1
|
Tram TTB, Trieu LPT, Nhat LTH, Thu DDA, Quang NL, Bang ND, Chau TTH, Thwaites GE, Walker TM, Ha VTN, Thuong NTT. Targeted sequencing from cerebrospinal fluid for rapid identification of drug-resistant tuberculous meningitis. J Clin Microbiol 2024; 62:e0128723. [PMID: 38466092 PMCID: PMC11005362 DOI: 10.1128/jcm.01287-23] [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: 10/02/2023] [Accepted: 02/03/2024] [Indexed: 03/12/2024] Open
Abstract
Mortality from tuberculous meningitis (TBM) remains around 30%, with most deaths occurring within 2 months of starting treatment. Mortality from drug-resistant strains is higher still, making early detection of drug resistance (DR) essential. Targeted next-generation sequencing (tNGS) produces high read depths, allowing the detection of DR-associated alleles with low frequencies. We applied Deeplex Myc-TB-a tNGS assay-to cerebrospinal fluid (CSF) samples from 72 adults with microbiologically confirmed TBM and compared its genomic drug susceptibility predictions to a composite reference standard of phenotypic susceptibility testing (pDST) and whole genome sequencing, as well as to clinical outcomes. Deeplex detected Mycobacterium tuberculosis complex DNA in 24/72 (33.3%) CSF samples and generated full DR reports for 22/24 (91.7%). The read depth generated by Deeplex correlated with semi-quantitative results from MTB/RIF Xpert. Alleles with <20% frequency were seen at canonical loci associated with first-line DR. Disregarding these low-frequency alleles, Deeplex had 100% concordance with the composite reference standard for all drugs except pyrazinamide and streptomycin. Three patients had positive CSF cultures after 30 days of treatment; reference tests and Deeplex identified isoniazid resistance in two, and Deeplex alone identified low-frequency rifampin resistance alleles in one. Five patients died, of whom one had pDST-identified pyrazinamide resistance. tNGS on CSF can rapidly and accurately detect drug-resistant TBM, but its application is limited to those with higher bacterial loads. In those with lower bacterial burdens, alternative approaches need to be developed for both diagnosis and resistance detection.
Collapse
Affiliation(s)
| | | | | | - Do Dang Anh Thu
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Nguyen Le Quang
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Nguyen Duc Bang
- Pham Ngoc Thach Hospital for Tuberculosis and Lung Disease, Ho Chi Minh City, Vietnam
| | | | - Guy E. Thwaites
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Timothy M. Walker
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Vu Thi Ngoc Ha
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Nguyen Thuy Thuong Thuong
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| |
Collapse
|
2
|
Spatola M, Nziza N, Irvine EB, Cizmeci D, Jung W, Van LH, Nhat LTH, Ha VTN, Phu NH, Nghia HDT, Thwaites G, Lauffenburger DA, Fortune S, Thuong NTT, Alter G. Distinctive antibody responses to Mycobacterium tuberculosis in pulmonary and brain infection. Brain 2024:awae066. [PMID: 38442687 DOI: 10.1093/brain/awae066] [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: 05/09/2023] [Revised: 02/07/2024] [Accepted: 02/24/2024] [Indexed: 03/07/2024] Open
Abstract
Mycobacterium tuberculosis (Mtb), the causative agent of tuberculosis (TB), remains a global health burden. While Mtb is primarily a respiratory pathogen, it can spread to other organs, including the brain and meninges, causing TB meningitis (TBM). However, little is known about the immunological mechanisms that leads to differential disease across organs. Attention has focused on differences in T cell responses in the control of Mtb in the lungs, but emerging data point to a role for antibodies, as both biomarkers of disease control and as antimicrobial molecules. Given an increasing appreciation for compartmentalized antibody responses across the blood brain barrier, here we characterized the antibody profiles across the blood and brain compartments during TBM, and determined whether Mtb-specific humoral immune responses differed between Mtb infection of the lung (pulmonary TB) and TBM. Using a high throughput systems serology approach, we deeply profiled the antibody responses against 10 different Mtb antigens, including lipoarabinomannan (LAM) and purified protein derivative (PPD), in HIV-negative adults with pulmonary TB (n=10) vs TBM (n=60). Antibody studies included analysis of immunoglobulin isotypes (IgG, IgM, IgA) and subclass levels (IgG1-4), the capacity of Mtb-specific antibodies to bind to Fc receptors or C1q, and to activate innate immune effectors functions (complement and NK cells activation, monocyte or neutrophil phagocytosis). Machine learning methods were applied to characterize serum and CSF responses in TBM, identify prognostic factors associated with disease severity, and define the key antibody features that distinguish TBM from pulmonary TB. In individuals with TBM, we identified CSF-specific antibody profiles that marked a unique and compartmentalized humoral response against Mtb, characterized by an enrichment of Mtb-specific antibodies able to robustly activate complement and drive phagocytosis by monocytes and neutrophils, all of which were associated with milder TBM severity at presentation. Moreover, individuals with TBM exhibited Mtb-specific antibodies in the serum with an increased capacity to activate phagocytosis by monocytes, compared to individuals with pulmonary TB, despite having lower IgG titers and Fcγ receptors (FcγR)-binding capacity. Collectively, these data point to functionally divergent humoral responses depending on the site of infection (i.e. lungs vs brain), and demonstrate a highly compartmentalized Mtb-specific antibody response within the CSF during TBM. Moreover, our results suggest that phagocytosis- and complement-mediating antibodies may promote attenuated neuropathology and milder TBM disease.
Collapse
Affiliation(s)
- Marianna Spatola
- Ragon Institute of MGH, MIT and Harvard, Cambridge, MA 02139, USA
| | - Nadège Nziza
- Ragon Institute of MGH, MIT and Harvard, Cambridge, MA 02139, USA
| | - Edward B Irvine
- Ragon Institute of MGH, MIT and Harvard, Cambridge, MA 02139, USA
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA
| | - Deniz Cizmeci
- Ragon Institute of MGH, MIT and Harvard, Cambridge, MA 02139, USA
- Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, MA0 2139, USA
| | - Wonyeong Jung
- Ragon Institute of MGH, MIT and Harvard, Cambridge, MA 02139, USA
- Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, MA0 2139, USA
| | - Le Hong Van
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, 700000 Ho Chi Minh City, Vietnam
| | - Le Thanh Hoang Nhat
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, 700000 Ho Chi Minh City, Vietnam
| | - Vu Thi Ngoc Ha
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, 700000 Ho Chi Minh City, Vietnam
| | - Nguyen Hoan Phu
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, 700000 Ho Chi Minh City, Vietnam
- Vietnam National University School of Medicine, 700000 Ho Chi Minh City, Vietnam
| | - Ho Dang Trung Nghia
- Hospital for Tropical Diseases, 700000 Ho Chi Minh City, Vietnam
- Pham Ngoc Thach University of Medicine, 700000 Ho Chi Minh City, Vietnam
| | - Guy Thwaites
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, 700000 Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Oxford University, Oxford, OX3 7LG, UK
| | - Douglas A Lauffenburger
- Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, MA0 2139, USA
| | - Sarah Fortune
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA
| | - Nguyen Thuy Thuong Thuong
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, 700000 Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Oxford University, Oxford, OX3 7LG, UK
| | - Galit Alter
- Ragon Institute of MGH, MIT and Harvard, Cambridge, MA 02139, USA
| |
Collapse
|
3
|
Du DH, Geskus RB, Zhao Y, Codecasa LR, Cirillo DM, van Crevel R, Pascapurnama DN, Chaidir L, Niemann S, Diel R, Omar SV, Grandjean L, Rokadiya S, Ortitz AT, Lân NH, Hà ĐTM, Smith EG, Robinson E, Dedicoat M, Nhat LTH, Thwaites GE, Van LH, Thuong NTT, Walker TM. The effect of M. tuberculosis lineage on clinical phenotype. PLOS Glob Public Health 2023; 3:e0001788. [PMID: 38117783 PMCID: PMC10732390 DOI: 10.1371/journal.pgph.0001788] [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: 03/09/2023] [Accepted: 11/17/2023] [Indexed: 12/22/2023]
Abstract
Six lineages of Mycobacterium tuberculosis sensu stricto (which excludes M. africanum) are described. Single-country or small observational data suggest differences in clinical phenotype between lineages. We present strain lineage and clinical phenotype data from 12,246 patients from 3 low-incidence and 5 high-incidence countries. We used multivariable logistic regression to explore the effect of lineage on site of disease and on cavities on chest radiography, given pulmonary TB; multivariable multinomial logistic regression to investigate types of extra-pulmonary TB, given lineage; and accelerated failure time and Cox proportional-hazards models to explore the effect of lineage on time to smear and culture-conversion. Mediation analyses quantified the direct effects of lineage on outcomes. Pulmonary disease was more likely among patients with lineage(L) 2, L3 or L4, than L1 (adjusted odds ratio (aOR) 1.79, (95% confidence interval 1.49-2.15), p<0.001; aOR = 1.40(1.09-1.79), p = 0.007; aOR = 2.04(1.65-2.53), p<0.001, respectively). Among patients with pulmonary TB, those with L1 had greater risk of cavities on chest radiography versus those with L2 (aOR = 0.69(0.57-0.83), p<0.001) and L4 strains (aOR = 0.73(0.59-0.90), p = 0.002). L1 strains were more likely to cause osteomyelitis among patients with extra-pulmonary TB, versus L2-4 (p = 0.033, p = 0.008 and p = 0.049 respectively). Patients with L1 strains showed shorter time-to-sputum smear conversion than for L2. Causal mediation analysis showed the effect of lineage in each case was largely direct. The pattern of clinical phenotypes seen with L1 strains differed from modern lineages (L2-4). This has implications for clinical management and could influence clinical trial selection strategies.
Collapse
Affiliation(s)
- Duc Hong Du
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Ronald B. Geskus
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | | | - Luigi Ruffo Codecasa
- Regional TB Reference Centre/ Istituto Villa Marelli- ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | | | - Reinout van Crevel
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Lidya Chaidir
- Department of Biomedical Sciences, Faculty of Medicine, Universitas Padjadjaran, Sumedang, West Java, Indonesia
| | - Stefan Niemann
- Research Center Borstel, Borstel, Germany
- German Center for Infection Research, Partner Site Hamburg-Lübeck-Borstel-Riems, Germany
| | - Roland Diel
- University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
- Lung Clinic Grosshansdorf, Airway Disease Center North (ARCN), German Center for Lung Research (DZL), Grosshansdorf, Germany
| | | | | | - Sakib Rokadiya
- University College London Hospital, London, United Kingdom
| | | | | | | | - E. Grace Smith
- TB Unit and National Mycobacterial Reference Service, UK Health Security Agency, Birmingham, United Kingdom
| | - Esther Robinson
- TB Unit and National Mycobacterial Reference Service, UK Health Security Agency, Birmingham, United Kingdom
| | - Martin Dedicoat
- TB Unit and National Mycobacterial Reference Service, UK Health Security Agency, Birmingham, United Kingdom
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | | | - Guy E. Thwaites
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Le Hong Van
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Nguyen Thuy Thuong Thuong
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Timothy M. Walker
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| |
Collapse
|
4
|
Vijay S, Bao NLH, Vinh DN, Nhat LTH, Thu DDA, Quang NL, Trieu LPT, Nhung HN, Ha VTN, Thai PVK, Ha DTM, Lan NH, Caws M, Thwaites GE, Javid B, Thuong NTT. Rifampicin tolerance and growth fitness among isoniazid-resistant clinical Mycobacterium tuberculosis isolates: an in-vitro longitudinal study. bioRxiv 2023:2023.11.22.568240. [PMID: 38045287 PMCID: PMC10690245 DOI: 10.1101/2023.11.22.568240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/05/2023]
Abstract
Antibiotic tolerance in Mycobacterium tuberculosis leads to less effective bacterial killing, poor treatment responses and resistant emergence. There is limited understanding of antibiotic tolerance in clinical isolates of M. tuberculosis . Therefore, we investigated the rifampicin tolerance of M. tuberculosis isolates, with or without pre-existing isoniazid-resistance. In-vitro rifampicin survival fractions determined by minimum duration of killing assay in isoniazid susceptible (n=119) and resistant (n=84) M. tuberculosis isolates. Rifampicin tolerance was correlated with bacterial growth, rifampicin minimum inhibitory concentrations (MICs) and isoniazid-resistant mutations. The longitudinal isoniazid-resistant isolates were analyzed for rifampicin tolerance based on collection time from patients and associated emergence of genetic variants. The median duration of rifampicin exposure reducing the M. tuberculosis surviving fraction by 90% (minimum duration of killing-MDK90) increased from 1.23 (95%CI 1.11; 1.37) and 1.31 (95%CI 1.14; 1.48) to 2.55 (95%CI 2.04; 2.97) and 1.98 (95%CI 1.69; 2.56) days, for IS and IR respectively, during 15 to 60 days of incubation respectively. Increase in MDK90 time indicated the presence of fast and slow growing tolerant sub-populations. A range of 6 log 10 -fold survival fraction enabled classification of tolerance as low, medium or high and revealed isoniazid-resistance association with increased tolerance with faster growth (OR=2.68 for low vs. medium, OR=4.42 for low vs. high, P -trend=0.0003). The high tolerance in longitudinal isoniazid-resistant isolates was specific to those collected during rifampicin treatment in patients and associated with bacterial genetic microvariants. Our study identifies a range of rifampicin tolerance and reveals that isoniazid resistance is associated with higher tolerance with growth fitness. Furthermore, rifampicin treatment may select isoniazid-resistant isolate microvariants with higher rifampicin tolerance, with survival potential similar to multi-drug resistant isolates. These findings suggest that isoniazid-resistant tuberculosis needs to be evaluated for rifampicin tolerance or needs further improvement in treatment regimen.
Collapse
|
5
|
Du DH, Geskus RB, Zhao Y, Codecasa LR, Cirillo DM, van Crevel R, Pascapurnama DN, Chaidir L, Niemann S, Diel R, Omar SV, Grandjean L, Rokadiya S, Ortitz AT, Lân NH, Hà ÐTM, Smith EG, Robinson E, Dedicoat M, Nhat LTH, Thwaites GE, Van LH, Thuong NTT, Walker TM. The effect of M. tuberculosis lineage on clinical phenotype. medRxiv 2023:2023.03.14.23287284. [PMID: 36993190 PMCID: PMC10055556 DOI: 10.1101/2023.03.14.23287284] [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] [Subscribe] [Scholar Register] [Indexed: 06/19/2023]
Abstract
Eight lineages of Mycobacterium tuberculosis sensu stricto are described. Single-country or small observational data suggest differences in clinical phenotype between lineages. We present strain lineage and clinical phenotype data from 12,246 patients from 3 low-incidence and 5 high-incidence countries. We used multivariable logistic regression to explore the effect of lineage on site of disease and on cavities on chest radiography, given pulmonary TB; multivariable multinomial logistic regression to investigate types of extra-pulmonary TB, given lineage; and accelerated failure time and Cox proportional-hazards models to explore the effect of lineage on time to smear and culture-conversion. Mediation analyses quantified the direct effects of lineage on outcomes. Pulmonary disease was more likely among patients with lineage(L) 2, L3 or L4, than L1 (adjusted odds ratio (aOR) 1.79, (95% confidence interval 1.49-2.15), p<0.001; aOR=1.40(1.09-1.79), p=0.007; aOR=2.04(1.65-2.53), p<0.001, respectively). Among patients with pulmonary TB, those with L1 had greater risk of cavities on chest radiography versus those with L2 (aOR=0.69(0.57-0.83), p<0.001) and L4 strains (aOR=0.73(0.59-0.90), p=0.002). L1 strains were more likely to cause osteomyelitis among patients with extra-pulmonary TB, versus L2-4 (p=0.033, p=0.008 and p=0.049 respectively). Patients with L1 strains showed shorter time-to-sputum smear conversion than for L2. Causal mediation analysis showed the effect of lineage in each case was largely direct. The pattern of clinical phenotypes seen with L1 strains differed from modern lineages (L2-4). This has implications for clinical management and could influence clinical trial selection strategies.
Collapse
Affiliation(s)
- Duc Hong Du
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Ronald B Geskus
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | | - Luigi Ruffo Codecasa
- Regional TB Reference Centre/Istituto Villa Marelli- ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | | | - Reinout van Crevel
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | - Lidya Chaidir
- Division of Microbiology, Department of Biomedical Science, Faculty of Medicine, Padjadjaran University, Bandung, West Java, Indonesia
| | - Stefan Niemann
- Research Center Borstel, Germany
- German Center for Infection Research, partner site Hamburg-Lübeck-Borstel-Riems, Germany
| | - Roland Diel
- University Hospital Schleswig-Holstein, Campus Kiel, Germany
- Lung Clinic Grosshansdorf, Germany, Airway Disease Center North (ARCN), German Center for Lung Research (DZL)
| | | | | | | | | | | | | | - E Grace Smith
- TB Unit and National Mycobacterial Reference Service, UK Health Security Agency, UK
| | - Esther Robinson
- TB Unit and National Mycobacterial Reference Service, UK Health Security Agency, UK
| | - Martin Dedicoat
- TB Unit and National Mycobacterial Reference Service, UK Health Security Agency, UK
- University Hospitals Birmingham NHS Foundation Trust, UK
| | | | - Guy E Thwaites
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Le Hong Van
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Nguyen Thuy Thuong Thuong
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Timothy M Walker
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| |
Collapse
|
6
|
Ardiansyah E, Pacheco JA, Nhat LTH, Dian S, Vinh DN, Hai HT, Bullock K, Alisjahbana B, Netea MG, Estiasari R, Tram TTB, Donovan J, Heemskerk D, Chau TTH, Bang ND, Ganiem AR, Ruslami R, Koeken VACM, Hamers RL, Imran D, Maharani K, Kumar V, Clish CB, van Crevel R, Thwaites G, van Laarhoven A, Thuong NTT. Tryptophan metabolism determines outcome in tuberculous meningitis: a targeted metabolomic analysis. medRxiv 2023:2023.01.08.23284316. [PMID: 36711829 PMCID: PMC9882445 DOI: 10.1101/2023.01.08.23284316] [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] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Background Cellular metabolism is critical for the host immune function against pathogens, and metabolomic analysis may help understand the characteristic immunopathology of tuberculosis. We performed targeted metabolomic analyses in a large cohort of patients with tuberculous meningitis (TBM), the most severe manifestation of tuberculosis, focusing on tryptophan metabolism. Methods We studied 1069 Indonesian and Vietnamese adults with TBM (26.6% HIV-positive), 54 non-infectious controls, 50 with bacterial meningitis, and 60 with cryptococcal meningitis. Tryptophan and downstream metabolites were measured in cerebrospinal fluid (CSF) and plasma using targeted liquid chromatography mass-spectrometry. Individual metabolite levels were associated with survival, clinical parameters, CSF bacterial load and 92 CSF inflammatory proteins. Results CSF tryptophan was associated with 60-day mortality from tuberculous meningitis (HR=1.16, 95%CI=1.10-1.24, for each doubling in CSF tryptophan) both in HIV-negative and HIV-positive patients. CSF tryptophan concentrations did not correlate with CSF bacterial load nor CSF inflammation but were negatively correlated with CSF interferon-gamma concentrations. Unlike tryptophan, CSF concentrations of an intercorrelating cluster of downstream kynurenine metabolites did not predict mortality. These CSF kynurenine metabolites did however correlate with CSF inflammation and markers of blood-CSF leakage, and plasma kynurenine predicted death (HR 1.54, 95%CI=1.22-1.93). These findings were mostly specific for TBM, although high CSF tryptophan was also associated with mortality from cryptococcal meningitis. Conclusion TBM patients with a high baseline CSF tryptophan or high systemic (plasma) kynurenine are at increased risk of mortality. These findings may reveal new targets for host-directed therapy. Funding This study was supported by National Institutes of Health (R01AI145781) and the Wellcome Trust (110179/Z/15/Z and 206724/Z/17/Z).
Collapse
Affiliation(s)
- Edwin Ardiansyah
- Research Center for Care and Control of Infectious Diseases, Universitas Padjadjaran, Bandung, Indonesia,Department of Internal Medicine and Radboud Center of Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, Netherlands
| | | | | | - Sofiati Dian
- Research Center for Care and Control of Infectious Diseases, Universitas Padjadjaran, Bandung, Indonesia,Department of Neurology, Hasan Sadikin Hospital, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Dao Nguyen Vinh
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Hoang Thanh Hai
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Kevin Bullock
- The Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Bachti Alisjahbana
- Research Center for Care and Control of Infectious Diseases, Universitas Padjadjaran, Bandung, Indonesia,Department of Internal Medicine, Hasan Sadikin Hospital, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Mihai G Netea
- Department of Internal Medicine and Radboud Center of Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, Netherlands
| | - Riwanti Estiasari
- Department of Neurology, Cipto Mangunkusumo Hospital, Faculty of Medicine Universitas Indonesia
| | | | - Joseph Donovan
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom,London School of Hygiene and Tropical Medicine, Keppel St, London, United Kingdom
| | - Dorothee Heemskerk
- Department of Medical Microbiology and Infection Prevention, Amsterdam University Medical Centre, Amsterdam, the Netherlands
| | - Tran Thi Hong Chau
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam,Hospital for Tropical Diseases, District 5, Ho Chi Minh City, Vietnam
| | - Nguyen Duc Bang
- Pham Ngoc Thach Hospital for Tuberculosis and Lung Disease, District 5, Ho Chi Minh City, Vietnam
| | - Ahmad Rizal Ganiem
- Research Center for Care and Control of Infectious Diseases, Universitas Padjadjaran, Bandung, Indonesia,Department of Neurology, Hasan Sadikin Hospital, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Rovina Ruslami
- Research Center for Care and Control of Infectious Diseases, Universitas Padjadjaran, Bandung, Indonesia,Department of Biomedical Science, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Valerie ACM Koeken
- Department of Internal Medicine and Radboud Center of Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, Netherlands,Department of Computational Biology for Individualised Infection Medicine, Centre for Individualised Infection Medicine (CiiM) & TWINCORE, joint ventures between the Helmholtz-Centre for Infection Research (HZI) and the Hannover Medical School (MHH), 30625 Hannover, Germany
| | - Raph L Hamers
- Oxford University Clinical Research Unit Indonesia, Faculty of Medicine Universitas Indonesia
| | - Darma Imran
- Department of Neurology, Cipto Mangunkusumo Hospital, Faculty of Medicine Universitas Indonesia
| | - Kartika Maharani
- Department of Neurology, Cipto Mangunkusumo Hospital, Faculty of Medicine Universitas Indonesia
| | - Vinod Kumar
- Department of Internal Medicine and Radboud Center of Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, Netherlands
| | - Clary B. Clish
- The Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Reinout van Crevel
- Department of Internal Medicine and Radboud Center of Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, Netherlands
| | - Guy Thwaites
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Arjan van Laarhoven
- Department of Internal Medicine and Radboud Center of Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, Netherlands,corresponding author
| | - Nguyen Thuy Thuong Thuong
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| |
Collapse
|
7
|
Toan ND, Darton TC, Huong NHT, Nhat LTH, Nguyen TNT, Tuyen HT, Thinh LQ, Mau NK, Tam PTT, Phuong CN, Nhan LNT, Minh NNQ, Xuan NM, Thuong TC, Hung NT, Boinett C, Reece S, Karkey A, Day JN, Baker S. Clinical and laboratory factors associated with neonatal sepsis mortality at a major Vietnamese children's hospital. PLOS Glob Public Health 2022; 2:e0000875. [PMID: 36962870 PMCID: PMC10021837 DOI: 10.1371/journal.pgph.0000875] [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] [Figures] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 07/13/2022] [Indexed: 06/18/2023]
Abstract
Sepsis is a major cause of neonatal mortality and children born in low- and middle-income countries (LMICs) are at greater risk of severe neonatal infections than those in higher-income countries. Despite this disparity, there are limited contemporaneous data linking the clinical features of neonatal sepsis with outcome in LMICs. Here, we aimed to identify factors associated with mortality from neonatal sepsis in Vietnam. We conducted a prospective, observational study to describe the clinical features, laboratory characteristics, and mortality rate of neonatal sepsis at a major children's hospital in Ho Chi Minh City. All in-patient neonates clinically diagnosed with probable or culture-confirmed sepsis meeting inclusion criteria from January 2017 to June 2018 were enrolled. We performed univariable analysis and logistic regression to identify factors independently associated with mortality. 524 neonates were recruited. Most cases were defined as late-onset neonatal sepsis and were hospital-acquired (91.4% and 73.3%, respectively). The median (IQR) duration of hospital stay was 23 (13-41) days, 344/524 (65.6%) had a positive blood culture (of which 393 non-contaminant organisms were isolated), and 69/524 (13.2%) patients died. Coagulase-negative staphylococci (232/405; 57.3%), Klebsiella spp. (28/405; 6.9%), and Escherichia coli (27/405; 6.7%) were the most isolated organisms. Sclerema (OR = 11.4), leukopenia <4,000/mm3 (OR = 7.8), thrombocytopenia <100,000/mm3 (OR = 3.7), base excess < -20 mEq/L (OR = 3.6), serum lactate >4 mmol/L (OR = 3.4), extremely low birth weight (OR = 3.2), and hyperglycaemia >180 mg/dL (OR = 2.6) were all significantly (p<0.05) associated with mortality. The identified risk factors can be adopted as prognostic factors for the diagnosis and treatment of neonatal sepsis and enable early risk stratification and interventions appropriate to reduce neonatal sepsis in LMIC settings.
Collapse
Affiliation(s)
- Nguyen Duc Toan
- Clinical Departments, Children’s Hospital 1, Ho Chi Minh City, Vietnam
- Hospital for Tropical Diseases, Wellcome Trust Africa and Asia Programmes, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
- Department of Paediatrics, Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Vietnam
| | - Thomas C. Darton
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield Medical School, Sheffield, United Kingdom
| | - Nguyen Hoang Thien Huong
- Clinical Departments, Children’s Hospital 1, Ho Chi Minh City, Vietnam
- Department of Paediatrics, Vietnam National University School of Medicine, Ho Chi Minh City, Vietnam
| | - Le Thanh Hoang Nhat
- Hospital for Tropical Diseases, Wellcome Trust Africa and Asia Programmes, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - To Nguyen Thi Nguyen
- Hospital for Tropical Diseases, Wellcome Trust Africa and Asia Programmes, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Ha Thanh Tuyen
- Hospital for Tropical Diseases, Wellcome Trust Africa and Asia Programmes, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Le Quoc Thinh
- Clinical Departments, Children’s Hospital 1, Ho Chi Minh City, Vietnam
| | - Nguyen Kien Mau
- Clinical Departments, Children’s Hospital 1, Ho Chi Minh City, Vietnam
| | - Pham Thi Thanh Tam
- Hospital for Tropical Diseases, Wellcome Trust Africa and Asia Programmes, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Cam Ngoc Phuong
- Hanh Phuc International Hospital, Binh Duong Province, Vietnam
| | - Le Nguyen Thanh Nhan
- Clinical Departments, Children’s Hospital 1, Ho Chi Minh City, Vietnam
- Hospital for Tropical Diseases, Wellcome Trust Africa and Asia Programmes, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | | | - Ngo Minh Xuan
- Department of Paediatrics, Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Vietnam
| | - Tang Chi Thuong
- Department of Paediatrics, Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Vietnam
- Department of Health, Ho Chi Minh City, Vietnam
| | - Nguyen Thanh Hung
- Clinical Departments, Children’s Hospital 1, Ho Chi Minh City, Vietnam
- Department of Paediatrics, Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Vietnam
- Department of Paediatrics, Vietnam National University School of Medicine, Ho Chi Minh City, Vietnam
| | | | - Stephen Reece
- Kymab, Babraham Research Campus, Cambridge, United Kingdom
| | - Abhilasha Karkey
- Wellcome Trust Africa and Asia Programmes, Oxford University Clinical Research Unit, Kathmandu, Nepal
| | - Jeremy N. Day
- Hospital for Tropical Diseases, Wellcome Trust Africa and Asia Programmes, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - Stephen Baker
- University of Cambridge School of Clinical Medicine, Cambridge Biomedical Campus, Cambridge, United Kingdom
- Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge Biomedical Campus, Cambridge, United Kingdom
| |
Collapse
|
8
|
Van Vinh Chau N, Lam VT, Dung NT, Yen LM, Minh NNQ, Hung LM, Ngoc NM, Dung NT, Man DNH, Nguyet LA, Nhat LTH, Nhu LNT, Ny NTH, Hong NTT, Kestelyn E, Dung NTP, Xuan TC, Hien TT, Phong NT, Tu TNH, Geskus RB, Thanh TT, Truong NT, Binh NT, Thuong TC, Thwaites G, Van Tan L. The Natural History and Transmission Potential of Asymptomatic Severe Acute Respiratory Syndrome Coronavirus 2 Infection. Clin Infect Dis 2020; 71:2679-2687. [PMID: 32497212 PMCID: PMC7314145 DOI: 10.1093/cid/ciaa711] [Citation(s) in RCA: 196] [Impact Index Per Article: 49.0] [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] [Received: 04/29/2020] [Accepted: 06/02/2020] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Little is known about the natural history of asymptomatic severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. METHODS We conducted a prospective study at a quarantine center for coronavirus disease 2019 in Ho Chi Minh City, Vietnam. We enrolled quarantined people with reverse-transcription polymerase chain reaction (RT-PCR)-confirmed SARS-CoV-2 infection, collecting clinical data, travel and contact history, and saliva at enrollment and daily nasopharyngeal/throat swabs (NTSs) for RT-PCR testing. We compared the natural history and transmission potential of asymptomatic and symptomatic individuals. RESULTS Between 10 March and 4 April 2020, 14 000 quarantined people were tested for SARS-CoV-2; 49 were positive. Of these, 30 participated in the study: 13 (43%) never had symptoms and 17 (57%) were symptomatic. Seventeen (57%) participants imported cases. Compared with symptomatic individuals, asymptomatic people were less likely to have detectable SARS-CoV-2 in NTS collected at enrollment (8/13 [62%] vs 17/17 [100%]; P = .02). SARS-CoV-2 RNA was detected in 20 of 27 (74%) available saliva samples (7 of 11 [64%] in the asymptomatic group and 13 of 16 [81%] in the symptomatic group; P = .56). Analysis of RT-PCR positivity probability showed that asymptomatic participants had faster viral clearance than symptomatic participants (P < .001 for difference over the first 19 days). This difference was most pronounced during the first week of follow-up. Two of the asymptomatic individuals appeared to transmit SARS-CoV-2 to 4 contacts. CONCLUSIONS Asymptomatic SARS-CoV-2 infection is common and can be detected by analysis of saliva or NTSs. The NTS viral loads fall faster in asymptomatic individuals, but these individuals appear able to transmit the virus to others.
Collapse
Affiliation(s)
| | - Vo Thanh Lam
- Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | | | - Lam Minh Yen
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | | | - Le Manh Hung
- Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Nghiem My Ngoc
- Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Nguyen Tri Dung
- Center for Disease Control and Prevention, Ho Chi Minh City, Vietnam
| | | | - Lam Anh Nguyet
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | | | | | | | | | - Evelyne Kestelyn
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | | | | | - Tran Tinh Hien
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | | | | | - Ronald B Geskus
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Tran Tan Thanh
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | | | | | | | - Guy Thwaites
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Le Van Tan
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| |
Collapse
|
9
|
de Alwis R, My Phuc T, Yu Hang Bai B, Le Thi Quynh N, Thi Thanh Tam P, Thi Ngoc Dung T, Thi Thanh Nhan N, Vinh C, Van Hien H, Thanh Hoang Nhat L, Thi Thu Hong N, Thi Mong Tuyen N, Thi Thuy Trang H, Phuong Thao L, Thi Ngoc Diep V, Thi Hai Chau P, Quan Thinh L, Thi Ngoc Thu H, Nguyet Hang N, Cong Danh M, Doan Hao T, Anh Dao T, Dai L, Thi Huyen Diu V, Thi En N, Thi Tuyet Hanh N, Thi Hanh L, Pham Thu Hien H, Thi Thuy Linh N, Darton TC, Thwaites GE, Kestelyn E, Lan Vi L, Thi Thuy Tien B, Thi Diem Tuyet H, Anderson C, Baker S. The influence of human genetic variation on early transcriptional responses and protective immunity following immunization with Rotarix vaccine in infants in Ho Chi Minh City in Vietnam: A study protocol for an open single-arm interventional trial. Wellcome Open Res 2020. [DOI: 10.12688/wellcomeopenres.16090.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Rotavirus (RoV) remains the leading cause of acute gastroenteritis in infants and children aged under five years in both high- and low-middle-income countries (LMICs). In LMICs, RoV infections are associated with substantial mortality. Two RoV vaccines (Rotarix and Rotateq) are widely available for use in infants, both of which have been shown to be highly efficacious in Europe and North America. However, for unknown reasons, these RoV vaccines have markedly lower efficacy in LMICs. We hypothesize that poor RoV vaccine efficacy across in certain regions may be associated with genetic heritability or gene expression in the human host. Methods/design: We designed an open-label single-arm interventional trial with the Rotarix RoV vaccine to identify genetic and transcriptomic markers associated with generating a protective immune response against RoV. Overall, 1,000 infants will be recruited prior to Expanded Program on Immunization (EPI) vaccinations at two months of age and vaccinated with oral Rotarix vaccine at two and three months, after which the infants will be followed-up for diarrheal disease until 18 months of age. Blood sampling for genetics, transcriptomics, and immunological analysis will be conducted before each Rotarix vaccination, 2-3 days post-vaccination, and at each follow-up visit (i.e. 6, 12 and 18 months of age). Stool samples will be collected during each diarrheal episode to identify RoV infection. The primary outcome will be Rotarix vaccine failure events (i.e. symptomatic RoV infection despite vaccination), secondary outcomes will be antibody responses and genotypic characterization of the infection virus in Rotarix failure events. Discussion: This study will be the largest and best powered study of its kind to be conducted to date in infants, and will be critical for our understanding of RoV immunity, human genetics in the Vietnam population, and mechanisms determining RoV vaccine-mediated protection. Registration: ClinicalTrials.gov, ID: NCT03587389. Registered on 16 July 2018.
Collapse
|
10
|
Darton TC, Thi Hong Chau T, Parry CM, Campbell JI, Minh Ngoc N, Le Chau Ngoc T, Thanh Tuyen H, Thuy Duong V, Thanh Hoang Nhat L, van Minh P, Kestelyn E, Thwaites GE, Huu Tung T, Baker S. The CIPAZ study protocol: an open label randomised controlled trial of azithromycin versus ciprofloxacin for the treatment of children hospitalised with dysentery in Ho Chi Minh City, Vietnam. Wellcome Open Res 2020. [DOI: 10.12688/wellcomeopenres.16093.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Diarrhoeal disease remains a common cause of illness and death in children <5 years of age. Faecal-oral infection by Shigella spp. causing bacillary dysentery is a leading cause of moderate-to-severe diarrhoea, particularly in low and middle-income countries. In Southeast Asia, S. sonnei predominates and infections are frequently resistant to first-line treatment with the fluoroquinolone, ciprofloxacin. While resistance to all antimicrobials is increasing, there may be theoretical and clinical benefits to prioritizing treatment of bacillary dysentery with the azalide, azithromycin. In this study we aim to measure the efficacy of treatment with azithromycin compared with ciprofloxacin, the current standard of care, for the treatment of children with bacillary dysentery. Methods and analysis: We will perform a multicentre, open-label, randomized controlled trial of two therapeutic options for the antimicrobial treatment of children hospitalised with dysentery. Children (6–60 months of age) presenting with symptoms and signs of dysentery at Children’s Hospital 2 in Ho Chi Minh City will be randomised (1:1) to treatment with either oral ciprofloxacin (15mg/kg/twice daily for 3 days, standard-of-care) or oral azithromycin (10mg/kg/daily for 3 days). The primary endpoint will be the proportion of treatment failure (defined by clinical and microbiological parameters) by day 28 (+3 days) and will be compared between study arms by logistic regression modelling using treatment allocation as the main variable. Ethics and dissemination: The study protocol (version 1.2 dated 27th December 2018) has been approved by the Oxford Tropical Research Ethics Committee (47–18) and the ethical review boards of Children's Hospital 2 (1341/NĐ2-CĐT). The study has also been approved by the Vietnamese Ministry of Health (5044/QĐ-BYT). Trial registration: Clinicaltrials.gov: NCT03854929 (February 26th 2019).
Collapse
|
11
|
Kestelyn E, Dung NTP, Lam Minh Y, Hung LM, Quan NM, Dung NT, Minh NNQ, Xuan TC, Phong NT, Ninh Thi Thanh V, Donovan J, Tu TNH, Nhat LTH, Truong NT, Man DNH, Thao HP, Ngoc NM, Lam VT, Phat HH, Phuong PM, Geskus RB, Ha VTN, Quang NN, Tran Tinh H, Tan LV, Thwaites GE, Day JN, Chau NVV. A multi centre randomized open label trial of chloroquine for the treatment of adults with SARS-CoV-2 infection in Vietnam. Wellcome Open Res 2020; 5:141. [PMID: 33110944 PMCID: PMC7573712 DOI: 10.12688/wellcomeopenres.15936.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/05/2020] [Indexed: 12/02/2022] Open
Abstract
Background: COVID-19 is a respiratory disease caused by a novel coronavirus (SARS-CoV-2) and causes substantial morbidity and mortality. There is currently no vaccine to prevent COVID-19 or therapeutic agent to treat COVID-19. This clinical trial is designed to evaluate chloroquine as a potential therapeutic for the treatment of hospitalised people with COVID-19. We hypothesise that chloroquine slows viral replication in patients with COVID-19, attenuating the infection, and resulting in more rapid decline of viral load in throat/nose swabs. This viral attenuation should be associated with improved patient outcomes. Method: The study will start with a 10-patient prospective observational pilot study following the same entry and exclusion criteria as for the randomized trial and undergoing the same procedures. The main study is an open label, randomised, controlled trial with two parallel arms of standard of care (control arm) versus standard of care with 10 days of chloroquine (intervention arm) with a loading dose over the first 24 hours, followed by 300mg base orally once daily for nine days. The study will recruit patients in three sites in Ho Chi Minh City, Vietnam: the Hospital for Tropical Diseases, the Cu Chi Field Hospital, and the Can Gio COVID hospital. The primary endpoint is the time to viral clearance from throat/nose swab, defined as the time following randomization until the midpoint between the last positive and the first of the negative throat/nose swabs. Viral presence will be determined using RT-PCR to detect SARS-CoV-2 RNA. Discussion: The results of the study will add to the evidence-based guidelines for management of COVID-19. Given the enormous experience of its use in malaria chemoprophylaxis, excellent safety and tolerability profile, and its very low cost, if proved effective then chloroquine would be a readily deployable and affordable treatment for patients with COVID-19. Trial registration: Clinicaltrials.gov
NCT04328493 31/03/2020
Collapse
Affiliation(s)
- Evelyne Kestelyn
- Oxford University Clinical Research Unit, University of Oxford, Ho Chi Minh City, Vietnam.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Nguyen Thi Phuong Dung
- Oxford University Clinical Research Unit, University of Oxford, Ho Chi Minh City, Vietnam
| | - Yen Lam Minh
- Oxford University Clinical Research Unit, University of Oxford, Ho Chi Minh City, Vietnam
| | - Le Manh Hung
- Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | | | | | | | | | | | - Van Ninh Thi Thanh
- Oxford University Clinical Research Unit, University of Oxford, Ho Chi Minh City, Vietnam
| | - Joseph Donovan
- Oxford University Clinical Research Unit, University of Oxford, Ho Chi Minh City, Vietnam.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | | | - Le Thanh Hoang Nhat
- Oxford University Clinical Research Unit, University of Oxford, Ho Chi Minh City, Vietnam
| | | | | | | | - Nghiêm My Ngoc
- Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Vo Thanh Lam
- Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | | | | | - Ronald B Geskus
- Oxford University Clinical Research Unit, University of Oxford, Ho Chi Minh City, Vietnam.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Vo Thi Nhi Ha
- Administration of Science, Technology and Training (ASTT), Ministry of Health, Hanoi, Vietnam
| | - Nguyen Ngo Quang
- Administration of Science, Technology and Training (ASTT), Ministry of Health, Hanoi, Vietnam
| | - Hien Tran Tinh
- Oxford University Clinical Research Unit, University of Oxford, Ho Chi Minh City, Vietnam.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Le Van Tan
- Oxford University Clinical Research Unit, University of Oxford, Ho Chi Minh City, Vietnam
| | - Guy E Thwaites
- Oxford University Clinical Research Unit, University of Oxford, Ho Chi Minh City, Vietnam.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Jeremy N Day
- Oxford University Clinical Research Unit, University of Oxford, Ho Chi Minh City, Vietnam.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | | | | |
Collapse
|
12
|
Duong HTH, Tadesse GA, Nhat PTH, Hao NV, Prince J, Duong TD, Kien TT, Nhat LTH, Tan LV, Pugh C, Loan HT, Chau NVV, Minh Yen L, Zhu T, Clifton D, Thwaites L. Heart Rate Variability as an Indicator of Autonomic Nervous System Disturbance in Tetanus. Am J Trop Med Hyg 2020; 102:403-407. [PMID: 31833471 PMCID: PMC7008337 DOI: 10.4269/ajtmh.19-0720] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Autonomic nervous system dysfunction (ANSD) is a significant cause of mortality in tetanus. Currently, diagnosis relies on nonspecific clinical signs. Heart rate variability (HRV) may indicate underlying autonomic nervous system activity and represents a potentially valuable noninvasive tool for ANSD diagnosis in tetanus. HRV was measured from three 5-minute electrocardiogram recordings during a 24-hour period in a cohort of patients with severe tetanus, all receiving mechanical ventilation. HRV measurements from all subjects—five with ANSD (Ablett Grade 4) and four patients without ANSD (Ablett Grade 3)—showed HRV was lower than reported ranges for healthy individuals. Comparing different severities of tetanus, raw data for both time and frequency measurements of HRV were reduced in those with ANSD compared with those without. Differences were statistically significant in all except root mean square SD, indicating HRV may be a valuable tool in ANSD diagnosis.
Collapse
Affiliation(s)
| | - Girmaw Abebe Tadesse
- Institute of Biomedical Engineering, University of Oxford, Oxford, United Kingdom
| | | | - Nguyen Van Hao
- University of Medicine and Pharmacy, Ho Chi Minh City, Vietnam.,Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - John Prince
- Institute of Biomedical Engineering, University of Oxford, Oxford, United Kingdom
| | - Tran Duc Duong
- Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Trịnh Trung Kien
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | | | - Le Van Tan
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Chris Pugh
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Huynh Thi Loan
- Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | | | - Lam Minh Yen
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Tingting Zhu
- Institute of Biomedical Engineering, University of Oxford, Oxford, United Kingdom
| | - David Clifton
- Institute of Biomedical Engineering, University of Oxford, Oxford, United Kingdom
| | - Louise Thwaites
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom.,Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| |
Collapse
|
13
|
Van LH, Phu PT, Vinh DN, Son VT, Hanh NT, Nhat LTH, Lan NH, Vinh TV, Trang NTM, Ha DTM, Thwaites GE, Thuong NTT. Risk factors for poor treatment outcomes of 2266 multidrug-resistant tuberculosis cases in Ho Chi Minh City: a retrospective study. BMC Infect Dis 2020; 20:164. [PMID: 32087682 PMCID: PMC7036193 DOI: 10.1186/s12879-020-4887-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 02/13/2020] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Multidrug resistant tuberculosis (MDR-TB) remains a serious public health problem with poor treatment outcomes. Predictors of poor outcomes vary in different regions. Vietnam is among the top 30 high burden of MDR-TB countries. We describe demographic characteristics and identify risk factors for poor outcome among patients with MDR-TB in Ho Chi Minh City (HCMC), the most populous city in Vietnam. METHODS This retrospective study included 2266 patients who initiated MDR-TB treatment between 2011 and 2015 in HCMC. Treatment outcomes were available for 2240 patients. Data was collected from standardized paper-based treatment cards and electronic records. A Kruskal Wallis test was used to assess changes in median age and body mass index (BMI) over time, and a Wilcoxon test was used to compare the median BMI of patients with and without diabetes mellitus. Chi squared test was used to compare categorical variables. Multivariate logistic regression with multiple imputation for missing data was used to identify risk factors for poor outcomes. Statistical analysis was performed using R program. RESULTS Among 2266 eligible cases, 60.2% had failed on a category I or II treatment regimen, 57.7% were underweight, 30.2% had diabetes mellitus and 9.6% were HIV positive. The notification rate increased 24.7% from 2011 to 2015. The treatment success rate was 73.3%. Risk factors for poor treatment outcome included HIV co-infection (adjusted odds ratio (aOR): 2.94), advanced age (aOR: 1.45 for every increase of 5 years for patients 60 years or older), having history of MDR-TB treatment (aOR: 5.53), sputum smear grade scanty or 1+ (aOR: 1.47), smear grade 2+ or 3+ (aOR: 2.06), low BMI (aOR: 0.83 for every increase of 1 kg/m2 of BMI for patients with BMI < 21). CONCLUSION The number of patients diagnosed with MDR-TB in HCMC increased by almost a quarter between 2011 and 2015. Patients with HIV, high smear grade, malnutrition or a history of previous MDR-TB treatment are at greatest risk of poor treatment outcome.
Collapse
Affiliation(s)
- Le Hong Van
- Tuberculosis group, Oxford University Clinical Research Unit, 764 Vo Van Kiet street, District 5, Ho Chi Minh City, Vietnam.
| | - Phan Trieu Phu
- Tuberculosis group, Oxford University Clinical Research Unit, 764 Vo Van Kiet street, District 5, Ho Chi Minh City, Vietnam
| | - Dao Nguyen Vinh
- Tuberculosis group, Oxford University Clinical Research Unit, 764 Vo Van Kiet street, District 5, Ho Chi Minh City, Vietnam
| | - Vo Thanh Son
- Tuberculosis group, Oxford University Clinical Research Unit, 764 Vo Van Kiet street, District 5, Ho Chi Minh City, Vietnam
| | - Nguyen Thi Hanh
- Tuberculosis group, Oxford University Clinical Research Unit, 764 Vo Van Kiet street, District 5, Ho Chi Minh City, Vietnam
| | - Le Thanh Hoang Nhat
- Tuberculosis group, Oxford University Clinical Research Unit, 764 Vo Van Kiet street, District 5, Ho Chi Minh City, Vietnam
| | | | | | | | | | - Guy E Thwaites
- Tuberculosis group, Oxford University Clinical Research Unit, 764 Vo Van Kiet street, District 5, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Nguyen Thuy Thuong Thuong
- Tuberculosis group, Oxford University Clinical Research Unit, 764 Vo Van Kiet street, District 5, Ho Chi Minh City, Vietnam.
| |
Collapse
|
14
|
Colas RA, Nhat LTH, Thuong NTT, Gómez EA, Ly L, Thanh HH, Mai NTH, Phu NH, Thwaites GE, Dalli J. Proresolving mediator profiles in cerebrospinal fluid are linked with disease severity and outcome in adults with tuberculous meningitis. FASEB J 2019; 33:13028-13039. [PMID: 31500466 PMCID: PMC6902685 DOI: 10.1096/fj.201901590r] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [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: 07/10/2019] [Accepted: 08/12/2019] [Indexed: 01/25/2023]
Abstract
Tuberculous meningitis (TBM) is the most lethal form of tuberculosis infection, characterized by a dysregulated immune response that frequently leads to neurologic injury and death despite the best available treatment. The mechanisms driving the inflammatory response in TBM are not well understood. To gain insights into these mechanisms, we used a lipid mediator-profiling approach to investigate the regulation of a novel group of host protective mediators, termed specialized proresolving mediators (SPMs), in the cerebrospinal fluid (CSF) of adults with TBM. Herein, using CSF from patients enrolled into a randomized placebo-controlled trial of adjunctive aspirin treatment, we found distinct lipid mediator profiles with increasing disease severity. These changes were linked with an up-regulation of inflammatory eicosanoids in patients with severe TBM and a decrease in the production of a number of SPMs. CSF proresolving mediator concentrations were also associated with 80-d survival. In survivors, we found a significant increase in proresolving mediator concentrations, including the lipoxygenase 5-derived 13-series resolvin (RvT)2, RvT4, and 15-epi-lipoxin B4, compared with those who died. Of note, treatment of patients with high-dose aspirin led to a decrease in the concentrations of the prothrombic mediator thromboxane A2, reduced brain infarcts, and decreased death in patients with TBM. Together, these findings identify a CSF SPM signature that is associated with disease severity and 80-d mortality in TBM.-Colas, R. A., Nhat, L. T. H., Thuong, N. T. T., Gómez, E. A., Ly, L., Thanh, H. H., Mai, N. T. H., Phu, N. H., Thwaites, G. E., Dalli, J. Proresolving mediator profiles in cerebrospinal fluid are linked with disease severity and outcome in adults with tuberculous meningitis.
Collapse
Affiliation(s)
- Romain A. Colas
- William Harvey Research Institute, Barts and The
London School of Medicine and Dentistry, Queen Mary University of London, London,
United Kingdom
| | | | | | - Esteban A. Gómez
- William Harvey Research Institute, Barts and The
London School of Medicine and Dentistry, Queen Mary University of London, London,
United Kingdom
| | - Lucy Ly
- William Harvey Research Institute, Barts and The
London School of Medicine and Dentistry, Queen Mary University of London, London,
United Kingdom
| | - Hai Hoang Thanh
- Oxford University Clinical Research Unit, Ho Chi
Minh City, Vietnam
| | | | - Nguyen Hoan Phu
- Oxford University Clinical Research Unit, Ho Chi
Minh City, Vietnam
| | - Guy E. Thwaites
- Oxford University Clinical Research Unit, Ho Chi
Minh City, Vietnam
- Nuffield Department of Medicine, Centre for
Tropical Medicine and Global Health, University of Oxford, Oxford, United
Kingdom
| | - Jesmond Dalli
- William Harvey Research Institute, Barts and The
London School of Medicine and Dentistry, Queen Mary University of London, London,
United Kingdom
- Centre for Inflammation and Therapeutic
Innovation, Queen Mary University of London, London, United Kingdom
| |
Collapse
|
15
|
Hai TP, Van AD, Ngan NTT, Nhat LTH, Lan NPH, Vinh Chau NV, Thwaites GE, Krysan D, Day JN. The combination of tamoxifen with amphotericin B, but not with fluconazole, has synergistic activity against the majority of clinical isolates of Cryptococcus neoformans. Mycoses 2019; 62:818-825. [PMID: 31173410 PMCID: PMC6771715 DOI: 10.1111/myc.12955] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 06/04/2019] [Accepted: 06/04/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND Cryptococcal meningitis has fatality rates of 40%-70%, resulting in 200 000 deaths each year. The best outcomes are achieved with amphotericin combined with flucytosine but flucytosine is expensive and unavailable where most disease occurs. More effective and affordable treatments are needed. Tamoxifen, a selective oestrogen receptor modulator frequently indicated for breast cancer, has been found to have synergistic activity against the Cryptococcus neoformans type strain when combined with amphotericin or fluconazole. It is cheap, off-licence, widely available and well-tolerated, and thus a pragmatic potential treatment for cryptococcal disease. OBJECTIVES We wanted to determine the susceptibility of clinical isolates of C. neoformans to tamoxifen alone and in combination with other antifungals, to determine whether there is sufficient evidence of activity to justify a clinical trial. METHODS We used the CLSI broth microdilution protocol to test the susceptibility of 30 randomly selected clinical isolates of C. neoformans to tamoxifen, in dual combination with amphotericin, fluconazole or flucytosine, and in triple combination with amphotericin and fluconazole. Evidence of drug interactions was assessed using the fractional inhibitory concentration index. RESULTS The MIC50 and MIC90 of tamoxifen were 4 and 16 mg/L, respectively. The combination of tamoxifen and amphotericin suggested a synergistic interaction in 20 of 30 (67%) isolates. There was no interaction between tamoxifen and either fluconazole or flucytosine. Synergy was maintained in 3-Dimensional chequerboard testing. There was no evidence of antagonism. CONCLUSIONS Tamoxifen may be a useful addition to treatment with amphotericin and fluconazole for cryptococcal meningitis; a trial is justified.
Collapse
Affiliation(s)
- Trieu Phan Hai
- Oxford University Clinical Research UnitHo Chi Minh CityViet Nam
| | - Anh Duong Van
- Oxford University Clinical Research UnitHo Chi Minh CityViet Nam
| | - Nguyen Thi Thuy Ngan
- Oxford University Clinical Research UnitHo Chi Minh CityViet Nam
- Cho Ray HospitalHo Chi Minh cityViet Nam
| | | | | | | | - Guy E. Thwaites
- Oxford University Clinical Research UnitHo Chi Minh CityViet Nam
- Centre for Tropical Medicine, Nuffield Department of MedicineUniversity of OxfordOxfordUK
| | - Damian Krysan
- Department of Pediatrics and Microbiology/ImmunologyUniversity of IowaIowa CityIowaUSA
| | - Jeremy N. Day
- Oxford University Clinical Research UnitHo Chi Minh CityViet Nam
- Centre for Tropical Medicine, Nuffield Department of MedicineUniversity of OxfordOxfordUK
| |
Collapse
|
16
|
Ashton PM, Thanh LT, Trieu PH, Van Anh D, Trinh NM, Beardsley J, Kibengo F, Chierakul W, Dance DAB, Rattanavong S, Davong V, Hung LQ, Chau NVV, Tung NLN, Chan AK, Thwaites GE, Lalloo DG, Anscombe C, Nhat LTH, Perfect J, Dougan G, Baker S, Harris S, Day JN. Three phylogenetic groups have driven the recent population expansion of Cryptococcus neoformans. Nat Commun 2019; 10:2035. [PMID: 31048698 PMCID: PMC6497710 DOI: 10.1038/s41467-019-10092-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Accepted: 04/15/2019] [Indexed: 01/04/2023] Open
Abstract
Cryptococcus neoformans (C. neoformans var. grubii) is an environmentally acquired pathogen causing 181,000 HIV-associated deaths each year. We sequenced 699 isolates, primarily C. neoformans from HIV-infected patients, from 5 countries in Asia and Africa. The phylogeny of C. neoformans reveals a recent exponential population expansion, consistent with the increase in the number of susceptible hosts. In our study population, this expansion has been driven by three sub-clades of the C. neoformans VNIa lineage; VNIa-4, VNIa-5 and VNIa-93. These three sub-clades account for 91% of clinical isolates sequenced in our study. Combining the genome data with clinical information, we find that the VNIa-93 sub-clade, the most common sub-clade in Uganda and Malawi, was associated with better outcomes than VNIa-4 and VNIa-5, which predominate in Southeast Asia. This study lays the foundation for further work investigating the dominance of VNIa-4, VNIa-5 and VNIa-93 and the association between lineage and clinical phenotype.
Collapse
Affiliation(s)
- P M Ashton
- Wellcome Trust Asia Programme, Oxford University Clinical Research Unit, 764 Vo Van Kiet, Ho Chi Minh City, Vietnam
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, OX3 7FZ, UK
| | - L T Thanh
- Wellcome Trust Asia Programme, Oxford University Clinical Research Unit, 764 Vo Van Kiet, Ho Chi Minh City, Vietnam
| | - P H Trieu
- Wellcome Trust Asia Programme, Oxford University Clinical Research Unit, 764 Vo Van Kiet, Ho Chi Minh City, Vietnam
| | - D Van Anh
- Wellcome Trust Asia Programme, Oxford University Clinical Research Unit, 764 Vo Van Kiet, Ho Chi Minh City, Vietnam
| | - N M Trinh
- Wellcome Trust Asia Programme, Oxford University Clinical Research Unit, 764 Vo Van Kiet, Ho Chi Minh City, Vietnam
| | - J Beardsley
- Wellcome Trust Asia Programme, Oxford University Clinical Research Unit, 764 Vo Van Kiet, Ho Chi Minh City, Vietnam
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, OX3 7FZ, UK
- Marie Bashir Institute, University of Sydney, Sydney, 2050, NSW, Australia
| | - F Kibengo
- MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
| | - W Chierakul
- Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | - D A B Dance
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, OX3 7FZ, UK
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Vientiane, Laos
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - S Rattanavong
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Vientiane, Laos
| | - V Davong
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Vientiane, Laos
| | - L Q Hung
- Cho Ray Hospital, Ho Chi Minh City, Vietnam
| | - N V V Chau
- Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - N L N Tung
- Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - A K Chan
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, M4N 3M5, ON, Canada
- Dignitas International, Zomba, Malawi
| | - G E Thwaites
- Wellcome Trust Asia Programme, Oxford University Clinical Research Unit, 764 Vo Van Kiet, Ho Chi Minh City, Vietnam
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, OX3 7FZ, UK
| | - D G Lalloo
- Liverpool School of Tropical Medicine, Liverpool, L3 5QA, UK
| | - C Anscombe
- Wellcome Trust Asia Programme, Oxford University Clinical Research Unit, 764 Vo Van Kiet, Ho Chi Minh City, Vietnam
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, OX3 7FZ, UK
| | - L T H Nhat
- Wellcome Trust Asia Programme, Oxford University Clinical Research Unit, 764 Vo Van Kiet, Ho Chi Minh City, Vietnam
| | - J Perfect
- Department of Medicine and Department of Molecular Genetics and Microbiology, Division of Infectious Diseases, Duke University, Durham, NC, 27710, USA
| | - G Dougan
- Wellcome Trust-Cambridge Centre for Global Health Research, Cambridge, CB2 0XY, UK
- Pathogen Genomics, The Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Cambridge, CB10 1SA, Cambridgeshire, UK
- Department of Medicine, University of Cambridge, Cambridge, CB2 0SP, UK
| | - S Baker
- Wellcome Trust Asia Programme, Oxford University Clinical Research Unit, 764 Vo Van Kiet, Ho Chi Minh City, Vietnam
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, OX3 7FZ, UK
- Wellcome Trust-Cambridge Centre for Global Health Research, Cambridge, CB2 0XY, UK
- Department of Medicine, University of Cambridge, Cambridge, CB2 0SP, UK
| | - S Harris
- Pathogen Genomics, The Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Cambridge, CB10 1SA, Cambridgeshire, UK
| | - J N Day
- Wellcome Trust Asia Programme, Oxford University Clinical Research Unit, 764 Vo Van Kiet, Ho Chi Minh City, Vietnam.
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, OX3 7FZ, UK.
| |
Collapse
|
17
|
Ngan NTT, Mai NTH, Tung NLN, Lan NPH, Tai LTH, Phu NH, Chau NVV, Binh TQ, Hung LQ, Beardsley J, White N, Lalloo D, Krysan D, Hope W, Geskus R, Wolbers M, Nhat LTH, Thwaites G, Kestelyn E, Day J. A randomized open label trial of tamoxifen combined with amphotericin B and fluconazole for cryptococcal meningitis. Wellcome Open Res 2019; 4:8. [PMID: 30801037 PMCID: PMC6381443 DOI: 10.12688/wellcomeopenres.15010.1] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/11/2019] [Indexed: 01/02/2023] Open
Abstract
Background: Cryptococcal meningitis is a leading cause of death in HIV-infected patients. International treatment guidelines recommend induction therapy with amphotericin B and flucytosine. This antifungal combination is most effective, but unfortunately flucytosine is expensive and unavailable where the burden of disease is greatest. Where unavailable, guidelines recommend treatment with amphotericin and fluconazole, but this is less effective, with mortality rates of 40-50%. Faster rates of clearance of yeast from cerebrospinal fluid (CSF) are associated with better outcomes - improving the potency of antifungal therapy is likely to be an effective strategy to improve survival. Tamoxifen, a selective estrogen receptor modulator used to treat breast cancer, has anti-cryptococcal activity, appearing synergistic when combined in vitro with amphotericin, and fungicidal when combined with fluconazole. It is concentrated in the brain and macrophages, off-patent, cheap and widely available. We designed a randomized trial to deliver initial efficacy and safety data for tamoxifen combined with amphotericin and fluconazole. Method: A phase II, open-label, randomized (1:1) controlled trial of tamoxifen (300mg/day) combined with amphotericin (1mg/kg/day) and fluconazole (800mg/day) for the first 2 weeks therapy for HIV infected or uninfected adults with cryptococcal meningitis. The study recruits at Cho Ray Hospital and the Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam. The primary end point is Early Fungicidal Activity (EFA-the rate of yeast clearance from CSF), over the first two weeks of treatment. 50 patients will be recruited providing ≈80% and 90% power to detect a difference in the EFA of -0.11 or -0.13 log10CFU/ml/day, respectively. Discussion: The results of the study will inform the decision to proceed to a larger trial powered to mortality. The size of effect detectable has previously been associated with reduced mortality from this devastating disease. Particular side effects of interest include QT prolongation. Trial registration: Clinicaltrials.gov NCT03112031 (11/04/2017).
Collapse
Affiliation(s)
- Nguyen Thi Thuy Ngan
- Oxford University Clinical Research Unit, University of Oxford, Ho Chi Minh City, Vietnam
- Dept of Tropical Medicine, Cho Ray Hospital, Ho Chi Minh City, Vietnam
| | - Nguyen Thi Hoang Mai
- Oxford University Clinical Research Unit, University of Oxford, Ho Chi Minh City, Vietnam
| | | | | | | | - Nguyen Hoan Phu
- Oxford University Clinical Research Unit, University of Oxford, Ho Chi Minh City, Vietnam
- Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | | | - Tran Quang Binh
- Dept of Tropical Medicine, Cho Ray Hospital, Ho Chi Minh City, Vietnam
| | - Le Quoc Hung
- Dept of Tropical Medicine, Cho Ray Hospital, Ho Chi Minh City, Vietnam
| | - Justin Beardsley
- Oxford University Clinical Research Unit, University of Oxford, Ho Chi Minh City, Vietnam
| | - Nicholas White
- Oxford University Clinical Research Unit, University of Oxford, Ho Chi Minh City, Vietnam
- Cente for Tropical Medicine, University of Oxford, Oxford, UK
| | - David Lalloo
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - Damian Krysan
- Depatrment of Pediatrics and Microbiology/Immunology, University of Iowa, Iowa City, USA
| | - William Hope
- Molecular and Clinical Pharmacology, Universitly of Liverpool, Liverpool, UK
| | - Ronald Geskus
- Oxford University Clinical Research Unit, University of Oxford, Ho Chi Minh City, Vietnam
- Cente for Tropical Medicine, University of Oxford, Oxford, UK
| | - Marcel Wolbers
- Oxford University Clinical Research Unit, University of Oxford, Ho Chi Minh City, Vietnam
| | - Le Thanh Hoang Nhat
- Oxford University Clinical Research Unit, University of Oxford, Ho Chi Minh City, Vietnam
| | - Guy Thwaites
- Oxford University Clinical Research Unit, University of Oxford, Ho Chi Minh City, Vietnam
- Cente for Tropical Medicine, University of Oxford, Oxford, UK
| | - Evelyne Kestelyn
- Oxford University Clinical Research Unit, University of Oxford, Ho Chi Minh City, Vietnam
- Cente for Tropical Medicine, University of Oxford, Oxford, UK
| | - Jeremy Day
- Oxford University Clinical Research Unit, University of Oxford, Ho Chi Minh City, Vietnam
- Cente for Tropical Medicine, University of Oxford, Oxford, UK
| |
Collapse
|
18
|
Thuy DB, Campbell J, Nhat LTH, Hoang NVM, Hao NV, Baker S, Geskus RB, Thwaites GE, Chau NVV, Thwaites CL. Hospital-acquired colonization and infections in a Vietnamese intensive care unit. PLoS One 2018; 13:e0203600. [PMID: 30192894 PMCID: PMC6128614 DOI: 10.1371/journal.pone.0203600] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Accepted: 08/23/2018] [Indexed: 12/16/2022] Open
Abstract
Data concerning intensive care unit (ICU)-acquired bacterial colonization and infections are scarce from low and middle-income countries (LMICs). ICU patients in these settings are at high risk of becoming colonized and infected with antimicrobial-resistant organisms (AROs). We conducted a prospective observational study at the Ho Chi Minh City Hospital for Tropical Diseases, Vietnam from November 2014 to January 2016 to assess the ICU-acquired colonization and infections, focusing on the five major pathogens in our setting: Staphylococcus aureus (S. aureus), Escherichia coli (E. coli), Klebsiella spp., Pseudomonas spp. and Acinetobacter spp., among adult patients with more than 48 hours of ICU stay. We found that 61.3% (223/364) of ICU patients became colonized with AROs: 44.2% (161/364) with rectal ESBL-producing E. coli and Klebsiella spp.; 30.8% (40/130) with endotracheal carbapenemase-producing Acinetobacter spp.; and 14.3% (52/364) with nasal methicillin-resistant S. aureus. The incidence rate of ICU patients becoming colonized with AROs was 9.8 (223/2,276) per 100 patient days. Significant risk factor for AROs colonization was the Charlson Comorbidity Index score. The proportion of ICU patients with HAIs was 23.4% (85/364), and the incidence rate of ICU patients contracting HAIs was 2.3 (85/3,701) per 100 patient days. The vascular catheterization (central venous, arterial and hemofiltration catheter) was significantly associated with hospital-acquired bloodstream infection. Of the 77 patients who developed ICU-acquired infections with one of the five specified bacteria, 44 (57.1%) had prior colonization with the same organism. Vietnamese ICU patients have a high colonization rate with AROs and a high risk of subsequent infections. Future research should focus on monitoring colonization and the development of preventive measures that may halt spread of AROs in ICU settings.
Collapse
Affiliation(s)
- Duong Bich Thuy
- Hospital for Tropical Diseases, Wellcome Trust Asia Programme, Oxford University Clinical Research Unit (OUCRU), Ho Chi Minh City, Vietnam
- Adult Intensive Care Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - James Campbell
- Hospital for Tropical Diseases, Wellcome Trust Asia Programme, Oxford University Clinical Research Unit (OUCRU), Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, Oxford University, Oxford, United Kingdom
| | - Le Thanh Hoang Nhat
- Hospital for Tropical Diseases, Wellcome Trust Asia Programme, Oxford University Clinical Research Unit (OUCRU), Ho Chi Minh City, Vietnam
| | - Nguyen Van Minh Hoang
- Hospital for Tropical Diseases, Wellcome Trust Asia Programme, Oxford University Clinical Research Unit (OUCRU), Ho Chi Minh City, Vietnam
| | - Nguyen Van Hao
- Adult Intensive Care Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
- Department of Infectious Diseases, University of Medicine and Pharmacy, Ho Chi Minh City, Vietnam
| | - Stephen Baker
- Hospital for Tropical Diseases, Wellcome Trust Asia Programme, Oxford University Clinical Research Unit (OUCRU), Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, Oxford University, Oxford, United Kingdom
- Department of Medicine, Cambridge University, Cambridge, United Kingdom
| | - Ronald B. Geskus
- Hospital for Tropical Diseases, Wellcome Trust Asia Programme, Oxford University Clinical Research Unit (OUCRU), Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, Oxford University, Oxford, United Kingdom
| | - Guy E. Thwaites
- Hospital for Tropical Diseases, Wellcome Trust Asia Programme, Oxford University Clinical Research Unit (OUCRU), Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, Oxford University, Oxford, United Kingdom
| | - Nguyen Van Vinh Chau
- Department of Infectious Diseases, University of Medicine and Pharmacy, Ho Chi Minh City, Vietnam
- Board of Directors, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - C. Louise Thwaites
- Hospital for Tropical Diseases, Wellcome Trust Asia Programme, Oxford University Clinical Research Unit (OUCRU), Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, Oxford University, Oxford, United Kingdom
| |
Collapse
|
19
|
Minh Tu Van H, To Anh N, Tan Thanh T, Thi Ty Hang V, Nguyen Truc Nhu L, Thi Han Ny N, Thanh Hoang Nhat L, Truc Trang N, Thi Thu Hong N, Thanh Hung N, Nguyen Thanh Nhan L, Huu Khanh T, Manh Tuan H, Lu Viet H, Viet C, Tran Nam N, Thi My Thanh N, Sabanathan S, Tu Qui P, Van Vinh Chau N, Thwaites GE, Louise Thwaites C, Van Tan L, Rogier van Doorn H. A57 Clinical features and virology of hand, foot, and mouth disease in southern Vietnam from July 2013 to July 2015. Virus Evol 2018. [PMCID: PMC5905567 DOI: 10.1093/ve/vey010.056] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Phan Tu Qui
- Oxford Clinical Research Unit, Ha Noi, Vietnam
- Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | | | - Guy E Thwaites
- Oxford Clinical Research Unit, Ha Noi, Vietnam
- Nuffield Medical Department, Oxford University, Oxford, UK
| | - C Louise Thwaites
- Oxford Clinical Research Unit, Ha Noi, Vietnam
- Nuffield Medical Department, Oxford University, Oxford, UK
| | - Le Van Tan
- Oxford Clinical Research Unit, Ha Noi, Vietnam
| | | |
Collapse
|