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Pernica JM, Arscott-Mills T, Steenhoff AP, Mokomane M, Moorad B, Bapabi M, Lechiile K, Mangwegape O, Batisani B, Mawoko N, Muthoga C, Vanniyasingam T, Ewusie J, Lowe A, Bonsu JM, Gezmu AM, Smieja M, Mazhani L, Stordal K, Thabane L, Kelly MS, Goldfarb DM. Optimising the management of childhood acute diarrhoeal disease using a rapid test-and- treat strategy and/or Lactobacillus reuteri DSM 17938: a multicentre, randomised, controlled, factorial trial in Botswana. BMJ Glob Health 2022; 7:bmjgh-2021-007826. [PMID: 35418412 PMCID: PMC9014020 DOI: 10.1136/bmjgh-2021-007826] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 03/14/2022] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION The study aim was to determine if rapid enteric diagnostics followed by the provision of targeted antibiotic therapy ('test-and-treat') and/or Lactobacillus reuteri DSM 17938 would improve outcomes in children hospitalised in Botswana with acute gastroenteritis. METHODS This was a multicentre, randomised, factorial, controlled, trial. Children aged 2-60 months admitted for acute non-bloody diarrhoea to four hospitals in southern Botswana were eligible. Participants were assigned to treatment groups by web-based block randomisation. Test-and-treat results were not blinded, but participants and research staff were blinded to L. reuteri/placebo assignment; this was dosed as 1×108 cfu/mL by mouth daily and continued for 60 days. The primary outcome was 60-day age-standardised height (HAZ) adjusted for baseline HAZ. All analyses were by intention to treat. The trial was registered at Clinicaltrials.gov. RESULTS Recruitment began on 12 June 2016 and continued until 24 October 2018. There were 66 participants randomised to the test-and-treat plus L. reuteri group, 68 randomised to the test-and-treat plus placebo group, 69 to the standard care plus L. reuteri group and 69 to the standard care plus placebo group. There was no demonstrable impact of the test-and-treat intervention (mean increase of 0.01 SD, 95% CI -0.14 to 0.16 SD) or the L. reuteri intervention (mean decrease of 0.07 SD, 95% CI -0.22 to 0.08 SD) on adjusted HAZ at 60 days. CONCLUSIONS In children hospitalised for acute gastroenteritis in Botswana, neither a test-and-treat algorithm targeting enteropathogens, nor a 60-day course of L. reuteri DSM 17938, were found to markedly impact linear growth or other important outcomes. We cannot exclude the possibility that test-and-treat will improve the care of children with significant enteropathogens (such as Shigella) in their stool. TRIAL REGISTRATION NUMBER NCT02803827.
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Affiliation(s)
- Jeffrey M Pernica
- Department of Pediatrics, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada .,Department of Health Research Methods, Evidence, and Impact, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - Tonya Arscott-Mills
- Botswana-UPenn Partnership, Gaborone, Botswana.,The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Global Health Center, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Andrew P Steenhoff
- Global Health Center, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Margaret Mokomane
- Department of Microbiology, University of Botswana, Gaborone, South-East District, Botswana
| | | | | | | | | | | | | | - Charles Muthoga
- Botswana-UPenn Partnership, Gaborone, Botswana.,Botswana-Harvard AIDS Institute Partnership, Gaborone, Gaborone, Botswana
| | - Thuvaraha Vanniyasingam
- Department of Health Research Methods, Evidence, and Impact, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - Joycelyne Ewusie
- Department of Health Research Methods, Evidence, and Impact, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada.,The Research Institute-Biostatistics Unit, St Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Amy Lowe
- Department of Global Health, McMaster University, Hamilton, Ontario, Canada
| | - Janice M Bonsu
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Alemayehu M Gezmu
- Department of Pediatrics and Adolescent Health, University of Botswana, Gaborone, Botswana
| | - Marek Smieja
- Department of Health Research Methods, Evidence, and Impact, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada.,Department of Pathology and Molecular Medicine, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - Loeto Mazhani
- Department of Pediatrics and Adolescent Health, University of Botswana, Gaborone, Botswana
| | - Ketil Stordal
- Pediatric Research Institute, University of Oslo Faculty of Medicine, Oslo, Norway
| | - Lehana Thabane
- Department of Pediatrics, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada.,The Research Institute-Biostatistics Unit, St Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada.,University of Johannesburg Faculty of Health Sciences, Johannesburg, South Africa
| | - Matthew S Kelly
- Department of Pediatrics, Duke University, Durham, North Carolina, USA
| | - David M Goldfarb
- Department of Pathology and Laboratory Medicine, The University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
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Jarvis JN, Leeme TB, Molefi M, Chofle AA, Bidwell G, Tsholo K, Tlhako N, Mawoko N, Patel RKK, Tenforde MW, Muthoga C, Bisson GP, Kidola J, Changalucha J, Lawrence D, Jaffar S, Hope W, Molloy SF, Harrison TS. Short-course High-dose Liposomal Amphotericin B for Human Immunodeficiency Virus-associated Cryptococcal Meningitis: A Phase 2 Randomized Controlled Trial. Clin Infect Dis 2019; 68:393-401. [PMID: 29945252 PMCID: PMC6336908 DOI: 10.1093/cid/ciy515] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [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: 01/30/2018] [Accepted: 06/18/2018] [Indexed: 01/03/2023] Open
Abstract
Background We performed a phase 2 noninferiority trial examining the early fungicidal activity (EFA) of 3 short-course, high-dose liposomal amphotericin B (L-AmB) regimens for cryptococcal meningitis (CM) in Tanzania and Botswana. Methods Human immunodeficiency virus (HIV)-infected adults with CM were randomized to (i) L-AmB 10 mg/kg on day 1 (single dose); (ii) L-AmB 10 mg/kg on day 1 and 5 mg/kg on day 3 (2 doses); (iii) L-AmB 10 mg/kg on day 1 and 5 mg/kg on days 3 and 7 (3 doses); or (iv) L-AmB 3 mg/kg/day for 14 days (control). All patients also received oral fluconazole 1200 mg/day for 14 days. Primary endpoint was mean rate of clearance of cerebrospinal fluid cryptococcal infection (EFA). Noninferiority was defined as an upper limit of the 2-sided 95% confidence interval (CI) of difference in EFA between intervention and control <0.2 log10 colony-forming units (CFU)/mL/day. Results Eighty participants were enrolled. EFA for daily L-AmB was -0.41 log10 CFU/mL/day (standard deviation, 0.11; n = 17). Difference in mean EFA from control was -0.11 (95% CI, -.29 to .07) log10 CFU/mL/day faster with single dose (n = 16); -0.05 (95% CI, -.20 to .10) log10 CFU/mL/day faster with 2 doses (n = 18); and -0.13 (95% CI, -.35 to .09) log10 CFU/mL/day faster with 3 doses (n = 18). EFA in all short-course arms was noninferior to control. Ten-week mortality was 29% (n = 23) with no statistical difference between arms. All arms were well tolerated. Conclusions Single-dose 10 mg/kg L-AmB was well tolerated and led to noninferior EFA compared to 14 days of 3 mg/kg/day L-AmB in HIV-associated CM. Induction based on a single 10 mg/kg L-AmB dose is being taken forward to a phase 3 clinical endpoint trial. Clinical Trials Registration ISRCTN 10248064.
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Affiliation(s)
- Joseph N Jarvis
- Botswana–University of Pennsylvania Partnership, Gaborone
- Division of Infectious Diseases, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, United Kingdom
- University of Botswana, Gaborone
| | - Tshepo B Leeme
- Botswana–University of Pennsylvania Partnership, Gaborone
| | | | | | | | - Katlego Tsholo
- Botswana–University of Pennsylvania Partnership, Gaborone
| | - Nametso Tlhako
- Botswana–University of Pennsylvania Partnership, Gaborone
| | - Norah Mawoko
- Botswana–University of Pennsylvania Partnership, Gaborone
| | - Raju K K Patel
- Botswana–University of Pennsylvania Partnership, Gaborone
| | | | | | - Gregory P Bisson
- Division of Infectious Diseases, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | | | | | - David Lawrence
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, United Kingdom
| | - Shabbar Jaffar
- Department of International Public Health, Liverpool School of Tropical Medicine, United Kingdom
| | - William Hope
- Antimicrobial Pharmacodynamics and Therapeutics, Department of Molecular and Clinical Pharmacology, University of Liverpool, United Kingdom
| | - Síle F Molloy
- Centre for Global Health, Institute for Infection and Immunity, St George’s University of London, United Kingdom
| | - Thomas S Harrison
- Centre for Global Health, Institute for Infection and Immunity, St George’s University of London, United Kingdom
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