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Giri A, Karkey A, Dangol S, Arjyal A, Pokharel S, Rijal S, Gajurel D, Sharma R, Lamsal K, Shrestha P, Prajapati G, Pathak S, Shrestha SR, K C RK, Pandey S, Thapa A, Shrestha N, Thapa RK, Poudyal B, Phuong DNT, Baker S, Kestelyn E, Geskus R, Thwaites G, Basnyat B. Trimethoprim-sulfamethoxazole Versus Azithromycin for the Treatment of Undifferentiated Febrile Illness in Nepal: A Double-blind, Randomized, Placebo-controlled Trial. Clin Infect Dis 2020; 73:e1478-e1486. [PMID: 32991678 PMCID: PMC8492158 DOI: 10.1093/cid/ciaa1489] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [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: 08/12/2020] [Indexed: 11/12/2022] Open
Abstract
Background Azithromycin and trimethoprim-sulfamethoxazole (SXT) are widely used to treat undifferentiated febrile illness (UFI). We hypothesized that azithromycin is superior to SXT for UFI treatment, but the drugs are noninferior to each other for culture-confirmed enteric fever treatment. Methods We conducted a double-blind, randomized, placebo-controlled trial of azithromycin (20 mg/kg/day) or SXT (trimethoprim 10 mg/kg/day plus sulfamethoxazole 50 mg/kg/day) orally for 7 days for UFI treatment in Nepal. We enrolled patients >2 years and <65 years of age presenting to 2 Kathmandu hospitals with temperature ≥38.0°C for ≥4 days without localizing signs. The primary endpoint was fever clearance time (FCT); secondary endpoints were treatment failure and adverse events. Results From June 2016 to May 2019, we randomized 326 participants (163 in each arm); 87 (26.7%) had blood culture–confirmed enteric fever. In all participants, the median FCT was 2.7 days (95% confidence interval [CI], 2.6–3.3 days) in the SXT arm and 2.1 days (95% CI, 1.6–3.2 days) in the azithromycin arm (hazard ratio [HR], 1.25 [95% CI, .99–1.58]; P = .059). The HR of treatment failures by 28 days between azithromycin and SXT was 0.62 (95% CI, .37–1.05; P = .073). Planned subgroup analysis showed that azithromycin resulted in faster FCT in those with sterile blood cultures and fewer relapses in culture-confirmed enteric fever. Nausea, vomiting, constipation, and headache were more common in the SXT arm. Conclusions Despite similar FCT and treatment failure in the 2 arms, significantly fewer complications and relapses make azithromycin a better choice for empirical treatment of UFI in Nepal. Clinical Trials Registration NCT02773407.
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Affiliation(s)
- Abhishek Giri
- Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Abhilasha Karkey
- Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Lalitpur, Nepal.,Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Sabina Dangol
- Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Lalitpur, Nepal.,Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Amit Arjyal
- Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Sunil Pokharel
- Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Samita Rijal
- Patan Academy of Health Sciences, Lalitpur, Nepal
| | | | - Rabi Sharma
- Civil Service Hospital, Minbhawan Kathmandu, Nepal
| | - Kamal Lamsal
- Civil Service Hospital, Minbhawan Kathmandu, Nepal
| | | | | | - Saruna Pathak
- Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Lalitpur, Nepal
| | | | - Raj Kumar K C
- Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Sujata Pandey
- Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Abishkar Thapa
- Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Nistha Shrestha
- Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Lalitpur, Nepal
| | | | | | | | - Stephen Baker
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.,University of Cambridge, Cambridge, United Kingdom
| | - Evelyne Kestelyn
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
| | - Ronald Geskus
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
| | - Guy Thwaites
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
| | - Buddha Basnyat
- Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Lalitpur, Nepal.,Patan Academy of Health Sciences, Lalitpur, Nepal.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
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Sharma GR, Joshi S, K C RK, Bhattachan M, Bhandari PK. Giant thrombosed aneurysm of P2 anterior segment of left posterior cerebral artery: Case Report and review of literature. Nep J Neurosci 2017. [DOI: 10.3126/njn.v14i3.20526] [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: 11/18/2022] Open
Abstract
P2A (anterior) segment aneurysm of posterior cerebral artery is one of the rare aneurysm of posterior circulation. We report a case of 30 years old right handed young man who presented with features of SAH in Emergency Department and cerebral angiogram confirmed left posterior cerebral artery P2A segment thrombosedfusi form aneurysm. Postoperative recovery was good except left sided ptosis after microsurgical trapping via left temporal approach. Treatment modality and outcome after intervention for P2A segment aneurysm will be discussed. Nepal Journal of Neuroscience, Volume 14, Number 3, 2017, Page : 42-45
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