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Musubire A, Kagimu E, Mugabi T, Meya DB, Boulware DR, Bahr NC. Complex Decisions in HIV-Related Cryptococcosis: Addressing Second Episodes of Cryptococcal Meningitis. Curr HIV/AIDS Rep 2024; 21:75-85. [PMID: 38400871 PMCID: PMC11016006 DOI: 10.1007/s11904-024-00691-3] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/08/2024] [Indexed: 02/26/2024]
Abstract
PURPOSE OF REVIEW This review highlights the difficulties in diagnosing and treating persons with a prior history of cryptococcal meningitis who improve but suffer from a recurrence of symptoms. This scenario is well known to those who frequently care for patients with cryptococcal meningitis but is not well understood. We highlight major gaps in knowledge. RECENT FINDINGS We recently summarized our experience with 28 persons with paradoxical immune reconstitution inflammatory syndrome (IRIS) and 81 persons with microbiological relapse. CD4 count and cerebrospinal fluid white blood cell count were higher in IRIS than relapse but neither was reliable enough to routinely differentiate these conditions. Second-episode cryptococcal meningitis remains a difficult clinical scenario as cryptococcal antigen, while excellent for initial diagnosis has no value in differentiating relapse of infection from other causes of recurrent symptoms. Updated research definitions are proposed and rapid, accurate diagnostic tests are urgently needed.
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Affiliation(s)
- Abdu Musubire
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Enock Kagimu
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Timothy Mugabi
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - David B Meya
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - David R Boulware
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Nathan C Bahr
- Division of Infectious Diseases, Department of Medicine, University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, 66160 KS, USA.
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Chang CC, Harrison TS, Bicanic TA, Chayakulkeeree M, Sorrell TC, Warris A, Hagen F, Spec A, Oladele R, Govender NP, Chen SC, Mody CH, Groll AH, Chen YC, Lionakis MS, Alanio A, Castañeda E, Lizarazo J, Vidal JE, Takazono T, Hoenigl M, Alffenaar JW, Gangneux JP, Soman R, Zhu LP, Bonifaz A, Jarvis JN, Day JN, Klimko N, Salmanton-García J, Jouvion G, Meya DB, Lawrence D, Rahn S, Bongomin F, McMullan BJ, Sprute R, Nyazika TK, Beardsley J, Carlesse F, Heath CH, Ayanlowo OO, Mashedi OM, Queiroz-Telles Filho F, Hosseinipour MC, Patel AK, Temfack E, Singh N, Cornely OA, Boulware DR, Lortholary O, Pappas PG, Perfect JR. Global guideline for the diagnosis and management of cryptococcosis: an initiative of the ECMM and ISHAM in cooperation with the ASM. Lancet Infect Dis 2024:S1473-3099(23)00731-4. [PMID: 38346436 DOI: 10.1016/s1473-3099(23)00731-4] [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] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 11/02/2023] [Accepted: 11/13/2023] [Indexed: 03/21/2024]
Abstract
Cryptococcosis is a major worldwide disseminated invasive fungal infection. Cryptococcosis, particularly in its most lethal manifestation of cryptococcal meningitis, accounts for substantial mortality and morbidity. The breadth of the clinical cryptococcosis syndromes, the different patient types at-risk and affected, and the vastly disparate resource settings where clinicians practice pose a complex array of challenges. Expert contributors from diverse regions of the world have collated data, reviewed the evidence, and provided insightful guideline recommendations for health practitioners across the globe. This guideline offers updated practical guidance and implementable recommendations on the clinical approaches, screening, diagnosis, management, and follow-up care of a patient with cryptococcosis and serves as a comprehensive synthesis of current evidence on cryptococcosis. This Review seeks to facilitate optimal clinical decision making on cryptococcosis and addresses the myriad of clinical complications by incorporating data from historical and contemporary clinical trials. This guideline is grounded on a set of core management principles, while acknowledging the practical challenges of antifungal access and resource limitations faced by many clinicians and patients. More than 70 societies internationally have endorsed the content, structure, evidence, recommendation, and pragmatic wisdom of this global cryptococcosis guideline to inform clinicians about the past, present, and future of care for a patient with cryptococcosis.
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Affiliation(s)
- Christina C Chang
- Department of Infectious Diseases, Alfred Hospital, Melbourne, VIC, Australia; Department of Infectious Diseases, Central Clinical School, Monash University, Melbourne, VIC, Australia; Centre for the AIDS Programme of Research in South Africa, Durban, South Africa.
| | - Thomas S Harrison
- Institute of Infection and Immunity, St George's University London, London, UK; Clinical Academic Group in Infection and Immunity, St George's University Hospitals NHS Foundation Trust, London, UK; Medical Research Centre for Medical Mycology, University of Exeter, Exeter, UK
| | - Tihana A Bicanic
- Institute of Infection and Immunity, St George's University London, London, UK; Clinical Academic Group in Infection and Immunity, St George's University Hospitals NHS Foundation Trust, London, UK; Medical Research Centre for Medical Mycology, University of Exeter, Exeter, UK
| | - Methee Chayakulkeeree
- Division of Infectious Diseases and Tropical Medicine, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Tania C Sorrell
- Sydney Infectious Diseases Institute, University of Sydney, Sydney, NSW, Australia; Department of Infectious Diseases, Westmead Hospital, Westmead, NSW, Australia
| | - Adilia Warris
- Medical Research Centre for Medical Mycology, University of Exeter, Exeter, UK; Department of Infectious Diseases, Great Ormond Street Hospital, London, UK
| | - Ferry Hagen
- Faculty of Science, Institute for Biodiversity and Ecosystem Dynamics, University of Amsterdam, Amsterdam, Netherlands; Department of Medical Mycology, Westerdijk Fungal Biodiversity Institute, Utrecht, Netherlands; Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Andrej Spec
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St Louis, MO, USA
| | - Rita Oladele
- College of Medicine, University of Lagos, Lagos, Nigeria
| | - Nelesh P Govender
- Institute of Infection and Immunity, St George's University London, London, UK; Medical Research Centre for Medical Mycology, University of Exeter, Exeter, UK; Department of Clinical Microbiology and Infectious Diseases, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Division of Medical Microbiology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Sharon C Chen
- Sydney Infectious Diseases Institute, University of Sydney, Sydney, NSW, Australia; Department of Infectious Diseases, Westmead Hospital, Westmead, NSW, Australia; Centre for Infectious Diseases and Microbiology Laboratory Services, Institute for Clinical Pathology and Medical Research, New South Wales Health Pathology, Westmead, NSW, Australia
| | - Christopher H Mody
- Department of Microbiology, Immunology and Infectious Diseases, Department of Medicine, Snyder Institute for Chronic Diseases, University of Calgary, Calgary, AB, Canada
| | - Andreas H Groll
- Infectious Disease Research Program, and Department of Pediatric Hematology/Oncology, University Children's Hospital, Münster, Germany; Center for Bone Marrow Transplantation, and Department of Pediatric Hematology/Oncology, University Children's Hospital, Münster, Germany
| | - Yee-Chun Chen
- Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan; National Institute of Infectious Diseases and Vaccinology, National Health Research Institutes, Zhunan, Taiwan
| | - Michail S Lionakis
- Fungal Pathogenesis Section, Laboratory of Clinical Immunology & Microbiology, National Institute of Allergy & Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Alexandre Alanio
- Institut Pasteur, Centre National de Référence Mycoses Invasives et Antifongiques, Groupe de recherche Mycologie Translationnelle, Département de Mycologie, Université Paris Cité, Paris, France; Laboratoire de parasitologie-mycologie, AP-HP, Hôpital Saint-Louis, Université Paris Cité, Paris, France
| | | | - Jairo Lizarazo
- Department of Internal Medicine, Hospital Universitario Erasmo Meoz, Faculty of Health, Univesidad de Pamplona, Cúcuta, Colombia
| | - José E Vidal
- Departmento de Neurologia, Instituto de Infectologia Emílio Ribas, São Paulo, Brazil; Departamento de Moléstias Infecciosas e Parasitárias, Hospital das Clinicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil; Instituto de Medicina Tropical, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Takahiro Takazono
- Department of Infectious Diseases, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan; Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
| | - Martin Hoenigl
- Division of Infectious Diseases, Translational Medical Mycology Research Unit, European Confederation of Medical Mycology Excellence Center for Medical Mycology, Medical University of Graz, Graz, Austria; BioTechMed, Graz, Austria
| | - Jan-Willem Alffenaar
- Sydney Infectious Diseases Institute, University of Sydney, Sydney, NSW, Australia; Department of Pharmacy, Westmead Hospital, Westmead, NSW, Australia; School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Jean-Pierre Gangneux
- Institute for Health, Environment and Work Research-Irset, Inserm UMR_S 1085, University of Rennes, Rennes, France; Laboratory for Parasitology and Mycology, Centre National de Référence Mycoses Invasives et Antifongiques LA Asp-C, University Hospital of Rennes, Rennes, France
| | - Rajeev Soman
- Jupiter Hospital, Pune, India; Deenanath Mangeshkar Hospital, Pune, India; Hinduja Hospital, Mumbai, India
| | - Li-Ping Zhu
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, National Medical Center for Infectious Diseases, Huashan Hospital, Fudan University, Shanghai China
| | - Alexandro Bonifaz
- Hospital General de México, Dermatology Service, Mycology section, Universidad Nacional Autónoma de México, Mexico City, Mexico
| | - Joseph N Jarvis
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK; Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Jeremy N Day
- Department of Clinical Microbiology and Infection, Royal Devon and Exeter University Hospital NHS Trust, Exeter, UK
| | - Nikolai Klimko
- Department of Clinical Mycology, Allergy and Immunology, I Mechnikov North Western State Medical University, Staint Petersburg, Russia
| | - Jon Salmanton-García
- Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany; Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf and Excellence Center for Medical Mycology, Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany; Partner Site Bonn-Cologne, German Centre for Infection Research, Cologne, Germany
| | - Grégory Jouvion
- Histology and Pathology Unit, Ecole nationale vétérinaire d'Alfort, Maisons-Alfort, France; Dynamyc Team, Université Paris Est Créteil and Ecole nationale vétérinaire d'Alfort, Créteil, France
| | - David B Meya
- Infectious Diseases Institute, School of Medicine, College of Heath Sciences, Makerere University, Kampala, Uganda
| | - David 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
| | - Sebastian Rahn
- Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany; Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf and Excellence Center for Medical Mycology, Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany; Partner Site Bonn-Cologne, German Centre for Infection Research, Cologne, Germany
| | - Felix Bongomin
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Gulu University, Gulu, Uganda
| | - Brendan J McMullan
- Discipline of Paediatrics, School of Clinical Medicine, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia; Department of Infectious Diseases, Sydney Children's Hospital, Randwick, Sydney, NSW, Australia
| | - Rosanne Sprute
- Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany; Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf and Excellence Center for Medical Mycology, Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany; Partner Site Bonn-Cologne, German Centre for Infection Research, Cologne, Germany
| | - Tinashe K Nyazika
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Justin Beardsley
- Sydney Infectious Diseases Institute, University of Sydney, Sydney, NSW, Australia; Department of Infectious Diseases, Westmead Hospital, Westmead, NSW, Australia
| | - Fabianne Carlesse
- Pediatric Department, Federal University of São Paulo, São Paulo, Brazil; Oncology Pediatric Institute-IOP-GRAACC, Federal Univeristy of São Paulo, São Paulo, Brazil
| | - Christopher H Heath
- Department of Microbiology, Fiona Stanley Hospital Network, PathWest Laboratory Medicine, Perth, WA, Australia; Department of Infectious Diseases, Fiona Stanley Hospital, Perth, WA, Australia; UWA Medical School, Internal Medicine, The University of Western Australia, Perth, WA, Australia
| | - Olusola O Ayanlowo
- Dermatology Unit, Department of Medicine, Lagos University Teaching Hospital, University of Lagos, Lagos, Nigeria
| | - Olga M Mashedi
- Centre for Respiratory Diseases Research, Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Mina C Hosseinipour
- Department of Medicine, Division of Infectious Diseases, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA; UNC Project Malawi, Lilongwe, Malawi
| | - Atul K Patel
- Department of Infectious Diseases, Sterling Hospitals, Ahmedabad, India
| | - Elvis Temfack
- Africa Centers for Disease Control and Prevention, Addis Ababa, Ethiopia
| | - Nina Singh
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Oliver A Cornely
- Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany; Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf and Excellence Center for Medical Mycology, Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany; Partner Site Bonn-Cologne, German Centre for Infection Research, Cologne, Germany; Clinical Trials Centre Cologne, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - David R Boulware
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Olivier Lortholary
- Université de Paris Cité, APHP, Service des Maladies Infectieuses et Tropicales, Hôpital Necker-Enfants Malades, Centre d'Infectiologie Necker-Pasteur, Institut Imagine, Paris, France; Institut Pasteur, CNRS, Unité de Mycologie Moléculaire, Centre National de Référence Mycoses Invasives et Antifongiques, UMR 2000, Paris, France
| | - Peter G Pappas
- Mycoses Study Group Central Unit, Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - John R Perfect
- Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, Durham, NC, USA; Department of Molecular Genetics and Microbiology, Duke University Medical Center, Durham, NC, USA.
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McCarthy MW, Lindsell CJ, Rajasingham R, Stewart TG, Boulware DR, Naggie S. Progress toward realizing the promise of decentralized clinical trials. J Clin Transl Sci 2024; 8:e19. [PMID: 38384913 PMCID: PMC10879994 DOI: 10.1017/cts.2023.706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 12/18/2023] [Indexed: 02/23/2024] Open
Affiliation(s)
| | - Christopher J. Lindsell
- Duke Clinical Research Institute, Durham, NC, USA
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - Radha Rajasingham
- Division of Infectious Disease & International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Thomas G. Stewart
- University of Virginia School of Data Science, Charlottesville, VA, USA
| | - David R. Boulware
- Division of Infectious Disease & International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Susanna Naggie
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
- Department of Medicine, Duke University, Durham, NC, USA
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Nakib N, Sutherland S, Hallman K, Mianulli M, R Boulware D. Randomized trial of mechanotherapy for the treatment of stress urinary incontinence in women. Ther Adv Urol 2024; 16:17562872241228023. [PMID: 38328552 PMCID: PMC10848796 DOI: 10.1177/17562872241228023] [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: 07/19/2023] [Accepted: 12/05/2023] [Indexed: 02/09/2024] Open
Abstract
Background Stress urinary incontinence (SUI) presents as unintentional urine leakage associated with activities. It significantly affects quality of life (QoL) and is the most common type of incontinence in women. Current treatment options, particularly non-surgical therapies, are lacking. Objective To assess the efficacy of mechanotherapy provided by the Flyte® intra-vaginal device during pelvic floor muscle training (PFMT). Design This was a randomized, controlled, double-blinded trial. Materials and methods Flyte is a repeat use device for conditioning and strengthening the pelvic floor muscles (PFMs). It provides two-part mechanotherapy. Part 1 is the stretching and preloading of the PFM from the internal wand. Part 2 integrates mechanical pulses which elicit muscle cellular and tissue level responses that trigger cellular regeneration, improve neuromuscular facilitation and motor learning. Subjects used the device for 5 min/day for 12 weeks. Subjects (144) were randomized and evaluated at 6 and 12 weeks. Arm A (72) received both Part 1 and Part 2 mechanotherapy for 12 weeks, whereas Arm B (72) received Part 1 therapy for 6 weeks, then crossed over to full therapy. Mean age was 50, 49, respectively, prior pelvic/abdominal surgery 26%, 46%, and previous incontinence treatments 13%, 22%. The primary endpoint was 24-h pad weight (24-HR PW) at 6 weeks. Secondary endpoints were 24-HR PW at 12 weeks and QoL [International Consultation on Incontinence Questionnaire (ICIQ), Urinary Incontinence Quality of Life (IQOL)]. Results Part 1 therapy had a greater than anticipated therapeutic effect. Thus, the study was underpowered to identify differences between study arms. Therefore, data were pooled to assess the effects of mechanotherapy. Twenty four-HR PW was significantly reduced at 6 weeks (p = <0.0001), with further reduction from 6 to 12 weeks (p = <0.0001). Data were stratified based on 24-HR PW severity. Significant reductions were noted in all severity groups (mild p = <0.0001, moderate p = <0.0001, severe p = <0.01). QoL was similarly improved at 6 weeks (ICIQ p = <0.0001, IQOL p = <0.0001), and 12 weeks (ICIQ p = <0.0001, IQOL p = <0.0001). Compliance was >80% at 6 weeks and 70% at 12 weeks. Conclusion Two-part mechanotherapy significantly improved 24-HR PW and QoL across all severities of SUI. Improvements were noted in as little as 2 weeks and appeared to be sustained through 2-year follow up. Trial registration Registered on ClinTrials.gov (NCT02954042).
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Affiliation(s)
- Nissrine Nakib
- Department of Urology, University of Minnesota, Minneapolis, MN, USA
| | | | | | - Marcus Mianulli
- Gnarus Medical Consulting Inc., 18615 27th Avenue North, Plymouth, MN 55447, USA
| | - David R Boulware
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, MN, USA
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Stewart TG, Rebolledo PA, Mourad A, Lindsell CJ, Boulware DR, McCarthy MW, Thicklin F, Garcia del Sol IT, Bramante CT, Lenert LA, Lim S, Williamson JC, Cardona OQ, Scott J, Schwasinger-Schmidt T, Ginde AA, Castro M, Jayaweera D, Sulkowski M, Gentile N, McTigue K, Felker GM, DeLong A, Wilder R, Rothman RL, Collins S, Dunsmore SE, Adam SJ, Hanna GJ, Shenkman E, Hernandez AF, Naggie S. Higher-Dose Fluvoxamine and Time to Sustained Recovery in Outpatients With COVID-19: The ACTIV-6 Randomized Clinical Trial. JAMA 2023; 330:2354-2363. [PMID: 37976072 PMCID: PMC10656670 DOI: 10.1001/jama.2023.23363] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 10/25/2023] [Indexed: 11/19/2023]
Abstract
Importance The effect of higher-dose fluvoxamine in reducing symptom duration among outpatients with mild to moderate COVID-19 remains uncertain. Objective To assess the effectiveness of fluvoxamine, 100 mg twice daily, compared with placebo, for treating mild to moderate COVID-19. Design, Setting, and Participants The ACTIV-6 platform randomized clinical trial aims to evaluate repurposed medications for mild to moderate COVID-19. Between August 25, 2022, and January 20, 2023, a total of 1175 participants were enrolled at 103 US sites for evaluating fluvoxamine; participants were 30 years or older with confirmed SARS-CoV-2 infection and at least 2 acute COVID-19 symptoms for 7 days or less. Interventions Participants were randomized to receive fluvoxamine, 50 mg twice daily on day 1 followed by 100 mg twice daily for 12 additional days (n = 601), or placebo (n = 607). Main Outcomes and Measures The primary outcome was time to sustained recovery (defined as at least 3 consecutive days without symptoms). Secondary outcomes included time to death; time to hospitalization or death; a composite of hospitalization, urgent care visit, emergency department visit, or death; COVID-19 clinical progression scale score; and difference in mean time unwell. Follow-up occurred through day 28. Results Among 1208 participants who were randomized and received the study drug, the median (IQR) age was 50 (40-60) years, 65.8% were women, 45.5% identified as Hispanic/Latino, and 76.8% reported receiving at least 2 doses of a SARS-CoV-2 vaccine. Among 589 participants who received fluvoxamine and 586 who received placebo included in the primary analysis, differences in time to sustained recovery were not observed (adjusted hazard ratio [HR], 0.99 [95% credible interval, 0.89-1.09]; P for efficacy = .40]). Additionally, unadjusted median time to sustained recovery was 10 (95% CI, 10-11) days in both the intervention and placebo groups. No deaths were reported. Thirty-five participants reported health care use events (a priori defined as death, hospitalization, or emergency department/urgent care visit): 14 in the fluvoxamine group compared with 21 in the placebo group (HR, 0.69 [95% credible interval, 0.27-1.21]; P for efficacy = .86) There were 7 serious adverse events in 6 participants (2 with fluvoxamine and 4 with placebo) but no deaths. Conclusions and Relevance Among outpatients with mild to moderate COVID-19, treatment with fluvoxamine does not reduce duration of COVID-19 symptoms. Trial Registration ClinicalTrials.gov Identifier: NCT04885530.
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Affiliation(s)
| | - Paulina A. Rebolledo
- Department of Medicine and Global Health, Division of Infectious Diseases, Emory University School of Medicine and Rollins School of Public Health, Atlanta, Georgia
| | - Ahmad Mourad
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | | | - David R. Boulware
- University of Minnesota Medical School, General Internal Medicine, Minneapolis
| | | | | | | | - Carolyn T. Bramante
- University of Minnesota Medical School, General Internal Medicine, Minneapolis
| | | | - Stephen Lim
- Louisiana State University Health Sciences Center New Orleans, University Medical Center New Orleans, New Orleans
| | - John C. Williamson
- Wake Forest University School of Medicine, Department of Internal Medicine, Section on Infectious Diseases, Winston-Salem, North Carolina
| | - Orlando Quintero Cardona
- Stanford University School of Medicine, Department of Medicine, Infectious Diseases and Geographic Medicine Division, Stanford, California
| | - Jake Scott
- Stanford University School of Medicine, Department of Medicine, Infectious Diseases and Geographic Medicine Division, Stanford, California
| | | | | | - Mario Castro
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Missouri-Kansas City School of Medicine, Kansas City
| | - Dushyantha Jayaweera
- Department of Medicine, Miller School of Medicine, University of Miami, Miami, Florida
| | - Mark Sulkowski
- Division of Infectious Diseases, Johns Hopkins University, Baltimore, Maryland
| | - Nina Gentile
- Department of Emergency Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Kathleen McTigue
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - G. Michael Felker
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Allison DeLong
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Rhonda Wilder
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | | | - Sean Collins
- Vanderbilt University Medical Center, Nashville, Tennessee
- Veterans Affairs Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), Nashville
| | - Sarah E. Dunsmore
- National Center for Advancing Translational Sciences, Bethesda, Maryland
| | - Stacey J. Adam
- Foundation for the National Institutes of Health, Bethesda, Maryland
| | - George J. Hanna
- Biomedical Advanced Research and Development Authority, Washington, DC
| | - Elizabeth Shenkman
- Department of Health Outcomes & Biomedical Informatics, College of Medicine, University of Florida, Gainesville
| | - Adrian F. Hernandez
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Susanna Naggie
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
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McHale TC, Boulware DR, Kasibante J, Ssebambulidde K, Skipper CP, Abassi M. Diagnosis and management of cryptococcal meningitis in HIV-infected adults. Clin Microbiol Rev 2023; 36:e0015622. [PMID: 38014977 PMCID: PMC10870732 DOI: 10.1128/cmr.00156-22] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2023] Open
Abstract
Cryptococcal meningitis is a leading cause of morbidity and mortality globally, especially in people with advanced HIV disease. Cryptococcal meningitis is responsible for nearly 20% of all deaths related to advanced HIV disease, with the burden of disease predominantly experienced by people in resource-limited countries. Major advancements in diagnostics have introduced low-cost, easy-to-use antigen tests with remarkably high sensitivity and specificity. These tests have led to improved diagnostic accuracy and are essential for screening campaigns to reduce the burden of cryptococcosis. In the last 5 years, several high-quality, multisite clinical trials have led to innovations in therapeutics that have allowed for simplified regimens, which are better tolerated and result in less intensive monitoring and management of medication adverse effects. One trial found that a shorter, 7-day course of deoxycholate amphotericin B is as effective as the longer 14-day course and that flucytosine is an essential partner drug for reducing mortality in the acute phase of disease. Single-dose liposomal amphotericin B has also been found to be as effective as a 7-day course of deoxycholate amphotericin B. These findings have allowed for simpler and safer treatment regimens that also reduce the burden on the healthcare system. This review provides a detailed discussion of the latest evidence guiding the clinical management and special circumstances that make cryptococcal meningitis uniquely difficult to treat.
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Affiliation(s)
- Thomas C. McHale
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - David R. Boulware
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - John Kasibante
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | - Caleb P. Skipper
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Mahsa Abassi
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
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Gress AR, Ronayne CE, Thiede JM, Meyerholz DK, Okurut S, Stumpf J, Mathes TV, Ssebambulidde K, Meya DB, Cresswell FV, Boulware DR, Bold TD. Recently activated CD4 T cells in tuberculosis express OX40 as a target for host-directed immunotherapy. Nat Commun 2023; 14:8423. [PMID: 38110410 PMCID: PMC10728168 DOI: 10.1038/s41467-023-44152-8] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 12/01/2023] [Indexed: 12/20/2023] Open
Abstract
After Mycobacterium tuberculosis (Mtb) infection, many effector T cells traffic to the lungs, but few become activated. Here we use an antigen receptor reporter mouse (Nur77-GFP) to identify recently activated CD4 T cells in the lungs. These Nur77-GFPHI cells contain expanded TCR clonotypes, have elevated expression of co-stimulatory genes such as Tnfrsf4/OX40, and are functionally more protective than Nur77-GFPLO cells. By contrast, Nur77-GFPLO cells express markers of terminal exhaustion and cytotoxicity, and the trafficking receptor S1pr5, associated with vascular localization. A short course of immunotherapy targeting OX40+ cells transiently expands CD4 T cell numbers and shifts their phenotype towards parenchymal protective cells. Moreover, OX40 agonist immunotherapy decreases the lung bacterial burden and extends host survival, offering an additive benefit to antibiotics. CD4 T cells from the cerebrospinal fluid of humans with HIV-associated tuberculous meningitis commonly express surface OX40 protein, while CD8 T cells do not. Our data thus propose OX40 as a marker of recently activated CD4 T cells at the infection site and a potential target for immunotherapy in tuberculosis.
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Affiliation(s)
- Abigail R Gress
- Department of Medicine, University of Minnesota, 420 Delaware Street, SE MMC 250, Minneapolis, MN, 55455, USA
- Center for Immunology, 2101 6th St SE, WMBB 2-118, University of Minnesota, Minneapolis, MN, 55455, USA
| | - Christine E Ronayne
- Department of Medicine, University of Minnesota, 420 Delaware Street, SE MMC 250, Minneapolis, MN, 55455, USA
- Center for Immunology, 2101 6th St SE, WMBB 2-118, University of Minnesota, Minneapolis, MN, 55455, USA
| | - Joshua M Thiede
- Department of Medicine, University of Minnesota, 420 Delaware Street, SE MMC 250, Minneapolis, MN, 55455, USA
- Center for Immunology, 2101 6th St SE, WMBB 2-118, University of Minnesota, Minneapolis, MN, 55455, USA
| | - David K Meyerholz
- Department of Pathology, Roy J. and Lucille A. Carver College of Medicine, 1165 Medical Laboratories (ML), 51 Newton Rd, University of Iowa, Iowa City, IA, 52242, USA
| | - Samuel Okurut
- Infectious Diseases Institute, P.O. Box 22418, Makerere University, Kampala, Uganda
| | - Julia Stumpf
- Department of Medicine, University of Minnesota, 420 Delaware Street, SE MMC 250, Minneapolis, MN, 55455, USA
| | - Tailor V Mathes
- Department of Medicine, University of Minnesota, 420 Delaware Street, SE MMC 250, Minneapolis, MN, 55455, USA
- Center for Immunology, 2101 6th St SE, WMBB 2-118, University of Minnesota, Minneapolis, MN, 55455, USA
| | | | - David B Meya
- Infectious Diseases Institute, P.O. Box 22418, Makerere University, Kampala, Uganda
| | - Fiona V Cresswell
- Infectious Diseases Institute, P.O. Box 22418, Makerere University, Kampala, Uganda
- MRC/UVRI and London School of Hygiene and Tropical Medicine Uganda Research Unit, PO Box 49, Plot 51-59, Nakiwogo Road Entebbe, Entebbe, Uganda
- Department of Global Health and Infection, Brighton and Sussex Medical School, Brighton, East Sussex, BN1 9PX, UK
| | - David R Boulware
- Department of Medicine, University of Minnesota, 420 Delaware Street, SE MMC 250, Minneapolis, MN, 55455, USA
| | - Tyler D Bold
- Department of Medicine, University of Minnesota, 420 Delaware Street, SE MMC 250, Minneapolis, MN, 55455, USA.
- Center for Immunology, 2101 6th St SE, WMBB 2-118, University of Minnesota, Minneapolis, MN, 55455, USA.
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Boulware DR, Atukunda M, Kagimu E, Musubire AK, Akampurira A, Tugume L, Ssebambulidde K, Kasibante J, Nsangi L, Mugabi T, Gakuru J, Kimuda S, Kasozi D, Namombwe S, Turyasingura I, Rutakingirwa MK, Mpoza E, Kigozi E, Muzoora C, Ellis J, Skipper CP, Matkovits T, Williamson PR, Williams DA, Fieberg A, Hullsiek KH, Abassi M, Dai B, Meya DB. Oral Lipid Nanocrystal Amphotericin B for Cryptococcal Meningitis: A Randomized Clinical Trial. Clin Infect Dis 2023; 77:1659-1667. [PMID: 37606364 PMCID: PMC10724459 DOI: 10.1093/cid/ciad440] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [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: 06/08/2023] [Indexed: 08/23/2023] Open
Abstract
BACKGROUND Amphotericin B is the gold standard treatment for severe mycoses. A new orally delivered, less-toxic formulation of amphotericin has been developed. METHODS In our randomized clinical trial, we tested oral lipid nanocrystal (LNC) amphotericin B (MAT2203, Matinas Biopharma) vs intravenous (IV) amphotericin for human immunodeficiency virus-associated cryptococcal meningitis in 4 sequential cohorts. Two pilot cohorts assessed safety and tolerability (n = 10 each), and 2 cohorts assessed efficacy with/without 2 IV loading doses (n = 40 each). The experimental arm received 1.8 g/d oral LNC amphotericin through 2 weeks with 100 mg/kg/d flucytosine, then 1.2 g/d LNC amphotericin through 6 weeks. The randomized control arm (n = 41) received 7 days of IV amphotericin with flucytosine, then 7 days of fluconazole 1200 mg/d. The primary end point was cerebrospinal fluid (CSF) early fungicidal activity (EFA). RESULTS We randomized 80 participants to oral LNC amphotericin + flucytosine with (n = 40) and without (n = 40) 2 IV loading doses and 41 control participants to IV amphotericin + flucytosine. Mean EFA was 0.40 log10 colony-forming units (CFU)/mL/d for all-oral LNC amphotericin, 0.42 log10 Cryptococcus CFU/mL/d for oral LNC amphotericin with IV loading doses, and 0.46 log10 CFU/mL/d for IV amphotericin controls. LNC amphotericin groups achieved 2-week CSF sterility in 63% (44 of 70) vs 68% (23 of 34) of controls. The 18-week survival was 85% (34 of 40) with all-oral LNC amphotericin, 90% (36 of 40) with oral LNC amphotericin given IV loading doses, and 85% (35 of 41) with IV amphotericin.Grade 3-4 laboratory adverse events occurred less frequently in LNC amphotericin groups (41%) than the IV amphotericin group (61%, P = .05), particularly for anemia (21% vs 44%; P = .01) and potassium (5% vs 17%; P = .04). CONCLUSIONS This new oral amphotericin B LNC formulation appears promising for cryptococcal meningitis with antifungal activity, similar survival, and less toxicity than IV amphotericin. CLINICAL TRIALS REGISTRATION NCT04031833.
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Affiliation(s)
- David R Boulware
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | | | - Enock Kagimu
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Abdu K Musubire
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | - Lillian Tugume
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Kenneth Ssebambulidde
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - John Kasibante
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Laura Nsangi
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Timothy Mugabi
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Jane Gakuru
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Sarah Kimuda
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Derrick Kasozi
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Suzan Namombwe
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | | | - Edward Mpoza
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Enos Kigozi
- Department of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Conrad Muzoora
- Department of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Jayne Ellis
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Caleb P Skipper
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | | | - Peter R Williamson
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Darlisha A Williams
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Ann Fieberg
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Kathy H Hullsiek
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Mahsa Abassi
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Biyue Dai
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - David B Meya
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
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Okurut S, Boulware DR, Okafor E, Rhein J, Kajumbula H, Bagaya BS, Bwanga F, Olobo JO, Manabe YC, Meya DB, Janoff EN. Divergent neuroimmune signatures in the cerebrospinal fluid predict differential gender-specific survival among patients with HIV-associated cryptococcal meningitis. Front Immunol 2023; 14:1275443. [PMID: 38152404 PMCID: PMC10752005 DOI: 10.3389/fimmu.2023.1275443] [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: 09/19/2023] [Accepted: 11/20/2023] [Indexed: 12/29/2023] Open
Abstract
Introduction Survival among people with HIV-associated cryptococcal meningitis (CM) remains low, particularly among women, despite the currently optimal use of antifungal drugs. Cryptococcus dissemination into the central nervous system [brain, spinal cord, and cerebrospinal fluid (CSF)] elicits the local production of cytokines, chemokines, and other biomarkers. However, no consistent diagnostic or prognostic neuroimmune signature is reported to underpin the risk of death or to identify mechanisms to improve treatment and survival. We hypothesized that distinct neuroimmune signatures in the CSF would distinguish survivors from people who died on antifungal treatment and who may benefit from tailored therapy. Methods We considered baseline clinical features, CSF cryptococcal fungal burden, and CSF neuroimmune signatures with survival at 18 weeks among 419 consenting adults by "gender" (168 women and 251 men by biological sex defined at birth). Results Survival at 18 weeks was significantly lower among women than among men {47% vs. 59%, respectively; hazard ratio (HR) = 1.4 [95% confidence interval (CI), 1.0 to 1.9; p = 0.023]}. Unsupervised principal component analysis (PCA) demonstrated divergent neuroimmune signatures by gender, survival, and intragender-specific survival. Overall, women had lower levels of programmed death ligand 1, Interleukin (IL) (IL-11RA/IL-1F30, and IL-15 (IL-15) than men (all p < 0.028). Female survivors compared with those who died expressed significant elevations in levels of CCL11 and CXCL10 chemokines (both p = 0.001), as well as increased T helper 1, regulatory, and T helper 17 cytokines (all p < 0.041). In contrast, male survivors expressed lower levels of IL-15 and IL-8 compared with men who died (p < 0.044). Conclusions Survivors of both genders demonstrated a significant increase in the levels of immune regulatory IL-10. In conclusion, the lower survival among women with CM was accompanied by distinct differential gender-specific neuroimmune signatures. These female and male intragender-specific survival-associated neuroimmune signatures provide potential targets for interventions to advance therapy to improve the low survival among people with HIV-associated CM.
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Affiliation(s)
- Samuel Okurut
- Translation Sciences Laboratory, Research Department, Infectious Diseases Institute, Makerere University, Kampala, Uganda
- Department of Medical Microbiology, School of Biomedical Sciences, College of Health Sciences, Makerere University, Kampala, Uganda
| | - David R. Boulware
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Elizabeth Okafor
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Joshua Rhein
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Henry Kajumbula
- Department of Medical Microbiology, School of Biomedical Sciences, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Bernard S. Bagaya
- Department of Immunology and Molecular Biology, School of Biomedical Sciences, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Freddie Bwanga
- Department of Medical Microbiology, School of Biomedical Sciences, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Joseph O. Olobo
- Department of Immunology and Molecular Biology, School of Biomedical Sciences, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Yukari C. Manabe
- Translation Sciences Laboratory, Research Department, Infectious Diseases Institute, Makerere University, Kampala, Uganda
- Division of Infectious Diseases, Department of Medicine, John Hopkins University School of Medicine, Baltimore, MD, United States
| | - David B. Meya
- Translation Sciences Laboratory, Research Department, Infectious Diseases Institute, Makerere University, Kampala, Uganda
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN, United States
- Department of Medicine, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Edward N. Janoff
- Mucosal and Vaccine Research Program Colorado, Department of Medicine, Division of Infectious Diseases, University of Colorado Denver, Aurora, CO, United States
- Department of Medicine and Infectious Disease, Denver Veterans Affairs Medical Center, Denver, CO, United States
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10
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Kasibante J, Irfanullah E, Wele A, Okafor E, Ssebambulidde K, Okurut S, Kagimu E, Gakuru J, Rutakingirwa MK, Mugabi T, Nuwagira E, Jjunju S, Mpoza E, Tugume L, Nsangi L, Musibire AK, Muzoora C, Rhein J, Meya DB, Boulware DR, Abassi M. Utility of Cerebrospinal Fluid Protein Levels as a Potential Predictive Biomarker of Disease Severity in HIV-Associated Cryptococcal Meningitis. medRxiv 2023:2023.12.10.23299793. [PMID: 38168371 PMCID: PMC10760268 DOI: 10.1101/2023.12.10.23299793] [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: 01/05/2024]
Abstract
Background Cerebrospinal fluid (CSF) protein levels exhibit high variability in HIV-associated cryptococcal meningitis from being normal to markedly elevated. However, the clinical implications of CSF protein levels in cryptococcal meningitis remain unclear. Methods We analysed data from 890 adults with HIV-associated cryptococcal meningitis randomized into two clinical trials in Uganda between 2015 and 2021. CSF protein was grouped into ≥100 mg/dL (n=249) and <100 mg/dL (n=641). We described baseline clinical variables and mortality by CSF protein levels. Results Approximately one-third of individuals had a baseline CSF protein ≥100 mg/dL. Those with CSF protein ≥100 mg/dL were more likely to present with Glasgow coma scale scores <15 (P<0.01), self-reported seizures at baseline (P=0.02), higher CD4 T-cells (p<0.001), and higher CSF white cells (p<0.001). Moreover, those with a baseline CSF protein ≥100 mg/dL also had a lower baseline CSF fungal burden (p<0.001) and a higher percentage of sterile CSF cultures at day 14 (p=0.02). Individuals with CSF protein ≥100 mg/dL demonstrated a more pronounced immune response consisting of upregulation of immune effector molecules pro-inflammatory cytokines, type-1 T-helper cell cytokines, type-3 chemokines, and immune-exhaustion marker (p<0.05). 18-week mortality risk in individuals with a CSF protein <100 mg/dL was 34% higher, (unadjusted Hazard Ratio 1.34; 95% CI, 1.05 to 1.70; p=0.02) than those with ≥100 mg/dL. Conclusion In cryptococcal meningitis, individuals with CSF protein ≥100 mg/dL more frequently presented with seizures, altered mental status, immune activation, and favourable fungal outcomes. Baseline CSF protein levels may serve as a surrogate marker of immune activation and prognosis.
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Affiliation(s)
- John Kasibante
- Infectious Diseases Institute, College of health sciences, Makerere University. P.O. Box 22418, Kampala, Uganda
| | - Eesha Irfanullah
- Division of Infectious Diseases & International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA
| | - Abduljewad Wele
- Division of Infectious Diseases & International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA
| | - Elizabeth Okafor
- Division of Infectious Diseases & International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA
| | - Kenneth Ssebambulidde
- Infectious Diseases Institute, College of health sciences, Makerere University. P.O. Box 22418, Kampala, Uganda
| | - Samuel Okurut
- Infectious Diseases Institute, College of health sciences, Makerere University. P.O. Box 22418, Kampala, Uganda
| | - Enock Kagimu
- Infectious Diseases Institute, College of health sciences, Makerere University. P.O. Box 22418, Kampala, Uganda
| | - Jane Gakuru
- Infectious Diseases Institute, College of health sciences, Makerere University. P.O. Box 22418, Kampala, Uganda
| | - Morris K. Rutakingirwa
- Infectious Diseases Institute, College of health sciences, Makerere University. P.O. Box 22418, Kampala, Uganda
| | - Timothy Mugabi
- Infectious Diseases Institute, College of health sciences, Makerere University. P.O. Box 22418, Kampala, Uganda
| | - Edwin Nuwagira
- Department of Medicine, Mbarara University of Science and Technology, P.O Box 1410, Mbarara, Uganda
| | - Samuel Jjunju
- Infectious Diseases Institute, College of health sciences, Makerere University. P.O. Box 22418, Kampala, Uganda
| | - Edward Mpoza
- Infectious Diseases Institute, College of health sciences, Makerere University. P.O. Box 22418, Kampala, Uganda
| | - Lillian Tugume
- Infectious Diseases Institute, College of health sciences, Makerere University. P.O. Box 22418, Kampala, Uganda
| | - Laura Nsangi
- Infectious Diseases Institute, College of health sciences, Makerere University. P.O. Box 22418, Kampala, Uganda
| | - Abdu K Musibire
- Infectious Diseases Institute, College of health sciences, Makerere University. P.O. Box 22418, Kampala, Uganda
| | - Conrad Muzoora
- Department of Medicine, Mbarara University of Science and Technology, P.O Box 1410, Mbarara, Uganda
| | - Joshua Rhein
- Division of Infectious Diseases & International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA
| | - David B. Meya
- Infectious Diseases Institute, College of health sciences, Makerere University. P.O. Box 22418, Kampala, Uganda
- Division of Infectious Diseases & International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA
| | - David R. Boulware
- Division of Infectious Diseases & International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA
| | - Mahsa Abassi
- Division of Infectious Diseases & International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA
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11
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McHale TC, Akampurira A, Gerlach ES, Mucunguzi A, Nicol MR, Williams DA, Nielsen K, Bicanic T, Fieberg A, Dai B, Meya DB, Boulware DR. 5-Flucytosine Longitudinal Antifungal Susceptibility Testing of Cryptococcus neoformans: A Substudy of the EnACT Trial Testing Oral Amphotericin. Open Forum Infect Dis 2023; 10:ofad596. [PMID: 38143852 PMCID: PMC10745249 DOI: 10.1093/ofid/ofad596] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 11/21/2023] [Indexed: 12/26/2023] Open
Abstract
Background The EnACT trial was a phase 2 randomized clinical trial conducted in Uganda, which evaluated a novel orally delivered lipid nanocrystal (LNC) amphotericin B in combination with flucytosine for the treatment of cryptococcal meningitis. When flucytosine (5FC) is used as monotherapy in cryptococcosis, 5FC can induce resistant Cryptococcus mutants. Oral amphotericin B uses a novel drug delivery mechanism, and we assessed whether resistance to 5FC develops during oral LNC-amphotericin B therapy. Methods We enrolled Ugandans with HIV diagnosed with cryptococcal meningitis and who were randomized to receive 5FC and either standard intravenous (IV) amphotericin B or oral LNC-amphotericin B. We used broth microdilution to measure the minimum inhibitory concentration (MIC) of the first and last cryptococcal isolates in each participant. Breakpoints are inferred from 5FC in Candida albicans. We measured cerebral spinal fluid (CSF) 5FC concentrations by liquid chromatography and tandem mass spectrometry. Results Cryptococcus 5FC MIC50 was 4 µg/mL, and MIC90 was 8 µg/mL. After 2 weeks of therapy, there was no evidence of 5FC resistance developing, defined as a >4-fold change in susceptibility in any Cryptococcus isolate tested. The median CSF 5FC concentration to MIC ratio (interquartile range) was 3.0 (1.7-5.5) µg/mL. There was no association between 5FC/MIC ratio and early fungicidal activity of the quantitative rate of CSF yeast clearance (R2 = 0.004; P = .63). Conclusions There is no evidence of baseline resistance to 5FC or incident resistance during combination therapy with oral or IV amphotericin B in Uganda. Oral amphotericin B can safely be used in combination with 5FC.
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Affiliation(s)
- Thomas C McHale
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | | | - Elliot S Gerlach
- Department of Microbiology & Immunology, University of Minnesota, Minneapolis, Minnesota, USA
| | | | - Melanie R Nicol
- Department of Experimental and Clinical Pharmacology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Darlisha A Williams
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Kirsten Nielsen
- Department of Microbiology & Immunology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Tihana Bicanic
- Institute of Infection and Immunity, St Georges, University of London, London, UK
| | - Ann Fieberg
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Biyue Dai
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - David B Meya
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - David R Boulware
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
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12
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Kimuda S, Kasozi D, Namombwe S, Gakuru J, Mugabi T, Kagimu E, Rutakingirwa MK, Leon KE, Chow F, Wasserman S, Boulware DR, Cresswell FV, Bahr NC. Advancing Diagnosis and Treatment in People Living with HIV and Tuberculosis Meningitis. Curr HIV/AIDS Rep 2023; 20:379-393. [PMID: 37947980 PMCID: PMC10719136 DOI: 10.1007/s11904-023-00678-6] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/18/2023] [Indexed: 11/12/2023]
Abstract
PURPOSE OF REVIEW Tuberculous meningitis (TBM) is the most severe form of tuberculosis. Inadequate diagnostic testing and treatment regimens adapted from pulmonary tuberculosis without consideration of the unique nature of TBM are among the potential drivers. This review focuses on the progress being made in relation to both diagnosis and treatment of TBM, emphasizing promising future directions. RECENT FINDINGS The molecular assay GeneXpert MTB/Rif Ultra has improved sensitivity but has inadequate negative predictive value to "rule-out" TBM. Evaluations of tests focused on the host response and bacterial components are ongoing. Clinical trials are in progress to explore the roles of rifampin, fluoroquinolones, linezolid, and adjunctive aspirin. Though diagnosis has improved, novel modalities are being explored to improve the rapid diagnosis of TBM. Multiple ongoing clinical trials may change current therapies for TBM in the near future.
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Affiliation(s)
- Sarah Kimuda
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Derrick Kasozi
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Suzan Namombwe
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Jane Gakuru
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Timothy Mugabi
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Enock Kagimu
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | - Kristoffer E Leon
- Departments of Neurology and Medicine (Infectious Diseases), University of California San Francisco, San Francisco, CA, USA
| | - Felicia Chow
- Departments of Neurology and Medicine (Infectious Diseases), University of California San Francisco, San Francisco, CA, USA
| | - Sean Wasserman
- Institute for Infection and Immunity, St George's, University of London, London, United Kingdom
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - David R Boulware
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Fiona V Cresswell
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
- HIV Interventions, MRC/UVRI-LSHTM Uganda Research Unit, Entebbe, Uganda
- Global Health and Infection, Brighton and Sussex Medical School, Brighton, UK
| | - Nathan C Bahr
- Division of Infectious Diseases, Department of Medicine, University of Kansas Medical Center, Kansas City, KS, USA.
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13
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Vidal JE, Oliveira FG, Vieira M, Pereira L, Lucas Junior RM, Guedes BF, Magri MC, Boulware DR. Finger-Prick Whole Blood Cryptococcal Antigen Lateral Flow Assay for the Diagnosis of Cryptococcosis in HIV-Negative Patients: A Case Series Study in Two Tertiary Centers in São Paulo, Brazil. J Fungi (Basel) 2023; 9:1140. [PMID: 38132741 PMCID: PMC10744370 DOI: 10.3390/jof9121140] [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: 10/22/2023] [Revised: 11/22/2023] [Accepted: 11/24/2023] [Indexed: 12/23/2023] Open
Abstract
Cryptococcosis in HIV-negative patients can be an opportunistic or endemic disease. There are no published studies on the use of the finger-prick whole blood (point-of-care) cryptococcal antigen lateral flow assay (CrAg LFA) for diagnosing cryptococcosis in HIV-negative patients. We conducted a case series study of HIV-negative patients with cryptococcosis in two centers in São Paulo, Brazil. The objectives were to identify the sensitivity of a finger-prick whole blood CrAg LFA and to describe the main characteristics of this population. We identified 30 HIV-negative patients with cryptococcosis [19 (63%), male; median age, 47 years]. Ten (33%) patients were immunosuppressed, ten (33%) had other comorbidities, and ten (33%) were apparently immunocompetent and without comorbidities. The distribution of the sites of cryptococcosis was as follows: the central nervous system, 90% (n = 27); pulmonary, 43% (n = 13); and other extrapulmonary sites, 40% (n = 12). The sensitivity of the finger-prick whole blood CrAg LFA for the diagnosis of cryptococcosis was 97% (29/30). Among 26 participants with cryptococcal meningitis, the sensitivity of testing cerebrospinal fluid was as follows: CrAg latex agglutination, 77% (20/26); CrAg LFA, 96% (25/26); and culture, 81% (21/26). Culture speciation identified Cryptococcus gattii in 16 (62%) cases, and all had a positive finger-prick whole blood CrAg LFA. This test presented high sensitivity to the diagnosis of cryptococcosis in HIV-negative patients, including those caused by C. gattii.
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Affiliation(s)
- José E. Vidal
- Departamento de Neurologia, Instituto de Infectologia Emílio Ribas, São Paulo 01246-900, Brazil
- Departamento de Moléstias Infecciosas e Parasitárias, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo 05403-000, Brazil;
- Laboratório de Investigação Médica (LIM 49) da Faculdade de Medicina da Universidade de São Paulo, São Paulo 05403-000, Brazil
| | - Fernanda Gurgel Oliveira
- Departamento de Infectologia, Instituto de Infectologia Emílio Ribas, São Paulo 01246-900, Brazil; (F.G.O.); (M.V.); (L.P.); (R.M.L.J.)
| | - Marcela Vieira
- Departamento de Infectologia, Instituto de Infectologia Emílio Ribas, São Paulo 01246-900, Brazil; (F.G.O.); (M.V.); (L.P.); (R.M.L.J.)
| | - Luisa Pereira
- Departamento de Infectologia, Instituto de Infectologia Emílio Ribas, São Paulo 01246-900, Brazil; (F.G.O.); (M.V.); (L.P.); (R.M.L.J.)
| | - Rodovaldo M. Lucas Junior
- Departamento de Infectologia, Instituto de Infectologia Emílio Ribas, São Paulo 01246-900, Brazil; (F.G.O.); (M.V.); (L.P.); (R.M.L.J.)
| | - Bruno Fukelman Guedes
- Departamento de Neurologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo 05403-000, Brazil;
| | - Marcello Chaves Magri
- Departamento de Moléstias Infecciosas e Parasitárias, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo 05403-000, Brazil;
| | - David R. Boulware
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA;
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Boulware DR. When Someone Should Do Something About This: How a Cryptococcal Clinical Trialist Became Involved With the Coronavirus Disease 2019 Pandemic. Clin Infect Dis 2023:ciad648. [PMID: 37968886 DOI: 10.1093/cid/ciad648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Accepted: 10/19/2023] [Indexed: 11/17/2023] Open
Affiliation(s)
- David R Boulware
- Division of Infectious Diseases & International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
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Tugume L, Ssebambulidde K, Kasibante J, Ellis J, Wake RM, Gakuru J, Lawrence DS, Abassi M, Rajasingham R, Meya DB, Boulware DR. Cryptococcal meningitis. Nat Rev Dis Primers 2023; 9:62. [PMID: 37945681 DOI: 10.1038/s41572-023-00472-z] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/09/2023] [Indexed: 11/12/2023]
Abstract
Cryptococcus neoformans and Cryptococcus gattii species complexes cause meningoencephalitis with high fatality rates and considerable morbidity, particularly in persons with deficient T cell-mediated immunity, most commonly affecting people living with HIV. Whereas the global incidence of HIV-associated cryptococcal meningitis (HIV-CM) has decreased over the past decade, cryptococcosis still accounts for one in five AIDS-related deaths globally due to the persistent burden of advanced HIV disease. Moreover, mortality remains high (~50%) in low-resource settings. The armamentarium to decrease cryptococcosis-associated mortality is expanding: cryptococcal antigen screening in the serum and pre-emptive azole therapy for cryptococcal antigenaemia are well established, whereas enhanced pre-emptive combination treatment regimens to improve survival of persons with cryptococcal antigenaemia are in clinical trials. Short courses (≤7 days) of amphotericin-based therapy combined with flucytosine are currently the preferred options for induction therapy of cryptococcal meningitis. Whether short-course induction regimens improve long-term morbidity such as depression, reduced neurocognitive performance and physical disability among survivors is the subject of further study. Here, we discuss underlying immunology, changing epidemiology, and updates on the management of cryptococcal meningitis with emphasis on HIV-associated disease.
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Affiliation(s)
- Lillian Tugume
- Infectious Diseases Institute, Makerere University, Kampala, Uganda.
| | - Kenneth Ssebambulidde
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - John Kasibante
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Jayne Ellis
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
- Clinical Research Department, Faculty of Infectious and Tropical Diseases London School of Hygiene and Tropical Medicine, London, UK
| | - Rachel M Wake
- Institute for Infection and Immunity, St George's University of London, London, UK
| | - Jane Gakuru
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - David S Lawrence
- Clinical Research Department, Faculty of Infectious and Tropical Diseases London School of Hygiene and Tropical Medicine, London, UK
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Mahsa Abassi
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Radha Rajasingham
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - David B Meya
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - David R Boulware
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
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Avula N, Kakach D, Tignanelli CJ, Liebovitz DM, Nicklas JM, Cohen K, Puskarich MA, Belani HK, Buse JB, Klatt NR, Anderson B, Karger AB, Hartman KM, Patel B, Fenno SL, Reddy NV, Erickson SM, Boulware DR, Murray TA, Bramante CT. Strategies used for the COVID-OUT decentralized trial of outpatient treatment of SARS-CoV-2. J Clin Transl Sci 2023; 7:e242. [PMID: 38033705 PMCID: PMC10685265 DOI: 10.1017/cts.2023.668] [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: 06/26/2023] [Revised: 09/20/2023] [Accepted: 10/24/2023] [Indexed: 12/02/2023] Open
Abstract
The COVID-19 pandemic accelerated the development of decentralized clinical trials (DCT). DCT's are an important and pragmatic method for assessing health outcomes yet comprise only a minority of clinical trials, and few published methodologies exist. In this report, we detail the operational components of COVID-OUT, a decentralized, multicenter, quadruple-blinded, randomized trial that rapidly delivered study drugs nation-wide. The trial examined three medications (metformin, ivermectin, and fluvoxamine) as outpatient treatment of SARS-CoV-2 for their effectiveness in preventing severe or long COVID-19. Decentralized strategies included HIPAA-compliant electronic screening and consenting, prepacking investigational product to accelerate delivery after randomization, and remotely confirming participant-reported outcomes. Of the 1417 individuals with the intention-to-treat sample, the remote nature of the study caused an additional 94 participants to not take any doses of study drug. Therefore, 1323 participants were in the modified intention-to-treat sample, which was the a priori primary study sample. Only 1.4% of participants were lost to follow-up. Decentralized strategies facilitated the successful completion of the COVID-OUT trial without any in-person contact by expediting intervention delivery, expanding trial access geographically, limiting contagion exposure, and making it easy for participants to complete follow-up visits. Remotely completed consent and follow-up facilitated enrollment.
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Affiliation(s)
- Nandini Avula
- Department of Medicine, Medical School, University of Minnesota, Minneapolis, MN, USA
| | - Dustin Kakach
- Investigational Drug Service, Fairview Health Services, University of Minnesota Medical Center, Minneapolis, MN, USA
| | | | - David M. Liebovitz
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Jacinda M. Nicklas
- Department of Medicine, School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora, CO, USA
| | - Kenneth Cohen
- UnitedHealth Group, Optum Health, Minnetonka, MN, USA
| | - Michael A. Puskarich
- Department of Emergency Medicine, School of Medicine, University of Minnesota, Minneapolis, MN, USA
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
| | - Hrishikesh K. Belani
- Department of Medicine, Olive View - University of California, Los Angeles, CA, USA
| | - John B. Buse
- Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Nichole R. Klatt
- Department of Surgery, Medical School, University of Minnesota, Minneapolis, MN, USA
| | - Blake Anderson
- Atlanta Veterans Affairs Medical Center and the Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Amy B. Karger
- Department of Laboratory Medicine and Pathology, Medical School, University of Minnesota, Minneapolis, MN, USA
| | - Katrina M. Hartman
- Department of Medicine, Medical School, University of Minnesota, Minneapolis, MN, USA
| | - Barkha Patel
- Department of Medicine, Medical School, University of Minnesota, Minneapolis, MN, USA
| | - Sarah L. Fenno
- Department of Medicine, Medical School, University of Minnesota, Minneapolis, MN, USA
| | - Neha V. Reddy
- Department of Medicine, Medical School, University of Minnesota, Minneapolis, MN, USA
| | - Spencer M. Erickson
- Department of Medicine, Medical School, University of Minnesota, Minneapolis, MN, USA
| | - David R. Boulware
- Department of Medicine, Medical School, University of Minnesota, Minneapolis, MN, USA
| | - Thomas A. Murray
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Carolyn T. Bramante
- Department of Medicine, Medical School, University of Minnesota, Minneapolis, MN, USA
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Pasqualotto AC, Lana DD, Godoy CSM, Leitão TDMJS, Bay MB, Damasceno LS, Soares RBA, Kist R, Silva LR, Wiltgen D, Melo M, Guimarães TF, Guimarães MR, Vechi HT, de Mesquita JRL, Monteiro GRDG, Adenis A, Bahr NC, Spec A, Boulware DR, Israelski D, Chiller T, Falci DR. Single High Dose of Liposomal Amphotericin B in Human Immunodeficiency Virus/AIDS-Related Disseminated Histoplasmosis: A Randomized Trial. Clin Infect Dis 2023; 77:1126-1132. [PMID: 37232940 PMCID: PMC10573726 DOI: 10.1093/cid/ciad313] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 05/09/2023] [Accepted: 05/23/2023] [Indexed: 05/27/2023] Open
Abstract
BACKGROUND Histoplasmosis is a major AIDS-defining illness in Latin America. Liposomal amphotericin B (L-AmB) is the drug of choice for treatment, but access is restricted due to the high drug and hospitalization costs of the conventional long regimens. METHODS Prospective randomized multicenter open-label trial of 1- or 2-dose induction therapy with L-AmB versus control for disseminated histoplasmosis in AIDS, followed by oral itraconazole therapy. We randomized subjects to: (i) single dose 10 mg/kg of L-AmB; (ii) 10 mg/kg of L-AmB on D1, and 5 mg/kg of L-AmB on D3; (iii) 3 mg/kg of L-AmB daily for 2 weeks (control). The primary outcome was clinical response (resolution of fever and signs/symptoms attributable to histoplasmosis) at day 14. RESULTS A total of 118 subjects were randomized, and median CD4+ counts, and clinical presentations were similar between arms. Infusion-related toxicity, kidney toxicity at multiple time-points, and frequency of anemia, hypokalemia, hypomagnesemia, and liver toxicity were similar. Day 14 clinical response was 84% for single-dose L-AmB, 69% 2-dose L-AmB, and 74% for control arm (P = .69). Overall survival on D14 was 89.0% (34/38) for single-dose L-AmB, 78.0% (29/37) for 2-dose L-AmB, and 92.1% (35/38) for control arm (P = .82). CONCLUSIONS One day induction therapy with 10 mg/kg of L-AmB in AIDS-related histoplasmosis was safe. Although clinical response may be non-inferior to standard L-AmB therapy, a confirmatory phase III clinical trial is needed. A single induction dose would markedly reduce drug-acquisition costs (>4-fold) and markedly shorten and simplify treatment, which are key points in terms of increased access.
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Affiliation(s)
- Alessandro C Pasqualotto
- Department of Clinical Medicine and Post-Graduation Program in Pathology, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Brazil
- Infectious Diseases and Internal Medicine Services, Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, Brazil
| | - Daiane Dalla Lana
- Department of Clinical Medicine and Post-Graduation Program in Pathology, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Brazil
| | - Cassia S M Godoy
- Infectious Diseases Service, Hospital de Doenças Tropicais, Goiânia, Brazil
- Department of Research and Education, Pontifícia Universidade Católica de Goiás, Goiânia, Brazil
| | - Terezinha do Menino Jesus Silva Leitão
- Infectious Diseases Service, Hospital São José de Doenças Infecciosas, Fortaleza, Brazil
- Department of Public Health, Federal University of Ceará, Fortaleza, Brazil
| | - Monica B Bay
- Department of Infectious Diseases, Federal University of Rio Grande do Norte, Natal, Brazil
- Infectious Diseases Service, Giselda Trigueiro Hospital and Instituto de Medicina Tropical do Rio Grande do Norte, Natal, Brazil
| | - Lisandra Serra Damasceno
- Infectious Diseases Service, Hospital São José de Doenças Infecciosas, Fortaleza, Brazil
- Department of Public Health, Federal University of Ceará, Fortaleza, Brazil
| | - Renata B A Soares
- Infectious Diseases Service, Hospital de Doenças Tropicais, Goiânia, Brazil
- Department of Research and Education, Pontifícia Universidade Católica de Goiás, Goiânia, Brazil
| | - Roger Kist
- Infectious Diseases and Internal Medicine Services, Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, Brazil
| | - Larissa R Silva
- Department of Clinical Medicine and Post-Graduation Program in Pathology, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Brazil
| | - Denusa Wiltgen
- Department of Clinical Medicine and Post-Graduation Program in Pathology, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Brazil
- Infectious Diseases and Internal Medicine Services, Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, Brazil
| | - Marineide Melo
- Infectious Diseases Service, Hospital Nossa Senhora da Conceição, Porto Alegre, Brazil
| | | | | | - Hareton T Vechi
- Department of Infectious Diseases, Federal University of Rio Grande do Norte, Natal, Brazil
| | - Jacó R L de Mesquita
- Infectious Diseases Service, Hospital São José de Doenças Infecciosas, Fortaleza, Brazil
| | - Gloria Regina de G Monteiro
- Department of Infectious Diseases, Federal University of Rio Grande do Norte, Natal, Brazil
- Infectious Diseases Service, Giselda Trigueiro Hospital and Instituto de Medicina Tropical do Rio Grande do Norte, Natal, Brazil
| | - Antoine Adenis
- Centre d’Investigation Clinique Antilles Guyane Inserm CIC1424, Centre Hospitalier de Cayenne, Cayenne, France
| | - Nathan C Bahr
- Division of Infectious Diseases, Department of Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Andrej Spec
- Division of Infectious Disease, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - David R Boulware
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minnesota, USA
| | - Dennis Israelski
- International Medical Affairs, Global Patient Solutions, Gilead Sciences, San Francisco, California, USA
| | - Tom Chiller
- Mycotic Division, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Diego R Falci
- Infectious Diseases Service, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
- Department of Clinical Medicine, Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, Brazil
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Bramante CT, Buse JB, Liebovitz DM, Nicklas JM, Puskarich MA, Cohen K, Belani HK, Anderson BJ, Huling JD, Tignanelli CJ, Thompson JL, Pullen M, Wirtz EL, Siegel LK, Proper JL, Odde DJ, Klatt NR, Sherwood NE, Lindberg SM, Karger AB, Beckman KB, Erickson SM, Fenno SL, Hartman KM, Rose MR, Mehta T, Patel B, Griffiths G, Bhat NS, Murray TA, Boulware DR. Outpatient treatment of COVID-19 and incidence of post-COVID-19 condition over 10 months (COVID-OUT): a multicentre, randomised, quadruple-blind, parallel-group, phase 3 trial. Lancet Infect Dis 2023; 23:1119-1129. [PMID: 37302406 DOI: 10.1016/s1473-3099(23)00299-2] [Citation(s) in RCA: 46] [Impact Index Per Article: 46.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 03/30/2023] [Accepted: 05/02/2023] [Indexed: 06/13/2023]
Abstract
BACKGROUND Post-COVID-19 condition (also known as long COVID) is an emerging chronic illness potentially affecting millions of people. We aimed to evaluate whether outpatient COVID-19 treatment with metformin, ivermectin, or fluvoxamine soon after SARS-CoV-2 infection could reduce the risk of long COVID. METHODS We conducted a decentralised, randomised, quadruple-blind, parallel-group, phase 3 trial (COVID-OUT) at six sites in the USA. We included adults aged 30-85 years with overweight or obesity who had COVID-19 symptoms for fewer than 7 days and a documented SARS-CoV-2 positive PCR or antigen test within 3 days before enrolment. Participants were randomly assigned via 2 × 3 parallel factorial randomisation (1:1:1:1:1:1) to receive metformin plus ivermectin, metformin plus fluvoxamine, metformin plus placebo, ivermectin plus placebo, fluvoxamine plus placebo, or placebo plus placebo. Participants, investigators, care providers, and outcomes assessors were masked to study group assignment. The primary outcome was severe COVID-19 by day 14, and those data have been published previously. Because the trial was delivered remotely nationwide, the a priori primary sample was a modified intention-to-treat sample, meaning that participants who did not receive any dose of study treatment were excluded. Long COVID diagnosis by a medical provider was a prespecified, long-term secondary outcome. This trial is complete and is registered with ClinicalTrials.gov, NCT04510194. FINDINGS Between Dec 30, 2020, and Jan 28, 2022, 6602 people were assessed for eligibility and 1431 were enrolled and randomly assigned. Of 1323 participants who received a dose of study treatment and were included in the modified intention-to-treat population, 1126 consented for long-term follow-up and completed at least one survey after the assessment for long COVID at day 180 (564 received metformin and 562 received matched placebo; a subset of participants in the metformin vs placebo trial were also randomly assigned to receive ivermectin or fluvoxamine). 1074 (95%) of 1126 participants completed at least 9 months of follow-up. 632 (56·1%) of 1126 participants were female and 494 (43·9%) were male; 44 (7·0%) of 632 women were pregnant. The median age was 45 years (IQR 37-54) and median BMI was 29·8 kg/m2 (IQR 27·0-34·2). Overall, 93 (8·3%) of 1126 participants reported receipt of a long COVID diagnosis by day 300. The cumulative incidence of long COVID by day 300 was 6·3% (95% CI 4·2-8·2) in participants who received metformin and 10·4% (7·8-12·9) in those who received identical metformin placebo (hazard ratio [HR] 0·59, 95% CI 0·39-0·89; p=0·012). The metformin beneficial effect was consistent across prespecified subgroups. When metformin was started within 3 days of symptom onset, the HR was 0·37 (95% CI 0·15-0·95). There was no effect on cumulative incidence of long COVID with ivermectin (HR 0·99, 95% CI 0·59-1·64) or fluvoxamine (1·36, 0·78-2·34) compared with placebo. INTERPRETATION Outpatient treatment with metformin reduced long COVID incidence by about 41%, with an absolute reduction of 4·1%, compared with placebo. Metformin has clinical benefits when used as outpatient treatment for COVID-19 and is globally available, low-cost, and safe. FUNDING Parsemus Foundation; Rainwater Charitable Foundation; Fast Grants; UnitedHealth Group Foundation; National Institute of Diabetes, Digestive and Kidney Diseases; National Institutes of Health; and National Center for Advancing Translational Sciences.
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Affiliation(s)
- Carolyn T Bramante
- Division of General Internal Medicine, University of Minnesota, Minneapolis, MN, USA.
| | - John B Buse
- Endocrinology, University of North Carolina, Chapel Hill, NC, USA
| | - David M Liebovitz
- General Internal Medicine, Northwestern University, Chicago, IL, USA
| | | | | | - Ken Cohen
- UnitedHealth Group, Optum Labs, Minnetonka, MN, USA
| | - Hrishikesh K Belani
- Department of Medicine, Olive View, University of California, Los Angeles, CA, USA
| | - Blake J Anderson
- Atlanta Veterans Affairs Medical Center, Atlanta, GA, USA; Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Jared D Huling
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | | | - Jennifer L Thompson
- Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Matthew Pullen
- Division of Infectious Diseases and International Medicine, Department of Medicine, Medical School, University of Minnesota, Minneapolis, MN, USA
| | - Esteban Lemus Wirtz
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Lianne K Siegel
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Jennifer L Proper
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - David J Odde
- Department of Biomedical Engineering, University of Minnesota, Minneapolis, MN, USA
| | - Nichole R Klatt
- Department of Surgery, Medical School, University of Minnesota, Minneapolis, MN, USA
| | - Nancy E Sherwood
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Sarah M Lindberg
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Amy B Karger
- Department of Laboratory Medicine and Pathology, Medical School, University of Minnesota, Minneapolis, MN, USA
| | | | - Spencer M Erickson
- Division of General Internal Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Sarah L Fenno
- Division of General Internal Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Katrina M Hartman
- Division of General Internal Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Michael R Rose
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Tanvi Mehta
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Barkha Patel
- Division of General Internal Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Gwendolyn Griffiths
- Division of General Internal Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Neeta S Bhat
- Division of General Internal Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Thomas A Murray
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - David R Boulware
- Division of Infectious Diseases and International Medicine, Department of Medicine, Medical School, University of Minnesota, Minneapolis, MN, USA
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Boulware DR, Lindsell CJ, Stewart TG, Hernandez AF, Collins S, McCarthy MW, Jayaweera D, Gentile N, Castro M, Sulkowski M, McTigue K, Felker GM, Ginde AA, Dunsmore SE, Adam SJ, DeLong A, Hanna G, Remaly A, Thicklin F, Wilder R, Wilson S, Shenkman E, Naggie S. Inhaled Fluticasone Furoate for Outpatient Treatment of Covid-19. N Engl J Med 2023; 389:1085-1095. [PMID: 37733308 PMCID: PMC10597427 DOI: 10.1056/nejmoa2209421] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/22/2023]
Abstract
BACKGROUND The effectiveness of inhaled glucocorticoids in shortening the time to symptom resolution or preventing hospitalization or death among outpatients with mild-to-moderate coronavirus disease 2019 (Covid-19) is unclear. METHODS We conducted a decentralized, double-blind, randomized, placebo-controlled platform trial in the United States to assess the use of repurposed medications in outpatients with confirmed coronavirus disease 2019 (Covid-19). Nonhospitalized adults 30 years of age or older who had at least two symptoms of acute infection that had been present for no more than 7 days before enrollment were randomly assigned to receive inhaled fluticasone furoate at a dose of 200 μg once daily for 14 days or placebo. The primary outcome was the time to sustained recovery, defined as the third of 3 consecutive days without symptoms. Key secondary outcomes included hospitalization or death by day 28 and a composite outcome of the need for an urgent-care or emergency department visit or hospitalization or death through day 28. RESULTS Of the 1407 enrolled participants who underwent randomization, 715 were assigned to receive inhaled fluticasone furoate and 692 to receive placebo, and 656 and 621, respectively, were included in the analysis. There was no evidence that the use of fluticasone furoate resulted in a shorter time to recovery than placebo (hazard ratio, 1.01; 95% credible interval, 0.91 to 1.12; posterior probability of benefit [defined as a hazard ratio >1], 0.56). A total of 24 participants (3.7%) in the fluticasone furoate group had urgent-care or emergency department visits or were hospitalized, as compared with 13 participants (2.1%) in the placebo group (hazard ratio, 1.9; 95% credible interval, 0.8 to 3.5). Three participants in each group were hospitalized, and no deaths occurred. Adverse events were uncommon in both groups. CONCLUSIONS Treatment with inhaled fluticasone furoate for 14 days did not result in a shorter time to recovery than placebo among outpatients with Covid-19 in the United States. (Funded by the National Center for Advancing Translational Sciences and others; ACTIV-6 ClinicalTrials.gov number, NCT04885530.).
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Affiliation(s)
- David R Boulware
- From the University of Minnesota, Minneapolis (D.R.B.); Vanderbilt University Medical Center, Nashville (C.J.L., S.C.); the University of Virginia, Charlottesville (T.G.S.); the Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (A.F.H., G.M.F., A.D., A.R., R.W., S.W., S.N.); Weill Cornell Medicine, New York (M.W.M.); the University of Miami, Miami (D.J.), and the University of Florida, Gainesville (E.S.); the Lewis Katz School of Medicine at Temple University, Philadelphia (N.G.); the University of Kansas Medical Center, Kansas City (M.C.); Johns Hopkins University, Baltimore (M.S.), and the National Center for Advancing Translational Sciences (S.E.D.) and the Foundation for the National Institutes of Health (S.J.A.), Bethesda - all in Maryland; the University of Pittsburgh Medical Center (K.M.) and the ACTIV-6 Stakeholder Advisory Committee, University of Pittsburgh (F.T.) - both in Pittsburgh; the University of Colorado Denver-Anschutz, Denver (A.A.G.); and the Biomedical Advanced Research and Development Authority, Washington, DC (G.H.)
| | - Christopher J Lindsell
- From the University of Minnesota, Minneapolis (D.R.B.); Vanderbilt University Medical Center, Nashville (C.J.L., S.C.); the University of Virginia, Charlottesville (T.G.S.); the Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (A.F.H., G.M.F., A.D., A.R., R.W., S.W., S.N.); Weill Cornell Medicine, New York (M.W.M.); the University of Miami, Miami (D.J.), and the University of Florida, Gainesville (E.S.); the Lewis Katz School of Medicine at Temple University, Philadelphia (N.G.); the University of Kansas Medical Center, Kansas City (M.C.); Johns Hopkins University, Baltimore (M.S.), and the National Center for Advancing Translational Sciences (S.E.D.) and the Foundation for the National Institutes of Health (S.J.A.), Bethesda - all in Maryland; the University of Pittsburgh Medical Center (K.M.) and the ACTIV-6 Stakeholder Advisory Committee, University of Pittsburgh (F.T.) - both in Pittsburgh; the University of Colorado Denver-Anschutz, Denver (A.A.G.); and the Biomedical Advanced Research and Development Authority, Washington, DC (G.H.)
| | - Thomas G Stewart
- From the University of Minnesota, Minneapolis (D.R.B.); Vanderbilt University Medical Center, Nashville (C.J.L., S.C.); the University of Virginia, Charlottesville (T.G.S.); the Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (A.F.H., G.M.F., A.D., A.R., R.W., S.W., S.N.); Weill Cornell Medicine, New York (M.W.M.); the University of Miami, Miami (D.J.), and the University of Florida, Gainesville (E.S.); the Lewis Katz School of Medicine at Temple University, Philadelphia (N.G.); the University of Kansas Medical Center, Kansas City (M.C.); Johns Hopkins University, Baltimore (M.S.), and the National Center for Advancing Translational Sciences (S.E.D.) and the Foundation for the National Institutes of Health (S.J.A.), Bethesda - all in Maryland; the University of Pittsburgh Medical Center (K.M.) and the ACTIV-6 Stakeholder Advisory Committee, University of Pittsburgh (F.T.) - both in Pittsburgh; the University of Colorado Denver-Anschutz, Denver (A.A.G.); and the Biomedical Advanced Research and Development Authority, Washington, DC (G.H.)
| | - Adrian F Hernandez
- From the University of Minnesota, Minneapolis (D.R.B.); Vanderbilt University Medical Center, Nashville (C.J.L., S.C.); the University of Virginia, Charlottesville (T.G.S.); the Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (A.F.H., G.M.F., A.D., A.R., R.W., S.W., S.N.); Weill Cornell Medicine, New York (M.W.M.); the University of Miami, Miami (D.J.), and the University of Florida, Gainesville (E.S.); the Lewis Katz School of Medicine at Temple University, Philadelphia (N.G.); the University of Kansas Medical Center, Kansas City (M.C.); Johns Hopkins University, Baltimore (M.S.), and the National Center for Advancing Translational Sciences (S.E.D.) and the Foundation for the National Institutes of Health (S.J.A.), Bethesda - all in Maryland; the University of Pittsburgh Medical Center (K.M.) and the ACTIV-6 Stakeholder Advisory Committee, University of Pittsburgh (F.T.) - both in Pittsburgh; the University of Colorado Denver-Anschutz, Denver (A.A.G.); and the Biomedical Advanced Research and Development Authority, Washington, DC (G.H.)
| | - Sean Collins
- From the University of Minnesota, Minneapolis (D.R.B.); Vanderbilt University Medical Center, Nashville (C.J.L., S.C.); the University of Virginia, Charlottesville (T.G.S.); the Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (A.F.H., G.M.F., A.D., A.R., R.W., S.W., S.N.); Weill Cornell Medicine, New York (M.W.M.); the University of Miami, Miami (D.J.), and the University of Florida, Gainesville (E.S.); the Lewis Katz School of Medicine at Temple University, Philadelphia (N.G.); the University of Kansas Medical Center, Kansas City (M.C.); Johns Hopkins University, Baltimore (M.S.), and the National Center for Advancing Translational Sciences (S.E.D.) and the Foundation for the National Institutes of Health (S.J.A.), Bethesda - all in Maryland; the University of Pittsburgh Medical Center (K.M.) and the ACTIV-6 Stakeholder Advisory Committee, University of Pittsburgh (F.T.) - both in Pittsburgh; the University of Colorado Denver-Anschutz, Denver (A.A.G.); and the Biomedical Advanced Research and Development Authority, Washington, DC (G.H.)
| | - Matthew William McCarthy
- From the University of Minnesota, Minneapolis (D.R.B.); Vanderbilt University Medical Center, Nashville (C.J.L., S.C.); the University of Virginia, Charlottesville (T.G.S.); the Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (A.F.H., G.M.F., A.D., A.R., R.W., S.W., S.N.); Weill Cornell Medicine, New York (M.W.M.); the University of Miami, Miami (D.J.), and the University of Florida, Gainesville (E.S.); the Lewis Katz School of Medicine at Temple University, Philadelphia (N.G.); the University of Kansas Medical Center, Kansas City (M.C.); Johns Hopkins University, Baltimore (M.S.), and the National Center for Advancing Translational Sciences (S.E.D.) and the Foundation for the National Institutes of Health (S.J.A.), Bethesda - all in Maryland; the University of Pittsburgh Medical Center (K.M.) and the ACTIV-6 Stakeholder Advisory Committee, University of Pittsburgh (F.T.) - both in Pittsburgh; the University of Colorado Denver-Anschutz, Denver (A.A.G.); and the Biomedical Advanced Research and Development Authority, Washington, DC (G.H.)
| | - Dushyantha Jayaweera
- From the University of Minnesota, Minneapolis (D.R.B.); Vanderbilt University Medical Center, Nashville (C.J.L., S.C.); the University of Virginia, Charlottesville (T.G.S.); the Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (A.F.H., G.M.F., A.D., A.R., R.W., S.W., S.N.); Weill Cornell Medicine, New York (M.W.M.); the University of Miami, Miami (D.J.), and the University of Florida, Gainesville (E.S.); the Lewis Katz School of Medicine at Temple University, Philadelphia (N.G.); the University of Kansas Medical Center, Kansas City (M.C.); Johns Hopkins University, Baltimore (M.S.), and the National Center for Advancing Translational Sciences (S.E.D.) and the Foundation for the National Institutes of Health (S.J.A.), Bethesda - all in Maryland; the University of Pittsburgh Medical Center (K.M.) and the ACTIV-6 Stakeholder Advisory Committee, University of Pittsburgh (F.T.) - both in Pittsburgh; the University of Colorado Denver-Anschutz, Denver (A.A.G.); and the Biomedical Advanced Research and Development Authority, Washington, DC (G.H.)
| | - Nina Gentile
- From the University of Minnesota, Minneapolis (D.R.B.); Vanderbilt University Medical Center, Nashville (C.J.L., S.C.); the University of Virginia, Charlottesville (T.G.S.); the Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (A.F.H., G.M.F., A.D., A.R., R.W., S.W., S.N.); Weill Cornell Medicine, New York (M.W.M.); the University of Miami, Miami (D.J.), and the University of Florida, Gainesville (E.S.); the Lewis Katz School of Medicine at Temple University, Philadelphia (N.G.); the University of Kansas Medical Center, Kansas City (M.C.); Johns Hopkins University, Baltimore (M.S.), and the National Center for Advancing Translational Sciences (S.E.D.) and the Foundation for the National Institutes of Health (S.J.A.), Bethesda - all in Maryland; the University of Pittsburgh Medical Center (K.M.) and the ACTIV-6 Stakeholder Advisory Committee, University of Pittsburgh (F.T.) - both in Pittsburgh; the University of Colorado Denver-Anschutz, Denver (A.A.G.); and the Biomedical Advanced Research and Development Authority, Washington, DC (G.H.)
| | - Mario Castro
- From the University of Minnesota, Minneapolis (D.R.B.); Vanderbilt University Medical Center, Nashville (C.J.L., S.C.); the University of Virginia, Charlottesville (T.G.S.); the Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (A.F.H., G.M.F., A.D., A.R., R.W., S.W., S.N.); Weill Cornell Medicine, New York (M.W.M.); the University of Miami, Miami (D.J.), and the University of Florida, Gainesville (E.S.); the Lewis Katz School of Medicine at Temple University, Philadelphia (N.G.); the University of Kansas Medical Center, Kansas City (M.C.); Johns Hopkins University, Baltimore (M.S.), and the National Center for Advancing Translational Sciences (S.E.D.) and the Foundation for the National Institutes of Health (S.J.A.), Bethesda - all in Maryland; the University of Pittsburgh Medical Center (K.M.) and the ACTIV-6 Stakeholder Advisory Committee, University of Pittsburgh (F.T.) - both in Pittsburgh; the University of Colorado Denver-Anschutz, Denver (A.A.G.); and the Biomedical Advanced Research and Development Authority, Washington, DC (G.H.)
| | - Mark Sulkowski
- From the University of Minnesota, Minneapolis (D.R.B.); Vanderbilt University Medical Center, Nashville (C.J.L., S.C.); the University of Virginia, Charlottesville (T.G.S.); the Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (A.F.H., G.M.F., A.D., A.R., R.W., S.W., S.N.); Weill Cornell Medicine, New York (M.W.M.); the University of Miami, Miami (D.J.), and the University of Florida, Gainesville (E.S.); the Lewis Katz School of Medicine at Temple University, Philadelphia (N.G.); the University of Kansas Medical Center, Kansas City (M.C.); Johns Hopkins University, Baltimore (M.S.), and the National Center for Advancing Translational Sciences (S.E.D.) and the Foundation for the National Institutes of Health (S.J.A.), Bethesda - all in Maryland; the University of Pittsburgh Medical Center (K.M.) and the ACTIV-6 Stakeholder Advisory Committee, University of Pittsburgh (F.T.) - both in Pittsburgh; the University of Colorado Denver-Anschutz, Denver (A.A.G.); and the Biomedical Advanced Research and Development Authority, Washington, DC (G.H.)
| | - Kathleen McTigue
- From the University of Minnesota, Minneapolis (D.R.B.); Vanderbilt University Medical Center, Nashville (C.J.L., S.C.); the University of Virginia, Charlottesville (T.G.S.); the Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (A.F.H., G.M.F., A.D., A.R., R.W., S.W., S.N.); Weill Cornell Medicine, New York (M.W.M.); the University of Miami, Miami (D.J.), and the University of Florida, Gainesville (E.S.); the Lewis Katz School of Medicine at Temple University, Philadelphia (N.G.); the University of Kansas Medical Center, Kansas City (M.C.); Johns Hopkins University, Baltimore (M.S.), and the National Center for Advancing Translational Sciences (S.E.D.) and the Foundation for the National Institutes of Health (S.J.A.), Bethesda - all in Maryland; the University of Pittsburgh Medical Center (K.M.) and the ACTIV-6 Stakeholder Advisory Committee, University of Pittsburgh (F.T.) - both in Pittsburgh; the University of Colorado Denver-Anschutz, Denver (A.A.G.); and the Biomedical Advanced Research and Development Authority, Washington, DC (G.H.)
| | - G Michael Felker
- From the University of Minnesota, Minneapolis (D.R.B.); Vanderbilt University Medical Center, Nashville (C.J.L., S.C.); the University of Virginia, Charlottesville (T.G.S.); the Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (A.F.H., G.M.F., A.D., A.R., R.W., S.W., S.N.); Weill Cornell Medicine, New York (M.W.M.); the University of Miami, Miami (D.J.), and the University of Florida, Gainesville (E.S.); the Lewis Katz School of Medicine at Temple University, Philadelphia (N.G.); the University of Kansas Medical Center, Kansas City (M.C.); Johns Hopkins University, Baltimore (M.S.), and the National Center for Advancing Translational Sciences (S.E.D.) and the Foundation for the National Institutes of Health (S.J.A.), Bethesda - all in Maryland; the University of Pittsburgh Medical Center (K.M.) and the ACTIV-6 Stakeholder Advisory Committee, University of Pittsburgh (F.T.) - both in Pittsburgh; the University of Colorado Denver-Anschutz, Denver (A.A.G.); and the Biomedical Advanced Research and Development Authority, Washington, DC (G.H.)
| | - Adit A Ginde
- From the University of Minnesota, Minneapolis (D.R.B.); Vanderbilt University Medical Center, Nashville (C.J.L., S.C.); the University of Virginia, Charlottesville (T.G.S.); the Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (A.F.H., G.M.F., A.D., A.R., R.W., S.W., S.N.); Weill Cornell Medicine, New York (M.W.M.); the University of Miami, Miami (D.J.), and the University of Florida, Gainesville (E.S.); the Lewis Katz School of Medicine at Temple University, Philadelphia (N.G.); the University of Kansas Medical Center, Kansas City (M.C.); Johns Hopkins University, Baltimore (M.S.), and the National Center for Advancing Translational Sciences (S.E.D.) and the Foundation for the National Institutes of Health (S.J.A.), Bethesda - all in Maryland; the University of Pittsburgh Medical Center (K.M.) and the ACTIV-6 Stakeholder Advisory Committee, University of Pittsburgh (F.T.) - both in Pittsburgh; the University of Colorado Denver-Anschutz, Denver (A.A.G.); and the Biomedical Advanced Research and Development Authority, Washington, DC (G.H.)
| | - Sarah E Dunsmore
- From the University of Minnesota, Minneapolis (D.R.B.); Vanderbilt University Medical Center, Nashville (C.J.L., S.C.); the University of Virginia, Charlottesville (T.G.S.); the Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (A.F.H., G.M.F., A.D., A.R., R.W., S.W., S.N.); Weill Cornell Medicine, New York (M.W.M.); the University of Miami, Miami (D.J.), and the University of Florida, Gainesville (E.S.); the Lewis Katz School of Medicine at Temple University, Philadelphia (N.G.); the University of Kansas Medical Center, Kansas City (M.C.); Johns Hopkins University, Baltimore (M.S.), and the National Center for Advancing Translational Sciences (S.E.D.) and the Foundation for the National Institutes of Health (S.J.A.), Bethesda - all in Maryland; the University of Pittsburgh Medical Center (K.M.) and the ACTIV-6 Stakeholder Advisory Committee, University of Pittsburgh (F.T.) - both in Pittsburgh; the University of Colorado Denver-Anschutz, Denver (A.A.G.); and the Biomedical Advanced Research and Development Authority, Washington, DC (G.H.)
| | - Stacey J Adam
- From the University of Minnesota, Minneapolis (D.R.B.); Vanderbilt University Medical Center, Nashville (C.J.L., S.C.); the University of Virginia, Charlottesville (T.G.S.); the Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (A.F.H., G.M.F., A.D., A.R., R.W., S.W., S.N.); Weill Cornell Medicine, New York (M.W.M.); the University of Miami, Miami (D.J.), and the University of Florida, Gainesville (E.S.); the Lewis Katz School of Medicine at Temple University, Philadelphia (N.G.); the University of Kansas Medical Center, Kansas City (M.C.); Johns Hopkins University, Baltimore (M.S.), and the National Center for Advancing Translational Sciences (S.E.D.) and the Foundation for the National Institutes of Health (S.J.A.), Bethesda - all in Maryland; the University of Pittsburgh Medical Center (K.M.) and the ACTIV-6 Stakeholder Advisory Committee, University of Pittsburgh (F.T.) - both in Pittsburgh; the University of Colorado Denver-Anschutz, Denver (A.A.G.); and the Biomedical Advanced Research and Development Authority, Washington, DC (G.H.)
| | - Allison DeLong
- From the University of Minnesota, Minneapolis (D.R.B.); Vanderbilt University Medical Center, Nashville (C.J.L., S.C.); the University of Virginia, Charlottesville (T.G.S.); the Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (A.F.H., G.M.F., A.D., A.R., R.W., S.W., S.N.); Weill Cornell Medicine, New York (M.W.M.); the University of Miami, Miami (D.J.), and the University of Florida, Gainesville (E.S.); the Lewis Katz School of Medicine at Temple University, Philadelphia (N.G.); the University of Kansas Medical Center, Kansas City (M.C.); Johns Hopkins University, Baltimore (M.S.), and the National Center for Advancing Translational Sciences (S.E.D.) and the Foundation for the National Institutes of Health (S.J.A.), Bethesda - all in Maryland; the University of Pittsburgh Medical Center (K.M.) and the ACTIV-6 Stakeholder Advisory Committee, University of Pittsburgh (F.T.) - both in Pittsburgh; the University of Colorado Denver-Anschutz, Denver (A.A.G.); and the Biomedical Advanced Research and Development Authority, Washington, DC (G.H.)
| | - George Hanna
- From the University of Minnesota, Minneapolis (D.R.B.); Vanderbilt University Medical Center, Nashville (C.J.L., S.C.); the University of Virginia, Charlottesville (T.G.S.); the Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (A.F.H., G.M.F., A.D., A.R., R.W., S.W., S.N.); Weill Cornell Medicine, New York (M.W.M.); the University of Miami, Miami (D.J.), and the University of Florida, Gainesville (E.S.); the Lewis Katz School of Medicine at Temple University, Philadelphia (N.G.); the University of Kansas Medical Center, Kansas City (M.C.); Johns Hopkins University, Baltimore (M.S.), and the National Center for Advancing Translational Sciences (S.E.D.) and the Foundation for the National Institutes of Health (S.J.A.), Bethesda - all in Maryland; the University of Pittsburgh Medical Center (K.M.) and the ACTIV-6 Stakeholder Advisory Committee, University of Pittsburgh (F.T.) - both in Pittsburgh; the University of Colorado Denver-Anschutz, Denver (A.A.G.); and the Biomedical Advanced Research and Development Authority, Washington, DC (G.H.)
| | - April Remaly
- From the University of Minnesota, Minneapolis (D.R.B.); Vanderbilt University Medical Center, Nashville (C.J.L., S.C.); the University of Virginia, Charlottesville (T.G.S.); the Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (A.F.H., G.M.F., A.D., A.R., R.W., S.W., S.N.); Weill Cornell Medicine, New York (M.W.M.); the University of Miami, Miami (D.J.), and the University of Florida, Gainesville (E.S.); the Lewis Katz School of Medicine at Temple University, Philadelphia (N.G.); the University of Kansas Medical Center, Kansas City (M.C.); Johns Hopkins University, Baltimore (M.S.), and the National Center for Advancing Translational Sciences (S.E.D.) and the Foundation for the National Institutes of Health (S.J.A.), Bethesda - all in Maryland; the University of Pittsburgh Medical Center (K.M.) and the ACTIV-6 Stakeholder Advisory Committee, University of Pittsburgh (F.T.) - both in Pittsburgh; the University of Colorado Denver-Anschutz, Denver (A.A.G.); and the Biomedical Advanced Research and Development Authority, Washington, DC (G.H.)
| | - Florence Thicklin
- From the University of Minnesota, Minneapolis (D.R.B.); Vanderbilt University Medical Center, Nashville (C.J.L., S.C.); the University of Virginia, Charlottesville (T.G.S.); the Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (A.F.H., G.M.F., A.D., A.R., R.W., S.W., S.N.); Weill Cornell Medicine, New York (M.W.M.); the University of Miami, Miami (D.J.), and the University of Florida, Gainesville (E.S.); the Lewis Katz School of Medicine at Temple University, Philadelphia (N.G.); the University of Kansas Medical Center, Kansas City (M.C.); Johns Hopkins University, Baltimore (M.S.), and the National Center for Advancing Translational Sciences (S.E.D.) and the Foundation for the National Institutes of Health (S.J.A.), Bethesda - all in Maryland; the University of Pittsburgh Medical Center (K.M.) and the ACTIV-6 Stakeholder Advisory Committee, University of Pittsburgh (F.T.) - both in Pittsburgh; the University of Colorado Denver-Anschutz, Denver (A.A.G.); and the Biomedical Advanced Research and Development Authority, Washington, DC (G.H.)
| | - Rhonda Wilder
- From the University of Minnesota, Minneapolis (D.R.B.); Vanderbilt University Medical Center, Nashville (C.J.L., S.C.); the University of Virginia, Charlottesville (T.G.S.); the Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (A.F.H., G.M.F., A.D., A.R., R.W., S.W., S.N.); Weill Cornell Medicine, New York (M.W.M.); the University of Miami, Miami (D.J.), and the University of Florida, Gainesville (E.S.); the Lewis Katz School of Medicine at Temple University, Philadelphia (N.G.); the University of Kansas Medical Center, Kansas City (M.C.); Johns Hopkins University, Baltimore (M.S.), and the National Center for Advancing Translational Sciences (S.E.D.) and the Foundation for the National Institutes of Health (S.J.A.), Bethesda - all in Maryland; the University of Pittsburgh Medical Center (K.M.) and the ACTIV-6 Stakeholder Advisory Committee, University of Pittsburgh (F.T.) - both in Pittsburgh; the University of Colorado Denver-Anschutz, Denver (A.A.G.); and the Biomedical Advanced Research and Development Authority, Washington, DC (G.H.)
| | - Sybil Wilson
- From the University of Minnesota, Minneapolis (D.R.B.); Vanderbilt University Medical Center, Nashville (C.J.L., S.C.); the University of Virginia, Charlottesville (T.G.S.); the Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (A.F.H., G.M.F., A.D., A.R., R.W., S.W., S.N.); Weill Cornell Medicine, New York (M.W.M.); the University of Miami, Miami (D.J.), and the University of Florida, Gainesville (E.S.); the Lewis Katz School of Medicine at Temple University, Philadelphia (N.G.); the University of Kansas Medical Center, Kansas City (M.C.); Johns Hopkins University, Baltimore (M.S.), and the National Center for Advancing Translational Sciences (S.E.D.) and the Foundation for the National Institutes of Health (S.J.A.), Bethesda - all in Maryland; the University of Pittsburgh Medical Center (K.M.) and the ACTIV-6 Stakeholder Advisory Committee, University of Pittsburgh (F.T.) - both in Pittsburgh; the University of Colorado Denver-Anschutz, Denver (A.A.G.); and the Biomedical Advanced Research and Development Authority, Washington, DC (G.H.)
| | - Elizabeth Shenkman
- From the University of Minnesota, Minneapolis (D.R.B.); Vanderbilt University Medical Center, Nashville (C.J.L., S.C.); the University of Virginia, Charlottesville (T.G.S.); the Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (A.F.H., G.M.F., A.D., A.R., R.W., S.W., S.N.); Weill Cornell Medicine, New York (M.W.M.); the University of Miami, Miami (D.J.), and the University of Florida, Gainesville (E.S.); the Lewis Katz School of Medicine at Temple University, Philadelphia (N.G.); the University of Kansas Medical Center, Kansas City (M.C.); Johns Hopkins University, Baltimore (M.S.), and the National Center for Advancing Translational Sciences (S.E.D.) and the Foundation for the National Institutes of Health (S.J.A.), Bethesda - all in Maryland; the University of Pittsburgh Medical Center (K.M.) and the ACTIV-6 Stakeholder Advisory Committee, University of Pittsburgh (F.T.) - both in Pittsburgh; the University of Colorado Denver-Anschutz, Denver (A.A.G.); and the Biomedical Advanced Research and Development Authority, Washington, DC (G.H.)
| | - Susanna Naggie
- From the University of Minnesota, Minneapolis (D.R.B.); Vanderbilt University Medical Center, Nashville (C.J.L., S.C.); the University of Virginia, Charlottesville (T.G.S.); the Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (A.F.H., G.M.F., A.D., A.R., R.W., S.W., S.N.); Weill Cornell Medicine, New York (M.W.M.); the University of Miami, Miami (D.J.), and the University of Florida, Gainesville (E.S.); the Lewis Katz School of Medicine at Temple University, Philadelphia (N.G.); the University of Kansas Medical Center, Kansas City (M.C.); Johns Hopkins University, Baltimore (M.S.), and the National Center for Advancing Translational Sciences (S.E.D.) and the Foundation for the National Institutes of Health (S.J.A.), Bethesda - all in Maryland; the University of Pittsburgh Medical Center (K.M.) and the ACTIV-6 Stakeholder Advisory Committee, University of Pittsburgh (F.T.) - both in Pittsburgh; the University of Colorado Denver-Anschutz, Denver (A.A.G.); and the Biomedical Advanced Research and Development Authority, Washington, DC (G.H.)
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Ellis J, Bangdiwala AS, Skipper CP, Tugume L, Nsangi L, Matovu J, Pastick KA, Ssebambulidde K, Morawski BM, Musubire AK, Schleiss MR, Moore DAJ, Jarvis JN, Boulware DR, Meya DB, Castelnuovo B. Baseline Cytomegalovirus Viremia at Cryptococcal Meningitis Diagnosis Is Associated With Long-term Increased Incident TB Disease and Mortality in a Prospective Cohort of Ugandan Adults With HIV. Open Forum Infect Dis 2023; 10:ofad449. [PMID: 37732168 PMCID: PMC10508356 DOI: 10.1093/ofid/ofad449] [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] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 08/25/2023] [Indexed: 09/22/2023] Open
Abstract
Background Adults with HIV-associated cryptococcal meningitis have overlapping burdens of cytomegalovirus (CMV) and tuberculosis (TB) coinfections. CMV infection/reactivation is strongly associated with CMV-specific memory T-cell activation and upregulation of type 1 interferons, which may lead to increased risk of TB disease and poor outcomes. Methods We conducted a cohort study of 2-week survivors of cryptococcal meningitis during 2010-2021 to determine TB incidence and all-cause mortality over time stratified by baseline CMV status. Results We followed 497 Ugandans with HIV-associated cryptococcal meningitis for a median (interquartile range) of 4.6 (2.6-53.9) months. Overall, 42% (210/497) developed incident TB disease or died. One-fifth (98/497, 19.7%) developed incident TB disease, and 29% (142/497) of participants died during follow-up. Of 259 participants with CMV viral load measured at baseline, 37% (96/259) had concurrent CMV viremia (defined as anyone with detectable CMV DNA in plasma/serum by qualitative polymerase chain reaction [PCR] detection). Of 59 with measured CMV immunoglobulin G (IgG), 100% had positive CMV IgG antibody serology (≥10 enzyme-linked immunosorbent assay units/mL). CMV viremia was positively associated with higher HIV viral load (196 667 vs 73 295 copies/mL; P = .002) and higher cerebrospinal fluid fungal burden (68 500 vs 14 000 cfu/mL; P = .002) compared with those without. Participants with high-level CMV viremia (defined as CMV viral load ≥1000 IU/mL) had twice the risk of incident TB (subdistribution adjusted hazard ratio [aHR], 2.18; 95% CI, 1.11-4.27) and death (aHR, 1.99; 95% CI, 1.14-3.49) compared with participants with no or low-level CMV viremia. There was no association between the CMV IgG index and the incidence of TB/death (P = .75). Conclusions CMV viremia >1000 IU/mL at meningitis diagnosis was associated with increased incident TB disease and mortality during long-term follow-up. Future studies to determine the causal relationship and potential for therapeutic intervention are warranted.
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Affiliation(s)
- Jayne Ellis
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK
| | | | | | - Lillian Tugume
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Laura Nsangi
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - John Matovu
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | | | - Kenneth Ssebambulidde
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | | | - Abdu K Musubire
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | | | - David A J Moore
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK
| | - Joseph N Jarvis
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | | | - David B Meya
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
- University of Minnesota, Minneapolis, Minnesota, USA
| | - Barbara Castelnuovo
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
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Titanji BK, Boulware DR, Bender Ignacio RA. Strategies for Expediting Clinical Trials in the Next Public Health Emergency. JAMA Health Forum 2023; 4:e233191. [PMID: 37773506 DOI: 10.1001/jamahealthforum.2023.3191] [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] [Indexed: 10/01/2023] Open
Abstract
This Viewpoint highlights areas for improving implementation of future epidemic clinical trials, focusing on research among nonhospitalized persons.
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Affiliation(s)
| | - David R Boulware
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis
| | - Rachel A Bender Ignacio
- Division of Allergy and Infectious Diseases, University of Washington, Seattle
- Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Center, Seattle, Washington
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Okurut S, Boulware DR, Okafor E, Rhein J, Kajumbula H, Bagaya B, Bwanga F, Olobo JO, Manabe YC, Meya DB, Janoff EN. Divergent Neuroimmune Signatures in the Cerebrospinal Fluid Predict Differential Gender-Specific Survival Among Patients With HIV-Associated Cryptococcal Meningitis. medRxiv 2023:2023.08.09.23293903. [PMID: 37645984 PMCID: PMC10462187 DOI: 10.1101/2023.08.09.23293903] [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: 09/01/2023]
Abstract
Survival among people with HIV-associated cryptococcal meningitis (CM) remains low, exceptionally among women with the increased threat of death on current optimal use of antifungal drugs. Cryptococcus dissemination into the central nervous system (CNS) prompts a neuroimmune reaction to activate pathogen concomitant factors. However, no consistent diagnostic or prognostic immune-mediated signature is reported to underpin the risk of death or mechanism to improve treatment or survival. We theorized that the distinct neuroimmune cytokine or chemokine signatures in the cerebrospinal fluid (CSF), distinguish survivors from people who died on antifungal treatment, who may benefit from tailored therapy. We considered the baseline clinical disease features, cryptococcal microbiologic factors, and CSF neuroimmune modulated signatures among 419 consenting adults by gender (biological sex assigned at birth) (168 females and 251 males) by 18 weeks of survival on antifungal management. Survival at 18 weeks was inferior among females than males (47% vs. 59%; hazard ratio HR=1.4, 95% CI: 1.0 to 1.9, and p=0.023). Unsupervised principal component analysis (PCA) demonstrated the divergent neuroimmune signatures by gender, survival, and intragender-specific survival. Overall, females displayed lower levels of PD-L1, IL-1RA, and IL-15 than males (all p≤0.028). Female survivors compared with those who died, expressed significant fold elevations in levels of CSF (CCL11 - myeloid and CXCL10 - lymphoid chemokine (in both p=0.001), and CSF Th1, Th2, and Th17 cytokines. In contrast, male survivors expressed distinctly lower levels of CSF IL-15 and IL-8 compared with those who died. Survivors of either gender demonstrated a significant increase in the levels of immune regulatory element, IL-10. In the finale, we classified divergent neuroimmune key signatures in CSF by gender, survival, and intragender-specific survival among people with HIV-associated cryptococcal meningitis. These intragender-specific survival associated-neuroimmune signatures, suggests the discrete role of gender immune regulating mechanisms as the possible targets for interventions to advance therapy to improve survival among people with HIV-associated cryptococcal meningitis.
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Affiliation(s)
- Samuel Okurut
- Translation Sciences Laboratory, Research Department, Infectious Diseases Institute, Makerere University, Box 22418, Kampala, Uganda
- Department of Medical Microbiology, School of Biomedical Sciences, College of Health Sciences, Makerere University, 7072, Kampala, Uganda
| | - David R Boulware
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN, 55455, USA
| | - Elizabeth Okafor
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN, 55455, USA
| | - Joshua Rhein
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN, 55455, USA
| | - Henry Kajumbula
- Department of Medical Microbiology, School of Biomedical Sciences, College of Health Sciences, Makerere University, 7072, Kampala, Uganda
| | - Bernard Bagaya
- Department of Immunology and Molecular Biology, School of Biomedical Sciences, College of Health Sciences, Makerere University, Box 7072, Kampala, Uganda
| | - Freddie Bwanga
- Department of Medical Microbiology, School of Biomedical Sciences, College of Health Sciences, Makerere University, 7072, Kampala, Uganda
| | - Joseph O Olobo
- Department of Immunology and Molecular Biology, School of Biomedical Sciences, College of Health Sciences, Makerere University, Box 7072, Kampala, Uganda
| | - Yukari C Manabe
- Translation Sciences Laboratory, Research Department, Infectious Diseases Institute, Makerere University, Box 22418, Kampala, Uganda
- Division of Infectious Diseases, Department of Medicine, John Hopkins University School of Medicine, Baltimore, Maryland, MD, 21205, USA
| | - David B Meya
- Translation Sciences Laboratory, Research Department, Infectious Diseases Institute, Makerere University, Box 22418, Kampala, Uganda
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN, 55455, USA
- Department of Medicine, School of Medicine, College of Health Sciences, Makerere University, 7072, Kampala, Uganda
| | - Edward N Janoff
- Mucosal and Vaccine Research Program Colorado, Department of Medicine, Division of Infectious Diseases, University of Colorado Denver, Aurora, Colorado, 80045, USA
- Denver Veterans Affairs Medical Center, Denver CO, 80045, USA
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23
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Tufa TB, Orth HM, Wienemann T, Jensen BEO, Mackenzie CR, Boulware DR, Luedde T, Feldt T. Disseminated Cryptococcosis Is a Common Finding among Human Immunodeficiency Virus-Infected Patients with Suspected Sepsis and Is Associated with Higher Mortality Rates. J Fungi (Basel) 2023; 9:836. [PMID: 37623607 PMCID: PMC10456031 DOI: 10.3390/jof9080836] [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: 05/22/2023] [Revised: 07/31/2023] [Accepted: 08/03/2023] [Indexed: 08/26/2023] Open
Abstract
Cryptococcosis is the leading cause of death among people with HIV in Sub-Saharan Africa. The lack of optimum diagnoses and medications significantly impair the management of the disease. We investigated the burden of cryptococcosis and related mortality among people with HIV and suspected sepsis in Ethiopia. We conducted a prospective study at (1) Adama Hospital Medical College and (2) Asella Referral and Teaching Hospital from September 2019 to November 2020. We enrolled adult, HIV-infected patients presenting with suspected sepsis and assessed their 28-day survival rates. We performed blood cultures and cryptococcal antigen (CrAg) testing. In total, 82 participants were enrolled with a median age of 35 years, and 61% were female. Overall, eleven (13%) had positive CrAg tests, of which five grew Cryptococcus in blood cultures. Despite high-dose fluconazole (1200 mg/d) monotherapy being given to those with positive CrAg tests, the 28-day mortality was 64% (7/11), with mortality being significantly higher than among the CrAg-negative patients (9% (6/71); p < 0.001). Cryptococcosis was the leading cause of mortality among HIV-infected sepsis patients in this Ethiopian cohort. The CrAg screening of HIV-infected patients attending an emergency department can minimize the number of missed cryptococcosis cases irrespective of the CD4 T cell count and viral load. These findings warrant the need for a bundle approach for the diagnosis of HIV-infected persons presenting with sepsis in low- and middle-income countries.
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Affiliation(s)
- Tafese Beyene Tufa
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital and Medical Faculty of the Heinrich, Heine University, 40225 Düsseldorf, Germany; (H.M.O.); (B.-E.O.J.); (T.L.)
- Hirsch Institute of Tropical Medicine, Asella P.O. Box 04, Ethiopia
- College of Health Sciences, Arsi University, Asella P.O. Box 04, Ethiopia
| | - Hans Martin Orth
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital and Medical Faculty of the Heinrich, Heine University, 40225 Düsseldorf, Germany; (H.M.O.); (B.-E.O.J.); (T.L.)
- Hirsch Institute of Tropical Medicine, Asella P.O. Box 04, Ethiopia
| | - Tobias Wienemann
- Institute of Medical Microbiology and Hospital Hygiene, University Hospital Duesseldorf, Medical Faculty, Heinrich Heine University, Universitätsstr. 1, 40225 Düsseldorf, Germany; (T.W.); (C.R.M.)
| | - Bjoern-Erik Ole Jensen
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital and Medical Faculty of the Heinrich, Heine University, 40225 Düsseldorf, Germany; (H.M.O.); (B.-E.O.J.); (T.L.)
| | - Colin R. Mackenzie
- Institute of Medical Microbiology and Hospital Hygiene, University Hospital Duesseldorf, Medical Faculty, Heinrich Heine University, Universitätsstr. 1, 40225 Düsseldorf, Germany; (T.W.); (C.R.M.)
| | - David R. Boulware
- Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA;
| | - Tom Luedde
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital and Medical Faculty of the Heinrich, Heine University, 40225 Düsseldorf, Germany; (H.M.O.); (B.-E.O.J.); (T.L.)
- Hirsch Institute of Tropical Medicine, Asella P.O. Box 04, Ethiopia
| | - Torsten Feldt
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital and Medical Faculty of the Heinrich, Heine University, 40225 Düsseldorf, Germany; (H.M.O.); (B.-E.O.J.); (T.L.)
- Hirsch Institute of Tropical Medicine, Asella P.O. Box 04, Ethiopia
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24
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Reiersen AM, Mattar C, Bender Ignacio RA, Boulware DR, Lee TC, Hess R, Lankowski AJ, McDonald EG, Miller JP, Powderly WG, Pullen MF, Rado JT, Rich MW, Schiffer JT, Schweiger J, Spivak AM, Stevens A, Vigod SN, Agarwal P, Yang L, Yingling M, Gettinger TR, Zorumski CF, Lenze EJ. The STOP COVID 2 Study: Fluvoxamine vs Placebo for Outpatients With Symptomatic COVID-19, a Fully Remote Randomized Controlled Trial. Open Forum Infect Dis 2023; 10:ofad419. [PMID: 37622035 PMCID: PMC10445518 DOI: 10.1093/ofid/ofad419] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 08/06/2023] [Indexed: 08/26/2023] Open
Abstract
Background Prior randomized clinical trials have reported benefit of fluvoxamine ≥200 mg/d vs placebo for patients infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Methods This randomized, double-blind, placebo-controlled, fully remote multisite clinical trial evaluated whether fluvoxamine prevents clinical deterioration in higher-risk outpatients with acute coronavirus disease 2019 (COVID-19). Between December 2020 and May 2021, nonhospitalized US and Canadian participants with confirmed symptomatic infection received fluvoxamine (50 mg on day 1, 100 mg twice daily thereafter) or placebo for 15 days. The primary modified intent-to-treat (mITT) population included participants who started the intervention within 7 days of symptom onset with a baseline oxygen saturation ≥92%. The primary outcome was clinical deterioration within 15 days of randomization, defined as having both (1) shortness of breath (severity ≥4 on a 0-10 scale or requiring hospitalization) and (2) oxygen saturation <92% on room air or need for supplemental oxygen. Results A total of 547 participants were randomized and met mITT criteria (n = 272 fluvoxamine, n = 275 placebo). The Data Safety Monitoring Board recommended stopping early for futility related to lower-than-predicted event rates and declining accrual concurrent with vaccine availability in the United States and Canada. Clinical deterioration occurred in 13 (4.8%) participants in the fluvoxamine group and 15 (5.5%) participants in the placebo group (absolute difference at day 15, 0.68%; 95% CI, -3.0% to 4.4%; log-rank P = .91). Conclusions This trial did not find fluvoxamine efficacious in preventing clinical deterioration in unvaccinated outpatients with symptomatic COVID-19. It was stopped early and underpowered due to low primary outcome rates. Clinical Trials Registration ClinicalTrials.gov Identifier: NCT04668950.
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Affiliation(s)
- Angela M Reiersen
- Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Caline Mattar
- Division of Infectious Diseases, Department of Internal Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Rachel A Bender Ignacio
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
- Allergy & Infectious Diseases Division, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - David R Boulware
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Todd C Lee
- Division of Infectious Diseases, Department of Medicine, McGill University Health Centre, Montréal, Québec, Canada
- Department of Medicine, Clinical Practice Assessment Unit, McGill University Health Centre, Montréal, Québec, Canada
- Division of Experimental Medicine, Department of Medicine, McGill University, Montréal, Québec, Canada
| | - Rachel Hess
- Division of Health System Innovation and Research, University of Utah, Salt Lake City, Utah, USA
- Division of General Internal Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Alexander J Lankowski
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
| | - Emily G McDonald
- Department of Medicine, Clinical Practice Assessment Unit, McGill University Health Centre, Montréal, Québec, Canada
- Division of Experimental Medicine, Department of Medicine, McGill University, Montréal, Québec, Canada
- Division of General Internal Medicine, Department of Medicine, McGill University Health Centre, Montréal, Québec, Canada
| | - J Philip Miller
- Institute for Informatics, Data Science and Biostatistics, Washington University School of Medicine, St. Louis, Missouri, USA
| | - William G Powderly
- Division of Infectious Diseases, Department of Internal Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Matthew F Pullen
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Jeffrey T Rado
- Departments of Psychiatry & Behavioral Sciences and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Michael W Rich
- Department of Medicine, Cardiovascular Division, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Joshua T Schiffer
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
- Allergy & Infectious Diseases Division, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Julie Schweiger
- Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Adam M Spivak
- Division of Infectious Diseases, University of Utah, Salt Lake City, Utah, USA
| | - Angela Stevens
- Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Simone N Vigod
- Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto and Women's College Hospital, Toronto, Ontario, Canada
| | - Payal Agarwal
- Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto and Women's College Hospital, Toronto, Ontario, Canada
| | - Lei Yang
- Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Michael Yingling
- Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Torie R Gettinger
- Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Charles F Zorumski
- Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Eric J Lenze
- Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri, USA
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
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25
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Sekar P, Nalintya E, Kwizera R, Mukashyaka C, Niyonzima G, Namakula LO, Nerima P, Fieberg A, Dai B, Ellis J, Boulware DR, Meya DB, Bahr NC, Rajasingham R. Prevalence of Histoplasma Antigenuria among Outpatient Cohort with Advanced HIV in Kampala, Uganda. J Fungi (Basel) 2023; 9:757. [PMID: 37504745 PMCID: PMC10381727 DOI: 10.3390/jof9070757] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 07/12/2023] [Accepted: 07/13/2023] [Indexed: 07/29/2023] Open
Abstract
In sub-Saharan Africa, an estimated 25% of people with HIV present with advanced HIV and are at high risk of opportunistic infections. Whereas histoplasmosis has occasionally been seen in Uganda, the understanding of the local risk of acute infection is limited. We sought to determine the prevalence of Histoplasma antigenuria using an enzyme immunoassay (EIA, clarus Histoplasma GM EIA, IMMY; Norman, OK, USA) in a cohort of outpatients with advanced HIV disease in Kampala, Uganda. Among the persons with positive urine Histoplasma antigen tests, we assessed their clinical presentation and outcomes. The EIA was run on stored urine samples as per the manufacturer's instructions. Specimens ≥1 EIA units were considered positive. Among the 388 tested urine samples, 4 (1.2%) were positive for Histoplasma antigen. The histoplasmosis prevalence among participants with a CD4 < 100 cells/mcL was 2.5% (4/158). Three of the four participants with a positive Histoplasma antigen test reported systemic symptoms consistent with histoplasmosis. All four participants had a positive urine lipoarabinomannan test and were treated for tuberculosis. By the four-week follow-up visit, all participants were clinically improved, alive, and in care without antifungal therapy. In advanced HIV, the clinical presentations of tuberculosis and histoplasmosis overlap. The value of histoplasmosis screening and pre-emptive treatment is an area of future research.
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Affiliation(s)
- Preethiya Sekar
- Infectious Diseases Institute, Makerere University, Kampala P.O. Box 22418, Uganda
| | - Elizabeth Nalintya
- Infectious Diseases Institute, Makerere University, Kampala P.O. Box 22418, Uganda
| | - Richard Kwizera
- Infectious Diseases Institute, Makerere University, Kampala P.O. Box 22418, Uganda
| | - Claudine Mukashyaka
- Infectious Diseases Institute, Makerere University, Kampala P.O. Box 22418, Uganda
| | - Godfrey Niyonzima
- Infectious Diseases Institute, Makerere University, Kampala P.O. Box 22418, Uganda
| | | | - Patricia Nerima
- Infectious Diseases Institute, Makerere University, Kampala P.O. Box 22418, Uganda
| | - Ann Fieberg
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA
| | - Biyue Dai
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA
| | - Jayne Ellis
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | - David R Boulware
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA
| | - David B Meya
- Infectious Diseases Institute, Makerere University, Kampala P.O. Box 22418, Uganda
| | - Nathan C Bahr
- Division of Infectious Diseases, University of Kansas, Kansas City, KS 66160, USA
| | - Radha Rajasingham
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA
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26
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Hong H, Friedland A, Hu M, Anstrom KJ, Halabi S, McKinnon JE, Amaravadi R, Rojas-Serrano J, Abella BS, Portillo-Vázquez AM, Woods CW, Hernandez AF, Boulware DR, Naggie S, Rajasingham R. Safety and efficacy of hydroxychloroquine as prophylactic against COVID-19 in healthcare workers: a meta-analysis of randomised clinical trials. BMJ Open 2023; 13:e065305. [PMID: 37328184 PMCID: PMC10276967 DOI: 10.1136/bmjopen-2022-065305] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 05/31/2023] [Indexed: 06/18/2023] Open
Abstract
OBJECTIVE We studied the safety and efficacy of hydroxychloroquine (HCQ) as pre-exposure prophylaxis for COVID-19 in healthcare workers (HCWs), using a meta-analysis of randomised controlled trials (RCTs). DATA SOURCES PubMed and EMBASE databases were searched to identify randomised trials studying HCQ. STUDY SELECTION Ten RCTs were identified (n=5079 participants). DATA EXTRACTION AND SYNTHESIS The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used in this systematic review and meta-analysis between HCQ and placebo using a Bayesian random-effects model. A pre-hoc statistical analysis plan was written. MAIN OUTCOMES The primary efficacy outcome was PCR-confirmed SARS-CoV-2 infection and the primary safety outcome was incidence of adverse events. The secondary outcome included clinically suspected SARS-CoV-2 infection. RESULTS Compared with placebo, HCWs randomised to HCQ had no significant difference in PCR-confirmed SARS-CoV-2 infection (OR 0.92, 95% credible interval (CI): 0.58, 1.37) or clinically suspected SARS-CoV-2 infection (OR 0.78, 95% CI: 0.57, 1.10), but significant difference in adverse events (OR 1.35, 95% CI: 1.03, 1.73). CONCLUSIONS AND RELEVANCE Our meta-analysis of 10 RCTs investigating the safety and efficacy of HCQ as pre-exposure prophylaxis in HCWs found that compared with placebo, HCQ does not significantly reduce the risk of confirmed or clinically suspected SARS-CoV-2 infection, while HCQ significantly increases adverse events. PROSPERO REGISTRATION NUMBER CRD42021285093.
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Affiliation(s)
- Hwanhee Hong
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, USA
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Anne Friedland
- Department of Infectious Disease, UNC School of Medicine, Chapel Hill, North Carolina, USA
| | - Mengyi Hu
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, USA
| | - Kevin J Anstrom
- Collaborative Studies Coordinating Center, University of North Carolina System, Chapel Hill, North Carolina, USA
| | - Susan Halabi
- Duke Clinical Research Institute, Durham, North Carolina, USA
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | - John E McKinnon
- Division of Infectious Diseases, Henry Ford Hospital, Detroit, Michigan, USA
| | - Ravi Amaravadi
- Division of Hematology Oncology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jorge Rojas-Serrano
- Interstitial Lung Disease and Rheumatology Units, Instituto Nacional de Enfermedades Respiratorias, Mexico City, Mexico
| | - Benjamin S Abella
- Division of Hematology Oncology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | | | | | - David R Boulware
- Division of Infectious Diseases & International Medicine, University of Minnesota Twin Cities, Minneapolis, Minnesota, USA
| | - Susanna Naggie
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Radha Rajasingham
- Division of Infectious Diseases & International Medicine, University of Minnesota Twin Cities, Minneapolis, Minnesota, USA
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27
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Nalintya E, Sekar P, Kavuma P, Kigozi J, Ssuna M, Kirumira P, Naluyima R, Namuli T, Musa FT, Skipper CP, Hullsiek KH, Ellis J, Boulware DR, Meya DB, Rajasingham R. Effect of Coronavirus Disease 2019 Lockdowns on Identification of Advanced Human Immunodeficiency Virus Disease in Outpatient Clinics in Uganda. Clin Infect Dis 2023; 76:2014-2017. [PMID: 36799434 PMCID: PMC10249983 DOI: 10.1093/cid/ciad087] [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: 09/27/2022] [Revised: 01/31/2023] [Accepted: 02/14/2023] [Indexed: 02/18/2023] Open
Abstract
Using data from 67 Ugandan human immunodeficiency virus (HIV) clinics (July 2019-January 2022), we report a 40% (1005/1662) reduction in the number of people with HIV presenting to care after August 2021 compared to prepandemic levels, with a greater proportion presenting with advanced HIV disease (20% vs 16% in the pre-coronavirus disease 2019 period).
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Affiliation(s)
| | - Preethiya Sekar
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, USA
| | - Paul Kavuma
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Joanita Kigozi
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Martin Ssuna
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Paul Kirumira
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Rose Naluyima
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Teopista Namuli
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Fred Turya Musa
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Caleb P Skipper
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, USA
| | - Kathy Huppler Hullsiek
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, USA
| | - Jayne Ellis
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
- Clinical Research Department, London School of Hygiene and Tropical Medicine, United Kingdom
| | - David R Boulware
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, USA
| | - David B Meya
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Radha Rajasingham
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, USA
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28
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Bramante CT, Beckman KB, Mehta T, Karger AB, Odde DJ, Tignanelli CJ, Buse JB, Johnson DM, Watson RHB, Daniel JJ, Liebovitz DM, Nicklas JM, Cohen K, Puskarich MA, Belani HK, Siegel LK, Klatt NR, Anderson B, Hartman KM, Rao V, Hagen AA, Patel B, Fenno SL, Avula N, Reddy NV, Erickson SM, Fricton RD, Lee S, Griffiths G, Pullen MF, Thompson JL, Sherwood N, Murray TA, Rose MR, Boulware DR, Huling JD. Metformin reduces SARS-CoV-2 in a Phase 3 Randomized Placebo Controlled Clinical Trial. medRxiv 2023:2023.06.06.23290989. [PMID: 37333243 PMCID: PMC10275003 DOI: 10.1101/2023.06.06.23290989] [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] [Subscribe] [Scholar Register] [Indexed: 06/20/2023]
Abstract
Current antiviral treatment options for SARS-CoV-2 infections are not available globally, cannot be used with many medications, and are limited to virus-specific targets.1-3 Biophysical modeling of SARS-CoV-2 replication predicted that protein translation is an especially attractive target for antiviral therapy.4 Literature review identified metformin, widely known as a treatment for diabetes, as a potential suppressor of protein translation via targeting of the host mTor pathway.5 In vitro, metformin has antiviral activity against RNA viruses including SARS-CoV-2.6,7 In the COVID-OUT phase 3, randomized, placebo-controlled trial of outpatient treatment of COVID-19, metformin had a 42% reduction in ER visits/hospitalizations/death through 14 days; a 58% reduction in hospitalizations/death through 28 days, and a 42% reduction in Long COVID through 10 months.8,9 Here we show viral load analysis of specimens collected in the COVID-OUT trial that the mean SARS-CoV-2 viral load was reduced 3.6-fold with metformin relative to placebo (-0.56 log10 copies/mL; 95%CI, -1.05 to -0.06, p=0.027) while there was no virologic effect for ivermectin or fluvoxamine vs placebo. The metformin effect was consistent across subgroups and with emerging data.10,11 Our results demonstrate, consistent with model predictions, that a safe, widely available,12 well-tolerated, and inexpensive oral medication, metformin, can be repurposed to significantly reduce SARS-CoV-2 viral load.
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Affiliation(s)
| | | | - Tanvi Mehta
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN
| | - Amy B Karger
- Department of Laboratory Medicine and Pathology, Medical School, University of Minnesota, Minneapolis, MN
| | - David J Odde
- Department of Biomedical Engineering University of Minnesota, Minneapolis, MN
| | | | - John B Buse
- Endocrinology, University of North Carolina, Chapel Hill, NC
| | | | - Ray H B Watson
- Genomics Center, University of Minnesota, Minneapolis, MN
| | - Jerry J Daniel
- Genomics Center, University of Minnesota, Minneapolis, MN
| | | | | | | | | | - Hrishikesh K Belani
- Department of Medicine, Olive View - University of California, Los Angeles, CA
| | - Lianne K Siegel
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN
| | - Nichole R Klatt
- Department of Surgery, Medical School, University of Minnesota, Minneapolis, MN
| | - Blake Anderson
- Atlanta Veterans Affairs Medical Center, Atlanta, Georgia; Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | | | - Via Rao
- General Internal Medicine, University of Minnesota, Minneapolis, MN
| | - Aubrey A Hagen
- General Internal Medicine, University of Minnesota, Minneapolis, MN
| | - Barkha Patel
- General Internal Medicine, University of Minnesota, Minneapolis, MN
| | - Sarah L Fenno
- General Internal Medicine, University of Minnesota, Minneapolis, MN
| | - Nandini Avula
- General Internal Medicine, University of Minnesota, Minneapolis, MN
| | - Neha V Reddy
- General Internal Medicine, University of Minnesota, Minneapolis, MN
| | | | | | - Samuel Lee
- General Internal Medicine, Northwestern University, Chicago, IL
| | | | - Matthew F Pullen
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, MN
| | - Jennifer L Thompson
- Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN
| | - Nancy Sherwood
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN
| | - Thomas A Murray
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN
| | - Michael R Rose
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN
| | - David R Boulware
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, MN
| | - Jared D Huling
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN
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Izco S, Garcia-Basteiro AL, Denning DW, Boulware DR, Penn-Nicholson A, Letang E. Management of advanced HIV disease in Africa. Lancet HIV 2023:S2352-3018(23)00078-4. [PMID: 37105215 DOI: 10.1016/s2352-3018(23)00078-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 03/25/2023] [Accepted: 03/29/2023] [Indexed: 04/29/2023]
Affiliation(s)
- Santiago Izco
- National Program of STD/HIV/AIDS, Tuberculosis and Viral Hepatitis, Ministry of Health and Social Welfare, Malabo 399, Equatorial Guinea.
| | - Alberto L Garcia-Basteiro
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique; Barcelona Institute for Global Health, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain; Biomédica en Red de Enfermedades Infecciosas, Barcelona, Spain
| | | | - David R Boulware
- Department of Medicine, University of Minnesota Microbiology Research Facility, Minneapolis, MN, USA
| | | | - Emilio Letang
- Universitat de Barcelona, Faculty of Medicine, Barcelona, Spain
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30
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Reis G, Dos Santos Moreira Silva EA, Silva DCM, Thabane L, de Souza Campos VH, Ferreira TS, Quirino Dos Santos CV, Ribeiro Nogueira AM, Figueiredo Guimaraes Almeida AP, Cançado Monteiro Savassi L, de Figueiredo Neto AD, Bitarães C, Cruz Milagres A, Diniz Callegari E, Campos Simplicio MI, Barra Ribeiro L, Oliveira R, Harari O, Wilson LA, Forrest JI, Ruton H, Sprague S, McKay P, Guo CM, Guyatt GH, Rayner CR, Boulware DR, Ezer N, Lee TC, McDonald EG, Bafadhel M, Butler C, Silva JR, Dybul M, Mills EJ. Oral Fluvoxamine With Inhaled Budesonide for Treatment of Early-Onset COVID-19 : A Randomized Platform Trial. Ann Intern Med 2023; 176:667-675. [PMID: 37068273 PMCID: PMC10111398 DOI: 10.7326/m22-3305] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/19/2023] Open
Abstract
BACKGROUND Previous trials have demonstrated the effects of fluvoxamine alone and inhaled budesonide alone for prevention of disease progression among outpatients with COVID-19. OBJECTIVE To determine whether the combination of fluvoxamine and inhaled budesonide would increase treatment effects in a highly vaccinated population. DESIGN Randomized, placebo-controlled, adaptive platform trial. (ClinicalTrials.gov: NCT04727424). SETTING 12 clinical sites in Brazil. PARTICIPANTS Symptomatic adults with confirmed SARS-CoV-2 infection and a known risk factor for progression to severe disease. INTERVENTION Patients were randomly assigned to either fluvoxamine (100 mg twice daily for 10 days) plus inhaled budesonide (800 mcg twice daily for 10 days) or matching placebos. MEASUREMENTS The primary outcome was a composite of emergency setting retention for COVID-19 for more than 6 hours, hospitalization, and/or suspected complications due to clinical progression of COVID-19 within 28 days of randomization. Secondary outcomes included health care attendance (defined as hospitalization for any cause or emergency department visit lasting >6 hours), time to hospitalization, mortality, patient-reported outcomes, and adverse drug reactions. RESULTS Randomization occurred from 15 January to 6 July 2022. A total of 738 participants were allocated to oral fluvoxamine plus inhaled budesonide, and 738 received placebo. The proportion of patients observed in an emergency setting for COVID-19 for more than 6 hours or hospitalized due to COVID-19 was lower in the treatment group than the placebo group (1.8% [95% credible interval {CrI}, 1.1% to 3.0%] vs. 3.7% [95% CrI, 2.5% to 5.3%]; relative risk, 0.50 [95% CrI, 0.25 to 0.92]), with a probability of superiority of 98.7%. No relative effects were found between groups for any of the secondary outcomes. More adverse events occurred in the intervention group than the placebo group, but no important differences between the groups were detected. LIMITATION Low event rate overall, consistent with contemporary trials in vaccinated populations. CONCLUSION Treatment with oral fluvoxamine plus inhaled budesonide among high-risk outpatients with early COVID-19 reduced the incidence of severe disease requiring advanced care. PRIMARY FUNDING SOURCE Latona Foundation, FastGrants, and Rainwater Charitable Foundation.
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Affiliation(s)
- Gilmar Reis
- ViRx@Stanford, Stanford Biosecurity and Pandemic Preparedness Initiative, Stanford, California; Research Division, Cardresearch - Cardiologia Assistencial e de Pesquisa, Belo Horizonte, Brazil; Department of Medicine, Pontifícia Universidade Católica de Minas Gerais, Minas Gerais, Brazil; and Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada (G.R.)
| | - Eduardo Augusto Dos Santos Moreira Silva
- Research Division, Cardresearch - Cardiologia Assistencial e de Pesquisa, Belo Horizonte, Brazil, and Department of Medicine, Pontifícia Universidade Católica de Minas Gerais, Minas Gerais, Brazil (E.A.d.S.M.S., D.C.M.S., V.H.d.S.C., C.V.Q.d.S.)
| | - Daniela Carla Medeiros Silva
- Research Division, Cardresearch - Cardiologia Assistencial e de Pesquisa, Belo Horizonte, Brazil, and Department of Medicine, Pontifícia Universidade Católica de Minas Gerais, Minas Gerais, Brazil (E.A.d.S.M.S., D.C.M.S., V.H.d.S.C., C.V.Q.d.S.)
| | - Lehana Thabane
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada (L.T., S.S., P.M., G.H.G.)
| | - Vitoria Helena de Souza Campos
- Research Division, Cardresearch - Cardiologia Assistencial e de Pesquisa, Belo Horizonte, Brazil, and Department of Medicine, Pontifícia Universidade Católica de Minas Gerais, Minas Gerais, Brazil (E.A.d.S.M.S., D.C.M.S., V.H.d.S.C., C.V.Q.d.S.)
| | - Thiago Santiago Ferreira
- Research Division, Cardresearch - Cardiologia Assistencial e de Pesquisa, Belo Horizonte, Brazil (T.S.F., M.I.C.S., L.B.R., R.O.)
| | - Castilho Vitor Quirino Dos Santos
- Research Division, Cardresearch - Cardiologia Assistencial e de Pesquisa, Belo Horizonte, Brazil, and Department of Medicine, Pontifícia Universidade Católica de Minas Gerais, Minas Gerais, Brazil (E.A.d.S.M.S., D.C.M.S., V.H.d.S.C., C.V.Q.d.S.)
| | | | | | | | | | - Carina Bitarães
- Public Health, Mental and Family Medicine Department, Ouro Preto Federal University, Minas Gerais, Brazil, and Public Health Care Division, City of Ibirité, Brazil (C.B., A.C.M.)
| | - Aline Cruz Milagres
- Public Health, Mental and Family Medicine Department, Ouro Preto Federal University, Minas Gerais, Brazil, and Public Health Care Division, City of Ibirité, Brazil (C.B., A.C.M.)
| | - Eduardo Diniz Callegari
- Department of Public Health at UNIFIPMoc and Family Medicine Fellowship Program, City of Montes Claros, Brazil, and Public Health Care Division, City of Brumadinho, Brazil (E.D.C.)
| | - Maria Izabel Campos Simplicio
- Research Division, Cardresearch - Cardiologia Assistencial e de Pesquisa, Belo Horizonte, Brazil (T.S.F., M.I.C.S., L.B.R., R.O.)
| | - Luciene Barra Ribeiro
- Research Division, Cardresearch - Cardiologia Assistencial e de Pesquisa, Belo Horizonte, Brazil (T.S.F., M.I.C.S., L.B.R., R.O.)
| | - Rosemary Oliveira
- Research Division, Cardresearch - Cardiologia Assistencial e de Pesquisa, Belo Horizonte, Brazil (T.S.F., M.I.C.S., L.B.R., R.O.)
| | - Ofir Harari
- Cytel, Vancouver, British Columbia, Canada (O.H., H.R.)
| | - Lindsay A Wilson
- Platform Life Sciences, Vancouver, British Columbia, Canada (L.A.W., J.I.F., C.M.G., J.R.S.)
| | - Jamie I Forrest
- Platform Life Sciences, Vancouver, British Columbia, Canada (L.A.W., J.I.F., C.M.G., J.R.S.)
| | - Hinda Ruton
- Cytel, Vancouver, British Columbia, Canada (O.H., H.R.)
| | - Sheila Sprague
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada (L.T., S.S., P.M., G.H.G.)
| | - Paula McKay
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada (L.T., S.S., P.M., G.H.G.)
| | - Christina M Guo
- Platform Life Sciences, Vancouver, British Columbia, Canada (L.A.W., J.I.F., C.M.G., J.R.S.)
| | - Gordon H Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada (L.T., S.S., P.M., G.H.G.)
| | - Craig R Rayner
- Certara, Princeton, New Jersey, and Monash Institute of Pharmaceutical Sciences, Monash University, Melbourne, Victoria, Australia (C.R.R.)
| | - David R Boulware
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota (D.R.B.)
| | - Nicole Ezer
- Department of Medicine, Division of Respiratory Medicine, McGill University Health Centre, Montréal, Québec, Canada (N.E.)
| | - Todd C Lee
- Division of Infectious Diseases, Department of Medicine, McGill University Health Centre, Montréal, Québec, Canada (T.C.L.)
| | - Emily Gibson McDonald
- Division of General Internal Medicine, Department of Medicine, McGill University Health Centre, Montréal, Québec, Canada (E.G.M.)
| | - Mona Bafadhel
- School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom (M.B.)
| | - Christopher Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (C.B.)
| | - Josue Rodrigues Silva
- Platform Life Sciences, Vancouver, British Columbia, Canada (L.A.W., J.I.F., C.M.G., J.R.S.)
| | - Mark Dybul
- Global Health Institute, Georgetown University, Washington, DC (M.D.)
| | - Edward J Mills
- ViRx@Stanford, Stanford Biosecurity and Pandemic Preparedness Initiative, Stanford, California; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; Cytel, Vancouver, British Columbia, Canada; and Platform Life Sciences, Vancouver, British Columbia, Canada (E.J.M.)
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Naggie S, Boulware DR, Lindsell CJ, Stewart TG, Slandzicki AJ, Lim SC, Cohen J, Kavtaradze D, Amon AP, Gabriel A, Gentile N, Felker GM, Jayaweera D, McCarthy MW, Sulkowski M, Rothman RL, Wilson S, DeLong A, Remaly A, Wilder R, Collins S, Dunsmore SE, Adam SJ, Thicklin F, Hanna GJ, Ginde AA, Castro M, McTigue K, Shenkman E, Hernandez AF. Effect of Higher-Dose Ivermectin for 6 Days vs Placebo on Time to Sustained Recovery in Outpatients With COVID-19: A Randomized Clinical Trial. JAMA 2023; 329:888-897. [PMID: 36807465 PMCID: PMC9941969 DOI: 10.1001/jama.2023.1650] [Citation(s) in RCA: 25] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 02/01/2023] [Indexed: 02/22/2023]
Abstract
Importance It is unknown whether ivermectin, with a maximum targeted dose of 600 μg/kg, shortens symptom duration or prevents hospitalization among outpatients with mild to moderate COVID-19. Objective To evaluate the effectiveness of ivermectin at a maximum targeted dose of 600 μg/kg daily for 6 days, compared with placebo, for the treatment of early mild to moderate COVID-19. Design, Setting, and Participants The ongoing Accelerating COVID-19 Therapeutic Interventions and Vaccines 6 (ACTIV-6) platform randomized clinical trial was designed to evaluate repurposed therapies among outpatients with mild to moderate COVID-19. A total of 1206 participants older than 30 years with confirmed COVID-19 experiencing at least 2 symptoms of acute infection for less than or equal to 7 days were enrolled at 93 sites in the US from February 16, 2022, through July 22, 2022, with follow-up data through November 10, 2022. Interventions Participants were randomly assigned to receive ivermectin, with a maximum targeted dose of 600 μg/kg (n = 602) daily, or placebo (n = 604) for 6 days. Main Outcomes and Measures The primary outcome was time to sustained recovery, defined as at least 3 consecutive days without symptoms. The 7 secondary outcomes included a composite of hospitalization, death, or urgent/emergent care utilization by day 28. Results Among 1206 randomized participants who received study medication or placebo, the median (IQR) age was 48 (38-58) years, 713 (59.1%) were women, and 1008 (83.5%) reported receiving at least 2 SARS-CoV-2 vaccine doses. The median (IQR) time to sustained recovery was 11 (11-12) days in the ivermectin group and 11 (11-12) days in the placebo group. The hazard ratio (posterior probability of benefit) for improvement in time to recovery was 1.02 (95% credible interval, 0.92-1.13; P = .68). Among those receiving ivermectin, 34 (5.7%) were hospitalized, died, or had urgent or emergency care visits compared with 36 (6.0%) receiving placebo (hazard ratio, 1.0 [95% credible interval, 0.6-1.5]; P = .53). In the ivermectin group, 1 participant died and 4 were hospitalized (0.8%); 2 participants (0.3%) were hospitalized in the placebo group and there were no deaths. Adverse events were uncommon in both groups. Conclusions and Relevance Among outpatients with mild to moderate COVID-19, treatment with ivermectin, with a maximum targeted dose of 600 μg/kg daily for 6 days, compared with placebo did not improve time to sustained recovery. These findings do not support the use of ivermectin in patients with mild to moderate COVID-19. Trial Registration ClinicalTrials.gov Identifier: NCT04885530.
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Affiliation(s)
- Susanna Naggie
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - David R. Boulware
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis
| | | | | | | | - Stephen C. Lim
- University Medical Center New Orleans, Louisiana State University Health Sciences Center, New Orleans
| | - Jonathan Cohen
- Jadestone Clinical Research, LLC, Silver Spring, Maryland
| | | | - Arch P. Amon
- Lakeland Regional Medical Center, Lakeland, Florida
| | - Ahab Gabriel
- Focus Clinical Research Solutions, Charlotte, North Carolina
| | - Nina Gentile
- Department of Emergency Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - G. Michael Felker
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Dushyantha Jayaweera
- Department of Medicine, Miller School of Medicine, University of Miami, Miami, Florida
| | | | - Mark Sulkowski
- Division of Infectious Diseases, Johns Hopkins University, Baltimore, Maryland
| | | | - Sybil Wilson
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Allison DeLong
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - April Remaly
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Rhonda Wilder
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Sean Collins
- Vanderbilt University Medical Center, Nashville, Tennessee
- Veterans Affairs Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), Nashville
| | - Sarah E. Dunsmore
- National Center for Advancing Translational Sciences, Bethesda, Maryland
| | - Stacey J. Adam
- Foundation for the National Institutes of Health, Bethesda, Maryland
| | | | - George J. Hanna
- Biomedical Advanced Research and Development Authority, Washington, DC
| | | | - Mario Castro
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Missouri-Kansas City School of Medicine, Kansas City
| | - Kathleen McTigue
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Elizabeth Shenkman
- Department of Health Outcomes & Biomedical Informatics, College of Medicine, University of Florida, Gainesville
| | - Adrian F. Hernandez
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
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Bahr NC, Skipper CP, Huppler-Hullsiek K, Ssebambulidde K, Morawski BM, Engen NW, Nuwagira E, Quinn CM, Ramachandran PS, Evans EE, Lofgren SM, Abassi M, Muzoora C, Wilson MR, Meya DB, Rhein J, Boulware DR. Recurrence of Symptoms Following Cryptococcal Meningitis: Characterizing a Diagnostic Conundrum With Multiple Etiologies. Clin Infect Dis 2023; 76:1080-1087. [PMID: 36303432 PMCID: PMC10226736 DOI: 10.1093/cid/ciac853] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [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: 08/09/2022] [Revised: 10/12/2022] [Accepted: 10/26/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Cryptococcal meningitis is a common cause of AIDS-related mortality. Although symptom recurrence after initial treatment is common, the etiology is often difficult to decipher. We sought to summarize characteristics, etiologies, and outcomes among persons with second-episode symptomatic recurrence. METHODS We prospectively enrolled Ugandans with cryptococcal meningitis and obtained patient characteristics, antiretroviral therapy (ART) and cryptococcosis histories, clinical outcomes, and cerebrospinal fluid (CSF) analysis results. We independently adjudicated cases of second-episode meningitis to categorize patients as (1) microbiological relapse, (2) paradoxical immune reconstitution inflammatory syndrome (IRIS), (3) persistent elevated intracranial pressure (ICP) only, or (4) persistent symptoms only, along with controls of primary cryptococcal meningitis. We compared groups with chi-square or Kruskal-Wallis tests as appropriate. RESULTS 724 participants were included (n = 607 primary episode, 81 relapse, 28 paradoxical IRIS, 2 persistently elevated ICP, 6 persistent symptoms). Participants with culture-positive relapse had lower CD4 (25 cells/μL; IQR: 9-76) and lower CSF white blood cell (WBC; 4 cells/μL; IQR: 4-85) counts than paradoxical IRIS (CD4: 78 cells/μL; IQR: 47-142; WBC: 45 cells/μL; IQR: 8-128). Among those with CSF WBC <5 cells/μL, 86% (43/50) had relapse. Among those with CD4 counts <50 cells/μL, 91% (39/43) had relapse. Eighteen-week mortality (from current symptom onset) was 47% among first episodes of cryptococcal meningitis, 31% in culture-positive relapses, and 14% in paradoxical IRIS. CONCLUSIONS Poor immune reconstitution was noted more often in relapse than IRIS as evidenced by lower CSF WBC and blood CD4 counts. These easily obtained laboratory values should prompt initiation of antifungal treatment while awaiting culture results. CLINICAL TRIALS REGISTRATION NCT01802385.
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Affiliation(s)
- Nathan C Bahr
- Division of Infectious Diseases, Department of Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Caleb P Skipper
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Kathy Huppler-Hullsiek
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | | | - Bozena M Morawski
- Cancer Data Registry of Idaho, Idaho Hospital Association, Boise, Idaho, USA
| | - Nicole W Engen
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Edwin Nuwagira
- Department of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Carson M Quinn
- Department of Neurology, Harvard Medical School, Boston, Massachusetts, USA
- Weill Institute of Neurosciences, Department of Neurology, University of California, San Francisco, San Francisco, California, USA
| | - Prashanth S Ramachandran
- Weill Institute of Neurosciences, Department of Neurology, University of California, San Francisco, San Francisco, California, USA
| | - Emily E Evans
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Sarah M Lofgren
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Mahsa Abassi
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Conrad Muzoora
- Department of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Michael R Wilson
- Weill Institute of Neurosciences, Department of Neurology, University of California, San Francisco, San Francisco, California, USA
| | - David B Meya
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Joshua Rhein
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - David R Boulware
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
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Boulware DR, Jarvis JN. Timing of antiretroviral therapy in cryptococcal meningitis: What we can (and cannot) learn from observational data. Clin Infect Dis 2023:7072298. [PMID: 36883585 DOI: 10.1093/cid/ciad123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 02/25/2023] [Accepted: 03/02/2023] [Indexed: 03/09/2023] Open
Affiliation(s)
- David R Boulware
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Joseph N Jarvis
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
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Harrison TS, Lawrence DS, Mwandumba HC, Boulware DR, Hosseinipour MC, Lortholary O, Meintjes G, Mosepele M, Jarvis JN. How Applicable Is the Single-Dose AMBITION Regimen for Human Immunodeficiency Virus-Associated Cryptococcal Meningitis to High-Income Settings? Clin Infect Dis 2023; 76:944-949. [PMID: 36166405 PMCID: PMC9989135 DOI: 10.1093/cid/ciac792] [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: 07/01/2022] [Revised: 09/05/2022] [Accepted: 09/23/2022] [Indexed: 11/12/2022] Open
Abstract
The AmBisome Therapy Induction Optimization (AMBITION-cm) trial, conducted in eastern and southern Africa, showed that a single, high dose (10 mg/kg) of liposomal amphotericin B, given with an oral backbone of fluconazole and flucytosine, was noninferior to the World Health Organization (WHO)-recommended regimen of 7 days of amphotericin B deoxycholate plus flucytosine for treatment of human immunodeficiency virus (HIV)-associated cryptococcal meningitis and has been incorporated into WHO treatment guidelines. We believe that the trial also has important implications for the treatment of HIV-associated cryptococcal meningitis in high-income settings. We advance the arguments, supported by evidence where available, that the AMBITION-cm trial regimen is likely to be as fungicidal as the currently recommended 14-day liposomal amphotericin-based treatments, better tolerated with fewer adverse effects, and confer significant economic and practical benefits and, therefore, should be included as a treatment option in guidance for HIV-associated cryptococcal treatment in high-income settings.
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Affiliation(s)
- Thomas S Harrison
- Institute of Infection and Immunity, St George's University London, London, United Kingdom
- Clinical Academic Group in Infection and Immunity, St George's University Hospitals NHS Foundation Trust, London, United Kingdom
- Medical Research Council Centre for Medical Mycology, University of Exeter, Exeter, United Kingdom
| | - David S Lawrence
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Henry C Mwandumba
- Clinical Sciences Department, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
- Malawi-Liverpool-Wellcome Clinical Research Programme, Blantyre, Malawi
- Department of Medicine, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - David R Boulware
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Mina C Hosseinipour
- Lilongwe Medical Relief Trust (University of North Carolina Project), Lilongwe, Malawi
- Department of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Olivier Lortholary
- Institut Pasteur, National Center for Scientific Research, Molecular Mycology Unit and National Reference Center for Invasive Mycoses and Antifungals, Unités Mixtes de Recherche 2000, Paris, France
- Université de Paris-Cité, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, Hôpital Necker Enfants Malades, Assistance Publique–Hôpitaux de Paris, IHU Imagine, Paris, France
| | - Graeme Meintjes
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Mosepele Mosepele
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- Department of Internal Medicine, University of Botswana, Gaborone, Botswana
| | - Joseph N Jarvis
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
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35
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Mitjà O, Reis G, Boulware DR, Spivak AM, Sarwar A, Johnston C, Webb B, Hill MD, Smith D, Kremsner P, Curran M, Carter D, Alexander J, Corbacho M, Lee TC, Hullsiek KH, McDonald EG, Hess R, Hughes M, Baeten JM, Schwartz I, Metz L, Richer L, Chew KW, Daar E, Wohl D, Dunne M. Hydroxychloroquine for treatment of non-hospitalized adults with COVID-19: A meta-analysis of individual participant data of randomized trials. Clin Transl Sci 2023; 16:524-535. [PMID: 36601684 PMCID: PMC10014689 DOI: 10.1111/cts.13468] [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: 08/19/2022] [Revised: 11/18/2022] [Accepted: 11/22/2022] [Indexed: 01/06/2023] Open
Abstract
Hydroxychloroquine (HCQ) was initially promoted as an oral therapy for early treatment of coronavirus disease 2019 (COVID-19). Conventional meta-analyses cannot fully address the heterogeneity of different designs and outcomes of randomized controlled trials (RCTs) assessing the efficacy of HCQ in outpatients with mild COVID-19. We conducted a pooled analysis of individual participant data from RCTs that evaluated the effect of HCQ on hospitalization and viral load reduction in outpatients with confirmed COVID-19. We evaluated the overall treatment group effect by log-likelihood ratio test (-2LL) from a generalized linear mixed model to accommodate correlated longitudinal binary data. The analysis included data from 11 RCTs. The outcome of virological effect, assessed in 1560 participants (N = 795 HCQ, N = 765 control), did not differ significantly between the two treatment groups (-2LL = 7.66; p = 0.18) when adjusting for cohort, duration of symptoms, and comorbidities. The decline in polymerase chain reaction positive tests from day 1 to 7 was 42.0 and 41.6 percentage points in the HCQ and control groups, respectively. Among the 2037 participants evaluable for hospitalization (N = 1058 HCQ, N = 979 control), we found no significant differences in hospitalization rate between participants receiving HCQ and controls (odds ratio 0.995; 95% confidence interval 0.614-1.610; -2LL = 0.0; p = 0.98) when adjusting for cohort, duration of symptoms, and comorbidities. This individual participant data meta-analysis of 11 HCQ trials that evaluated severe acute respiratory syndrome-coronavirus 2 viral clearance and COVID-19 hospitalization did not show a clinical benefit of HCQ. Our meta-analysis provides evidence to support the interruption in the use of HCQ in mild COVID-19 outpatients to reduce progression to severe disease.
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Affiliation(s)
- Oriol Mitjà
- Fight AIDS and Infectious Diseases Foundation, Barcelona, Spain
- Hospital Universitari Germans Trias i Pujol, Badalona, Spain
- Lihir Medical Center-International SOS, Lihir Island, Papua New Guinea
| | - Gilmar Reis
- Research Division, Cardresearch Cardiologia Assistencial e de Pesquisa, Pontifícia Universidade Católica de Minas Gerais, Bello Horizonte, Brazil
- Cytel Inc., Vancouver, British Columbia, Canada
| | - David R Boulware
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | | | - Ammar Sarwar
- Harvard Medical School, Boston, Massachusetts, USA
| | - Christine Johnston
- Department of Medicine and Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA
| | - Brandon Webb
- Intermountain Health Care, University of Utah, Salt Lake City, Utah, USA
| | | | - Davey Smith
- Division of Infectious Diseases & Global Public Health, UC San Diego School of Medicine, San Diego, California, USA
| | - Peter Kremsner
- University Hospital of Tübingen, Tübingen, Germany
- Centre de Recherches Médicales de Lambaréné, Lambaréné, Gabon
| | - Marla Curran
- Bill & Melinda Gates Medical Research Institute, Cambridge, Massachusetts, USA
| | | | - Jim Alexander
- Bill & Melinda Gates Medical Research Institute, Cambridge, Massachusetts, USA
| | - Marc Corbacho
- Fight AIDS and Infectious Diseases Foundation, Barcelona, Spain
| | - Todd C Lee
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Katherine Huppler Hullsiek
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Emily G McDonald
- Division of General Internal Medicine, McGill University Health Center, Montreal, Quebec, Canada
| | - Rachel Hess
- University of Utah, Salt Lake City, Utah, USA
| | | | - Jared M Baeten
- Department of Medicine and Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA
| | | | - Luanne Metz
- University of Calgary, Calgary, Alberta, Canada
| | | | - Kara W Chew
- Division of Infectious Diseases, Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles, California, USA
| | - Eric Daar
- Lundquist Institute at Harbor-UCLA Medical Center, Torrance, California, USA
| | - David Wohl
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Michael Dunne
- Bill & Melinda Gates Medical Research Institute, Cambridge, Massachusetts, USA
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Lehman A, Nalintya E, Wele A, Kirumira P, Naluyima R, Namuli T, Turya Musa F, Skipper CP, Meya DB, Boulware DR, Rajasingham R. Hyponatremia as a Predictor of Cryptococcal Meningitis and Death Among Asymptomatic Persons With HIV and Cryptococcal Antigenemia. Open Forum Infect Dis 2023; 10:ofad156. [PMID: 37008569 PMCID: PMC10061560 DOI: 10.1093/ofid/ofad156] [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: 12/13/2022] [Accepted: 03/24/2023] [Indexed: 03/30/2023] Open
Abstract
Among persons with human immunodeficiency virus-associated cryptococcal meningitis serum hyponatremia is a risk factor for mortality; however, the role of hyponatremia in persons with asymptomatic cryptococcal antigenemia is unknown. We found that serum hyponatremia ≤130 mmol/L is an independent risk factor for progression to meningitis and death in asymptomatic persons with cryptococcal antigenemia.
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Affiliation(s)
- Alice Lehman
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | | | - Abduljewad Wele
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Paul Kirumira
- Infectious Disease Institute, Makerere University, Kampala, Uganda
| | - Rose Naluyima
- Infectious Disease Institute, Makerere University, Kampala, Uganda
| | - Teopista Namuli
- Infectious Disease Institute, Makerere University, Kampala, Uganda
| | - Fred Turya Musa
- Infectious Disease Institute, Makerere University, Kampala, Uganda
| | - Caleb P Skipper
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - David B Meya
- Infectious Disease Institute, Makerere University, Kampala, Uganda
| | - David R Boulware
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Radha Rajasingham
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, Minnesota, USA
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37
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Levin AE, Bangdiwala AS, Nalintya E, Kagimu E, Kasibante J, Rutakingirwa MK, Mpoza E, Jjunju S, Nuwagira E, Naluyima R, Kirumira P, Hou C, Ssebambulidde K, Musubire AK, Williams DA, Abassi M, Muzoora C, Hullsiek KH, Rajasingham R, Meya DB, Boulware DR, Skipper CP. Outpatient Cryptococcal Antigen Screening Is Associated With Favorable Baseline Characteristics and Improved Survival in Persons With Cryptococcal Meningitis in Uganda. Clin Infect Dis 2023; 76:e759-e765. [PMID: 35859045 PMCID: PMC10169421 DOI: 10.1093/cid/ciac599] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 07/09/2022] [Accepted: 07/15/2022] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND It is unknown whether persons with symptomatic cryptococcal meningitis detected during routine blood cryptococcal antigen (CrAg) screening have better survival than persons presenting with overt meningitis. METHODS We prospectively enrolled Ugandans with HIV and cryptocococcal meningitis from December 2018 to December 2021. Participants were treated with amphotericin-based combination therapy. We compared outcomes between persons who were CrAg screened then referred to hospital with those presenting directly to the hospital with symptomatic meningitis. RESULTS Among 489 participants with cryptococcal meningitis, 40% (194/489) received blood CrAg screening and were referred to hospital (median time to referral 2 days; interquartile range [IQR], 1-6). CrAg-screened persons referred to hospital had lower 14-day mortality than non-CrAg-screened persons who presented directly to hospital with symptomatic meningitis (12% vs 21%; hazard ratio, .51; 95% confidence interval, .32-.83; P = .006). Fewer CrAg-screened participants had altered mental status versus non-CrAg-screened participants (29% vs 41%; P = .03). CrAg-screened persons had lower quantitative cerebrospinal fluid (CSF) culture burden (median [IQR], 4570 [11-100 000] vs 26 900 [182-324 000] CFU/mL; P = .01) and lower CSF opening pressures (median [IQR], 190 [120-270] vs 225 [140-340] mmH2O; P = .004) compared with non-CrAg-screened persons. CONCLUSIONS Survival from cryptococcal meningitis was higher in persons with prior CrAg screening than those without CrAg screening. Altered mental status was the most potent predictor for mortality in a multivariate model. We suggest that CrAg screening detects cryptococcal meningitis at an earlier stage, as evidenced by a favorable baseline risk profile and notably fewer persons with altered mental status.
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Affiliation(s)
- Anna E Levin
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Ananta S Bangdiwala
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | | | - Enock Kagimu
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - John Kasibante
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | - Edward Mpoza
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Samuel Jjunju
- Department of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Edwin Nuwagira
- Department of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Rose Naluyima
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Paul Kirumira
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Cody Hou
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | | | - Abdu K Musubire
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Darlisha A Williams
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Mahsa Abassi
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Conrad Muzoora
- Department of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Katherine H Hullsiek
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Radha Rajasingham
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - David B Meya
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
- Department of Medicine, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - David R Boulware
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Caleb P Skipper
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
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McCarthy MW, Naggie S, Boulware DR, Lindsell CJ, Stewart TG, Felker GM, Jayaweera D, Sulkowski M, Gentile N, Bramante C, Singh U, Dolor RJ, Ruiz-Unger J, Wilson S, DeLong A, Remaly A, Wilder R, Collins S, Dunsmore SE, Adam SJ, Thicklin F, Hanna G, Ginde AA, Castro M, McTigue K, Shenkman E, Hernandez AF. Effect of Fluvoxamine vs Placebo on Time to Sustained Recovery in Outpatients With Mild to Moderate COVID-19: A Randomized Clinical Trial. JAMA 2023; 329:296-305. [PMID: 36633838 PMCID: PMC9857647 DOI: 10.1001/jama.2022.24100] [Citation(s) in RCA: 27] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 12/13/2022] [Indexed: 01/13/2023]
Abstract
Importance The effectiveness of fluvoxamine to shorten symptom duration or prevent hospitalization among outpatients with mild to moderate symptomatic COVID-19 is unclear. Objective To evaluate the efficacy of low-dose fluvoxamine (50 mg twice daily) for 10 days compared with placebo for the treatment of mild to moderate COVID-19 in the US. Design, Setting, and Participants The ongoing Accelerating COVID-19 Therapeutic Interventions and Vaccines (ACTIV-6) platform randomized clinical trial was designed to test repurposed medications in outpatients with mild to moderate COVID-19. A total of 1288 participants aged 30 years or older with test-confirmed SARS-CoV-2 infection and experiencing 2 or more symptoms of acute COVID-19 for 7 days or less were enrolled between August 6, 2021, and May 27, 2022, at 91 sites in the US. Interventions Participants were randomized to receive 50 mg of fluvoxamine twice daily for 10 days or placebo. Main Outcomes and Measures The primary outcome was time to sustained recovery (defined as the third day of 3 consecutive days without symptoms). There were 7 secondary outcomes, including a composite outcome of hospitalization, urgent care visit, emergency department visit, or death through day 28. Results Among 1331 participants who were randomized (median age, 47 years [IQR, 38-57 years]; 57% were women; and 67% reported receiving ≥2 doses of a SARS-CoV-2 vaccine), 1288 completed the trial (674 in the fluvoxamine group and 614 in the placebo group). The median time to sustained recovery was 12 days (IQR, 11-14 days) in the fluvoxamine group and 13 days (IQR, 12-13 days) in the placebo group (hazard ratio [HR], 0.96 [95% credible interval, 0.86-1.06], posterior P = .21 for the probability of benefit [determined by an HR >1]). For the composite outcome, 26 participants (3.9%) in the fluvoxamine group were hospitalized, had an urgent care visit, had an emergency department visit, or died compared with 23 participants (3.8%) in the placebo group (HR, 1.1 [95% credible interval, 0.5-1.8], posterior P = .35 for the probability of benefit [determined by an HR <1]). One participant in the fluvoxamine group and 2 participants in the placebo group were hospitalized; no deaths occurred in either group. Adverse events were uncommon in both groups. Conclusions and Relevance Among outpatients with mild to moderate COVID-19, treatment with 50 mg of fluvoxamine twice daily for 10 days, compared with placebo, did not improve time to sustained recovery. These findings do not support the use of fluvoxamine at this dose and duration in patients with mild to moderate COVID-19. Trial Registration ClinicalTrials.gov Identifier: NCT04885530.
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Affiliation(s)
| | - Susanna Naggie
- Duke Clinical Research Institute, School of Medicine, Duke University, Durham, North Carolina
- Department of Medicine, School of Medicine, Duke University, Durham, North Carolina
| | - David R. Boulware
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis
| | | | - Thomas G. Stewart
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
- Now with School of Data Science, University of Virginia, Charlottesville
| | - G. Michael Felker
- Duke Clinical Research Institute, School of Medicine, Duke University, Durham, North Carolina
- Department of Medicine, School of Medicine, Duke University, Durham, North Carolina
| | - Dushyantha Jayaweera
- Department of Medicine, Miller School of Medicine, University of Miami, Miami, Florida
| | - Mark Sulkowski
- Division of Infectious Diseases, Johns Hopkins University, Baltimore, Maryland
| | - Nina Gentile
- Department of Emergency Medicine, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania
| | - Carolyn Bramante
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis
| | - Upinder Singh
- Departments of Internal Medicine and Microbiology and Immunology, School of Medicine, Stanford University, Stanford, California
| | - Rowena J. Dolor
- Duke Clinical Research Institute, School of Medicine, Duke University, Durham, North Carolina
- Department of Medicine, School of Medicine, Duke University, Durham, North Carolina
| | | | - Sybil Wilson
- Duke Clinical Research Institute, School of Medicine, Duke University, Durham, North Carolina
| | - Allison DeLong
- Duke Clinical Research Institute, School of Medicine, Duke University, Durham, North Carolina
| | - April Remaly
- Duke Clinical Research Institute, School of Medicine, Duke University, Durham, North Carolina
| | - Rhonda Wilder
- Duke Clinical Research Institute, School of Medicine, Duke University, Durham, North Carolina
| | - Sean Collins
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sarah E. Dunsmore
- National Center for Advancing Translational Sciences, Bethesda, Maryland
| | - Stacey J. Adam
- Foundation for the National Institutes of Health, Bethesda, Maryland
| | | | - George Hanna
- Biomedical Advanced Research and Development Authority, Washington, DC
| | - Adit A. Ginde
- Department of Emergency Medicine, University of Colorado, Denver
| | - Mario Castro
- Division of Pulmonary, Critical Care, and Sleep Medicine, School of Medicine, University of Missouri, Kansas City, Kansas
| | - Kathleen McTigue
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Elizabeth Shenkman
- Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, Gainesville
| | - Adrian F. Hernandez
- Duke Clinical Research Institute, School of Medicine, Duke University, Durham, North Carolina
- Department of Medicine, School of Medicine, Duke University, Durham, North Carolina
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Namuju OC, Namuwenge PM, Kwizera R, Obuya E, Kirumira P, Naluyima R, Ahimbisibwe C, Ndyetukira J, Nakato H, Kirungi R, Gakuru J, Junju S, Nuwagira E, Rutakagirwa M, Nsibirwa S, Nabitaka V, Nalintya E, Mpoza E, Muzoora CK, Musubire AK, Boulware DR, Meya DB. Adherence of health workers to guidelines for screening and management of cryptococcal meningitis in Uganda. PLoS One 2023; 18:e0284165. [PMID: 37036886 PMCID: PMC10085016 DOI: 10.1371/journal.pone.0284165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 03/24/2023] [Indexed: 04/11/2023] Open
Abstract
INTRODUCTION Health workers' failure to adhere to guidelines for screening, diagnosis and management of HIV-associated cryptococcal meningitis (CM) remains a significant public health concern. We aimed to assess adherence to the standards of care and management of HIV patients at risk of CM per the MoH guidelines and assess stock management of CM supplies in the period of January to June 2021 at selected public health facilities (HFs) in Uganda. METHODS The study employed an observational cross-sectional design to assess the level of adherence of health workers to standards of clinical care and management of HIV positive patients at risk of CM as per the clinical guidelines for Uganda, and stock management of CM supplies in the period of January to June 2021in selected public health facilities. The study team used a survey guide designed by MoH to assess and score the screening, diagnosis and management practices of Health Facilities towards CM. Scoring was categorized as red (< 80%), light green (80%-95%), and dark green (˃95%) in the order from worst to best adherence. The data was transcribed into a spread sheet and analysed using STATA-v15. RESULTS The study team visited a total of 15 public health facilities including 5 general hospitals, 9 regional referral hospitals (RRHs) and 1 National Referral hospital (NRH). The mean score for adherence to screening and management of CM for all the combined facilities was 15 (64.7%) classified as red. 10 (66.7%) HFs had not performed a baseline CD4 test for eligible patients within 2 weeks of ART initiation. With regards to treatment, 9 (60%) of the HFs were scored as light green on knowledge of the procedure for reconstituting intravenous Liposomal Amphotericin B. None of the HFs visited had potassium chloride tablets in stock. CONCLUSION Major MoH guidelines are generally not being adhered to by health workers while managing cryptococcal meningitis. It is vital that government and implementing partners regularly support HFs with training, mentorship, and support supervision on CM management to improve adherence to CM screening and treatment guidelines.
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Affiliation(s)
- Olivie C Namuju
- Department of Research, Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Proscovia M Namuwenge
- Department of Advanced HIV Disease and Treatment, Ministry of Health, Kampala, Uganda
| | - Richard Kwizera
- Department of Research, Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Emmanuel Obuya
- School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Paul Kirumira
- Department of Research, Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Rose Naluyima
- Department of Research, Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Cynthia Ahimbisibwe
- Department of Research, Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - JaneFrancis Ndyetukira
- Department of Research, Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Hawa Nakato
- Department of Advanced HIV Disease and Treatment, Ministry of Health, Kampala, Uganda
| | - Robert Kirungi
- HIV Department, Clinton Health Access Initiative (CHAI), Kampala, Uganda
| | - Jane Gakuru
- Department of Research, Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Samuel Junju
- Department of Research, Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Edwin Nuwagira
- Department of Research, Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Morris Rutakagirwa
- Department of Research, Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Sara Nsibirwa
- Department of Research, Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Vennie Nabitaka
- HIV Department, Clinton Health Access Initiative (CHAI), Kampala, Uganda
| | - Elizabeth Nalintya
- Department of Research, Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Edward Mpoza
- Department of Research, Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Conrad K Muzoora
- Department of Research, Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Abdu K Musubire
- Department of Research, Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - David R Boulware
- Department of Medicine and International Health, University of Minnesota, Minneapolis, Minnesota, United States of America
| | - David B Meya
- Department of Research, Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
- Department of Medicine and International Health, University of Minnesota, Minneapolis, Minnesota, United States of America
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40
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Lofgren SM, Tsui S, Natala N, Nakasujja N, Sebuliba R, Ndyetukira JF, Arinda A, Akinyange V, Hullsiek KH, Nalintya E, Sadiq A, Pastick KA, Stadleman A, Meya D, Boulware DR. Differences in Reasons for Late Presentation to HIV Care in Uganda Among Men and Women. AIDS Behav 2023; 27:303-313. [PMID: 35916948 PMCID: PMC9343575 DOI: 10.1007/s10461-022-03764-9] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/15/2022] [Indexed: 01/24/2023]
Abstract
Late presentation to HIV care, i.e., presenting with < 200 CD4 cells/mL, is associated with higher mortality and worse outcomes. Despite that, a quarter of people living with HIV in Uganda still present late to care. We surveyed Ugandans living with HIV who enrolled in clinic ≤ 90 days prior. We compared groups who presented 'late' with CD4 < 200 and 'early' with CD4 > 350, stratifying by sex. We found men who presented late had higher externalized stigma than early presenters. Thirty-six percent of the entire cohort were depressed. Social support was stronger in late presenters versus early, although weak overall. Social support was inversely correlated with depression, with social support dropping as depression increased. Interventions to improve clinic privacy, reduce stigma, improve social support, and help women disclose their HIV status to male partners are needed to reduce late presentation to HIV care.
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Affiliation(s)
- Sarah M Lofgren
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, 689 23rd Avenue S.E., Minneapolis, MN, 55455, USA.
- Infectious Diseases Institute, Makerere University, Kampala, Uganda.
| | - Sharon Tsui
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Nakita Natala
- Department of Psychiatry and Behavioral Sciences, University of Minnesota, Minneapolis, MN, USA
| | | | - Raymond Sebuliba
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | - Anita Arinda
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
- Department of Psychiatry, Makerere University, Kampala, Uganda
| | | | - Kathy H Hullsiek
- Division of Biostatistics, University of Minnesota, School of Public Health, Minneapolis, MN, USA
| | | | - Alisat Sadiq
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Katelyn A Pastick
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, 689 23rd Avenue S.E., Minneapolis, MN, 55455, USA
| | - Anna Stadleman
- Division of Biostatistics, University of Minnesota, School of Public Health, Minneapolis, MN, USA
| | - David Meya
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - David R Boulware
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, 689 23rd Avenue S.E., Minneapolis, MN, 55455, USA
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41
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Mills FP, Reis G, Wilson LA, Thorlund K, Forrest JI, Guo CM, Boulware DR, Mills EJ. Early Treatment with Fluvoxamine among Patients with COVID-19: A Cost-Consequence Model. Am J Trop Med Hyg 2023; 108:101-106. [PMID: 36379209 PMCID: PMC9833089 DOI: 10.4269/ajtmh.22-0106] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 09/21/2022] [Indexed: 11/16/2022] Open
Abstract
To date, two published randomized trials have indicated a clinical benefit of early treatment with fluvoxamine versus placebo for adults with symptomatic COVID-19. Using the results of the largest of these trials, the TOGETHER trial, we conducted a cost-consequence analysis to assess the health system benefits of preventing progression to severe COVID-19 in outpatient populations in the United States. A decision-analytic model in the form of a decision tree was constructed to evaluate two treatment strategies for high-risk patients with confirmed, symptomatic COVID-19 in the primary analysis: treatment with a 10-day course of fluvoxamine (100 mg twice daily) and current standard-of-care. A secondary analysis comparing a 5-day course of nirmatrelvir-ritonavir was also conducted. We used a time horizon of 28 days. Reported outcomes included cost-savings and hospitalization days avoided. The results of our analysis indicated that administration of fluvoxamine to symptomatic outpatients at high risk of progressing to severe COVID-19 was substantially cost-saving, in the amount of $232 per eligible patient and prevented an average of 0.15 hospital days per patient treated, compared with standard of care. Nirmatrelvir-ritonavir was also shown to be cost-saving despite its higher acquisition cost and provided savings to the healthcare system of $625 per patient treated. These findings suggest that fluvoxamine is likely to be a cost-effective addition to frontline COVID-19 mitigation strategies in many settings, particularly where access to nirmaltrevir-ritonavir or monoclonal antibodies is limited.
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Affiliation(s)
| | - Gilmar Reis
- Research Division, Cardresearch–Cardiologia Assistencial e de Pesquisa, Belo Horizonte, Brazil
| | - Lindsay A. Wilson
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Kristian Thorlund
- Platform Life Sciences Inc., Vancouver, Canada;,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | | | | | - David R. Boulware
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Edward J. Mills
- Platform Life Sciences Inc., Vancouver, Canada;,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada;,Address correspondence to Edward J. Mills, Platform Life Sciences Inc., 802-777 West Broadway, Vancouver, BC V5Z 1J5, Canada. E-mail:
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Lee TC, Boulware DR. Ongoing Need for Clinical Trials and Contemporary End Points for Outpatient COVID-19. Ann Intern Med 2023; 176:137-138. [PMID: 36442058 PMCID: PMC9707697 DOI: 10.7326/m22-3317] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
The American College of Physicians presents recommendations for the outpatient treatment of COVID-19 based on Sommer and colleagues' systematic review. The editorialists commend the authors of the recommendations and review for trying to summarize the rapidly evolving literature into clear practice points and discuss the challenges of continually updating reviews and associated recommendations as new evidence emerges and relevant outcomes evolve.
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Affiliation(s)
- Todd C Lee
- Division of Infectious Diseases, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - David R Boulware
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
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Skipper CP, Hullsiek KH, Stadelman A, Williams DA, Ssebambulidde K, Okafor E, Tugume L, Nuwagira E, Akampurira A, Musubire AK, Abassi M, Muzoora C, Rhein J, Boulware DR, Meya DB. Sterile Cerebrospinal Fluid Culture at Cryptococcal Meningitis Diagnosis Is Associated with High Mortality. J Fungi (Basel) 2022; 9:46. [PMID: 36675867 PMCID: PMC9866844 DOI: 10.3390/jof9010046] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 12/21/2022] [Accepted: 12/22/2022] [Indexed: 12/29/2022] Open
Abstract
Cryptococcus is the leading cause of AIDS-related meningitis in sub-Saharan Africa. The clinical implications of a sterile cerebrospinal fluid (CSF) culture among individuals diagnosed with cryptococcal meningitis using CSF cryptococcal antigen (CrAg) are unclear. We prospectively enrolled 765 HIV-positive Ugandans with first-episode cryptococcal meningitis from November 2010 to May 2017. All persons were treated with amphotericin-based induction therapy. We grouped participants by tertile of baseline CSF quantitative Cryptococcus culture burden and compared clinical characteristics, CSF immune profiles, and 18-week mortality. We found 55 (7%) CSF CrAg-positive participants with sterile CSF cultures. Compared to the non-sterile groups, participants with sterile CSF cultures had higher CD4 counts, lower CSF opening pressures, and were more frequently receiving ART. By 18 weeks, 47% [26/55] died in the sterile culture group versus 35% [83/235] in the low culture tertile, 46% [107/234] in the middle tertile, and 56% [135/241] in the high tertile (p < 0.001). The sterile group had higher levels of CSF interferon-gamma (IFN-γ), IFN-α, interleukin (IL)-6, IL-17, G-CSF, GM-CSF, and chemokine CXCL2 compared with non-sterile groups. Despite persons with sterile CSF cultures having higher CD4 counts, lower CSF opening pressures, and CSF cytokine profiles associated with better Cryptococcus control (e.g., IFN-γ predominant), mortality was similar to those with higher fungal burdens. This unexpected finding challenges the traditional paradigm that increasing CSF fungal burdens are associated with increased mortality but is consistent with a damage-response framework model.
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Affiliation(s)
- Caleb P Skipper
- Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA
- Infectious Diseases Institute, Makerere University, Kampala 7062, Uganda
| | | | - Anna Stadelman
- School of Public Health, University of Minnesota, Minneapolis, MN 55455, USA
| | - Darlisha A Williams
- Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA
- Infectious Diseases Institute, Makerere University, Kampala 7062, Uganda
| | | | - Elizabeth Okafor
- Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA
| | - Lillian Tugume
- Infectious Diseases Institute, Makerere University, Kampala 7062, Uganda
| | - Edwin Nuwagira
- Department of Medicine, Mbarara University of Science and Technology, Mbarara 1410, Uganda
| | - Andrew Akampurira
- Infectious Diseases Institute, Makerere University, Kampala 7062, Uganda
| | - Abdu K Musubire
- Infectious Diseases Institute, Makerere University, Kampala 7062, Uganda
| | - Mahsa Abassi
- Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA
- Infectious Diseases Institute, Makerere University, Kampala 7062, Uganda
| | - Conrad Muzoora
- Department of Medicine, Mbarara University of Science and Technology, Mbarara 1410, Uganda
| | - Joshua Rhein
- Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA
- Infectious Diseases Institute, Makerere University, Kampala 7062, Uganda
| | - David R Boulware
- Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA
| | - David B Meya
- Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA
- Infectious Diseases Institute, Makerere University, Kampala 7062, Uganda
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Bramante CT, Buse JB, Liebovitz D, Nicklas J, Puskarich MA, Cohen K, Belani H, Anderson B, Huling JD, Tignanelli C, Thompson J, Pullen M, Siegel L, Proper J, Odde DJ, Klatt N, Sherwood N, Lindberg S, Wirtz EL, Karger A, Beckman K, Erickson S, Fenno S, Hartman K, Rose M, Patel B, Griffiths G, Bhat N, Murray TA, Boulware DR. Outpatient treatment of Covid-19 with metformin, ivermectin, and fluvoxamine and the development of Long Covid over 10-month follow-up. medRxiv 2022:2022.12.21.22283753. [PMID: 36597543 PMCID: PMC9810227 DOI: 10.1101/2022.12.21.22283753] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background Long Covid is an emerging chronic illness potentially affecting millions, sometimes preventing the ability to work or participate in normal daily activities. COVID-OUT was an investigator-initiated, multi-site, phase 3, randomized, quadruple-blinded placebo-controlled clinical trial (NCT04510194). The design simultaneously assessed three oral medications (metformin, ivermectin, fluvoxamine) using two by three parallel treatment factorial assignment to efficiently share placebo controls and assessed Long Covid outcomes for 10 months to understand whether early outpatient treatment of SARS-CoV-2 with metformin, ivermectin, or fluvoxamine prevents Long Covid. Methods This was a decentralized, remotely delivered trial in the US of 1,125 adults age 30 to 85 with overweight or obesity, fewer than 7 days of symptoms, and enrolled within three days of a documented SARS-CoV-2 infection. Immediate release metformin titrated over 6 days to 1,500mg per day 14 days total; ivermectin 430mcg/kg/day for 3 days; fluvoxamine, 50mg on day one then 50mg twice daily through 14 days. Medical-provider diagnosis of Long Covid, reported by participant by day 300 after randomization was a pre-specified secondary outcome; the primary outcome of the trial was severe Covid by day 14. Result The median age was 45 years (IQR 37 to 54), 56% female of whom 7% were pregnant. Two percent identified as Native American; 3.7% as Asian; 7.4% as Black/African American; 82.8% as white; and 12.7% as Hispanic/Latino. The median BMI was 29.8 kg/m2 (IQR 27 to 34); 51% had a BMI >30kg/m2. Overall, 8.4% reported having received a diagnosis of Long Covid from a medical provider: 6.3% in the metformin group and 10.6% in the metformin control; 8.0% in the ivermectin group and 8.1% in the ivermectin control; and 10.1% in the fluvoxamine group and 7.5% in the fluvoxamine control. The Hazard Ratio (HR) for Long Covid in the metformin group versus control was 0.58 (95% CI 0.38 to 0.88); 0.99 (95% CI 0.592 to 1.643) in the ivermectin group; and 1.36 in the fluvoxamine group (95% CI 0.785 to 2.385). Conclusions There was a 42% relative decrease in the incidence of Long Covid in the metformin group compared to its blinded control in a secondary outcome of this randomized phase 3 trial.
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Affiliation(s)
| | - John B Buse
- Endocrinology, University of North Carolina, Chapel Hill, ND
| | - David Liebovitz
- General Internal Medicine, Northwestern University, Chicago, IL
| | - Jacinda Nicklas
- General Internal Medicine, University of Colorado, Denver, CO
| | | | - Ken Cohen
- UnitedHealth Group, Optum Labs, Minnetonka, MN
| | - Hrishikesh Belani
- Department of Medicine, Olive View - University of California, Los Angeles, CA
| | - Blake Anderson
- Atlanta Veterans Affairs Medical Center, Atlanta, Georgia; Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Jared D Huling
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN
| | | | - Jennifer Thompson
- Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN
| | - Matthew Pullen
- Infectious Diseases, University of Minnesota Medical School, Minneapolis, MN
| | - Lianne Siegel
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN
| | - Jennifer Proper
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN
| | - David J Odde
- Department of Biomedical Engineering University of Minnesota, Minneapolis, MN
| | - Nichole Klatt
- Department of Surgery, Medical School, University of Minnesota, Minneapolis, MN
| | - Nancy Sherwood
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN
| | - Sarah Lindberg
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN
| | - Esteban Lemus Wirtz
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN
| | - Amy Karger
- Department of Laboratory Medicine and Pathology, Medical School, University of Minnesota, Minneapolis, MN
| | - Kenny Beckman
- Department of Laboratory Medicine and Pathology, Medical School, University of Minnesota, Minneapolis, MN
| | - Spencer Erickson
- General Internal Medicine, University of Minnesota, Minneapolis, MN
| | - Sarah Fenno
- General Internal Medicine, University of Minnesota, Minneapolis, MN
| | - Katrina Hartman
- General Internal Medicine, University of Minnesota, Minneapolis, MN
| | - Michael Rose
- General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Barkha Patel
- General Internal Medicine, University of Minnesota, Minneapolis, MN
| | | | - Neeta Bhat
- General Internal Medicine, University of Minnesota, Minneapolis, MN
| | - Thomas A Murray
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN
| | - David R Boulware
- Infectious Diseases, University of Minnesota Medical School, Minneapolis, MN
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Chang B, Wele A, Atoma B, Kagimu E, Muzoora C, Musubire A, Boulware DR, Meya D. 2361. Timing of antiretroviral therapy prior to diagnosis of cryptococcal meningitis. Open Forum Infect Dis 2022. [DOI: 10.1093/ofid/ofac492.168] [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] [Indexed: 12/23/2022] Open
Abstract
Abstract
Background
Cryptococcal meningitis (CM) is the most common cause of meningitis in adults in Sub-Saharan Africa (SSA), causing significant morbidity and mortality in people living with HIV. Early initiation of antiretroviral therapy (ART) after cryptococcal diagnosis is associated with increased mortality. With increasing access to ART in SSA, an increasing proportion of CM patients are now presenting on ART, and outcomes remain unclear.
Methods
We performed a retrospective study of 724 participants with positive CSF cryptococcal antigen in four clinical trials performed in Uganda from June 2017 to February 2022. We compared survival outcomes based on ART experience at the time of CM diagnosis. We had implemented structured ART interruption when ART had recently been initiated (< 2weeks).
Results
Sixty-one percent (445/724) of participants were ART-naïve at the time of CM diagnosis. Compared to those receiving ART, those ART-naïve had lower CD4 counts and higher Cryptococcus colony forming units (CFUs)/mL on quantitative CSF culture (p< 0.001). However, the two-week mortality between ART-naïve and ART-experienced groups did not statistically differ (16.6% vs. 16.8%, Hazard Ratio = 0.97 (95%CI, 0.67–1.40) as well as for ten-week mortality (25.4% vs. 26.2%, Hazard Ratio = 0.98 (95%CI, 0.73–1.31)). Further stratification of ART-experienced participants by length of ART experience (< =2 weeks vs. >2 weeks prior to diagnosis) and ART continuation status (ART continued vs. discontinued if ART started < =2 weeks prior to diagnosis) demonstrated no statistically significant difference between the groups for two- or ten-week mortality.
Conclusion
Cryptococcal diagnosis after ART initiation is now increasingly common. In this study, we found no significant mortality differences between ART-naïve and ART-experienced participants at 2 weeks and 10 weeks. Accounting for length of ART experience did not change these short-term mortality outcomes. One potential limitation of our study is different CM treatment regimens were used across clinical trials.
Disclosures
All Authors: No reported disclosures.
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Affiliation(s)
| | | | | | - Enock Kagimu
- Infectious Diseases Institute, Makerere University , kampala, Kampala , Uganda
| | - Conrad Muzoora
- Mbarara University of Science and Technology , Mbarara, Mbarara , Uganda
| | - Abdu Musubire
- Infectious Diseases Institute, Makerere University , kampala, Kampala , Uganda
| | | | - David Meya
- Infectious Diseases Institute, Makerere University , kampala, Kampala , Uganda
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Sekar P, Nalintya E, Kavuma P, Kigozi J, Ssuna M, Kirumira P, Naluyima R, Namuli T, Skipper C, Hullsiek KH, Boulware DR, Meya D, Rajasingham R. 2058. Effect of Covid-19 lockdowns on identification of advanced HIV disease in outpatient clinics in Uganda. Open Forum Infect Dis 2022. [DOI: 10.1093/ofid/ofac492.1680] [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] [Indexed: 12/23/2022] Open
Abstract
Abstract
Background
Despite HIV test and treat initiatives, the World Health Organization (WHO) estimates that 25% to 40% of persons living with HIV (PLWH) have advanced HIV disease (CD4< 200 cells/mcL). The objective of this study is to understand how the Covid-19 pandemic affected identification of persons with advanced HIV disease in Ugandan HIV clinics.
Methods
We retrospectively reviewed data from 67 HIV clinics surrounding Kampala, Uganda. As part of routine data collection for PEPFAR reporting, number of persons entering care by clinic and number of persons presenting with CD4< 200 cells/mcL were summarized by month between July 2019 and January 2022. We used the Johns Hopkins Coronavirus Resource Center website to summarize Ugandan Covid-19 cases by month. Covid-19 lockdown dates were taken from the Ugandan government’s COVID-19 information website. Specifically, between March and May 2020, there was a period of strict lockdown where public transportation was halted. Between May and July 2020 there was a less stringent lockdown (public transportation was available, but schools and many businesses remained closed). Again between June and July 2021 a strict lockdown occurred.
Results
Prior to the Covid-19 pandemic, between July 2019 and February 2020, an average of 16% (265/1675) of PLWH presented monthly with advanced HIV disease. During Covid-19 lockdowns from March 2020 to July 2020, only 9% (102/1124) of PLWH presented with advanced HIV disease. During the period of lockdown, there was a 33% reduction in the monthly average number of PLWH presenting to HIV clinics, and a 62% reduction in the monthly average number of PLWH presenting with advanced HIV disease. From February 2021 to January 2022, 18% (185/987) of PLWH presented with advanced HIV disease. During this period, there was a 42% reduction in the number of persons presenting to HIV care; of those who presented, a larger portion presented with advanced HIV disease.
Conclusion
The Covid-19 lockdowns negatively affected presentation of PLWH to care, most significantly among persons with advanced HIV disease. This reduction in presentation to care has persisted and not recovered to pre-Covid levels. In the past year, 18% of PLWH presented with advanced HIV disease.
Disclosures
All Authors: No reported disclosures.
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Affiliation(s)
| | - Elizabeth Nalintya
- Infectious Diseases Institute, Makerere University college of Health Sciences , Kampala, Kampala , Uganda
| | - Paul Kavuma
- Infectious Diseases Insititute -Makerere Uganda , kampala, Kampala , Uganda
| | - Joanita Kigozi
- Infectious Diseases Institute , Kampala, Kampala , Uganda
| | - Martin Ssuna
- Infectious Disease Institute , Kampala, Kampala , Uganda
| | - Paul Kirumira
- Infectious Disease Institute , Kampala, Kampala , Uganda
| | - Rose Naluyima
- Infectious Disease Institute , Kampala, Kampala , Uganda
| | | | | | | | | | - David Meya
- Infectious Diseases Institute, Makerere University , Kampala, Kampala , Uganda
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Naggie S, Boulware DR, Lindsell CJ, Stewart TG, Lim SC, Cohen J, Kavtaradze D, Amon AP, Gabriel A, Gentile N, Felker GM, Rothman RL, Jayaweera D, McCarthy MW, Sulkowski M, Wilson S, DeLong A, Remaly A, Wilder R, Collins S, Dunsmore SE, Adam SJ, Thicklin F, Hanna GJ, Ginde AA, Castro M, McTigue K, Shenkman E, Hernandez AF. Effect of Ivermectin 600 μg/kg for 6 days vs Placebo on Time to Sustained Recovery in Outpatients with Mild to Moderate COVID-19: A Randomized Clinical Trial. medRxiv 2022:2022.12.15.22283488. [PMID: 36561174 PMCID: PMC9774212 DOI: 10.1101/2022.12.15.22283488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Background Whether ivermectin, with a maximum targeted dose of 600 μg/kg, shortens symptom duration or prevents hospitalization among outpatients with mild to moderate coronavirus disease 2019 (COVID-19) remains unknown. Our objective was to evaluate the effectiveness of ivermectin, dosed at 600 μg/kg, daily for 6 days compared with placebo for the treatment of early mild to moderate COVID-19. Methods ACTIV-6, an ongoing, decentralized, randomized, double-blind, placebo-controlled, platform trial, was designed to evaluate repurposed therapies in outpatients with mild to moderate COVID-19. A total of 1206 participants age ≥30 years with confirmed COVID-19, experiencing ≥2 symptoms of acute infection for ≤7 days, were enrolled from February 16, 2022, through July 22, 2022, with follow-up data through November 10, 2022, at 93 sites in the US. Participants were randomized to ivermectin, with a maximum targeted dose of 600 μg/kg (n=602), daily vs. placebo daily (n=604) for 6 days. The primary outcome was time to sustained recovery, defined as at least 3 consecutive days without symptoms. The 7 secondary outcomes included a composite of hospitalization, death, or urgent/emergent care utilization by day 28. Results Among 1206 randomized participants who received study medication or placebo, median (interquartile range) age was 48 (38-58) years; 713 (59%) were women; and 1008 (84%) reported ≥2 SARS-CoV-2 vaccine doses. Median time to recovery was 11 (11-12) days in the ivermectin group and 11 (11-12) days in the placebo group. The hazard ratio (HR) (95% credible interval [CrI], posterior probability of benefit) for improvement in time to recovery was 1.02 (0.92-1.13; P[HR>1]=0.68). In those receiving ivermectin, 34 (5.7%) were hospitalized, died, or had urgent or emergency care visits compared with 36 (6.0%) receiving placebo (HR 1.0, 0.6- 1.5; P[HR<1]=0.53). In the ivermectin group, 1 participant died and 4 were hospitalized (0.8%); 2 participants (0.3%) were hospitalized in the placebo group and there were no deaths. Adverse events were uncommon in both groups. Conclusions Among outpatients with mild to moderate COVID-19, treatment with ivermectin, with a maximum targeted dose of 600 μg/kg daily for 6 days, compared with placebo did not improve time to recovery. These findings do not support the use of ivermectin in patients with mild to moderate COVID-19. Trial registration ClinicalTrials.gov Identifier: NCT04885530 .
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Atukunda M, Kagimu E, Rutakingirwa MK, Tugume L, Nsangi L, Musubire A, Gakuru J, Mugabi T, Akampurira A, Ssebambulidde K, Kasibante J, Ellis J, Mpoza E, Williams DA, Fieberg AM, Skipper C, Abassi M, Hullsiek KH, Meya D, Boulware DR. 869. Oral Encochleated Amphotericin B for Cryptococcal Meningitis: a Phase II Randomized Trial. Open Forum Infect Dis 2022. [PMCID: PMC9752325 DOI: 10.1093/ofid/ofac492.062] [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] [Indexed: 12/23/2022] Open
Abstract
Background Intravenous (IV) amphotericin B is the gold standard treatment of severe mycoses. A new orally absorbed, less-toxic formulation of amphotericin has been developed (Matinas Biopharma). We evaluated the efficacy of this novel anti-fungal agent amongst adults with cryptococcal meningitis. Methods We conducted a phase II randomized clinical trial testing oral encochleated amphotericin B (cAMB) versus IV amphotericin B for first episode cryptococcal meningitis in Kampala, Uganda from December 2020 to August 2021. Participants were HIV-positive, CSF cryptococcal antigen (CrAg) positive, and had the capacity to consent and take oral medications (GCS=15). Participants in the experimental arm received two loading doses of either IV deoxycholate amphotericin B 1.0 mg/kg/day or liposomal amphotericin 3 mg/kg/day, followed by 1.8g oral cAMB daily in 6 divided doses through 2 weeks with flucytosine (5FC) at 100mg/kg/day, and thereafter cAMB at 1.2g daily in 4 divided doses through 6 weeks. Participants in the control arm received 7 days of IV amphotericin B (deoxycholate or liposomal) with 5FC, then 7 days of fluconazole 1200mg/day. After 14 days, all participants received fluconazole 800mg/day through 10 weeks and thereafter a maintenance dose of 200mg/day. Results We randomized 40 participants to oral cAMB + 5FC and 30 control participants to IV amphotericin + 5FC. With cAMB the 30-day survival was 97.5% (39/40) and 18-week survival was 90% (36/40) compared with 87% (26/30) 18-week survival in IV amphotericin controls. The CSF Early Fungicidal Activity (EFA) was lower with oral cAMB (mean EFA = 0.42 log10Cryptococcus CFU/mL/day; 95%CI, 0.29 to 0.54) versus IV amphotericin (mean EFA = 0.52 log10 CFU/mL/day; 95%CI, 0.39 to 0.66). Among those CSF culture positive at baseline, CSF sterility was achieved by 2 weeks in 65% (24/37) of cAMB participants and 68% (17/25) of controls. Grade >=3 laboratory adverse events were more common with IV amphotericin. Grade 3–4 anaemia occurred in 10% (n=4) with cAMB versus 37% (n=11) with IV amphotericin. Grade 3 hypokalaemia (< 3mEq/L) occurred in 5% (n=2) with cAMB versus 27% (n=8) with IV amphotericin. Conclusion Novel oral cAMB appears to be a safe agent with promising efficacy for HIV-related cryptococcal meningitis. Disclosures All Authors: No reported disclosures.
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Affiliation(s)
- Mucunguzi Atukunda
- Infectious Diseases Institute, Makerere University, Kampala, Kampala, Uganda
| | - Enock Kagimu
- Infectious Diseases Institute, Makerere University, Kampala, Kampala, Uganda
| | - Morris K Rutakingirwa
- Infectious diseases institute, College of health sciences, Makerere University, Kampala Uganda, Kampala, Kampala, Uganda
| | - Lillian Tugume
- Infectious Diseases Institute, Makerere University, Kampala, Kampala, Uganda
| | - Laura Nsangi
- Infectious Diseases Institute, Makerere University, Kampala, Kampala, Uganda
| | - Abdu Musubire
- Infectious Diseases Institute, Makerere University, Kampala, Kampala, Uganda
| | - Jane Gakuru
- Infectious Diseases Institute, Makerere University, Kampala, Kampala, Uganda
| | - Timothy Mugabi
- Infectious Diseases Institute, Makerere University, Kampala, Kampala, Uganda
| | - Andrew Akampurira
- Infectious Diseases Institute, Makerere University, Kampala, Kampala, Uganda
| | | | - John Kasibante
- Infectious Diseases Institute, Makerere University, Kampala, Kampala, Uganda
| | - Jayne Ellis
- Infectious Diseases Institute, Makerere University, Kampala, Kampala, Uganda
| | - Edward Mpoza
- Infectious Diseases Institute, Makerere University, Kampala, Kampala, Uganda
| | | | | | | | | | | | - David Meya
- Infectious Diseases Institute, Makerere University, Kampala, Kampala, Uganda
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Boulware DR. LB1528B. Inhaled Fluticasone for Outpatient Treatment of Covid-19: A Decentralized, Placebo-controlled, Randomized, Platform Clinical Trial. Open Forum Infect Dis 2022. [DOI: 10.1093/ofid/ofac492.1882] [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] [Indexed: 12/23/2022] Open
Abstract
Abstract
Background
The effectiveness of inhaled corticosteroids to shorten time to symptom resolution or prevent hospitalization or death among outpatients with mild-to-moderate coronavirus 2019 (Covid-19) is unclear.
Methods
ACTIV-6 is an ongoing, decentralized, double-blind, randomized, placebo-controlled platform trial testing repurposed medications in outpatients with confirmed SARS-CoV-2 infection. Non-hospitalized adults aged ≥ 30 years, experiencing ≥ 2 symptoms of acute infection for ≤ 7 days were randomized to inhaled fluticasone furoate 200 μg once daily for 14 days or placebo. The primary outcome was time to sustained recovery, defined as the third of 3 consecutive days without symptoms. Secondary outcomes included composites of hospitalization or death with or without urgent care or emergency department visit by day 28.
Results
Of those eligible for the fluticasone arm, 656 were randomized to and received inhaled fluticasone; 621 received concurrent placebo. There was no evidence of improvement in time to recovery with fluticasone compared with placebo (hazard ratio [HR] 1.01, 95% credible interval [CrI] 0.91–1.12; posterior probability for benefit [HR > 1]=0.56). Twenty-four participants (3.7%) in the fluticasone arm had urgent care or emergency department visits or were hospitalized compared with 13 (2.1%) in the pooled, concurrent placebo arm (HR 1.9, 95% CrI 0.8–3.5; posterior probability for benefit [HR< 1]=0.03). Three participants in each arm were hospitalized, and no deaths occurred. Adverse events were uncommon in both arms.
Conclusion
Treatment with inhaled fluticasone furoate for 14 days did not result in improved time to recovery among outpatients with Covid-19 in the United States during the delta and omicron variant surges.
Disclosures
All Authors: No reported disclosures.
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50
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Pasqualotto AC, Godoy CM, Lana DD, Leitao TS, Bay MB, Damasceno LS, Soares RB, Falci DR, Kist R, Silva LR, Melo M, Guimaraes TF, Guimaraes MR, Vechi HT, Mesquita J, Macedo EY, Adenis AA, Bahr NC, Spec A, Boulware DR, Israelski D, Chiller TM. LB2303. Single High-dose of Liposomal Amphotericin B in HIV/AIDS-related Disseminated Histoplasmosis: a Randomized Trial. Open Forum Infect Dis 2022. [DOI: 10.1093/ofid/ofac492.1893] [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] [Indexed: 12/23/2022] Open
Abstract
Abstract
Background
Histoplasmosis is a major AIDS-defining infection in Latin America. Liposomal amphotericin B (L-AmB) is the drug of choice for treatment, but access is limited.
Methods
Prospective randomized open-label trial of induction therapy with L-AmB for disseminated histoplasmosis in AIDS, followed by oral itraconazole therapy (started on the day after L-AmB was finished). We conducted this trial at 6 centers in Brazil (2019-2022). We randomized subjects to 3 arms of: Single dose 10 mg/kg of L-AmB;10 mg/kg of L-AmB on D1, and 5 mg/kg of L-AmB on D3;3 mg/kg of L-AmB for 2 weeks (control).
As a non-inferiority trial, 80% power could detect > 20% non-inferiority margin for a one-sided alpha=0.05 with a sample size of 29 subjects per arm. Clinical response at day 14 was the primary outcome.
Results
Of 512 screened patients, 118 subjects were randomized (Arm 1, n=40; Arm 2, n=39; Arm 3, n=39). Median CD4 was 25 cells/µL. Subjects presented with weight loss (70%), pulmonary complaints (67%), fever (66%), abdominal findings (59%), skin lesions (38%), lymphadenopathy (38%), and oral lesions (36%). Clinical and lab findings did not differ among arms. Histoplasmosis diagnosis was predominantly via urine antigen (97%).
Infusion-related toxicity on D1 was similar in each arm (p=0.56). Kidney toxicity was similar on D3 (p=0.83), D7 (p=0.10), and D14 (p=0.17) as was frequency of anemia, hypokalemia, hypomagnesemia, and liver toxicity (all p >0.05). No subject withdrew due to drug toxicities.
D14 clinical response was 82% for Arm 1, 68% Arm 2, and 72% Arm 3 (p=0.69). Absolute risk difference for Arm 1 was 10.3% (95%CI, -8.3% to 28.8%) vs. Arm 3 controls; Arm 2 was -4.2% (95%CI, -24.9% to 16.4%) to controls. Overall survival on D14 was 89.5% (34/38) for Arm 1, 78.4% (29/37) for Arm 2, and 92.1% (35/38) for Arm 3 (p=0.82); 2 subjects were excluded from efficacy analysis due to meningitis and tuberculosis, and 3 were lost to follow up.
Conclusion
Induction therapy with 10 mg/kg of L-AmB in AIDS-related histoplasmosis was safe. Although efficacy is likely to be non-inferior to standard L-AmB therapy, a confirmatory phase III trial is needed. Such a strategy would markedly reduce drug-acquisition costs (> 4-fold), therefore improving access to L-AmB across the globe.
Disclosures
Alessandro C. Pasqualotto, FECMM, Gilead: Grant/Research Support|United Medical: Advisor/Consultant|United Medical: Honoraria Diego R. Falci, MD, United Medical: Advisor/Consultant|United Medical: Honoraria Andrej Spec, MD, MSCI, Astellas: Grant/Research Support Dennis Israelski, MD, Gilead Sciences: Empoyee.
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Affiliation(s)
- Alessandro C Pasqualotto
- Universidade Federal de Ciencias da Saude de Porto Alegre , Porto Alegre, Rio Grande do Sul , Brazil
| | | | - Daiane Dalla Lana
- Universidade Federal de Ciencias da Saude de Porto Alegre , Porto Alegre, Rio Grande do Sul , Brazil
| | | | - Monica B Bay
- Universidade Federal do Rio Grande do Norte , Natal, Rio Grande do Norte , Brazil
| | | | | | | | - Roger Kist
- Santa Casa de Misericordia de Porto Alegre , Porto Alegre, Rio Grande do Sul , Brazil
| | - Larissa R Silva
- Universidade Federal de Ciencias da Saude de Porto Alegre , Porto Alegre, Rio Grande do Sul , Brazil
| | - Marineide Melo
- Hospital Nossa Senhora da Conceicao , Porto Alegre, Rio Grande do Sul , Brazil
| | | | | | - Hareton T Vechi
- Universidade Federal do Rio Grande do Norte , Natal, Rio Grande do Norte , Brazil
| | | | | | - Antoine A Adenis
- Centre d'Investigation Clinique Antilles-Guyane , Cayenne, Not Applicable , French Guiana
| | | | - Andrej Spec
- Washington University in St. Louis , St. Louis, Missouri
| | | | | | - Tom M Chiller
- Centers for Disease Control and Prevention , Atlanta , Georgia
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