many PEPFAR-supported countries, PEPFAR is increasingly focusing on understanding and decreasing mortality among PLHIV, specifically by addressing advanced HIV disease (AHD) and its attendant opportunistic infections (OIs). Several developments in identifying AHD, in preventing, diagnosing, and treating selected OIs, and in PEPFAR's support for mortality surveillance make this an opportune moment for PEPFAR to address HIV-related mortality. DISCUSSION AHD upon diagnosis or re-engagement in HIV care is not uncommon, and it substantially increases risk of death from OIs. The World Health Organization provides evidence-based guidelines for a package of interventions for preventing, diagnosing, and treating common OIs, including tuberculosis (TB), cryptococcal meningitis, and severe bacterial infections. PEPFAR facilitates implementation of these guidelines. To identify PLHIV with low CD4, PEPFAR plans to support expanded access to CD4 testing, including a point-of-care assay that differentiates CD4 cell count as a binary of greater than or less than 200 cells/µL. To prevent AHD-related mortality, PEPFAR supports rapid ART initiation with integrase inhibitor-based regimens and implementation and documentation of TB preventive treatment. To diagnose selected OIs, PEPFAR is implementing urine lateral flow lipoarabinomannan use to identify TB among PLHIV who have a CD4 cell count < 200 cells/µL. To treat selected OIs, PEPFAR has focused on improving patient-centered care in TB/HIV co-infection services and scaling up implementation of new drug regimens for cryptococcal meningitis. To better understand mortality, PEPFAR has introduced an indicator, TX_ML, to routinely and systematically categorize outcomes, including deaths, among PLHIV on ART. CONCLUSIONS PEPFAR is increasing its efforts to identify AHD; to prevent, diagnose, and treat OIs; and to track mortality in its programs. These ongoing efforts, done in collaboration with other stakeholders, seek to decrease mortality among PLHIV.
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Li Y, Huang X, Qin Y, Wu H, Yan X, Chen Y. What Is the Most Appropriate Induction Regimen for the Treatment of HIV-Associated Cryptococcal Meningitis When the Recommended Regimen Is Not Available? Evidence From a Network Meta-Analysis. Front Pharmacol 2020; 11:963. [PMID: 32714189 PMCID: PMC7344322 DOI: 10.3389/fphar.2020.00963] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Accepted: 06/12/2020] [Indexed: 02/06/2023] Open
Abstract
Aims Our object was to find the most appropriate, most effective, and most readily available of four induction regimens for HIV-associated cryptococcal meningitis (CM) (Regimen A: 1 week of AmB plus 5-FC followed by 1 week of fluconazole, Regimen B: 1 week of AmB plus fluconazole followed by 1 week of fluconazole, Regimen C: 2 weeks of AmB plus 5-FC, Regimen D: 2 weeks of AmB plus fluconazole), given the vast differences between resource-limited and resource-abundant settings regarding therapeutic drug accessibility, availability, and affordability for HIV-associated (CM). Methods We conducted a network meta-analysis to compare the therapeutic efficacy and safety of four different induction treatment regimens. Results The 10-week mortality of Regimen A was significantly lower than that of Regimen B and D, and the 2-week mortality of Regimen A was significantly lower than that of Regimen B. Furthermore, there were no statistically significant differences in 10-week mortality, 2-week mortality, as well as in effective fungicidal activity (EFA) over the first 2 weeks among Regimens B, C, and D. The statistical differences in adverse events between Regimen B and Regimen D, and Regimen C and Regimen D were not calculated to be significant. Conclusions Our results indicate that, 1 week of AmB plus 5-FC followed by 1 week of fluconazole is superior to the three other studied regimens, and that when 5-FC is not available, accessible, or affordable, 2 weeks of AmB plus fluconazole or 1 week of AmB plus fluconazole followed by 1 week of fluconazole is an appropriate substitution for 2 weeks of AmB plus 5-FC.
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Affiliation(s)
- Yao Li
- Division of Infectious Diseases, Chongqing Public Health Medical Center, Chongqing, China
| | - Xiaojie Huang
- Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Yuanyuan Qin
- Division of Infectious Diseases, Chongqing Public Health Medical Center, Chongqing, China
| | - Hao Wu
- Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Xiaofeng Yan
- Division of Infectious Diseases, Chongqing Public Health Medical Center, Chongqing, China
| | - Yaokai Chen
- Division of Infectious Diseases, Chongqing Public Health Medical Center, Chongqing, China
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Affiliation(s)
- Joseph N Jarvis
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, United Kingdom.,Botswana Harvard AIDS Institute Partnership, Gaborone.,Botswana UPenn Partnership, Gaborone.,Division of Infectious Diseases, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Thomas S Harrison
- Centre for Global Health, Institute for Infection and Immunity, St George's University of London, United Kingdom
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Tenforde MW, Jarvis JN. HIV-associated cryptococcal meningitis: ongoing challenges and new opportunities. Lancet Infect Dis 2020; 19:793-794. [PMID: 31345446 DOI: 10.1016/s1473-3099(19)30295-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 04/04/2019] [Indexed: 11/25/2022]
Affiliation(s)
- Mark W Tenforde
- Division of Allergy and Infectious Diseases, University of Washington School of Medicine, Seattle, WA 98195, USA; Department of Epidemiology, University of Washington School of Public Health, Seattle, WA, USA.
| | - Joseph N Jarvis
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana; Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
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von Gottberg A, Meintjes G. Meningitis: a frequently fatal diagnosis in Africa. Lancet Infect Dis 2019; 19:676-8. [PMID: 31250809 DOI: 10.1016/S1473-3099(19)30111-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 03/04/2019] [Indexed: 11/23/2022]
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