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Lee H, Koo Y, Yun T, Lee D, Chae Y, Min KD, Kim H, Yang MP, Kang BT. A single-blind randomised study comparing the efficacy of fluconazole and itraconazole for the treatment of Malassezia dermatitis in client-owned dogs. Vet Dermatol 2024; 35:284-295. [PMID: 38169074 DOI: 10.1111/vde.13233] [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: 01/27/2023] [Revised: 09/30/2023] [Accepted: 12/16/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND No reports have compared the clinical therapeutic efficacy of fluconazole and itraconazole in canine Malassezia dermatitis. OBJECTIVES The study aimed to compare the clinical therapeutic efficacy of fluconazole and itraconazole and to evaluate the adverse effects of fluconazole in canine Malassezia dermatitis. ANIMALS Sixty-one client-owned dogs with Malassezia dermatitis. MATERIALS AND METHODS The enrolled animals were randomly divided into groups receiving 5 mg/kg fluconazole (5FZ), 10 mg/kg fluconazole (10FZ) or 5 mg/kg itraconazole (5IZ). The drugs were orally administered once daily for 28 days. Cytological examination, clinical index score (CIS), pruritus Visual Analog Scale (PVAS) evaluation and blood analysis (for 5FZ only) were performed on Day (D)0, D14 and D28. RESULTS On D14, significant reductions in mean yeast count (MYC), CIS and PVAS were observed in the 5FZ (n = 20, p < 0.01), 10FZ (n = 17, p < 0.01) and 5IZ (n = 16, p < 0.05) groups. In all three groups, a significant reduction (p < 0.001) in MYC, CIS and PVAS expression was observed on D28. There was no significant difference in the percentage reduction of MYC, CIS and PVAS among the groups. Moreover, there was a significant difference (p < 0.05) in each group between D14 and D28, except for the percentage reduction in MYC in the 10FZ and 5IZ groups. No adverse effects of fluconazole were observed in the 5FZ or 10FZ groups. CONCLUSIONS AND CLINICAL RELEVANCE This study indicates that 5FZ and 10FZ are as effective as itraconazole in canine Malassezia dermatitis.
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Affiliation(s)
- Hayoon Lee
- Laboratory of Veterinary Internal Medicine and Dermatology, College of Veterinary Medicine, Chungbuk National University, Cheongju, Chungbuk, Korea
| | - Yoonhoi Koo
- College of Veterinary Medicine, Kyungpook National University, Daegu, Korea
| | - Taesik Yun
- Laboratory of Veterinary Internal Medicine and Dermatology, College of Veterinary Medicine, Chungbuk National University, Cheongju, Chungbuk, Korea
| | - Dohee Lee
- Laboratory of Veterinary Internal Medicine and Dermatology, College of Veterinary Medicine, Chungbuk National University, Cheongju, Chungbuk, Korea
| | - Yeon Chae
- Laboratory of Veterinary Internal Medicine and Dermatology, College of Veterinary Medicine, Chungbuk National University, Cheongju, Chungbuk, Korea
| | - Kyung-Duk Min
- Laboratory of Veterinary Epidemiology, College of Veterinary Medicine, Chungbuk National University, Cheongju, Chungbuk, Korea
| | - Hakhyun Kim
- Laboratory of Veterinary Internal Medicine and Dermatology, College of Veterinary Medicine, Chungbuk National University, Cheongju, Chungbuk, Korea
| | - Mhan-Pyo Yang
- Laboratory of Veterinary Internal Medicine and Dermatology, College of Veterinary Medicine, Chungbuk National University, Cheongju, Chungbuk, Korea
| | - Byeong-Teck Kang
- Laboratory of Veterinary Internal Medicine and Dermatology, College of Veterinary Medicine, Chungbuk National University, Cheongju, Chungbuk, Korea
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Gupta C, Dogra P, Jain V, Kaur R, Sharma JB. HIV-associated disseminated cryptococcosis-An unusual clinical and diagnostic picture with successful cure by single dose liposomal amphotericin B treatment. Diagn Microbiol Infect Dis 2024; 109:116217. [PMID: 38513558 DOI: 10.1016/j.diagmicrobio.2024.116217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 02/15/2024] [Accepted: 02/15/2024] [Indexed: 03/23/2024]
Abstract
BACKGROUND Cryptococcosis is an invasive, opportunistic fungal infection seen especially in human immunodeficiency virus (HIV) infected patients. Cryptococcal meningitis (CM) is the second leading cause of mortality in HIV patients. We report a case of disseminated cryptococcosis presenting with altered mental status in a newly diagnosed HIV infection. METHODS AND RESULTS A 50-year-old with a short history of altered mental sensorium and a history of low-grade fever and weight loss for few months presented at a tertiary care hospital in North India. He was detected positive for HIV-1. Cryptococcal antigen (CRAG) was positive in Cerebrospinal fluid (CSF), and negative in serum. The fungal culture in CSF was sterile while the fungal blood culture grew Cryptococcus neoformans. The patient was treated with single high-dose Liposomal Amphotericin B (LAmB) therapy followed by Fluconazole and Flucytosine for the next two weeks followed by fluconazole daily for consolidation and maintenance therapy. Antiretroviral therapy (ART) was started 4 weeks after induction therapy. After 6 months, the patient is doing fine. CONCLUSION Single dose LAmB along with the backbone of fluconazole and flucytosine appears promising in disseminated cryptococcal infection in HIV-infected individuals.
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Affiliation(s)
- Chhavi Gupta
- Infectious disease, Yashoda Superpseciality Hospital, Kaushambi, India.
| | | | - Varun Jain
- Neuroanaesthesia and Critical Care, Fortis Hospital, Noida, India
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Aziz AYR, Mahfufah U, Syahirah NA, Habibie, Asri RM, Yulianty R, Kastian RF, Sari YW, Chabib L, Hamzah H, Permana AD. Dual delivery systems combining nanocrystals and dissolving microneedles for improved local vaginal delivery of fluconazole. Drug Deliv Transl Res 2024; 14:1678-1692. [PMID: 38036850 DOI: 10.1007/s13346-023-01483-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/13/2023] [Indexed: 12/02/2023]
Abstract
Fluconazole (FLZ) has been widely used in the treatment of infection caused by Candida albicans, including the treatment of vulvovaginal candidiasis (VVC). However, when delivered orally, FLZ faces numerous limitations due to its poor solubility and undergoes the symptoms of first-pass metabolism. In this study, we developed the combinatorial approach of nanocrystals (NCs) and dissolving microneedles (DMNs) for effective local vaginal delivery of FLZ. The formulation containing 1.0% w/v PVA as stabilizer with 12 h of milling time process was found to be an optimal combination to fabricate FLZ as NCs (FLZ-NCs) with optimum size particle and PDI value (less than 0.25). Furthermore, the in vitro release study also showed a superior percentage of FLZ release up to 89.51 ± 7.52%. In combination with the DMNs, the FLZ recovery was 96.45 ± 2.38% with the insertion percentage in average of 76.14 ± 2.28% and height decreased percentage was only 7.53 ± 0.56%. Moreover, the ex vivo investigation and anti-candidiasis activity of DMNs-FLZ-NCs in vaginal model showed better results compared to other conventional preparations, such as film patch and hydrogel containing FLZ.
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Affiliation(s)
| | - Ulfah Mahfufah
- Department of Pharmaceutics, Faculty of Pharmacy, Universitas Hasanuddin, Makassar, 90245, Indonesia
| | - Nor Atikah Syahirah
- Department of Pharmaceutics, Faculty of Pharmacy, Universitas Hasanuddin, Makassar, 90245, Indonesia
| | - Habibie
- Department of Pharmacology-Toxicology, Faculty of Pharmacy, Universitas Hasanuddin, Makassar, 90245, Indonesia
| | - Rangga Meidianto Asri
- Department of Pharmaceutics, Faculty of Pharmacy, Universitas Hasanuddin, Makassar, 90245, Indonesia
| | - Risfah Yulianty
- Department of Pharmaceutical Chemistry, Faculty of Pharmacy, Universitas Hasanuddin, Makassar, 90245, Indonesia
| | - Ria Fajarwati Kastian
- Center for Genetic Engineering, National Research and Innovation Agency (BRIN), Cibinong, 16911, Indonesia
| | | | - Lutfi Chabib
- Department of Pharmacy, Universitas Islam Indonesia, Yogyakarta, 55584, Indonesia
| | - Hasyrul Hamzah
- Faculty of Pharmacy, Universitas Muhammadiyah Kalimantan Timur, Samarinda, 75124, Indonesia
| | - Andi Dian Permana
- Department of Pharmaceutics, Faculty of Pharmacy, Universitas Hasanuddin, Makassar, 90245, Indonesia.
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Guo Q, Li Z, Cao F. Enhanced systematic delivery of fluconazole-loaded biotin-glutathione functionalized chitosan-g-proline carrier into the infected retinitis treatment. BMC Ophthalmol 2024; 24:48. [PMID: 38291379 PMCID: PMC10826221 DOI: 10.1186/s12886-024-03305-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 01/16/2024] [Indexed: 02/01/2024] Open
Abstract
BACKGROUND The polymer-based facile and effective drug carrier approach was developed to treat superficial fungal infected retinopathy infections. METHODS Here, biotin-glutathione (B-GHS) functionalized with chitosan grafted proline (CS-g-P) moieties were fabricated with the loading of fluconazole (FLZ) for the treatment of retinopathy. FT-IR and XRD techniques were used to characterize chemical structural and phase changes of the prepared carriers The SEM results show that the sphere morphology with interconnection particle nature. RESULTS The particle diameter was found as ~ 6.5 and ~ 8.6 nm for CS-g-P/B-GHS and FLZ-loaded CS-g-P/B-GHS carriers, respectively. The negative surface charge was found as the values of CS-g-P/B-GHS and FLZ-loaded CS-g-P/B-GHS, such as -20.7 mV and - 32.2 mV, from zeta potential analysis. The in-vitro FLZ releases from the CS-g-P/B-GHS were investigated at pH 7.4 (PBS) as the tear fluid environment, and it was observed at 85.02% of FLZ release in 8 h reaction time. The sustained release was observed, leading to the necessity for prolonged therapeutic effects. The antifungal effect of the carrier was studied by the minimum inhibitory concentration (MIC) and the percentage inhibition of viable fungal count against Candida albicans, and it observed 81.02% of the zone of inhibition by the FLZ carrier. CONCLUSION FLZ-loaded CS-g-P/B-GHS carrier could inhibit the biofilm formation in a concentration-dependent inhibition. Hence, A novel FLZ/B-GHS-CS-g-P carrier is a hopeful approach for effectively treating superficial fungal contaminations of the retina region.
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Affiliation(s)
- Qing Guo
- Ophthalmology, Department of Inner Mongolia Chaoju Eye Hospital, Hohhot Inner Mongolia, Hohhot, 010050, China
| | - Zheng Li
- Department of Ophthalmology, Affiliated Chenzhou Hospital, The First School of Clinical Medicine, Southern Medical University, The First People's Hospital of Chenzhou), Chenzhou, Hunan, 423000, China
| | - Fang Cao
- Department of Ophthalmology, The 940 Hospital of PLA Joint Logistic Support Force, Lanzhou, Gansu, 730050, China.
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Jarvis JN, Lawrence DS, Meya DB, Kagimu E, Kasibante J, Mpoza E, Rutakingirwa MK, Ssebambulidde K, Tugume L, Rhein J, Boulware DR, Mwandumba HC, Moyo M, Mzinganjira H, Kanyama C, Hosseinipour MC, Chawinga C, Meintjes G, Schutz C, Comins K, Singh A, Muzoora C, Jjunju S, Nuwagira E, Mosepele M, Leeme T, Siamisang K, Ndhlovu CE, Hlupeni A, Mutata C, van Widenfelt E, Chen T, Wang D, Hope W, Boyer-Chammard T, Loyse A, Molloy SF, Youssouf N, Lortholary O, Lalloo DG, Jaffar S, Harrison TS. Single-Dose Liposomal Amphotericin B Treatment for Cryptococcal Meningitis. N Engl J Med 2022; 386:1109-1120. [PMID: 35320642 PMCID: PMC7612678 DOI: 10.1056/nejmoa2111904] [Citation(s) in RCA: 96] [Impact Index Per Article: 48.0] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Cryptococcal meningitis is a leading cause of human immunodeficiency virus (HIV)-related death in sub-Saharan Africa. Whether a treatment regimen that includes a single high dose of liposomal amphotericin B would be efficacious is not known. METHODS In this phase 3 randomized, controlled, noninferiority trial conducted in five African countries, we assigned HIV-positive adults with cryptococcal meningitis in a 1:1 ratio to receive either a single high dose of liposomal amphotericin B (10 mg per kilogram of body weight) on day 1 plus 14 days of flucytosine (100 mg per kilogram per day) and fluconazole (1200 mg per day) or the current World Health Organization-recommended treatment, which includes amphotericin B deoxycholate (1 mg per kilogram per day) plus flucytosine (100 mg per kilogram per day) for 7 days, followed by fluconazole (1200 mg per day) for 7 days (control). The primary end point was death from any cause at 10 weeks; the trial was powered to show noninferiority at a 10-percentage-point margin. RESULTS A total of 844 participants underwent randomization; 814 were included in the intention-to-treat population. At 10 weeks, deaths were reported in 101 participants (24.8%; 95% confidence interval [CI], 20.7 to 29.3) in the liposomal amphotericin B group and 117 (28.7%; 95% CI, 24.4 to 33.4) in the control group (difference, -3.9 percentage points); the upper boundary of the one-sided 95% confidence interval was 1.2 percentage points (within the noninferiority margin; P<0.001 for noninferiority). Fungal clearance from cerebrospinal fluid was -0.40 log10 colony-forming units (CFU) per milliliter per day in the liposomal amphotericin B group and -0.42 log10 CFU per milliliter per day in the control group. Fewer participants had grade 3 or 4 adverse events in the liposomal amphotericin B group than in the control group (50.0% vs. 62.3%). CONCLUSIONS Single-dose liposomal amphotericin B combined with flucytosine and fluconazole was noninferior to the WHO-recommended treatment for HIV-associated cryptococcal meningitis and was associated with fewer adverse events. (Funded by the European and Developing Countries Clinical Trials Partnership and others; Ambition ISRCTN number, ISRCTN72509687.).
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Affiliation(s)
- Joseph N Jarvis
- From the Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine (J.N.J., D.S.L., N.Y.), the Institute for Infection and Immunity, St. George's University London (A.L., S.F.M., T.S.H.), and the Clinical Academic Group in Infection and Immunity, St. George's University Hospitals NHS Foundation Trust (T.S.H.), London, Liverpool School of Tropical Medicine (H.C.M., E.W., D.W., D.G.L., S. Jaffar) and the Department of Public Health, Policy, and Systems, Institute of Population Health (T.C.), and the Department of Pharmacology and Therapeutics, Institute of Systems, Molecular, and Integrative Biology (W.H.), University of Liverpool, Liverpool, and the Medical Research Council Centre for Medical Mycology, University of Exeter, Exeter (T.S.H.) - all in the United Kingdom; the Botswana-Harvard AIDS Institute Partnership (J.N.J., D.S.L., M. Mosepele, T.L., K. Siamisang, N.Y.), the Departments of Internal Medicine (M. Mosepele) and Family Medicine and Public Health (K. Siamisang), University of Botswana, and the Department of Health Services Management, Ministry of Health and Wellness (K. Siamisang) - all in Gaborone, Botswana; the Infectious Diseases Institute, College of Health Sciences (D.B.M., E.K., J.K., E.M., M.K.R., K. Ssebambulidde, L.T., J.R., D.R.B., S. Jjunju, E.N.), and the Department of Medicine, School of Medicine (D.B.M.), Makerere University, Kampala, and Mbarara University of Science and Technology, Mbarara (C. Muzoora, E.N.) - both in Uganda; the University of Minnesota, Minneapolis (D.B.M., J.R., D.R.B.); the Malawi-Liverpool-Wellcome Trust Clinical Research Programme (H.C.M., M. Moyo, H.M., D.G.L.) and the Department of Medicine, Kamuzu University of Health Sciences (H.C.M., M. Moyo), Blantyre, and the Lilongwe Medical Relief Fund Trust (University of North Carolina-Malawi Project), Lilongwe (C.K., M.C.H., C.C.) - all in Malawi; the Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill (M.C.H.); the Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine (G.M., C.S., K.C., A.S.), and the Department of Medicine (G.M., C.S., K.C.), University of Cape Town, and the Department of Radiology, Groote Schuur Hospital (A.S.) - both in Cape Town, South Africa; the Internal Medicine Unit, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare (C.E.N., A.H., C. Mutata); Institut Pasteur, National Center for Scientific Research, Molecular Mycology Unit and National Reference Center for Invasive Mycoses and Antifungals, Unités Mixtes de Recherche 2000, and Université de Paris, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, Hôpital Necker Enfants Malades, Assistance Publique-Hôpitaux de Paris, Institut Hospitalo-Universitaire Imagine - both in Paris (T.B.-C., O.L.)
| | - David S Lawrence
- From the Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine (J.N.J., D.S.L., N.Y.), the Institute for Infection and Immunity, St. George's University London (A.L., S.F.M., T.S.H.), and the Clinical Academic Group in Infection and Immunity, St. George's University Hospitals NHS Foundation Trust (T.S.H.), London, Liverpool School of Tropical Medicine (H.C.M., E.W., D.W., D.G.L., S. Jaffar) and the Department of Public Health, Policy, and Systems, Institute of Population Health (T.C.), and the Department of Pharmacology and Therapeutics, Institute of Systems, Molecular, and Integrative Biology (W.H.), University of Liverpool, Liverpool, and the Medical Research Council Centre for Medical Mycology, University of Exeter, Exeter (T.S.H.) - all in the United Kingdom; the Botswana-Harvard AIDS Institute Partnership (J.N.J., D.S.L., M. Mosepele, T.L., K. Siamisang, N.Y.), the Departments of Internal Medicine (M. Mosepele) and Family Medicine and Public Health (K. Siamisang), University of Botswana, and the Department of Health Services Management, Ministry of Health and Wellness (K. Siamisang) - all in Gaborone, Botswana; the Infectious Diseases Institute, College of Health Sciences (D.B.M., E.K., J.K., E.M., M.K.R., K. Ssebambulidde, L.T., J.R., D.R.B., S. Jjunju, E.N.), and the Department of Medicine, School of Medicine (D.B.M.), Makerere University, Kampala, and Mbarara University of Science and Technology, Mbarara (C. Muzoora, E.N.) - both in Uganda; the University of Minnesota, Minneapolis (D.B.M., J.R., D.R.B.); the Malawi-Liverpool-Wellcome Trust Clinical Research Programme (H.C.M., M. Moyo, H.M., D.G.L.) and the Department of Medicine, Kamuzu University of Health Sciences (H.C.M., M. Moyo), Blantyre, and the Lilongwe Medical Relief Fund Trust (University of North Carolina-Malawi Project), Lilongwe (C.K., M.C.H., C.C.) - all in Malawi; the Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill (M.C.H.); the Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine (G.M., C.S., K.C., A.S.), and the Department of Medicine (G.M., C.S., K.C.), University of Cape Town, and the Department of Radiology, Groote Schuur Hospital (A.S.) - both in Cape Town, South Africa; the Internal Medicine Unit, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare (C.E.N., A.H., C. Mutata); Institut Pasteur, National Center for Scientific Research, Molecular Mycology Unit and National Reference Center for Invasive Mycoses and Antifungals, Unités Mixtes de Recherche 2000, and Université de Paris, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, Hôpital Necker Enfants Malades, Assistance Publique-Hôpitaux de Paris, Institut Hospitalo-Universitaire Imagine - both in Paris (T.B.-C., O.L.)
| | - David B Meya
- From the Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine (J.N.J., D.S.L., N.Y.), the Institute for Infection and Immunity, St. George's University London (A.L., S.F.M., T.S.H.), and the Clinical Academic Group in Infection and Immunity, St. George's University Hospitals NHS Foundation Trust (T.S.H.), London, Liverpool School of Tropical Medicine (H.C.M., E.W., D.W., D.G.L., S. Jaffar) and the Department of Public Health, Policy, and Systems, Institute of Population Health (T.C.), and the Department of Pharmacology and Therapeutics, Institute of Systems, Molecular, and Integrative Biology (W.H.), University of Liverpool, Liverpool, and the Medical Research Council Centre for Medical Mycology, University of Exeter, Exeter (T.S.H.) - all in the United Kingdom; the Botswana-Harvard AIDS Institute Partnership (J.N.J., D.S.L., M. Mosepele, T.L., K. Siamisang, N.Y.), the Departments of Internal Medicine (M. Mosepele) and Family Medicine and Public Health (K. Siamisang), University of Botswana, and the Department of Health Services Management, Ministry of Health and Wellness (K. Siamisang) - all in Gaborone, Botswana; the Infectious Diseases Institute, College of Health Sciences (D.B.M., E.K., J.K., E.M., M.K.R., K. Ssebambulidde, L.T., J.R., D.R.B., S. Jjunju, E.N.), and the Department of Medicine, School of Medicine (D.B.M.), Makerere University, Kampala, and Mbarara University of Science and Technology, Mbarara (C. Muzoora, E.N.) - both in Uganda; the University of Minnesota, Minneapolis (D.B.M., J.R., D.R.B.); the Malawi-Liverpool-Wellcome Trust Clinical Research Programme (H.C.M., M. Moyo, H.M., D.G.L.) and the Department of Medicine, Kamuzu University of Health Sciences (H.C.M., M. Moyo), Blantyre, and the Lilongwe Medical Relief Fund Trust (University of North Carolina-Malawi Project), Lilongwe (C.K., M.C.H., C.C.) - all in Malawi; the Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill (M.C.H.); the Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine (G.M., C.S., K.C., A.S.), and the Department of Medicine (G.M., C.S., K.C.), University of Cape Town, and the Department of Radiology, Groote Schuur Hospital (A.S.) - both in Cape Town, South Africa; the Internal Medicine Unit, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare (C.E.N., A.H., C. Mutata); Institut Pasteur, National Center for Scientific Research, Molecular Mycology Unit and National Reference Center for Invasive Mycoses and Antifungals, Unités Mixtes de Recherche 2000, and Université de Paris, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, Hôpital Necker Enfants Malades, Assistance Publique-Hôpitaux de Paris, Institut Hospitalo-Universitaire Imagine - both in Paris (T.B.-C., O.L.)
| | - Enock Kagimu
- From the Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine (J.N.J., D.S.L., N.Y.), the Institute for Infection and Immunity, St. George's University London (A.L., S.F.M., T.S.H.), and the Clinical Academic Group in Infection and Immunity, St. George's University Hospitals NHS Foundation Trust (T.S.H.), London, Liverpool School of Tropical Medicine (H.C.M., E.W., D.W., D.G.L., S. Jaffar) and the Department of Public Health, Policy, and Systems, Institute of Population Health (T.C.), and the Department of Pharmacology and Therapeutics, Institute of Systems, Molecular, and Integrative Biology (W.H.), University of Liverpool, Liverpool, and the Medical Research Council Centre for Medical Mycology, University of Exeter, Exeter (T.S.H.) - all in the United Kingdom; the Botswana-Harvard AIDS Institute Partnership (J.N.J., D.S.L., M. Mosepele, T.L., K. Siamisang, N.Y.), the Departments of Internal Medicine (M. Mosepele) and Family Medicine and Public Health (K. Siamisang), University of Botswana, and the Department of Health Services Management, Ministry of Health and Wellness (K. Siamisang) - all in Gaborone, Botswana; the Infectious Diseases Institute, College of Health Sciences (D.B.M., E.K., J.K., E.M., M.K.R., K. Ssebambulidde, L.T., J.R., D.R.B., S. Jjunju, E.N.), and the Department of Medicine, School of Medicine (D.B.M.), Makerere University, Kampala, and Mbarara University of Science and Technology, Mbarara (C. Muzoora, E.N.) - both in Uganda; the University of Minnesota, Minneapolis (D.B.M., J.R., D.R.B.); the Malawi-Liverpool-Wellcome Trust Clinical Research Programme (H.C.M., M. Moyo, H.M., D.G.L.) and the Department of Medicine, Kamuzu University of Health Sciences (H.C.M., M. Moyo), Blantyre, and the Lilongwe Medical Relief Fund Trust (University of North Carolina-Malawi Project), Lilongwe (C.K., M.C.H., C.C.) - all in Malawi; the Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill (M.C.H.); the Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine (G.M., C.S., K.C., A.S.), and the Department of Medicine (G.M., C.S., K.C.), University of Cape Town, and the Department of Radiology, Groote Schuur Hospital (A.S.) - both in Cape Town, South Africa; the Internal Medicine Unit, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare (C.E.N., A.H., C. Mutata); Institut Pasteur, National Center for Scientific Research, Molecular Mycology Unit and National Reference Center for Invasive Mycoses and Antifungals, Unités Mixtes de Recherche 2000, and Université de Paris, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, Hôpital Necker Enfants Malades, Assistance Publique-Hôpitaux de Paris, Institut Hospitalo-Universitaire Imagine - both in Paris (T.B.-C., O.L.)
| | - John Kasibante
- From the Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine (J.N.J., D.S.L., N.Y.), the Institute for Infection and Immunity, St. George's University London (A.L., S.F.M., T.S.H.), and the Clinical Academic Group in Infection and Immunity, St. George's University Hospitals NHS Foundation Trust (T.S.H.), London, Liverpool School of Tropical Medicine (H.C.M., E.W., D.W., D.G.L., S. Jaffar) and the Department of Public Health, Policy, and Systems, Institute of Population Health (T.C.), and the Department of Pharmacology and Therapeutics, Institute of Systems, Molecular, and Integrative Biology (W.H.), University of Liverpool, Liverpool, and the Medical Research Council Centre for Medical Mycology, University of Exeter, Exeter (T.S.H.) - all in the United Kingdom; the Botswana-Harvard AIDS Institute Partnership (J.N.J., D.S.L., M. Mosepele, T.L., K. Siamisang, N.Y.), the Departments of Internal Medicine (M. Mosepele) and Family Medicine and Public Health (K. Siamisang), University of Botswana, and the Department of Health Services Management, Ministry of Health and Wellness (K. Siamisang) - all in Gaborone, Botswana; the Infectious Diseases Institute, College of Health Sciences (D.B.M., E.K., J.K., E.M., M.K.R., K. Ssebambulidde, L.T., J.R., D.R.B., S. Jjunju, E.N.), and the Department of Medicine, School of Medicine (D.B.M.), Makerere University, Kampala, and Mbarara University of Science and Technology, Mbarara (C. Muzoora, E.N.) - both in Uganda; the University of Minnesota, Minneapolis (D.B.M., J.R., D.R.B.); the Malawi-Liverpool-Wellcome Trust Clinical Research Programme (H.C.M., M. Moyo, H.M., D.G.L.) and the Department of Medicine, Kamuzu University of Health Sciences (H.C.M., M. Moyo), Blantyre, and the Lilongwe Medical Relief Fund Trust (University of North Carolina-Malawi Project), Lilongwe (C.K., M.C.H., C.C.) - all in Malawi; the Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill (M.C.H.); the Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine (G.M., C.S., K.C., A.S.), and the Department of Medicine (G.M., C.S., K.C.), University of Cape Town, and the Department of Radiology, Groote Schuur Hospital (A.S.) - both in Cape Town, South Africa; the Internal Medicine Unit, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare (C.E.N., A.H., C. Mutata); Institut Pasteur, National Center for Scientific Research, Molecular Mycology Unit and National Reference Center for Invasive Mycoses and Antifungals, Unités Mixtes de Recherche 2000, and Université de Paris, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, Hôpital Necker Enfants Malades, Assistance Publique-Hôpitaux de Paris, Institut Hospitalo-Universitaire Imagine - both in Paris (T.B.-C., O.L.)
| | - Edward Mpoza
- From the Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine (J.N.J., D.S.L., N.Y.), the Institute for Infection and Immunity, St. George's University London (A.L., S.F.M., T.S.H.), and the Clinical Academic Group in Infection and Immunity, St. George's University Hospitals NHS Foundation Trust (T.S.H.), London, Liverpool School of Tropical Medicine (H.C.M., E.W., D.W., D.G.L., S. Jaffar) and the Department of Public Health, Policy, and Systems, Institute of Population Health (T.C.), and the Department of Pharmacology and Therapeutics, Institute of Systems, Molecular, and Integrative Biology (W.H.), University of Liverpool, Liverpool, and the Medical Research Council Centre for Medical Mycology, University of Exeter, Exeter (T.S.H.) - all in the United Kingdom; the Botswana-Harvard AIDS Institute Partnership (J.N.J., D.S.L., M. Mosepele, T.L., K. Siamisang, N.Y.), the Departments of Internal Medicine (M. Mosepele) and Family Medicine and Public Health (K. Siamisang), University of Botswana, and the Department of Health Services Management, Ministry of Health and Wellness (K. Siamisang) - all in Gaborone, Botswana; the Infectious Diseases Institute, College of Health Sciences (D.B.M., E.K., J.K., E.M., M.K.R., K. Ssebambulidde, L.T., J.R., D.R.B., S. Jjunju, E.N.), and the Department of Medicine, School of Medicine (D.B.M.), Makerere University, Kampala, and Mbarara University of Science and Technology, Mbarara (C. Muzoora, E.N.) - both in Uganda; the University of Minnesota, Minneapolis (D.B.M., J.R., D.R.B.); the Malawi-Liverpool-Wellcome Trust Clinical Research Programme (H.C.M., M. Moyo, H.M., D.G.L.) and the Department of Medicine, Kamuzu University of Health Sciences (H.C.M., M. Moyo), Blantyre, and the Lilongwe Medical Relief Fund Trust (University of North Carolina-Malawi Project), Lilongwe (C.K., M.C.H., C.C.) - all in Malawi; the Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill (M.C.H.); the Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine (G.M., C.S., K.C., A.S.), and the Department of Medicine (G.M., C.S., K.C.), University of Cape Town, and the Department of Radiology, Groote Schuur Hospital (A.S.) - both in Cape Town, South Africa; the Internal Medicine Unit, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare (C.E.N., A.H., C. Mutata); Institut Pasteur, National Center for Scientific Research, Molecular Mycology Unit and National Reference Center for Invasive Mycoses and Antifungals, Unités Mixtes de Recherche 2000, and Université de Paris, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, Hôpital Necker Enfants Malades, Assistance Publique-Hôpitaux de Paris, Institut Hospitalo-Universitaire Imagine - both in Paris (T.B.-C., O.L.)
| | - Morris K Rutakingirwa
- From the Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine (J.N.J., D.S.L., N.Y.), the Institute for Infection and Immunity, St. George's University London (A.L., S.F.M., T.S.H.), and the Clinical Academic Group in Infection and Immunity, St. George's University Hospitals NHS Foundation Trust (T.S.H.), London, Liverpool School of Tropical Medicine (H.C.M., E.W., D.W., D.G.L., S. Jaffar) and the Department of Public Health, Policy, and Systems, Institute of Population Health (T.C.), and the Department of Pharmacology and Therapeutics, Institute of Systems, Molecular, and Integrative Biology (W.H.), University of Liverpool, Liverpool, and the Medical Research Council Centre for Medical Mycology, University of Exeter, Exeter (T.S.H.) - all in the United Kingdom; the Botswana-Harvard AIDS Institute Partnership (J.N.J., D.S.L., M. Mosepele, T.L., K. Siamisang, N.Y.), the Departments of Internal Medicine (M. Mosepele) and Family Medicine and Public Health (K. Siamisang), University of Botswana, and the Department of Health Services Management, Ministry of Health and Wellness (K. Siamisang) - all in Gaborone, Botswana; the Infectious Diseases Institute, College of Health Sciences (D.B.M., E.K., J.K., E.M., M.K.R., K. Ssebambulidde, L.T., J.R., D.R.B., S. Jjunju, E.N.), and the Department of Medicine, School of Medicine (D.B.M.), Makerere University, Kampala, and Mbarara University of Science and Technology, Mbarara (C. Muzoora, E.N.) - both in Uganda; the University of Minnesota, Minneapolis (D.B.M., J.R., D.R.B.); the Malawi-Liverpool-Wellcome Trust Clinical Research Programme (H.C.M., M. Moyo, H.M., D.G.L.) and the Department of Medicine, Kamuzu University of Health Sciences (H.C.M., M. Moyo), Blantyre, and the Lilongwe Medical Relief Fund Trust (University of North Carolina-Malawi Project), Lilongwe (C.K., M.C.H., C.C.) - all in Malawi; the Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill (M.C.H.); the Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine (G.M., C.S., K.C., A.S.), and the Department of Medicine (G.M., C.S., K.C.), University of Cape Town, and the Department of Radiology, Groote Schuur Hospital (A.S.) - both in Cape Town, South Africa; the Internal Medicine Unit, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare (C.E.N., A.H., C. Mutata); Institut Pasteur, National Center for Scientific Research, Molecular Mycology Unit and National Reference Center for Invasive Mycoses and Antifungals, Unités Mixtes de Recherche 2000, and Université de Paris, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, Hôpital Necker Enfants Malades, Assistance Publique-Hôpitaux de Paris, Institut Hospitalo-Universitaire Imagine - both in Paris (T.B.-C., O.L.)
| | - Kenneth Ssebambulidde
- From the Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine (J.N.J., D.S.L., N.Y.), the Institute for Infection and Immunity, St. George's University London (A.L., S.F.M., T.S.H.), and the Clinical Academic Group in Infection and Immunity, St. George's University Hospitals NHS Foundation Trust (T.S.H.), London, Liverpool School of Tropical Medicine (H.C.M., E.W., D.W., D.G.L., S. Jaffar) and the Department of Public Health, Policy, and Systems, Institute of Population Health (T.C.), and the Department of Pharmacology and Therapeutics, Institute of Systems, Molecular, and Integrative Biology (W.H.), University of Liverpool, Liverpool, and the Medical Research Council Centre for Medical Mycology, University of Exeter, Exeter (T.S.H.) - all in the United Kingdom; the Botswana-Harvard AIDS Institute Partnership (J.N.J., D.S.L., M. Mosepele, T.L., K. Siamisang, N.Y.), the Departments of Internal Medicine (M. Mosepele) and Family Medicine and Public Health (K. Siamisang), University of Botswana, and the Department of Health Services Management, Ministry of Health and Wellness (K. Siamisang) - all in Gaborone, Botswana; the Infectious Diseases Institute, College of Health Sciences (D.B.M., E.K., J.K., E.M., M.K.R., K. Ssebambulidde, L.T., J.R., D.R.B., S. Jjunju, E.N.), and the Department of Medicine, School of Medicine (D.B.M.), Makerere University, Kampala, and Mbarara University of Science and Technology, Mbarara (C. Muzoora, E.N.) - both in Uganda; the University of Minnesota, Minneapolis (D.B.M., J.R., D.R.B.); the Malawi-Liverpool-Wellcome Trust Clinical Research Programme (H.C.M., M. Moyo, H.M., D.G.L.) and the Department of Medicine, Kamuzu University of Health Sciences (H.C.M., M. Moyo), Blantyre, and the Lilongwe Medical Relief Fund Trust (University of North Carolina-Malawi Project), Lilongwe (C.K., M.C.H., C.C.) - all in Malawi; the Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill (M.C.H.); the Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine (G.M., C.S., K.C., A.S.), and the Department of Medicine (G.M., C.S., K.C.), University of Cape Town, and the Department of Radiology, Groote Schuur Hospital (A.S.) - both in Cape Town, South Africa; the Internal Medicine Unit, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare (C.E.N., A.H., C. Mutata); Institut Pasteur, National Center for Scientific Research, Molecular Mycology Unit and National Reference Center for Invasive Mycoses and Antifungals, Unités Mixtes de Recherche 2000, and Université de Paris, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, Hôpital Necker Enfants Malades, Assistance Publique-Hôpitaux de Paris, Institut Hospitalo-Universitaire Imagine - both in Paris (T.B.-C., O.L.)
| | - Lillian Tugume
- From the Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine (J.N.J., D.S.L., N.Y.), the Institute for Infection and Immunity, St. George's University London (A.L., S.F.M., T.S.H.), and the Clinical Academic Group in Infection and Immunity, St. George's University Hospitals NHS Foundation Trust (T.S.H.), London, Liverpool School of Tropical Medicine (H.C.M., E.W., D.W., D.G.L., S. Jaffar) and the Department of Public Health, Policy, and Systems, Institute of Population Health (T.C.), and the Department of Pharmacology and Therapeutics, Institute of Systems, Molecular, and Integrative Biology (W.H.), University of Liverpool, Liverpool, and the Medical Research Council Centre for Medical Mycology, University of Exeter, Exeter (T.S.H.) - all in the United Kingdom; the Botswana-Harvard AIDS Institute Partnership (J.N.J., D.S.L., M. Mosepele, T.L., K. Siamisang, N.Y.), the Departments of Internal Medicine (M. Mosepele) and Family Medicine and Public Health (K. Siamisang), University of Botswana, and the Department of Health Services Management, Ministry of Health and Wellness (K. Siamisang) - all in Gaborone, Botswana; the Infectious Diseases Institute, College of Health Sciences (D.B.M., E.K., J.K., E.M., M.K.R., K. Ssebambulidde, L.T., J.R., D.R.B., S. Jjunju, E.N.), and the Department of Medicine, School of Medicine (D.B.M.), Makerere University, Kampala, and Mbarara University of Science and Technology, Mbarara (C. Muzoora, E.N.) - both in Uganda; the University of Minnesota, Minneapolis (D.B.M., J.R., D.R.B.); the Malawi-Liverpool-Wellcome Trust Clinical Research Programme (H.C.M., M. Moyo, H.M., D.G.L.) and the Department of Medicine, Kamuzu University of Health Sciences (H.C.M., M. Moyo), Blantyre, and the Lilongwe Medical Relief Fund Trust (University of North Carolina-Malawi Project), Lilongwe (C.K., M.C.H., C.C.) - all in Malawi; the Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill (M.C.H.); the Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine (G.M., C.S., K.C., A.S.), and the Department of Medicine (G.M., C.S., K.C.), University of Cape Town, and the Department of Radiology, Groote Schuur Hospital (A.S.) - both in Cape Town, South Africa; the Internal Medicine Unit, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare (C.E.N., A.H., C. Mutata); Institut Pasteur, National Center for Scientific Research, Molecular Mycology Unit and National Reference Center for Invasive Mycoses and Antifungals, Unités Mixtes de Recherche 2000, and Université de Paris, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, Hôpital Necker Enfants Malades, Assistance Publique-Hôpitaux de Paris, Institut Hospitalo-Universitaire Imagine - both in Paris (T.B.-C., O.L.)
| | - Joshua Rhein
- From the Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine (J.N.J., D.S.L., N.Y.), the Institute for Infection and Immunity, St. George's University London (A.L., S.F.M., T.S.H.), and the Clinical Academic Group in Infection and Immunity, St. George's University Hospitals NHS Foundation Trust (T.S.H.), London, Liverpool School of Tropical Medicine (H.C.M., E.W., D.W., D.G.L., S. Jaffar) and the Department of Public Health, Policy, and Systems, Institute of Population Health (T.C.), and the Department of Pharmacology and Therapeutics, Institute of Systems, Molecular, and Integrative Biology (W.H.), University of Liverpool, Liverpool, and the Medical Research Council Centre for Medical Mycology, University of Exeter, Exeter (T.S.H.) - all in the United Kingdom; the Botswana-Harvard AIDS Institute Partnership (J.N.J., D.S.L., M. Mosepele, T.L., K. Siamisang, N.Y.), the Departments of Internal Medicine (M. Mosepele) and Family Medicine and Public Health (K. Siamisang), University of Botswana, and the Department of Health Services Management, Ministry of Health and Wellness (K. Siamisang) - all in Gaborone, Botswana; the Infectious Diseases Institute, College of Health Sciences (D.B.M., E.K., J.K., E.M., M.K.R., K. Ssebambulidde, L.T., J.R., D.R.B., S. Jjunju, E.N.), and the Department of Medicine, School of Medicine (D.B.M.), Makerere University, Kampala, and Mbarara University of Science and Technology, Mbarara (C. Muzoora, E.N.) - both in Uganda; the University of Minnesota, Minneapolis (D.B.M., J.R., D.R.B.); the Malawi-Liverpool-Wellcome Trust Clinical Research Programme (H.C.M., M. Moyo, H.M., D.G.L.) and the Department of Medicine, Kamuzu University of Health Sciences (H.C.M., M. Moyo), Blantyre, and the Lilongwe Medical Relief Fund Trust (University of North Carolina-Malawi Project), Lilongwe (C.K., M.C.H., C.C.) - all in Malawi; the Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill (M.C.H.); the Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine (G.M., C.S., K.C., A.S.), and the Department of Medicine (G.M., C.S., K.C.), University of Cape Town, and the Department of Radiology, Groote Schuur Hospital (A.S.) - both in Cape Town, South Africa; the Internal Medicine Unit, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare (C.E.N., A.H., C. Mutata); Institut Pasteur, National Center for Scientific Research, Molecular Mycology Unit and National Reference Center for Invasive Mycoses and Antifungals, Unités Mixtes de Recherche 2000, and Université de Paris, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, Hôpital Necker Enfants Malades, Assistance Publique-Hôpitaux de Paris, Institut Hospitalo-Universitaire Imagine - both in Paris (T.B.-C., O.L.)
| | - David R Boulware
- From the Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine (J.N.J., D.S.L., N.Y.), the Institute for Infection and Immunity, St. George's University London (A.L., S.F.M., T.S.H.), and the Clinical Academic Group in Infection and Immunity, St. George's University Hospitals NHS Foundation Trust (T.S.H.), London, Liverpool School of Tropical Medicine (H.C.M., E.W., D.W., D.G.L., S. Jaffar) and the Department of Public Health, Policy, and Systems, Institute of Population Health (T.C.), and the Department of Pharmacology and Therapeutics, Institute of Systems, Molecular, and Integrative Biology (W.H.), University of Liverpool, Liverpool, and the Medical Research Council Centre for Medical Mycology, University of Exeter, Exeter (T.S.H.) - all in the United Kingdom; the Botswana-Harvard AIDS Institute Partnership (J.N.J., D.S.L., M. Mosepele, T.L., K. Siamisang, N.Y.), the Departments of Internal Medicine (M. Mosepele) and Family Medicine and Public Health (K. Siamisang), University of Botswana, and the Department of Health Services Management, Ministry of Health and Wellness (K. Siamisang) - all in Gaborone, Botswana; the Infectious Diseases Institute, College of Health Sciences (D.B.M., E.K., J.K., E.M., M.K.R., K. Ssebambulidde, L.T., J.R., D.R.B., S. Jjunju, E.N.), and the Department of Medicine, School of Medicine (D.B.M.), Makerere University, Kampala, and Mbarara University of Science and Technology, Mbarara (C. Muzoora, E.N.) - both in Uganda; the University of Minnesota, Minneapolis (D.B.M., J.R., D.R.B.); the Malawi-Liverpool-Wellcome Trust Clinical Research Programme (H.C.M., M. Moyo, H.M., D.G.L.) and the Department of Medicine, Kamuzu University of Health Sciences (H.C.M., M. Moyo), Blantyre, and the Lilongwe Medical Relief Fund Trust (University of North Carolina-Malawi Project), Lilongwe (C.K., M.C.H., C.C.) - all in Malawi; the Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill (M.C.H.); the Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine (G.M., C.S., K.C., A.S.), and the Department of Medicine (G.M., C.S., K.C.), University of Cape Town, and the Department of Radiology, Groote Schuur Hospital (A.S.) - both in Cape Town, South Africa; the Internal Medicine Unit, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare (C.E.N., A.H., C. Mutata); Institut Pasteur, National Center for Scientific Research, Molecular Mycology Unit and National Reference Center for Invasive Mycoses and Antifungals, Unités Mixtes de Recherche 2000, and Université de Paris, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, Hôpital Necker Enfants Malades, Assistance Publique-Hôpitaux de Paris, Institut Hospitalo-Universitaire Imagine - both in Paris (T.B.-C., O.L.)
| | - Henry C Mwandumba
- From the Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine (J.N.J., D.S.L., N.Y.), the Institute for Infection and Immunity, St. George's University London (A.L., S.F.M., T.S.H.), and the Clinical Academic Group in Infection and Immunity, St. George's University Hospitals NHS Foundation Trust (T.S.H.), London, Liverpool School of Tropical Medicine (H.C.M., E.W., D.W., D.G.L., S. Jaffar) and the Department of Public Health, Policy, and Systems, Institute of Population Health (T.C.), and the Department of Pharmacology and Therapeutics, Institute of Systems, Molecular, and Integrative Biology (W.H.), University of Liverpool, Liverpool, and the Medical Research Council Centre for Medical Mycology, University of Exeter, Exeter (T.S.H.) - all in the United Kingdom; the Botswana-Harvard AIDS Institute Partnership (J.N.J., D.S.L., M. Mosepele, T.L., K. Siamisang, N.Y.), the Departments of Internal Medicine (M. Mosepele) and Family Medicine and Public Health (K. Siamisang), University of Botswana, and the Department of Health Services Management, Ministry of Health and Wellness (K. Siamisang) - all in Gaborone, Botswana; the Infectious Diseases Institute, College of Health Sciences (D.B.M., E.K., J.K., E.M., M.K.R., K. Ssebambulidde, L.T., J.R., D.R.B., S. Jjunju, E.N.), and the Department of Medicine, School of Medicine (D.B.M.), Makerere University, Kampala, and Mbarara University of Science and Technology, Mbarara (C. Muzoora, E.N.) - both in Uganda; the University of Minnesota, Minneapolis (D.B.M., J.R., D.R.B.); the Malawi-Liverpool-Wellcome Trust Clinical Research Programme (H.C.M., M. Moyo, H.M., D.G.L.) and the Department of Medicine, Kamuzu University of Health Sciences (H.C.M., M. Moyo), Blantyre, and the Lilongwe Medical Relief Fund Trust (University of North Carolina-Malawi Project), Lilongwe (C.K., M.C.H., C.C.) - all in Malawi; the Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill (M.C.H.); the Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine (G.M., C.S., K.C., A.S.), and the Department of Medicine (G.M., C.S., K.C.), University of Cape Town, and the Department of Radiology, Groote Schuur Hospital (A.S.) - both in Cape Town, South Africa; the Internal Medicine Unit, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare (C.E.N., A.H., C. Mutata); Institut Pasteur, National Center for Scientific Research, Molecular Mycology Unit and National Reference Center for Invasive Mycoses and Antifungals, Unités Mixtes de Recherche 2000, and Université de Paris, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, Hôpital Necker Enfants Malades, Assistance Publique-Hôpitaux de Paris, Institut Hospitalo-Universitaire Imagine - both in Paris (T.B.-C., O.L.)
| | - Melanie Moyo
- From the Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine (J.N.J., D.S.L., N.Y.), the Institute for Infection and Immunity, St. George's University London (A.L., S.F.M., T.S.H.), and the Clinical Academic Group in Infection and Immunity, St. George's University Hospitals NHS Foundation Trust (T.S.H.), London, Liverpool School of Tropical Medicine (H.C.M., E.W., D.W., D.G.L., S. Jaffar) and the Department of Public Health, Policy, and Systems, Institute of Population Health (T.C.), and the Department of Pharmacology and Therapeutics, Institute of Systems, Molecular, and Integrative Biology (W.H.), University of Liverpool, Liverpool, and the Medical Research Council Centre for Medical Mycology, University of Exeter, Exeter (T.S.H.) - all in the United Kingdom; the Botswana-Harvard AIDS Institute Partnership (J.N.J., D.S.L., M. Mosepele, T.L., K. Siamisang, N.Y.), the Departments of Internal Medicine (M. Mosepele) and Family Medicine and Public Health (K. Siamisang), University of Botswana, and the Department of Health Services Management, Ministry of Health and Wellness (K. Siamisang) - all in Gaborone, Botswana; the Infectious Diseases Institute, College of Health Sciences (D.B.M., E.K., J.K., E.M., M.K.R., K. Ssebambulidde, L.T., J.R., D.R.B., S. Jjunju, E.N.), and the Department of Medicine, School of Medicine (D.B.M.), Makerere University, Kampala, and Mbarara University of Science and Technology, Mbarara (C. Muzoora, E.N.) - both in Uganda; the University of Minnesota, Minneapolis (D.B.M., J.R., D.R.B.); the Malawi-Liverpool-Wellcome Trust Clinical Research Programme (H.C.M., M. Moyo, H.M., D.G.L.) and the Department of Medicine, Kamuzu University of Health Sciences (H.C.M., M. Moyo), Blantyre, and the Lilongwe Medical Relief Fund Trust (University of North Carolina-Malawi Project), Lilongwe (C.K., M.C.H., C.C.) - all in Malawi; the Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill (M.C.H.); the Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine (G.M., C.S., K.C., A.S.), and the Department of Medicine (G.M., C.S., K.C.), University of Cape Town, and the Department of Radiology, Groote Schuur Hospital (A.S.) - both in Cape Town, South Africa; the Internal Medicine Unit, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare (C.E.N., A.H., C. Mutata); Institut Pasteur, National Center for Scientific Research, Molecular Mycology Unit and National Reference Center for Invasive Mycoses and Antifungals, Unités Mixtes de Recherche 2000, and Université de Paris, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, Hôpital Necker Enfants Malades, Assistance Publique-Hôpitaux de Paris, Institut Hospitalo-Universitaire Imagine - both in Paris (T.B.-C., O.L.)
| | - Henry Mzinganjira
- From the Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine (J.N.J., D.S.L., N.Y.), the Institute for Infection and Immunity, St. George's University London (A.L., S.F.M., T.S.H.), and the Clinical Academic Group in Infection and Immunity, St. George's University Hospitals NHS Foundation Trust (T.S.H.), London, Liverpool School of Tropical Medicine (H.C.M., E.W., D.W., D.G.L., S. Jaffar) and the Department of Public Health, Policy, and Systems, Institute of Population Health (T.C.), and the Department of Pharmacology and Therapeutics, Institute of Systems, Molecular, and Integrative Biology (W.H.), University of Liverpool, Liverpool, and the Medical Research Council Centre for Medical Mycology, University of Exeter, Exeter (T.S.H.) - all in the United Kingdom; the Botswana-Harvard AIDS Institute Partnership (J.N.J., D.S.L., M. Mosepele, T.L., K. Siamisang, N.Y.), the Departments of Internal Medicine (M. Mosepele) and Family Medicine and Public Health (K. Siamisang), University of Botswana, and the Department of Health Services Management, Ministry of Health and Wellness (K. Siamisang) - all in Gaborone, Botswana; the Infectious Diseases Institute, College of Health Sciences (D.B.M., E.K., J.K., E.M., M.K.R., K. Ssebambulidde, L.T., J.R., D.R.B., S. Jjunju, E.N.), and the Department of Medicine, School of Medicine (D.B.M.), Makerere University, Kampala, and Mbarara University of Science and Technology, Mbarara (C. Muzoora, E.N.) - both in Uganda; the University of Minnesota, Minneapolis (D.B.M., J.R., D.R.B.); the Malawi-Liverpool-Wellcome Trust Clinical Research Programme (H.C.M., M. Moyo, H.M., D.G.L.) and the Department of Medicine, Kamuzu University of Health Sciences (H.C.M., M. Moyo), Blantyre, and the Lilongwe Medical Relief Fund Trust (University of North Carolina-Malawi Project), Lilongwe (C.K., M.C.H., C.C.) - all in Malawi; the Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill (M.C.H.); the Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine (G.M., C.S., K.C., A.S.), and the Department of Medicine (G.M., C.S., K.C.), University of Cape Town, and the Department of Radiology, Groote Schuur Hospital (A.S.) - both in Cape Town, South Africa; the Internal Medicine Unit, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare (C.E.N., A.H., C. Mutata); Institut Pasteur, National Center for Scientific Research, Molecular Mycology Unit and National Reference Center for Invasive Mycoses and Antifungals, Unités Mixtes de Recherche 2000, and Université de Paris, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, Hôpital Necker Enfants Malades, Assistance Publique-Hôpitaux de Paris, Institut Hospitalo-Universitaire Imagine - both in Paris (T.B.-C., O.L.)
| | - Cecilia Kanyama
- From the Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine (J.N.J., D.S.L., N.Y.), the Institute for Infection and Immunity, St. George's University London (A.L., S.F.M., T.S.H.), and the Clinical Academic Group in Infection and Immunity, St. George's University Hospitals NHS Foundation Trust (T.S.H.), London, Liverpool School of Tropical Medicine (H.C.M., E.W., D.W., D.G.L., S. Jaffar) and the Department of Public Health, Policy, and Systems, Institute of Population Health (T.C.), and the Department of Pharmacology and Therapeutics, Institute of Systems, Molecular, and Integrative Biology (W.H.), University of Liverpool, Liverpool, and the Medical Research Council Centre for Medical Mycology, University of Exeter, Exeter (T.S.H.) - all in the United Kingdom; the Botswana-Harvard AIDS Institute Partnership (J.N.J., D.S.L., M. Mosepele, T.L., K. Siamisang, N.Y.), the Departments of Internal Medicine (M. Mosepele) and Family Medicine and Public Health (K. Siamisang), University of Botswana, and the Department of Health Services Management, Ministry of Health and Wellness (K. Siamisang) - all in Gaborone, Botswana; the Infectious Diseases Institute, College of Health Sciences (D.B.M., E.K., J.K., E.M., M.K.R., K. Ssebambulidde, L.T., J.R., D.R.B., S. Jjunju, E.N.), and the Department of Medicine, School of Medicine (D.B.M.), Makerere University, Kampala, and Mbarara University of Science and Technology, Mbarara (C. Muzoora, E.N.) - both in Uganda; the University of Minnesota, Minneapolis (D.B.M., J.R., D.R.B.); the Malawi-Liverpool-Wellcome Trust Clinical Research Programme (H.C.M., M. Moyo, H.M., D.G.L.) and the Department of Medicine, Kamuzu University of Health Sciences (H.C.M., M. Moyo), Blantyre, and the Lilongwe Medical Relief Fund Trust (University of North Carolina-Malawi Project), Lilongwe (C.K., M.C.H., C.C.) - all in Malawi; the Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill (M.C.H.); the Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine (G.M., C.S., K.C., A.S.), and the Department of Medicine (G.M., C.S., K.C.), University of Cape Town, and the Department of Radiology, Groote Schuur Hospital (A.S.) - both in Cape Town, South Africa; the Internal Medicine Unit, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare (C.E.N., A.H., C. Mutata); Institut Pasteur, National Center for Scientific Research, Molecular Mycology Unit and National Reference Center for Invasive Mycoses and Antifungals, Unités Mixtes de Recherche 2000, and Université de Paris, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, Hôpital Necker Enfants Malades, Assistance Publique-Hôpitaux de Paris, Institut Hospitalo-Universitaire Imagine - both in Paris (T.B.-C., O.L.)
| | - Mina C Hosseinipour
- From the Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine (J.N.J., D.S.L., N.Y.), the Institute for Infection and Immunity, St. George's University London (A.L., S.F.M., T.S.H.), and the Clinical Academic Group in Infection and Immunity, St. George's University Hospitals NHS Foundation Trust (T.S.H.), London, Liverpool School of Tropical Medicine (H.C.M., E.W., D.W., D.G.L., S. Jaffar) and the Department of Public Health, Policy, and Systems, Institute of Population Health (T.C.), and the Department of Pharmacology and Therapeutics, Institute of Systems, Molecular, and Integrative Biology (W.H.), University of Liverpool, Liverpool, and the Medical Research Council Centre for Medical Mycology, University of Exeter, Exeter (T.S.H.) - all in the United Kingdom; the Botswana-Harvard AIDS Institute Partnership (J.N.J., D.S.L., M. Mosepele, T.L., K. Siamisang, N.Y.), the Departments of Internal Medicine (M. Mosepele) and Family Medicine and Public Health (K. Siamisang), University of Botswana, and the Department of Health Services Management, Ministry of Health and Wellness (K. Siamisang) - all in Gaborone, Botswana; the Infectious Diseases Institute, College of Health Sciences (D.B.M., E.K., J.K., E.M., M.K.R., K. Ssebambulidde, L.T., J.R., D.R.B., S. Jjunju, E.N.), and the Department of Medicine, School of Medicine (D.B.M.), Makerere University, Kampala, and Mbarara University of Science and Technology, Mbarara (C. Muzoora, E.N.) - both in Uganda; the University of Minnesota, Minneapolis (D.B.M., J.R., D.R.B.); the Malawi-Liverpool-Wellcome Trust Clinical Research Programme (H.C.M., M. Moyo, H.M., D.G.L.) and the Department of Medicine, Kamuzu University of Health Sciences (H.C.M., M. Moyo), Blantyre, and the Lilongwe Medical Relief Fund Trust (University of North Carolina-Malawi Project), Lilongwe (C.K., M.C.H., C.C.) - all in Malawi; the Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill (M.C.H.); the Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine (G.M., C.S., K.C., A.S.), and the Department of Medicine (G.M., C.S., K.C.), University of Cape Town, and the Department of Radiology, Groote Schuur Hospital (A.S.) - both in Cape Town, South Africa; the Internal Medicine Unit, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare (C.E.N., A.H., C. Mutata); Institut Pasteur, National Center for Scientific Research, Molecular Mycology Unit and National Reference Center for Invasive Mycoses and Antifungals, Unités Mixtes de Recherche 2000, and Université de Paris, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, Hôpital Necker Enfants Malades, Assistance Publique-Hôpitaux de Paris, Institut Hospitalo-Universitaire Imagine - both in Paris (T.B.-C., O.L.)
| | - Chimwemwe Chawinga
- From the Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine (J.N.J., D.S.L., N.Y.), the Institute for Infection and Immunity, St. George's University London (A.L., S.F.M., T.S.H.), and the Clinical Academic Group in Infection and Immunity, St. George's University Hospitals NHS Foundation Trust (T.S.H.), London, Liverpool School of Tropical Medicine (H.C.M., E.W., D.W., D.G.L., S. Jaffar) and the Department of Public Health, Policy, and Systems, Institute of Population Health (T.C.), and the Department of Pharmacology and Therapeutics, Institute of Systems, Molecular, and Integrative Biology (W.H.), University of Liverpool, Liverpool, and the Medical Research Council Centre for Medical Mycology, University of Exeter, Exeter (T.S.H.) - all in the United Kingdom; the Botswana-Harvard AIDS Institute Partnership (J.N.J., D.S.L., M. Mosepele, T.L., K. Siamisang, N.Y.), the Departments of Internal Medicine (M. Mosepele) and Family Medicine and Public Health (K. Siamisang), University of Botswana, and the Department of Health Services Management, Ministry of Health and Wellness (K. Siamisang) - all in Gaborone, Botswana; the Infectious Diseases Institute, College of Health Sciences (D.B.M., E.K., J.K., E.M., M.K.R., K. Ssebambulidde, L.T., J.R., D.R.B., S. Jjunju, E.N.), and the Department of Medicine, School of Medicine (D.B.M.), Makerere University, Kampala, and Mbarara University of Science and Technology, Mbarara (C. Muzoora, E.N.) - both in Uganda; the University of Minnesota, Minneapolis (D.B.M., J.R., D.R.B.); the Malawi-Liverpool-Wellcome Trust Clinical Research Programme (H.C.M., M. Moyo, H.M., D.G.L.) and the Department of Medicine, Kamuzu University of Health Sciences (H.C.M., M. Moyo), Blantyre, and the Lilongwe Medical Relief Fund Trust (University of North Carolina-Malawi Project), Lilongwe (C.K., M.C.H., C.C.) - all in Malawi; the Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill (M.C.H.); the Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine (G.M., C.S., K.C., A.S.), and the Department of Medicine (G.M., C.S., K.C.), University of Cape Town, and the Department of Radiology, Groote Schuur Hospital (A.S.) - both in Cape Town, South Africa; the Internal Medicine Unit, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare (C.E.N., A.H., C. Mutata); Institut Pasteur, National Center for Scientific Research, Molecular Mycology Unit and National Reference Center for Invasive Mycoses and Antifungals, Unités Mixtes de Recherche 2000, and Université de Paris, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, Hôpital Necker Enfants Malades, Assistance Publique-Hôpitaux de Paris, Institut Hospitalo-Universitaire Imagine - both in Paris (T.B.-C., O.L.)
| | - Graeme Meintjes
- From the Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine (J.N.J., D.S.L., N.Y.), the Institute for Infection and Immunity, St. George's University London (A.L., S.F.M., T.S.H.), and the Clinical Academic Group in Infection and Immunity, St. George's University Hospitals NHS Foundation Trust (T.S.H.), London, Liverpool School of Tropical Medicine (H.C.M., E.W., D.W., D.G.L., S. Jaffar) and the Department of Public Health, Policy, and Systems, Institute of Population Health (T.C.), and the Department of Pharmacology and Therapeutics, Institute of Systems, Molecular, and Integrative Biology (W.H.), University of Liverpool, Liverpool, and the Medical Research Council Centre for Medical Mycology, University of Exeter, Exeter (T.S.H.) - all in the United Kingdom; the Botswana-Harvard AIDS Institute Partnership (J.N.J., D.S.L., M. Mosepele, T.L., K. Siamisang, N.Y.), the Departments of Internal Medicine (M. Mosepele) and Family Medicine and Public Health (K. Siamisang), University of Botswana, and the Department of Health Services Management, Ministry of Health and Wellness (K. Siamisang) - all in Gaborone, Botswana; the Infectious Diseases Institute, College of Health Sciences (D.B.M., E.K., J.K., E.M., M.K.R., K. Ssebambulidde, L.T., J.R., D.R.B., S. Jjunju, E.N.), and the Department of Medicine, School of Medicine (D.B.M.), Makerere University, Kampala, and Mbarara University of Science and Technology, Mbarara (C. Muzoora, E.N.) - both in Uganda; the University of Minnesota, Minneapolis (D.B.M., J.R., D.R.B.); the Malawi-Liverpool-Wellcome Trust Clinical Research Programme (H.C.M., M. Moyo, H.M., D.G.L.) and the Department of Medicine, Kamuzu University of Health Sciences (H.C.M., M. Moyo), Blantyre, and the Lilongwe Medical Relief Fund Trust (University of North Carolina-Malawi Project), Lilongwe (C.K., M.C.H., C.C.) - all in Malawi; the Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill (M.C.H.); the Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine (G.M., C.S., K.C., A.S.), and the Department of Medicine (G.M., C.S., K.C.), University of Cape Town, and the Department of Radiology, Groote Schuur Hospital (A.S.) - both in Cape Town, South Africa; the Internal Medicine Unit, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare (C.E.N., A.H., C. Mutata); Institut Pasteur, National Center for Scientific Research, Molecular Mycology Unit and National Reference Center for Invasive Mycoses and Antifungals, Unités Mixtes de Recherche 2000, and Université de Paris, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, Hôpital Necker Enfants Malades, Assistance Publique-Hôpitaux de Paris, Institut Hospitalo-Universitaire Imagine - both in Paris (T.B.-C., O.L.)
| | - Charlotte Schutz
- From the Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine (J.N.J., D.S.L., N.Y.), the Institute for Infection and Immunity, St. George's University London (A.L., S.F.M., T.S.H.), and the Clinical Academic Group in Infection and Immunity, St. George's University Hospitals NHS Foundation Trust (T.S.H.), London, Liverpool School of Tropical Medicine (H.C.M., E.W., D.W., D.G.L., S. Jaffar) and the Department of Public Health, Policy, and Systems, Institute of Population Health (T.C.), and the Department of Pharmacology and Therapeutics, Institute of Systems, Molecular, and Integrative Biology (W.H.), University of Liverpool, Liverpool, and the Medical Research Council Centre for Medical Mycology, University of Exeter, Exeter (T.S.H.) - all in the United Kingdom; the Botswana-Harvard AIDS Institute Partnership (J.N.J., D.S.L., M. Mosepele, T.L., K. Siamisang, N.Y.), the Departments of Internal Medicine (M. Mosepele) and Family Medicine and Public Health (K. Siamisang), University of Botswana, and the Department of Health Services Management, Ministry of Health and Wellness (K. Siamisang) - all in Gaborone, Botswana; the Infectious Diseases Institute, College of Health Sciences (D.B.M., E.K., J.K., E.M., M.K.R., K. Ssebambulidde, L.T., J.R., D.R.B., S. Jjunju, E.N.), and the Department of Medicine, School of Medicine (D.B.M.), Makerere University, Kampala, and Mbarara University of Science and Technology, Mbarara (C. Muzoora, E.N.) - both in Uganda; the University of Minnesota, Minneapolis (D.B.M., J.R., D.R.B.); the Malawi-Liverpool-Wellcome Trust Clinical Research Programme (H.C.M., M. Moyo, H.M., D.G.L.) and the Department of Medicine, Kamuzu University of Health Sciences (H.C.M., M. Moyo), Blantyre, and the Lilongwe Medical Relief Fund Trust (University of North Carolina-Malawi Project), Lilongwe (C.K., M.C.H., C.C.) - all in Malawi; the Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill (M.C.H.); the Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine (G.M., C.S., K.C., A.S.), and the Department of Medicine (G.M., C.S., K.C.), University of Cape Town, and the Department of Radiology, Groote Schuur Hospital (A.S.) - both in Cape Town, South Africa; the Internal Medicine Unit, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare (C.E.N., A.H., C. Mutata); Institut Pasteur, National Center for Scientific Research, Molecular Mycology Unit and National Reference Center for Invasive Mycoses and Antifungals, Unités Mixtes de Recherche 2000, and Université de Paris, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, Hôpital Necker Enfants Malades, Assistance Publique-Hôpitaux de Paris, Institut Hospitalo-Universitaire Imagine - both in Paris (T.B.-C., O.L.)
| | - Kyla Comins
- From the Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine (J.N.J., D.S.L., N.Y.), the Institute for Infection and Immunity, St. George's University London (A.L., S.F.M., T.S.H.), and the Clinical Academic Group in Infection and Immunity, St. George's University Hospitals NHS Foundation Trust (T.S.H.), London, Liverpool School of Tropical Medicine (H.C.M., E.W., D.W., D.G.L., S. Jaffar) and the Department of Public Health, Policy, and Systems, Institute of Population Health (T.C.), and the Department of Pharmacology and Therapeutics, Institute of Systems, Molecular, and Integrative Biology (W.H.), University of Liverpool, Liverpool, and the Medical Research Council Centre for Medical Mycology, University of Exeter, Exeter (T.S.H.) - all in the United Kingdom; the Botswana-Harvard AIDS Institute Partnership (J.N.J., D.S.L., M. Mosepele, T.L., K. Siamisang, N.Y.), the Departments of Internal Medicine (M. Mosepele) and Family Medicine and Public Health (K. Siamisang), University of Botswana, and the Department of Health Services Management, Ministry of Health and Wellness (K. Siamisang) - all in Gaborone, Botswana; the Infectious Diseases Institute, College of Health Sciences (D.B.M., E.K., J.K., E.M., M.K.R., K. Ssebambulidde, L.T., J.R., D.R.B., S. Jjunju, E.N.), and the Department of Medicine, School of Medicine (D.B.M.), Makerere University, Kampala, and Mbarara University of Science and Technology, Mbarara (C. Muzoora, E.N.) - both in Uganda; the University of Minnesota, Minneapolis (D.B.M., J.R., D.R.B.); the Malawi-Liverpool-Wellcome Trust Clinical Research Programme (H.C.M., M. Moyo, H.M., D.G.L.) and the Department of Medicine, Kamuzu University of Health Sciences (H.C.M., M. Moyo), Blantyre, and the Lilongwe Medical Relief Fund Trust (University of North Carolina-Malawi Project), Lilongwe (C.K., M.C.H., C.C.) - all in Malawi; the Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill (M.C.H.); the Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine (G.M., C.S., K.C., A.S.), and the Department of Medicine (G.M., C.S., K.C.), University of Cape Town, and the Department of Radiology, Groote Schuur Hospital (A.S.) - both in Cape Town, South Africa; the Internal Medicine Unit, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare (C.E.N., A.H., C. Mutata); Institut Pasteur, National Center for Scientific Research, Molecular Mycology Unit and National Reference Center for Invasive Mycoses and Antifungals, Unités Mixtes de Recherche 2000, and Université de Paris, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, Hôpital Necker Enfants Malades, Assistance Publique-Hôpitaux de Paris, Institut Hospitalo-Universitaire Imagine - both in Paris (T.B.-C., O.L.)
| | - Achita Singh
- From the Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine (J.N.J., D.S.L., N.Y.), the Institute for Infection and Immunity, St. George's University London (A.L., S.F.M., T.S.H.), and the Clinical Academic Group in Infection and Immunity, St. George's University Hospitals NHS Foundation Trust (T.S.H.), London, Liverpool School of Tropical Medicine (H.C.M., E.W., D.W., D.G.L., S. Jaffar) and the Department of Public Health, Policy, and Systems, Institute of Population Health (T.C.), and the Department of Pharmacology and Therapeutics, Institute of Systems, Molecular, and Integrative Biology (W.H.), University of Liverpool, Liverpool, and the Medical Research Council Centre for Medical Mycology, University of Exeter, Exeter (T.S.H.) - all in the United Kingdom; the Botswana-Harvard AIDS Institute Partnership (J.N.J., D.S.L., M. Mosepele, T.L., K. Siamisang, N.Y.), the Departments of Internal Medicine (M. Mosepele) and Family Medicine and Public Health (K. Siamisang), University of Botswana, and the Department of Health Services Management, Ministry of Health and Wellness (K. Siamisang) - all in Gaborone, Botswana; the Infectious Diseases Institute, College of Health Sciences (D.B.M., E.K., J.K., E.M., M.K.R., K. Ssebambulidde, L.T., J.R., D.R.B., S. Jjunju, E.N.), and the Department of Medicine, School of Medicine (D.B.M.), Makerere University, Kampala, and Mbarara University of Science and Technology, Mbarara (C. Muzoora, E.N.) - both in Uganda; the University of Minnesota, Minneapolis (D.B.M., J.R., D.R.B.); the Malawi-Liverpool-Wellcome Trust Clinical Research Programme (H.C.M., M. Moyo, H.M., D.G.L.) and the Department of Medicine, Kamuzu University of Health Sciences (H.C.M., M. Moyo), Blantyre, and the Lilongwe Medical Relief Fund Trust (University of North Carolina-Malawi Project), Lilongwe (C.K., M.C.H., C.C.) - all in Malawi; the Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill (M.C.H.); the Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine (G.M., C.S., K.C., A.S.), and the Department of Medicine (G.M., C.S., K.C.), University of Cape Town, and the Department of Radiology, Groote Schuur Hospital (A.S.) - both in Cape Town, South Africa; the Internal Medicine Unit, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare (C.E.N., A.H., C. Mutata); Institut Pasteur, National Center for Scientific Research, Molecular Mycology Unit and National Reference Center for Invasive Mycoses and Antifungals, Unités Mixtes de Recherche 2000, and Université de Paris, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, Hôpital Necker Enfants Malades, Assistance Publique-Hôpitaux de Paris, Institut Hospitalo-Universitaire Imagine - both in Paris (T.B.-C., O.L.)
| | - Conrad Muzoora
- From the Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine (J.N.J., D.S.L., N.Y.), the Institute for Infection and Immunity, St. George's University London (A.L., S.F.M., T.S.H.), and the Clinical Academic Group in Infection and Immunity, St. George's University Hospitals NHS Foundation Trust (T.S.H.), London, Liverpool School of Tropical Medicine (H.C.M., E.W., D.W., D.G.L., S. Jaffar) and the Department of Public Health, Policy, and Systems, Institute of Population Health (T.C.), and the Department of Pharmacology and Therapeutics, Institute of Systems, Molecular, and Integrative Biology (W.H.), University of Liverpool, Liverpool, and the Medical Research Council Centre for Medical Mycology, University of Exeter, Exeter (T.S.H.) - all in the United Kingdom; the Botswana-Harvard AIDS Institute Partnership (J.N.J., D.S.L., M. Mosepele, T.L., K. Siamisang, N.Y.), the Departments of Internal Medicine (M. Mosepele) and Family Medicine and Public Health (K. Siamisang), University of Botswana, and the Department of Health Services Management, Ministry of Health and Wellness (K. Siamisang) - all in Gaborone, Botswana; the Infectious Diseases Institute, College of Health Sciences (D.B.M., E.K., J.K., E.M., M.K.R., K. Ssebambulidde, L.T., J.R., D.R.B., S. Jjunju, E.N.), and the Department of Medicine, School of Medicine (D.B.M.), Makerere University, Kampala, and Mbarara University of Science and Technology, Mbarara (C. Muzoora, E.N.) - both in Uganda; the University of Minnesota, Minneapolis (D.B.M., J.R., D.R.B.); the Malawi-Liverpool-Wellcome Trust Clinical Research Programme (H.C.M., M. Moyo, H.M., D.G.L.) and the Department of Medicine, Kamuzu University of Health Sciences (H.C.M., M. Moyo), Blantyre, and the Lilongwe Medical Relief Fund Trust (University of North Carolina-Malawi Project), Lilongwe (C.K., M.C.H., C.C.) - all in Malawi; the Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill (M.C.H.); the Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine (G.M., C.S., K.C., A.S.), and the Department of Medicine (G.M., C.S., K.C.), University of Cape Town, and the Department of Radiology, Groote Schuur Hospital (A.S.) - both in Cape Town, South Africa; the Internal Medicine Unit, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare (C.E.N., A.H., C. Mutata); Institut Pasteur, National Center for Scientific Research, Molecular Mycology Unit and National Reference Center for Invasive Mycoses and Antifungals, Unités Mixtes de Recherche 2000, and Université de Paris, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, Hôpital Necker Enfants Malades, Assistance Publique-Hôpitaux de Paris, Institut Hospitalo-Universitaire Imagine - both in Paris (T.B.-C., O.L.)
| | - Samuel Jjunju
- From the Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine (J.N.J., D.S.L., N.Y.), the Institute for Infection and Immunity, St. George's University London (A.L., S.F.M., T.S.H.), and the Clinical Academic Group in Infection and Immunity, St. George's University Hospitals NHS Foundation Trust (T.S.H.), London, Liverpool School of Tropical Medicine (H.C.M., E.W., D.W., D.G.L., S. Jaffar) and the Department of Public Health, Policy, and Systems, Institute of Population Health (T.C.), and the Department of Pharmacology and Therapeutics, Institute of Systems, Molecular, and Integrative Biology (W.H.), University of Liverpool, Liverpool, and the Medical Research Council Centre for Medical Mycology, University of Exeter, Exeter (T.S.H.) - all in the United Kingdom; the Botswana-Harvard AIDS Institute Partnership (J.N.J., D.S.L., M. Mosepele, T.L., K. Siamisang, N.Y.), the Departments of Internal Medicine (M. Mosepele) and Family Medicine and Public Health (K. Siamisang), University of Botswana, and the Department of Health Services Management, Ministry of Health and Wellness (K. Siamisang) - all in Gaborone, Botswana; the Infectious Diseases Institute, College of Health Sciences (D.B.M., E.K., J.K., E.M., M.K.R., K. Ssebambulidde, L.T., J.R., D.R.B., S. Jjunju, E.N.), and the Department of Medicine, School of Medicine (D.B.M.), Makerere University, Kampala, and Mbarara University of Science and Technology, Mbarara (C. Muzoora, E.N.) - both in Uganda; the University of Minnesota, Minneapolis (D.B.M., J.R., D.R.B.); the Malawi-Liverpool-Wellcome Trust Clinical Research Programme (H.C.M., M. Moyo, H.M., D.G.L.) and the Department of Medicine, Kamuzu University of Health Sciences (H.C.M., M. Moyo), Blantyre, and the Lilongwe Medical Relief Fund Trust (University of North Carolina-Malawi Project), Lilongwe (C.K., M.C.H., C.C.) - all in Malawi; the Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill (M.C.H.); the Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine (G.M., C.S., K.C., A.S.), and the Department of Medicine (G.M., C.S., K.C.), University of Cape Town, and the Department of Radiology, Groote Schuur Hospital (A.S.) - both in Cape Town, South Africa; the Internal Medicine Unit, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare (C.E.N., A.H., C. Mutata); Institut Pasteur, National Center for Scientific Research, Molecular Mycology Unit and National Reference Center for Invasive Mycoses and Antifungals, Unités Mixtes de Recherche 2000, and Université de Paris, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, Hôpital Necker Enfants Malades, Assistance Publique-Hôpitaux de Paris, Institut Hospitalo-Universitaire Imagine - both in Paris (T.B.-C., O.L.)
| | - Edwin Nuwagira
- From the Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine (J.N.J., D.S.L., N.Y.), the Institute for Infection and Immunity, St. George's University London (A.L., S.F.M., T.S.H.), and the Clinical Academic Group in Infection and Immunity, St. George's University Hospitals NHS Foundation Trust (T.S.H.), London, Liverpool School of Tropical Medicine (H.C.M., E.W., D.W., D.G.L., S. Jaffar) and the Department of Public Health, Policy, and Systems, Institute of Population Health (T.C.), and the Department of Pharmacology and Therapeutics, Institute of Systems, Molecular, and Integrative Biology (W.H.), University of Liverpool, Liverpool, and the Medical Research Council Centre for Medical Mycology, University of Exeter, Exeter (T.S.H.) - all in the United Kingdom; the Botswana-Harvard AIDS Institute Partnership (J.N.J., D.S.L., M. Mosepele, T.L., K. Siamisang, N.Y.), the Departments of Internal Medicine (M. Mosepele) and Family Medicine and Public Health (K. Siamisang), University of Botswana, and the Department of Health Services Management, Ministry of Health and Wellness (K. Siamisang) - all in Gaborone, Botswana; the Infectious Diseases Institute, College of Health Sciences (D.B.M., E.K., J.K., E.M., M.K.R., K. Ssebambulidde, L.T., J.R., D.R.B., S. Jjunju, E.N.), and the Department of Medicine, School of Medicine (D.B.M.), Makerere University, Kampala, and Mbarara University of Science and Technology, Mbarara (C. Muzoora, E.N.) - both in Uganda; the University of Minnesota, Minneapolis (D.B.M., J.R., D.R.B.); the Malawi-Liverpool-Wellcome Trust Clinical Research Programme (H.C.M., M. Moyo, H.M., D.G.L.) and the Department of Medicine, Kamuzu University of Health Sciences (H.C.M., M. Moyo), Blantyre, and the Lilongwe Medical Relief Fund Trust (University of North Carolina-Malawi Project), Lilongwe (C.K., M.C.H., C.C.) - all in Malawi; the Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill (M.C.H.); the Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine (G.M., C.S., K.C., A.S.), and the Department of Medicine (G.M., C.S., K.C.), University of Cape Town, and the Department of Radiology, Groote Schuur Hospital (A.S.) - both in Cape Town, South Africa; the Internal Medicine Unit, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare (C.E.N., A.H., C. Mutata); Institut Pasteur, National Center for Scientific Research, Molecular Mycology Unit and National Reference Center for Invasive Mycoses and Antifungals, Unités Mixtes de Recherche 2000, and Université de Paris, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, Hôpital Necker Enfants Malades, Assistance Publique-Hôpitaux de Paris, Institut Hospitalo-Universitaire Imagine - both in Paris (T.B.-C., O.L.)
| | - Mosepele Mosepele
- From the Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine (J.N.J., D.S.L., N.Y.), the Institute for Infection and Immunity, St. George's University London (A.L., S.F.M., T.S.H.), and the Clinical Academic Group in Infection and Immunity, St. George's University Hospitals NHS Foundation Trust (T.S.H.), London, Liverpool School of Tropical Medicine (H.C.M., E.W., D.W., D.G.L., S. Jaffar) and the Department of Public Health, Policy, and Systems, Institute of Population Health (T.C.), and the Department of Pharmacology and Therapeutics, Institute of Systems, Molecular, and Integrative Biology (W.H.), University of Liverpool, Liverpool, and the Medical Research Council Centre for Medical Mycology, University of Exeter, Exeter (T.S.H.) - all in the United Kingdom; the Botswana-Harvard AIDS Institute Partnership (J.N.J., D.S.L., M. Mosepele, T.L., K. Siamisang, N.Y.), the Departments of Internal Medicine (M. Mosepele) and Family Medicine and Public Health (K. Siamisang), University of Botswana, and the Department of Health Services Management, Ministry of Health and Wellness (K. Siamisang) - all in Gaborone, Botswana; the Infectious Diseases Institute, College of Health Sciences (D.B.M., E.K., J.K., E.M., M.K.R., K. Ssebambulidde, L.T., J.R., D.R.B., S. Jjunju, E.N.), and the Department of Medicine, School of Medicine (D.B.M.), Makerere University, Kampala, and Mbarara University of Science and Technology, Mbarara (C. Muzoora, E.N.) - both in Uganda; the University of Minnesota, Minneapolis (D.B.M., J.R., D.R.B.); the Malawi-Liverpool-Wellcome Trust Clinical Research Programme (H.C.M., M. Moyo, H.M., D.G.L.) and the Department of Medicine, Kamuzu University of Health Sciences (H.C.M., M. Moyo), Blantyre, and the Lilongwe Medical Relief Fund Trust (University of North Carolina-Malawi Project), Lilongwe (C.K., M.C.H., C.C.) - all in Malawi; the Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill (M.C.H.); the Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine (G.M., C.S., K.C., A.S.), and the Department of Medicine (G.M., C.S., K.C.), University of Cape Town, and the Department of Radiology, Groote Schuur Hospital (A.S.) - both in Cape Town, South Africa; the Internal Medicine Unit, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare (C.E.N., A.H., C. Mutata); Institut Pasteur, National Center for Scientific Research, Molecular Mycology Unit and National Reference Center for Invasive Mycoses and Antifungals, Unités Mixtes de Recherche 2000, and Université de Paris, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, Hôpital Necker Enfants Malades, Assistance Publique-Hôpitaux de Paris, Institut Hospitalo-Universitaire Imagine - both in Paris (T.B.-C., O.L.)
| | - Tshepo Leeme
- From the Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine (J.N.J., D.S.L., N.Y.), the Institute for Infection and Immunity, St. George's University London (A.L., S.F.M., T.S.H.), and the Clinical Academic Group in Infection and Immunity, St. George's University Hospitals NHS Foundation Trust (T.S.H.), London, Liverpool School of Tropical Medicine (H.C.M., E.W., D.W., D.G.L., S. Jaffar) and the Department of Public Health, Policy, and Systems, Institute of Population Health (T.C.), and the Department of Pharmacology and Therapeutics, Institute of Systems, Molecular, and Integrative Biology (W.H.), University of Liverpool, Liverpool, and the Medical Research Council Centre for Medical Mycology, University of Exeter, Exeter (T.S.H.) - all in the United Kingdom; the Botswana-Harvard AIDS Institute Partnership (J.N.J., D.S.L., M. Mosepele, T.L., K. Siamisang, N.Y.), the Departments of Internal Medicine (M. Mosepele) and Family Medicine and Public Health (K. Siamisang), University of Botswana, and the Department of Health Services Management, Ministry of Health and Wellness (K. Siamisang) - all in Gaborone, Botswana; the Infectious Diseases Institute, College of Health Sciences (D.B.M., E.K., J.K., E.M., M.K.R., K. Ssebambulidde, L.T., J.R., D.R.B., S. Jjunju, E.N.), and the Department of Medicine, School of Medicine (D.B.M.), Makerere University, Kampala, and Mbarara University of Science and Technology, Mbarara (C. Muzoora, E.N.) - both in Uganda; the University of Minnesota, Minneapolis (D.B.M., J.R., D.R.B.); the Malawi-Liverpool-Wellcome Trust Clinical Research Programme (H.C.M., M. Moyo, H.M., D.G.L.) and the Department of Medicine, Kamuzu University of Health Sciences (H.C.M., M. Moyo), Blantyre, and the Lilongwe Medical Relief Fund Trust (University of North Carolina-Malawi Project), Lilongwe (C.K., M.C.H., C.C.) - all in Malawi; the Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill (M.C.H.); the Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine (G.M., C.S., K.C., A.S.), and the Department of Medicine (G.M., C.S., K.C.), University of Cape Town, and the Department of Radiology, Groote Schuur Hospital (A.S.) - both in Cape Town, South Africa; the Internal Medicine Unit, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare (C.E.N., A.H., C. Mutata); Institut Pasteur, National Center for Scientific Research, Molecular Mycology Unit and National Reference Center for Invasive Mycoses and Antifungals, Unités Mixtes de Recherche 2000, and Université de Paris, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, Hôpital Necker Enfants Malades, Assistance Publique-Hôpitaux de Paris, Institut Hospitalo-Universitaire Imagine - both in Paris (T.B.-C., O.L.)
| | - Keatlaretse Siamisang
- From the Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine (J.N.J., D.S.L., N.Y.), the Institute for Infection and Immunity, St. George's University London (A.L., S.F.M., T.S.H.), and the Clinical Academic Group in Infection and Immunity, St. George's University Hospitals NHS Foundation Trust (T.S.H.), London, Liverpool School of Tropical Medicine (H.C.M., E.W., D.W., D.G.L., S. Jaffar) and the Department of Public Health, Policy, and Systems, Institute of Population Health (T.C.), and the Department of Pharmacology and Therapeutics, Institute of Systems, Molecular, and Integrative Biology (W.H.), University of Liverpool, Liverpool, and the Medical Research Council Centre for Medical Mycology, University of Exeter, Exeter (T.S.H.) - all in the United Kingdom; the Botswana-Harvard AIDS Institute Partnership (J.N.J., D.S.L., M. Mosepele, T.L., K. Siamisang, N.Y.), the Departments of Internal Medicine (M. Mosepele) and Family Medicine and Public Health (K. Siamisang), University of Botswana, and the Department of Health Services Management, Ministry of Health and Wellness (K. Siamisang) - all in Gaborone, Botswana; the Infectious Diseases Institute, College of Health Sciences (D.B.M., E.K., J.K., E.M., M.K.R., K. Ssebambulidde, L.T., J.R., D.R.B., S. Jjunju, E.N.), and the Department of Medicine, School of Medicine (D.B.M.), Makerere University, Kampala, and Mbarara University of Science and Technology, Mbarara (C. Muzoora, E.N.) - both in Uganda; the University of Minnesota, Minneapolis (D.B.M., J.R., D.R.B.); the Malawi-Liverpool-Wellcome Trust Clinical Research Programme (H.C.M., M. Moyo, H.M., D.G.L.) and the Department of Medicine, Kamuzu University of Health Sciences (H.C.M., M. Moyo), Blantyre, and the Lilongwe Medical Relief Fund Trust (University of North Carolina-Malawi Project), Lilongwe (C.K., M.C.H., C.C.) - all in Malawi; the Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill (M.C.H.); the Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine (G.M., C.S., K.C., A.S.), and the Department of Medicine (G.M., C.S., K.C.), University of Cape Town, and the Department of Radiology, Groote Schuur Hospital (A.S.) - both in Cape Town, South Africa; the Internal Medicine Unit, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare (C.E.N., A.H., C. Mutata); Institut Pasteur, National Center for Scientific Research, Molecular Mycology Unit and National Reference Center for Invasive Mycoses and Antifungals, Unités Mixtes de Recherche 2000, and Université de Paris, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, Hôpital Necker Enfants Malades, Assistance Publique-Hôpitaux de Paris, Institut Hospitalo-Universitaire Imagine - both in Paris (T.B.-C., O.L.)
| | - Chiratidzo E Ndhlovu
- From the Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine (J.N.J., D.S.L., N.Y.), the Institute for Infection and Immunity, St. George's University London (A.L., S.F.M., T.S.H.), and the Clinical Academic Group in Infection and Immunity, St. George's University Hospitals NHS Foundation Trust (T.S.H.), London, Liverpool School of Tropical Medicine (H.C.M., E.W., D.W., D.G.L., S. Jaffar) and the Department of Public Health, Policy, and Systems, Institute of Population Health (T.C.), and the Department of Pharmacology and Therapeutics, Institute of Systems, Molecular, and Integrative Biology (W.H.), University of Liverpool, Liverpool, and the Medical Research Council Centre for Medical Mycology, University of Exeter, Exeter (T.S.H.) - all in the United Kingdom; the Botswana-Harvard AIDS Institute Partnership (J.N.J., D.S.L., M. Mosepele, T.L., K. Siamisang, N.Y.), the Departments of Internal Medicine (M. Mosepele) and Family Medicine and Public Health (K. Siamisang), University of Botswana, and the Department of Health Services Management, Ministry of Health and Wellness (K. Siamisang) - all in Gaborone, Botswana; the Infectious Diseases Institute, College of Health Sciences (D.B.M., E.K., J.K., E.M., M.K.R., K. Ssebambulidde, L.T., J.R., D.R.B., S. Jjunju, E.N.), and the Department of Medicine, School of Medicine (D.B.M.), Makerere University, Kampala, and Mbarara University of Science and Technology, Mbarara (C. Muzoora, E.N.) - both in Uganda; the University of Minnesota, Minneapolis (D.B.M., J.R., D.R.B.); the Malawi-Liverpool-Wellcome Trust Clinical Research Programme (H.C.M., M. Moyo, H.M., D.G.L.) and the Department of Medicine, Kamuzu University of Health Sciences (H.C.M., M. Moyo), Blantyre, and the Lilongwe Medical Relief Fund Trust (University of North Carolina-Malawi Project), Lilongwe (C.K., M.C.H., C.C.) - all in Malawi; the Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill (M.C.H.); the Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine (G.M., C.S., K.C., A.S.), and the Department of Medicine (G.M., C.S., K.C.), University of Cape Town, and the Department of Radiology, Groote Schuur Hospital (A.S.) - both in Cape Town, South Africa; the Internal Medicine Unit, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare (C.E.N., A.H., C. Mutata); Institut Pasteur, National Center for Scientific Research, Molecular Mycology Unit and National Reference Center for Invasive Mycoses and Antifungals, Unités Mixtes de Recherche 2000, and Université de Paris, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, Hôpital Necker Enfants Malades, Assistance Publique-Hôpitaux de Paris, Institut Hospitalo-Universitaire Imagine - both in Paris (T.B.-C., O.L.)
| | - Admire Hlupeni
- From the Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine (J.N.J., D.S.L., N.Y.), the Institute for Infection and Immunity, St. George's University London (A.L., S.F.M., T.S.H.), and the Clinical Academic Group in Infection and Immunity, St. George's University Hospitals NHS Foundation Trust (T.S.H.), London, Liverpool School of Tropical Medicine (H.C.M., E.W., D.W., D.G.L., S. Jaffar) and the Department of Public Health, Policy, and Systems, Institute of Population Health (T.C.), and the Department of Pharmacology and Therapeutics, Institute of Systems, Molecular, and Integrative Biology (W.H.), University of Liverpool, Liverpool, and the Medical Research Council Centre for Medical Mycology, University of Exeter, Exeter (T.S.H.) - all in the United Kingdom; the Botswana-Harvard AIDS Institute Partnership (J.N.J., D.S.L., M. Mosepele, T.L., K. Siamisang, N.Y.), the Departments of Internal Medicine (M. Mosepele) and Family Medicine and Public Health (K. Siamisang), University of Botswana, and the Department of Health Services Management, Ministry of Health and Wellness (K. Siamisang) - all in Gaborone, Botswana; the Infectious Diseases Institute, College of Health Sciences (D.B.M., E.K., J.K., E.M., M.K.R., K. Ssebambulidde, L.T., J.R., D.R.B., S. Jjunju, E.N.), and the Department of Medicine, School of Medicine (D.B.M.), Makerere University, Kampala, and Mbarara University of Science and Technology, Mbarara (C. Muzoora, E.N.) - both in Uganda; the University of Minnesota, Minneapolis (D.B.M., J.R., D.R.B.); the Malawi-Liverpool-Wellcome Trust Clinical Research Programme (H.C.M., M. Moyo, H.M., D.G.L.) and the Department of Medicine, Kamuzu University of Health Sciences (H.C.M., M. Moyo), Blantyre, and the Lilongwe Medical Relief Fund Trust (University of North Carolina-Malawi Project), Lilongwe (C.K., M.C.H., C.C.) - all in Malawi; the Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill (M.C.H.); the Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine (G.M., C.S., K.C., A.S.), and the Department of Medicine (G.M., C.S., K.C.), University of Cape Town, and the Department of Radiology, Groote Schuur Hospital (A.S.) - both in Cape Town, South Africa; the Internal Medicine Unit, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare (C.E.N., A.H., C. Mutata); Institut Pasteur, National Center for Scientific Research, Molecular Mycology Unit and National Reference Center for Invasive Mycoses and Antifungals, Unités Mixtes de Recherche 2000, and Université de Paris, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, Hôpital Necker Enfants Malades, Assistance Publique-Hôpitaux de Paris, Institut Hospitalo-Universitaire Imagine - both in Paris (T.B.-C., O.L.)
| | - Constantine Mutata
- From the Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine (J.N.J., D.S.L., N.Y.), the Institute for Infection and Immunity, St. George's University London (A.L., S.F.M., T.S.H.), and the Clinical Academic Group in Infection and Immunity, St. George's University Hospitals NHS Foundation Trust (T.S.H.), London, Liverpool School of Tropical Medicine (H.C.M., E.W., D.W., D.G.L., S. Jaffar) and the Department of Public Health, Policy, and Systems, Institute of Population Health (T.C.), and the Department of Pharmacology and Therapeutics, Institute of Systems, Molecular, and Integrative Biology (W.H.), University of Liverpool, Liverpool, and the Medical Research Council Centre for Medical Mycology, University of Exeter, Exeter (T.S.H.) - all in the United Kingdom; the Botswana-Harvard AIDS Institute Partnership (J.N.J., D.S.L., M. Mosepele, T.L., K. Siamisang, N.Y.), the Departments of Internal Medicine (M. Mosepele) and Family Medicine and Public Health (K. Siamisang), University of Botswana, and the Department of Health Services Management, Ministry of Health and Wellness (K. Siamisang) - all in Gaborone, Botswana; the Infectious Diseases Institute, College of Health Sciences (D.B.M., E.K., J.K., E.M., M.K.R., K. Ssebambulidde, L.T., J.R., D.R.B., S. Jjunju, E.N.), and the Department of Medicine, School of Medicine (D.B.M.), Makerere University, Kampala, and Mbarara University of Science and Technology, Mbarara (C. Muzoora, E.N.) - both in Uganda; the University of Minnesota, Minneapolis (D.B.M., J.R., D.R.B.); the Malawi-Liverpool-Wellcome Trust Clinical Research Programme (H.C.M., M. Moyo, H.M., D.G.L.) and the Department of Medicine, Kamuzu University of Health Sciences (H.C.M., M. Moyo), Blantyre, and the Lilongwe Medical Relief Fund Trust (University of North Carolina-Malawi Project), Lilongwe (C.K., M.C.H., C.C.) - all in Malawi; the Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill (M.C.H.); the Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine (G.M., C.S., K.C., A.S.), and the Department of Medicine (G.M., C.S., K.C.), University of Cape Town, and the Department of Radiology, Groote Schuur Hospital (A.S.) - both in Cape Town, South Africa; the Internal Medicine Unit, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare (C.E.N., A.H., C. Mutata); Institut Pasteur, National Center for Scientific Research, Molecular Mycology Unit and National Reference Center for Invasive Mycoses and Antifungals, Unités Mixtes de Recherche 2000, and Université de Paris, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, Hôpital Necker Enfants Malades, Assistance Publique-Hôpitaux de Paris, Institut Hospitalo-Universitaire Imagine - both in Paris (T.B.-C., O.L.)
| | - Erik van Widenfelt
- From the Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine (J.N.J., D.S.L., N.Y.), the Institute for Infection and Immunity, St. George's University London (A.L., S.F.M., T.S.H.), and the Clinical Academic Group in Infection and Immunity, St. George's University Hospitals NHS Foundation Trust (T.S.H.), London, Liverpool School of Tropical Medicine (H.C.M., E.W., D.W., D.G.L., S. Jaffar) and the Department of Public Health, Policy, and Systems, Institute of Population Health (T.C.), and the Department of Pharmacology and Therapeutics, Institute of Systems, Molecular, and Integrative Biology (W.H.), University of Liverpool, Liverpool, and the Medical Research Council Centre for Medical Mycology, University of Exeter, Exeter (T.S.H.) - all in the United Kingdom; the Botswana-Harvard AIDS Institute Partnership (J.N.J., D.S.L., M. Mosepele, T.L., K. Siamisang, N.Y.), the Departments of Internal Medicine (M. Mosepele) and Family Medicine and Public Health (K. Siamisang), University of Botswana, and the Department of Health Services Management, Ministry of Health and Wellness (K. Siamisang) - all in Gaborone, Botswana; the Infectious Diseases Institute, College of Health Sciences (D.B.M., E.K., J.K., E.M., M.K.R., K. Ssebambulidde, L.T., J.R., D.R.B., S. Jjunju, E.N.), and the Department of Medicine, School of Medicine (D.B.M.), Makerere University, Kampala, and Mbarara University of Science and Technology, Mbarara (C. Muzoora, E.N.) - both in Uganda; the University of Minnesota, Minneapolis (D.B.M., J.R., D.R.B.); the Malawi-Liverpool-Wellcome Trust Clinical Research Programme (H.C.M., M. Moyo, H.M., D.G.L.) and the Department of Medicine, Kamuzu University of Health Sciences (H.C.M., M. Moyo), Blantyre, and the Lilongwe Medical Relief Fund Trust (University of North Carolina-Malawi Project), Lilongwe (C.K., M.C.H., C.C.) - all in Malawi; the Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill (M.C.H.); the Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine (G.M., C.S., K.C., A.S.), and the Department of Medicine (G.M., C.S., K.C.), University of Cape Town, and the Department of Radiology, Groote Schuur Hospital (A.S.) - both in Cape Town, South Africa; the Internal Medicine Unit, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare (C.E.N., A.H., C. Mutata); Institut Pasteur, National Center for Scientific Research, Molecular Mycology Unit and National Reference Center for Invasive Mycoses and Antifungals, Unités Mixtes de Recherche 2000, and Université de Paris, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, Hôpital Necker Enfants Malades, Assistance Publique-Hôpitaux de Paris, Institut Hospitalo-Universitaire Imagine - both in Paris (T.B.-C., O.L.)
| | - Tao Chen
- From the Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine (J.N.J., D.S.L., N.Y.), the Institute for Infection and Immunity, St. George's University London (A.L., S.F.M., T.S.H.), and the Clinical Academic Group in Infection and Immunity, St. George's University Hospitals NHS Foundation Trust (T.S.H.), London, Liverpool School of Tropical Medicine (H.C.M., E.W., D.W., D.G.L., S. Jaffar) and the Department of Public Health, Policy, and Systems, Institute of Population Health (T.C.), and the Department of Pharmacology and Therapeutics, Institute of Systems, Molecular, and Integrative Biology (W.H.), University of Liverpool, Liverpool, and the Medical Research Council Centre for Medical Mycology, University of Exeter, Exeter (T.S.H.) - all in the United Kingdom; the Botswana-Harvard AIDS Institute Partnership (J.N.J., D.S.L., M. Mosepele, T.L., K. Siamisang, N.Y.), the Departments of Internal Medicine (M. Mosepele) and Family Medicine and Public Health (K. Siamisang), University of Botswana, and the Department of Health Services Management, Ministry of Health and Wellness (K. Siamisang) - all in Gaborone, Botswana; the Infectious Diseases Institute, College of Health Sciences (D.B.M., E.K., J.K., E.M., M.K.R., K. Ssebambulidde, L.T., J.R., D.R.B., S. Jjunju, E.N.), and the Department of Medicine, School of Medicine (D.B.M.), Makerere University, Kampala, and Mbarara University of Science and Technology, Mbarara (C. Muzoora, E.N.) - both in Uganda; the University of Minnesota, Minneapolis (D.B.M., J.R., D.R.B.); the Malawi-Liverpool-Wellcome Trust Clinical Research Programme (H.C.M., M. Moyo, H.M., D.G.L.) and the Department of Medicine, Kamuzu University of Health Sciences (H.C.M., M. Moyo), Blantyre, and the Lilongwe Medical Relief Fund Trust (University of North Carolina-Malawi Project), Lilongwe (C.K., M.C.H., C.C.) - all in Malawi; the Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill (M.C.H.); the Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine (G.M., C.S., K.C., A.S.), and the Department of Medicine (G.M., C.S., K.C.), University of Cape Town, and the Department of Radiology, Groote Schuur Hospital (A.S.) - both in Cape Town, South Africa; the Internal Medicine Unit, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare (C.E.N., A.H., C. Mutata); Institut Pasteur, National Center for Scientific Research, Molecular Mycology Unit and National Reference Center for Invasive Mycoses and Antifungals, Unités Mixtes de Recherche 2000, and Université de Paris, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, Hôpital Necker Enfants Malades, Assistance Publique-Hôpitaux de Paris, Institut Hospitalo-Universitaire Imagine - both in Paris (T.B.-C., O.L.)
| | - Duolao Wang
- From the Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine (J.N.J., D.S.L., N.Y.), the Institute for Infection and Immunity, St. George's University London (A.L., S.F.M., T.S.H.), and the Clinical Academic Group in Infection and Immunity, St. George's University Hospitals NHS Foundation Trust (T.S.H.), London, Liverpool School of Tropical Medicine (H.C.M., E.W., D.W., D.G.L., S. Jaffar) and the Department of Public Health, Policy, and Systems, Institute of Population Health (T.C.), and the Department of Pharmacology and Therapeutics, Institute of Systems, Molecular, and Integrative Biology (W.H.), University of Liverpool, Liverpool, and the Medical Research Council Centre for Medical Mycology, University of Exeter, Exeter (T.S.H.) - all in the United Kingdom; the Botswana-Harvard AIDS Institute Partnership (J.N.J., D.S.L., M. Mosepele, T.L., K. Siamisang, N.Y.), the Departments of Internal Medicine (M. Mosepele) and Family Medicine and Public Health (K. Siamisang), University of Botswana, and the Department of Health Services Management, Ministry of Health and Wellness (K. Siamisang) - all in Gaborone, Botswana; the Infectious Diseases Institute, College of Health Sciences (D.B.M., E.K., J.K., E.M., M.K.R., K. Ssebambulidde, L.T., J.R., D.R.B., S. Jjunju, E.N.), and the Department of Medicine, School of Medicine (D.B.M.), Makerere University, Kampala, and Mbarara University of Science and Technology, Mbarara (C. Muzoora, E.N.) - both in Uganda; the University of Minnesota, Minneapolis (D.B.M., J.R., D.R.B.); the Malawi-Liverpool-Wellcome Trust Clinical Research Programme (H.C.M., M. Moyo, H.M., D.G.L.) and the Department of Medicine, Kamuzu University of Health Sciences (H.C.M., M. Moyo), Blantyre, and the Lilongwe Medical Relief Fund Trust (University of North Carolina-Malawi Project), Lilongwe (C.K., M.C.H., C.C.) - all in Malawi; the Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill (M.C.H.); the Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine (G.M., C.S., K.C., A.S.), and the Department of Medicine (G.M., C.S., K.C.), University of Cape Town, and the Department of Radiology, Groote Schuur Hospital (A.S.) - both in Cape Town, South Africa; the Internal Medicine Unit, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare (C.E.N., A.H., C. Mutata); Institut Pasteur, National Center for Scientific Research, Molecular Mycology Unit and National Reference Center for Invasive Mycoses and Antifungals, Unités Mixtes de Recherche 2000, and Université de Paris, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, Hôpital Necker Enfants Malades, Assistance Publique-Hôpitaux de Paris, Institut Hospitalo-Universitaire Imagine - both in Paris (T.B.-C., O.L.)
| | - William Hope
- From the Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine (J.N.J., D.S.L., N.Y.), the Institute for Infection and Immunity, St. George's University London (A.L., S.F.M., T.S.H.), and the Clinical Academic Group in Infection and Immunity, St. George's University Hospitals NHS Foundation Trust (T.S.H.), London, Liverpool School of Tropical Medicine (H.C.M., E.W., D.W., D.G.L., S. Jaffar) and the Department of Public Health, Policy, and Systems, Institute of Population Health (T.C.), and the Department of Pharmacology and Therapeutics, Institute of Systems, Molecular, and Integrative Biology (W.H.), University of Liverpool, Liverpool, and the Medical Research Council Centre for Medical Mycology, University of Exeter, Exeter (T.S.H.) - all in the United Kingdom; the Botswana-Harvard AIDS Institute Partnership (J.N.J., D.S.L., M. Mosepele, T.L., K. Siamisang, N.Y.), the Departments of Internal Medicine (M. Mosepele) and Family Medicine and Public Health (K. Siamisang), University of Botswana, and the Department of Health Services Management, Ministry of Health and Wellness (K. Siamisang) - all in Gaborone, Botswana; the Infectious Diseases Institute, College of Health Sciences (D.B.M., E.K., J.K., E.M., M.K.R., K. Ssebambulidde, L.T., J.R., D.R.B., S. Jjunju, E.N.), and the Department of Medicine, School of Medicine (D.B.M.), Makerere University, Kampala, and Mbarara University of Science and Technology, Mbarara (C. Muzoora, E.N.) - both in Uganda; the University of Minnesota, Minneapolis (D.B.M., J.R., D.R.B.); the Malawi-Liverpool-Wellcome Trust Clinical Research Programme (H.C.M., M. Moyo, H.M., D.G.L.) and the Department of Medicine, Kamuzu University of Health Sciences (H.C.M., M. Moyo), Blantyre, and the Lilongwe Medical Relief Fund Trust (University of North Carolina-Malawi Project), Lilongwe (C.K., M.C.H., C.C.) - all in Malawi; the Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill (M.C.H.); the Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine (G.M., C.S., K.C., A.S.), and the Department of Medicine (G.M., C.S., K.C.), University of Cape Town, and the Department of Radiology, Groote Schuur Hospital (A.S.) - both in Cape Town, South Africa; the Internal Medicine Unit, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare (C.E.N., A.H., C. Mutata); Institut Pasteur, National Center for Scientific Research, Molecular Mycology Unit and National Reference Center for Invasive Mycoses and Antifungals, Unités Mixtes de Recherche 2000, and Université de Paris, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, Hôpital Necker Enfants Malades, Assistance Publique-Hôpitaux de Paris, Institut Hospitalo-Universitaire Imagine - both in Paris (T.B.-C., O.L.)
| | - Timothée Boyer-Chammard
- From the Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine (J.N.J., D.S.L., N.Y.), the Institute for Infection and Immunity, St. George's University London (A.L., S.F.M., T.S.H.), and the Clinical Academic Group in Infection and Immunity, St. George's University Hospitals NHS Foundation Trust (T.S.H.), London, Liverpool School of Tropical Medicine (H.C.M., E.W., D.W., D.G.L., S. Jaffar) and the Department of Public Health, Policy, and Systems, Institute of Population Health (T.C.), and the Department of Pharmacology and Therapeutics, Institute of Systems, Molecular, and Integrative Biology (W.H.), University of Liverpool, Liverpool, and the Medical Research Council Centre for Medical Mycology, University of Exeter, Exeter (T.S.H.) - all in the United Kingdom; the Botswana-Harvard AIDS Institute Partnership (J.N.J., D.S.L., M. Mosepele, T.L., K. Siamisang, N.Y.), the Departments of Internal Medicine (M. Mosepele) and Family Medicine and Public Health (K. Siamisang), University of Botswana, and the Department of Health Services Management, Ministry of Health and Wellness (K. Siamisang) - all in Gaborone, Botswana; the Infectious Diseases Institute, College of Health Sciences (D.B.M., E.K., J.K., E.M., M.K.R., K. Ssebambulidde, L.T., J.R., D.R.B., S. Jjunju, E.N.), and the Department of Medicine, School of Medicine (D.B.M.), Makerere University, Kampala, and Mbarara University of Science and Technology, Mbarara (C. Muzoora, E.N.) - both in Uganda; the University of Minnesota, Minneapolis (D.B.M., J.R., D.R.B.); the Malawi-Liverpool-Wellcome Trust Clinical Research Programme (H.C.M., M. Moyo, H.M., D.G.L.) and the Department of Medicine, Kamuzu University of Health Sciences (H.C.M., M. Moyo), Blantyre, and the Lilongwe Medical Relief Fund Trust (University of North Carolina-Malawi Project), Lilongwe (C.K., M.C.H., C.C.) - all in Malawi; the Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill (M.C.H.); the Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine (G.M., C.S., K.C., A.S.), and the Department of Medicine (G.M., C.S., K.C.), University of Cape Town, and the Department of Radiology, Groote Schuur Hospital (A.S.) - both in Cape Town, South Africa; the Internal Medicine Unit, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare (C.E.N., A.H., C. Mutata); Institut Pasteur, National Center for Scientific Research, Molecular Mycology Unit and National Reference Center for Invasive Mycoses and Antifungals, Unités Mixtes de Recherche 2000, and Université de Paris, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, Hôpital Necker Enfants Malades, Assistance Publique-Hôpitaux de Paris, Institut Hospitalo-Universitaire Imagine - both in Paris (T.B.-C., O.L.)
| | - Angela Loyse
- From the Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine (J.N.J., D.S.L., N.Y.), the Institute for Infection and Immunity, St. George's University London (A.L., S.F.M., T.S.H.), and the Clinical Academic Group in Infection and Immunity, St. George's University Hospitals NHS Foundation Trust (T.S.H.), London, Liverpool School of Tropical Medicine (H.C.M., E.W., D.W., D.G.L., S. Jaffar) and the Department of Public Health, Policy, and Systems, Institute of Population Health (T.C.), and the Department of Pharmacology and Therapeutics, Institute of Systems, Molecular, and Integrative Biology (W.H.), University of Liverpool, Liverpool, and the Medical Research Council Centre for Medical Mycology, University of Exeter, Exeter (T.S.H.) - all in the United Kingdom; the Botswana-Harvard AIDS Institute Partnership (J.N.J., D.S.L., M. Mosepele, T.L., K. Siamisang, N.Y.), the Departments of Internal Medicine (M. Mosepele) and Family Medicine and Public Health (K. Siamisang), University of Botswana, and the Department of Health Services Management, Ministry of Health and Wellness (K. Siamisang) - all in Gaborone, Botswana; the Infectious Diseases Institute, College of Health Sciences (D.B.M., E.K., J.K., E.M., M.K.R., K. Ssebambulidde, L.T., J.R., D.R.B., S. Jjunju, E.N.), and the Department of Medicine, School of Medicine (D.B.M.), Makerere University, Kampala, and Mbarara University of Science and Technology, Mbarara (C. Muzoora, E.N.) - both in Uganda; the University of Minnesota, Minneapolis (D.B.M., J.R., D.R.B.); the Malawi-Liverpool-Wellcome Trust Clinical Research Programme (H.C.M., M. Moyo, H.M., D.G.L.) and the Department of Medicine, Kamuzu University of Health Sciences (H.C.M., M. Moyo), Blantyre, and the Lilongwe Medical Relief Fund Trust (University of North Carolina-Malawi Project), Lilongwe (C.K., M.C.H., C.C.) - all in Malawi; the Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill (M.C.H.); the Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine (G.M., C.S., K.C., A.S.), and the Department of Medicine (G.M., C.S., K.C.), University of Cape Town, and the Department of Radiology, Groote Schuur Hospital (A.S.) - both in Cape Town, South Africa; the Internal Medicine Unit, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare (C.E.N., A.H., C. Mutata); Institut Pasteur, National Center for Scientific Research, Molecular Mycology Unit and National Reference Center for Invasive Mycoses and Antifungals, Unités Mixtes de Recherche 2000, and Université de Paris, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, Hôpital Necker Enfants Malades, Assistance Publique-Hôpitaux de Paris, Institut Hospitalo-Universitaire Imagine - both in Paris (T.B.-C., O.L.)
| | - Síle F Molloy
- From the Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine (J.N.J., D.S.L., N.Y.), the Institute for Infection and Immunity, St. George's University London (A.L., S.F.M., T.S.H.), and the Clinical Academic Group in Infection and Immunity, St. George's University Hospitals NHS Foundation Trust (T.S.H.), London, Liverpool School of Tropical Medicine (H.C.M., E.W., D.W., D.G.L., S. Jaffar) and the Department of Public Health, Policy, and Systems, Institute of Population Health (T.C.), and the Department of Pharmacology and Therapeutics, Institute of Systems, Molecular, and Integrative Biology (W.H.), University of Liverpool, Liverpool, and the Medical Research Council Centre for Medical Mycology, University of Exeter, Exeter (T.S.H.) - all in the United Kingdom; the Botswana-Harvard AIDS Institute Partnership (J.N.J., D.S.L., M. Mosepele, T.L., K. Siamisang, N.Y.), the Departments of Internal Medicine (M. Mosepele) and Family Medicine and Public Health (K. Siamisang), University of Botswana, and the Department of Health Services Management, Ministry of Health and Wellness (K. Siamisang) - all in Gaborone, Botswana; the Infectious Diseases Institute, College of Health Sciences (D.B.M., E.K., J.K., E.M., M.K.R., K. Ssebambulidde, L.T., J.R., D.R.B., S. Jjunju, E.N.), and the Department of Medicine, School of Medicine (D.B.M.), Makerere University, Kampala, and Mbarara University of Science and Technology, Mbarara (C. Muzoora, E.N.) - both in Uganda; the University of Minnesota, Minneapolis (D.B.M., J.R., D.R.B.); the Malawi-Liverpool-Wellcome Trust Clinical Research Programme (H.C.M., M. Moyo, H.M., D.G.L.) and the Department of Medicine, Kamuzu University of Health Sciences (H.C.M., M. Moyo), Blantyre, and the Lilongwe Medical Relief Fund Trust (University of North Carolina-Malawi Project), Lilongwe (C.K., M.C.H., C.C.) - all in Malawi; the Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill (M.C.H.); the Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine (G.M., C.S., K.C., A.S.), and the Department of Medicine (G.M., C.S., K.C.), University of Cape Town, and the Department of Radiology, Groote Schuur Hospital (A.S.) - both in Cape Town, South Africa; the Internal Medicine Unit, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare (C.E.N., A.H., C. Mutata); Institut Pasteur, National Center for Scientific Research, Molecular Mycology Unit and National Reference Center for Invasive Mycoses and Antifungals, Unités Mixtes de Recherche 2000, and Université de Paris, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, Hôpital Necker Enfants Malades, Assistance Publique-Hôpitaux de Paris, Institut Hospitalo-Universitaire Imagine - both in Paris (T.B.-C., O.L.)
| | - Nabila Youssouf
- From the Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine (J.N.J., D.S.L., N.Y.), the Institute for Infection and Immunity, St. George's University London (A.L., S.F.M., T.S.H.), and the Clinical Academic Group in Infection and Immunity, St. George's University Hospitals NHS Foundation Trust (T.S.H.), London, Liverpool School of Tropical Medicine (H.C.M., E.W., D.W., D.G.L., S. Jaffar) and the Department of Public Health, Policy, and Systems, Institute of Population Health (T.C.), and the Department of Pharmacology and Therapeutics, Institute of Systems, Molecular, and Integrative Biology (W.H.), University of Liverpool, Liverpool, and the Medical Research Council Centre for Medical Mycology, University of Exeter, Exeter (T.S.H.) - all in the United Kingdom; the Botswana-Harvard AIDS Institute Partnership (J.N.J., D.S.L., M. Mosepele, T.L., K. Siamisang, N.Y.), the Departments of Internal Medicine (M. Mosepele) and Family Medicine and Public Health (K. Siamisang), University of Botswana, and the Department of Health Services Management, Ministry of Health and Wellness (K. Siamisang) - all in Gaborone, Botswana; the Infectious Diseases Institute, College of Health Sciences (D.B.M., E.K., J.K., E.M., M.K.R., K. Ssebambulidde, L.T., J.R., D.R.B., S. Jjunju, E.N.), and the Department of Medicine, School of Medicine (D.B.M.), Makerere University, Kampala, and Mbarara University of Science and Technology, Mbarara (C. Muzoora, E.N.) - both in Uganda; the University of Minnesota, Minneapolis (D.B.M., J.R., D.R.B.); the Malawi-Liverpool-Wellcome Trust Clinical Research Programme (H.C.M., M. Moyo, H.M., D.G.L.) and the Department of Medicine, Kamuzu University of Health Sciences (H.C.M., M. Moyo), Blantyre, and the Lilongwe Medical Relief Fund Trust (University of North Carolina-Malawi Project), Lilongwe (C.K., M.C.H., C.C.) - all in Malawi; the Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill (M.C.H.); the Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine (G.M., C.S., K.C., A.S.), and the Department of Medicine (G.M., C.S., K.C.), University of Cape Town, and the Department of Radiology, Groote Schuur Hospital (A.S.) - both in Cape Town, South Africa; the Internal Medicine Unit, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare (C.E.N., A.H., C. Mutata); Institut Pasteur, National Center for Scientific Research, Molecular Mycology Unit and National Reference Center for Invasive Mycoses and Antifungals, Unités Mixtes de Recherche 2000, and Université de Paris, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, Hôpital Necker Enfants Malades, Assistance Publique-Hôpitaux de Paris, Institut Hospitalo-Universitaire Imagine - both in Paris (T.B.-C., O.L.)
| | - Olivier Lortholary
- From the Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine (J.N.J., D.S.L., N.Y.), the Institute for Infection and Immunity, St. George's University London (A.L., S.F.M., T.S.H.), and the Clinical Academic Group in Infection and Immunity, St. George's University Hospitals NHS Foundation Trust (T.S.H.), London, Liverpool School of Tropical Medicine (H.C.M., E.W., D.W., D.G.L., S. Jaffar) and the Department of Public Health, Policy, and Systems, Institute of Population Health (T.C.), and the Department of Pharmacology and Therapeutics, Institute of Systems, Molecular, and Integrative Biology (W.H.), University of Liverpool, Liverpool, and the Medical Research Council Centre for Medical Mycology, University of Exeter, Exeter (T.S.H.) - all in the United Kingdom; the Botswana-Harvard AIDS Institute Partnership (J.N.J., D.S.L., M. Mosepele, T.L., K. Siamisang, N.Y.), the Departments of Internal Medicine (M. Mosepele) and Family Medicine and Public Health (K. Siamisang), University of Botswana, and the Department of Health Services Management, Ministry of Health and Wellness (K. Siamisang) - all in Gaborone, Botswana; the Infectious Diseases Institute, College of Health Sciences (D.B.M., E.K., J.K., E.M., M.K.R., K. Ssebambulidde, L.T., J.R., D.R.B., S. Jjunju, E.N.), and the Department of Medicine, School of Medicine (D.B.M.), Makerere University, Kampala, and Mbarara University of Science and Technology, Mbarara (C. Muzoora, E.N.) - both in Uganda; the University of Minnesota, Minneapolis (D.B.M., J.R., D.R.B.); the Malawi-Liverpool-Wellcome Trust Clinical Research Programme (H.C.M., M. Moyo, H.M., D.G.L.) and the Department of Medicine, Kamuzu University of Health Sciences (H.C.M., M. Moyo), Blantyre, and the Lilongwe Medical Relief Fund Trust (University of North Carolina-Malawi Project), Lilongwe (C.K., M.C.H., C.C.) - all in Malawi; the Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill (M.C.H.); the Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine (G.M., C.S., K.C., A.S.), and the Department of Medicine (G.M., C.S., K.C.), University of Cape Town, and the Department of Radiology, Groote Schuur Hospital (A.S.) - both in Cape Town, South Africa; the Internal Medicine Unit, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare (C.E.N., A.H., C. Mutata); Institut Pasteur, National Center for Scientific Research, Molecular Mycology Unit and National Reference Center for Invasive Mycoses and Antifungals, Unités Mixtes de Recherche 2000, and Université de Paris, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, Hôpital Necker Enfants Malades, Assistance Publique-Hôpitaux de Paris, Institut Hospitalo-Universitaire Imagine - both in Paris (T.B.-C., O.L.)
| | - David G Lalloo
- From the Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine (J.N.J., D.S.L., N.Y.), the Institute for Infection and Immunity, St. George's University London (A.L., S.F.M., T.S.H.), and the Clinical Academic Group in Infection and Immunity, St. George's University Hospitals NHS Foundation Trust (T.S.H.), London, Liverpool School of Tropical Medicine (H.C.M., E.W., D.W., D.G.L., S. Jaffar) and the Department of Public Health, Policy, and Systems, Institute of Population Health (T.C.), and the Department of Pharmacology and Therapeutics, Institute of Systems, Molecular, and Integrative Biology (W.H.), University of Liverpool, Liverpool, and the Medical Research Council Centre for Medical Mycology, University of Exeter, Exeter (T.S.H.) - all in the United Kingdom; the Botswana-Harvard AIDS Institute Partnership (J.N.J., D.S.L., M. Mosepele, T.L., K. Siamisang, N.Y.), the Departments of Internal Medicine (M. Mosepele) and Family Medicine and Public Health (K. Siamisang), University of Botswana, and the Department of Health Services Management, Ministry of Health and Wellness (K. Siamisang) - all in Gaborone, Botswana; the Infectious Diseases Institute, College of Health Sciences (D.B.M., E.K., J.K., E.M., M.K.R., K. Ssebambulidde, L.T., J.R., D.R.B., S. Jjunju, E.N.), and the Department of Medicine, School of Medicine (D.B.M.), Makerere University, Kampala, and Mbarara University of Science and Technology, Mbarara (C. Muzoora, E.N.) - both in Uganda; the University of Minnesota, Minneapolis (D.B.M., J.R., D.R.B.); the Malawi-Liverpool-Wellcome Trust Clinical Research Programme (H.C.M., M. Moyo, H.M., D.G.L.) and the Department of Medicine, Kamuzu University of Health Sciences (H.C.M., M. Moyo), Blantyre, and the Lilongwe Medical Relief Fund Trust (University of North Carolina-Malawi Project), Lilongwe (C.K., M.C.H., C.C.) - all in Malawi; the Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill (M.C.H.); the Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine (G.M., C.S., K.C., A.S.), and the Department of Medicine (G.M., C.S., K.C.), University of Cape Town, and the Department of Radiology, Groote Schuur Hospital (A.S.) - both in Cape Town, South Africa; the Internal Medicine Unit, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare (C.E.N., A.H., C. Mutata); Institut Pasteur, National Center for Scientific Research, Molecular Mycology Unit and National Reference Center for Invasive Mycoses and Antifungals, Unités Mixtes de Recherche 2000, and Université de Paris, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, Hôpital Necker Enfants Malades, Assistance Publique-Hôpitaux de Paris, Institut Hospitalo-Universitaire Imagine - both in Paris (T.B.-C., O.L.)
| | - Shabbar Jaffar
- From the Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine (J.N.J., D.S.L., N.Y.), the Institute for Infection and Immunity, St. George's University London (A.L., S.F.M., T.S.H.), and the Clinical Academic Group in Infection and Immunity, St. George's University Hospitals NHS Foundation Trust (T.S.H.), London, Liverpool School of Tropical Medicine (H.C.M., E.W., D.W., D.G.L., S. Jaffar) and the Department of Public Health, Policy, and Systems, Institute of Population Health (T.C.), and the Department of Pharmacology and Therapeutics, Institute of Systems, Molecular, and Integrative Biology (W.H.), University of Liverpool, Liverpool, and the Medical Research Council Centre for Medical Mycology, University of Exeter, Exeter (T.S.H.) - all in the United Kingdom; the Botswana-Harvard AIDS Institute Partnership (J.N.J., D.S.L., M. Mosepele, T.L., K. Siamisang, N.Y.), the Departments of Internal Medicine (M. Mosepele) and Family Medicine and Public Health (K. Siamisang), University of Botswana, and the Department of Health Services Management, Ministry of Health and Wellness (K. Siamisang) - all in Gaborone, Botswana; the Infectious Diseases Institute, College of Health Sciences (D.B.M., E.K., J.K., E.M., M.K.R., K. Ssebambulidde, L.T., J.R., D.R.B., S. Jjunju, E.N.), and the Department of Medicine, School of Medicine (D.B.M.), Makerere University, Kampala, and Mbarara University of Science and Technology, Mbarara (C. Muzoora, E.N.) - both in Uganda; the University of Minnesota, Minneapolis (D.B.M., J.R., D.R.B.); the Malawi-Liverpool-Wellcome Trust Clinical Research Programme (H.C.M., M. Moyo, H.M., D.G.L.) and the Department of Medicine, Kamuzu University of Health Sciences (H.C.M., M. Moyo), Blantyre, and the Lilongwe Medical Relief Fund Trust (University of North Carolina-Malawi Project), Lilongwe (C.K., M.C.H., C.C.) - all in Malawi; the Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill (M.C.H.); the Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine (G.M., C.S., K.C., A.S.), and the Department of Medicine (G.M., C.S., K.C.), University of Cape Town, and the Department of Radiology, Groote Schuur Hospital (A.S.) - both in Cape Town, South Africa; the Internal Medicine Unit, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare (C.E.N., A.H., C. Mutata); Institut Pasteur, National Center for Scientific Research, Molecular Mycology Unit and National Reference Center for Invasive Mycoses and Antifungals, Unités Mixtes de Recherche 2000, and Université de Paris, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, Hôpital Necker Enfants Malades, Assistance Publique-Hôpitaux de Paris, Institut Hospitalo-Universitaire Imagine - both in Paris (T.B.-C., O.L.)
| | - Thomas S Harrison
- From the Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine (J.N.J., D.S.L., N.Y.), the Institute for Infection and Immunity, St. George's University London (A.L., S.F.M., T.S.H.), and the Clinical Academic Group in Infection and Immunity, St. George's University Hospitals NHS Foundation Trust (T.S.H.), London, Liverpool School of Tropical Medicine (H.C.M., E.W., D.W., D.G.L., S. Jaffar) and the Department of Public Health, Policy, and Systems, Institute of Population Health (T.C.), and the Department of Pharmacology and Therapeutics, Institute of Systems, Molecular, and Integrative Biology (W.H.), University of Liverpool, Liverpool, and the Medical Research Council Centre for Medical Mycology, University of Exeter, Exeter (T.S.H.) - all in the United Kingdom; the Botswana-Harvard AIDS Institute Partnership (J.N.J., D.S.L., M. Mosepele, T.L., K. Siamisang, N.Y.), the Departments of Internal Medicine (M. Mosepele) and Family Medicine and Public Health (K. Siamisang), University of Botswana, and the Department of Health Services Management, Ministry of Health and Wellness (K. Siamisang) - all in Gaborone, Botswana; the Infectious Diseases Institute, College of Health Sciences (D.B.M., E.K., J.K., E.M., M.K.R., K. Ssebambulidde, L.T., J.R., D.R.B., S. Jjunju, E.N.), and the Department of Medicine, School of Medicine (D.B.M.), Makerere University, Kampala, and Mbarara University of Science and Technology, Mbarara (C. Muzoora, E.N.) - both in Uganda; the University of Minnesota, Minneapolis (D.B.M., J.R., D.R.B.); the Malawi-Liverpool-Wellcome Trust Clinical Research Programme (H.C.M., M. Moyo, H.M., D.G.L.) and the Department of Medicine, Kamuzu University of Health Sciences (H.C.M., M. Moyo), Blantyre, and the Lilongwe Medical Relief Fund Trust (University of North Carolina-Malawi Project), Lilongwe (C.K., M.C.H., C.C.) - all in Malawi; the Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill (M.C.H.); the Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine (G.M., C.S., K.C., A.S.), and the Department of Medicine (G.M., C.S., K.C.), University of Cape Town, and the Department of Radiology, Groote Schuur Hospital (A.S.) - both in Cape Town, South Africa; the Internal Medicine Unit, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare (C.E.N., A.H., C. Mutata); Institut Pasteur, National Center for Scientific Research, Molecular Mycology Unit and National Reference Center for Invasive Mycoses and Antifungals, Unités Mixtes de Recherche 2000, and Université de Paris, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, Hôpital Necker Enfants Malades, Assistance Publique-Hôpitaux de Paris, Institut Hospitalo-Universitaire Imagine - both in Paris (T.B.-C., O.L.)
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Abstract
BACKGROUND Otomycosis is a fungal infection of the outer ear, which may be treated with topical antifungal medications. There are many types, with compounds belonging to the azole group ('azoles') being among the most widely used. OBJECTIVES To evaluate the benefits and harms of topical azole treatments for otomycosis. SEARCH METHODS The Cochrane ENT Information Specialist searched the Cochrane ENT Register; Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid Embase; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The search date was 11 November 2020. SELECTION CRITERIA We included randomised controlled trials (RCTs) in adults and children with otomycosis comparing any topical azole antifungal with: placebo, no treatment, another type of topical azole or the same type of azole but applied in different forms. A minimum follow-up of two weeks was required. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our primary outcomes were: 1) clinical resolution as measured by the proportion of participants with complete resolution at between two and four weeks after treatment (however defined by the authors of the studies) and 2) significant adverse events. Secondary outcomes were 3) mycological resolution and 4) other less serious adverse effects. We used GRADE to assess the certainty of evidence for each outcome. MAIN RESULTS We included four studies with 559 participants from Spain, Mexico and India. Three studies included children and adults; one included only adults. The duration of symptoms was not always explicitly stated. Mycological resolution results were only reported in one study. The studies assessed two comparisons: one type of topical azole versus another and the same azole but administered in different forms (cream versus solution). A. Topical azoles versus placebo None of the studies assessed this comparison. B. Topical azoles versus no treatment None of the studies assessed this comparison. C. One type of topical azole versus another type of topical azole i) Clotrimazole versus other types of azoles (eberconazole, fluconazole, miconazole) Three studies examined clotrimazole versus other types of azoles. The evidence is very uncertain about the difference between clotrimazole and other types of azole in achieving complete clinical resolution at four weeks (risk ratio (RR) 0.80, 95% confidence interval (CI) 0.59 to 1.07; 3 studies; 439 participants; very low-certainty evidence). The anticipated absolute effects are 668 per 1000 for clotrimazole versus 835 per 1000 for other azoles. One study planned a safety analysis and reported no significant adverse events in either group. The evidence is therefore very uncertain about any differences between clotrimazole and other types of azole (no events in either group; 1 study; 174 participants; very low-certainty evidence). Clotrimazole may result in little or no difference in mycological resolution at two weeks follow-up (RR 1.01, 95% CI 0.96 to 1.06; 1 study; 174 participants; low-certainty evidence) or in other (less serious) adverse events at two weeks follow-up (36 per 1000, compared to 45 per 1000, RR 0.79, 95% CI 0.18 to 3.41; 1 study; 174 participants; very low-certainty evidence). ii) Bifonazole cream versus bifonazole solution One study compared bifonazole 1% cream with solution. Bifonazole cream may have little or no effect on clinical resolution at two weeks follow-up when compared to solution, but the evidence is very uncertain (RR 1.07, 95% CI 0.73 to 1.57; 1 study; 40 ears; very low-certainty evidence). Bifonazole cream may achieve less mycological resolution compared to solution at two weeks after the end of therapy, but the evidence for this is also very uncertain (RR 0.53, 95% CI 0.29 to 0.96; 1 study; 40 ears; very low-certainty evidence). Five out of 35 patients sustained severe itching and burning from the bifonazole solution but none with the bifonazole cream (very low-certainty evidence). AUTHORS' CONCLUSIONS We found no studies that evaluated topical azoles compared to placebo or no treatment. The evidence is very uncertain about the effect of clotrimazole on clinical resolution of otomycosis, on significant adverse events or other (non-serious) adverse events when compared with other topical azoles (eberconazole, fluconazole, miconazole). There may be little or no difference between clotrimazole and other azoles in terms of mycological resolution. It may be difficult to generalise these results because the range of ethnic backgrounds of the participants in the studies is limited.
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Affiliation(s)
- Ambrose Lee
- Department of Otolaryngology - Head and Neck Surgery, University of Toronto, Toronto, Canada
| | - James R Tysome
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Shakeel R Saeed
- UCL Ear Institute & The Royal National Throat, Nose & Ear Hospital, Royal Free Hampstead NHS Foundation Trust, London, UK
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7
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De Rosa FG, Busca A, Capparella MR, Yan JL, Aram JA. Invasive Candidiasis in Patients with Solid Tumors Treated with Anidulafungin: A Post Hoc Analysis of Efficacy and Safety of Six Pooled Studies. Clin Drug Investig 2021; 41:539-548. [PMID: 33891293 PMCID: PMC8195786 DOI: 10.1007/s40261-021-01024-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/06/2021] [Indexed: 11/25/2022]
Abstract
Background Solid tumors are a common predisposing factor for invasive candidiasis (IC) or candidemia due to IC. Objectives Post hoc analysis of patient-level efficacy and safety data from six studies of anidulafungin (with similar protocols/endpoints) in adults with IC/candidemia summarized by past or recent diagnosis of solid tumors. Patients/methods Patients received a single intravenous (IV) dose of anidulafungin 200 mg, followed by 100 mg once daily. After ≥ 5 to ≥ 10 days of IV treatment, switch to oral voriconazole/fluconazole was permitted in all but one study. Time of solid tumor diagnosis was defined as past, ≥ 6; and recent, < 6 months prior to study entry. Primary endpoint: global response of success (GRS) rate at the end of IV therapy (EOIVT). Secondary endpoints included the GRS rate at the end of all therapy (EOT), all-cause mortality, and safety. Results The GRS rate in the overall population was 73.4% at EOIVT and 65.5% at EOT. Past or recent solid tumor diagnosis did not affect GRS at EOIVT or EOT (past: 75.5% and 71.4%; recent: 72.2% and 62.2%, respectively). All-cause mortality was 14.4% on day 14 and 20.1% at day 28. Most treatment-emergent adverse events were mild/moderate in severity (81.6%). Conclusions Treatment of IC was effective regardless of the time of solid tumor diagnosis. Trial Registration Data were pooled from six studies: NCT00496197 (first posted on ClinicalTrials.gov on July 4, 2007); NCT00548262 (first posted on ClinicalTrials.gov on October 23, 2007); NCT00537329 (first posted on ClinicalTrials.gov on October 1, 2007); NCT00689338 (first posted on ClinicalTrials.gov on June 3, 2008); NCT00806351 (first posted on ClinicalTrials.gov on December 10, 2008); NCT00805740 (first posted on ClinicalTrials.gov on December 10, 2008). Patients with solid tumor cancers (cancer of internal organs) have increased risk of fungal infections that can spread in the body through the blood. Infection with Candida species, known as invasive candidiasis (IC) (Candida invades the body in places normally free from germs) or candidemia (Candida infection in the blood), can cause severe illness and/or death. Anidulafungin is an antifungal drug recommended to treat IC/candidemia. This post hoc analysis looked at how effective and safe anidulafungin was in adult patients with IC/candidemia with ‘recent’ or ‘past’ history of solid tumors. The analysis included patients diagnosed with cancer less than 6 months before (recent history) or more than 6 months before (past history) they first received anidulafungin. Patients received anidulafungin by injection (intravenously [IV]) into the veins and, for continued treatment, were able to take a different antifungal drug orally. Of 539 patients from six studies, 139 had confirmed IC/candidemia and a history of solid tumors. Approximately 7 out of 10 (72%) patients were cured or no longer had signs of Candida infection at the end of IV anidulafungin treatment. Results were similar in patients with past or recent diagnosis of solid tumors. Treatment side effects reported in approximately 8 out of 10 (82%) patients were mild-to-moderate in severity. This analysis suggests anidulafungin was well tolerated and effective at treating IC/candidemia in patients with solid tumors, whether diagnosed recently or in the past.
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Affiliation(s)
| | - Alessandro Busca
- Department of Oncology and Hematology, Stem Cell Transplant Centre, Turin, Italy
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8
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Warrell CE, Macrae C, McLean ARD, Wilkins E, Ashley EA, Smithuis F, Tun NN. Ambulatory induction phase treatment of cryptococcal meningitis in HIV integrated primary care clinics, Yangon, Myanmar. BMC Infect Dis 2021; 21:375. [PMID: 33882845 PMCID: PMC8059000 DOI: 10.1186/s12879-021-06049-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 04/06/2021] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Cryptococcal meningitis (CM) is a common HIV-associated opportunistic-infection worldwide. Existing literature focusses on hospital-based outcomes of induction treatment. This paper reviews outpatient management in integrated primary care clinics in Yangon. METHOD This retrospective case note review analyses a Myanmar HIV-positive patient cohort managed using ambulatory induction-phase treatment with intravenous amphotericin-B-deoxycholate (0.7-1.0 mg/kg) and oral fluconazole (800 mg orally/day). RESULTS Seventy-six patients were diagnosed between 2010 and 2017. The median age of patients diagnosed was 35 years, 63% were male and 33 (45%) were on concurrent treatment for tuberculosis. The median CD4 count was 60 at the time of diagnosis. Amphotericin-B-deoxycholate infusions precipitated 56 episodes of toxicity, namely hypokalaemia, nephrotoxicity, anaemia, febrile reactions, phlebitis, observed in 44 patients (58%). One-year survival (86%) was higher than existing hospital-based treatment studies. CONCLUSION Ambulation of patients in this cohort saved 1029 hospital bed days and had better survival outcomes when compared to hospital-based studies in other resource constrained settings.
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Affiliation(s)
- Clare E Warrell
- Myanmar Oxford Clinical Research Unit (MOCRU), Yangon, Myanmar.
| | | | - Alistair R D McLean
- Myanmar Oxford Clinical Research Unit (MOCRU), Yangon, Myanmar
- Medical Action Myanmar, Yangon, Myanmar
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, OX3 7FZ, UK
| | | | - Elizabeth A Ashley
- Myanmar Oxford Clinical Research Unit (MOCRU), Yangon, Myanmar
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, OX3 7FZ, UK
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao People's Democratic Republic
| | - Frank Smithuis
- Myanmar Oxford Clinical Research Unit (MOCRU), Yangon, Myanmar
- Medical Action Myanmar, Yangon, Myanmar
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, OX3 7FZ, UK
| | - Ni Ni Tun
- Medical Action Myanmar, Yangon, Myanmar
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9
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Sandaradura I, Marriott DJE, Day RO, Norris RLG, Pang E, Stocker SL, Reuter SE. Current fluconazole treatment regimens result in under-dosing of critically ill adults during early therapy. Eur J Clin Microbiol Infect Dis 2021; 40:1521-1528. [PMID: 33638727 DOI: 10.1007/s10096-021-04201-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 02/16/2021] [Indexed: 01/30/2023]
Abstract
PURPOSE To evaluate current fluconazole treatment regimens in critically ill adults over the typical treatment course. METHODS Data from critically ill adults treated with fluconazole (n=30) were used to develop a population pharmacokinetic model. Probability of target attainment (PTA) (fAUC24/MIC >100) was determined from simulations for four previously proposed treatment regimens: (i) 400 mg once daily, (ii) an 800 mg loading dose followed by 400 mg once daily, (iii) 400 mg twice daily, and (iv) a 12 mg/kg loading dose followed by 6 mg/kg once daily. The effect of body weight (40, 70, 120 kg) and renal function (continuous renal replacement therapy (CRRT); 20, 60, 120, 180 mL/min creatinine clearance) on PTA was assessed. RESULTS Early (0-48 h) fluconazole target attainment for infections with a minimum inhibitory concentration (MIC) of 2 mg/L was highly variable. PTA was highest with an 800 mg loading dose for underweight (40 kg) patients and with a 12 mg/kg loading dose for the remainder. End-of-treatment PTA was highest with the 400 mg twice daily maintenance dosing for patients who were under- or normal weight and 6 mg/kg maintenance dosing for overweight (120 kg) patients. None of the fluconazole regimens reliably attained early targets for MICs of ≥4 mg/L. CONCLUSION Current fluconazole dosing regimens do not achieve adequate early target attainment in critically ill adults, particularly in those who are overweight, have higher creatinine clearance, or are undergoing CRRT. Current fluconazole dosing strategies are generally inadequate to treat organisms with an MIC of ≥4 mg/L.
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Affiliation(s)
- Indy Sandaradura
- Centre for Infectious Diseases and Microbiology, Westmead Hospital, Sydney, NSW, Australia.
- Department of Microbiology, St Vincent's Hospital, Sydney, NSW, Australia.
- St Vincent's Clinical School, University of New South Wales, Sydney, NSW, Australia.
- Faculty of Medicine and Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia.
| | - Deborah J E Marriott
- Department of Microbiology, St Vincent's Hospital, Sydney, NSW, Australia
- St Vincent's Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Richard O Day
- St Vincent's Clinical School, University of New South Wales, Sydney, NSW, Australia
- Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital, Sydney, NSW, Australia
| | - Ross L G Norris
- Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital, Sydney, NSW, Australia
- Discipline of Clinical Pharmacology, School of Medicine & Public Health, University of Newcastle, Newcastle, NSW, Australia
- Hunter Medical Research Institute, Kookaburra Circuit, New Lambton Heights, NSW, Australia
| | - Edna Pang
- Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital, Sydney, NSW, Australia
| | - Sophie L Stocker
- St Vincent's Clinical School, University of New South Wales, Sydney, NSW, Australia
- Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital, Sydney, NSW, Australia
- Faculty of Medicine and Health, Sydney Pharmacy School, University of Sydney, Sydney, NSW, Australia
| | - Stephanie E Reuter
- UniSA Clinical & Health Sciences, University of South Australia, Adelaide, SA, Australia
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10
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Hanna Pharm M, Mazkereth R. Which Patient in the Neonatal Intensive Care Unit should Receive Antifungal Prophylaxis Therapy? Isr Med Assoc J 2021; 23:116-120. [PMID: 33595218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Extremely preterm infants are at high risk for mortality and morbidity including neurodevelopmental impairment from invasive Candida infections. Prophylactic antifungal therapy has been shown to reduce both colonization and invasive candidemia in high-risk preterm infants. Prophylactic treatment should be started in the first 48 to 72 hours after birth to extremely low birth weight (ELBW) infants (weighing ≤ 1000 grams at birth) or below 27 weeks gestation age with risk factors, or in any NICU with moderate (5-10%) or high (≥ 10%) rates of invasive candidiasis. Studies demonstrated the benefits of fluconazole prophylaxis regarding its safety of the short-term and long-term without the development of fungal resistance. Empiric antifungal therapy may lower mortality and improve outcomes.
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MESH Headings
- Antifungal Agents/administration & dosage
- Antifungal Agents/adverse effects
- Candidiasis, Invasive/mortality
- Candidiasis, Invasive/prevention & control
- Drug Resistance, Fungal
- Fluconazole/administration & dosage
- Fluconazole/adverse effects
- Humans
- Infant, Extremely Low Birth Weight
- Infant, Newborn
- Infant, Premature
- Infant, Premature, Diseases/microbiology
- Infant, Premature, Diseases/mortality
- Infant, Premature, Diseases/prevention & control
- Intensive Care Units, Neonatal
- Patient Selection
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Affiliation(s)
- Marwan Hanna Pharm
- Department of Neonatology, Safra Children's Hospital
- Clinical Pharmacy Services, Sheba Medical Center, Tel Hashomer, Israel
| | - Ram Mazkereth
- Department of Neonatology, Safra Children's Hospital
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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11
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Abstract
RATIONALE Fungal endocarditis (FE) is a rare disease, in which antifungal treatment is necessary. When FE is complicated with prosthetic heart valve and/or atrial fibrillation, the coadministration of antifungal agents and warfarin is inevitable. We report a case of rheumatic heart disease with atrial fibrillation who developed FE following prosthetic heart valve replacement. The international normalized ratio (INR) increased significantly during the antifungal treatment with fluconazole. A discussion of the antifungal strategy in FE patients with prosthetic heart valves and/or atrial fibrillation and the interaction between antifungal agents and warfarin was performed. PATIENT CONCERNS A 54-year-old Chinese woman experienced intermittent fevers, aphemia, and weakness in her right extremities. Her temperature was 38.7°C, and there was atrial fibrillation with heart rate 110 times/min. Neurological examination revealed that she had drowsiness, Broca aphasia, right central facial paralysis, and hemiplegia (Medical Research Council scale, upper limb grade 0, lower limb grade II). DIAGNOSES Multiple infarction on magnetic resonance imaging and the occlusion of left middle cerebral artery suggested the occurrence of cerebral embolism. The presence of Candida parapsilosis in the results of 4 blood cultures and the existence of valve vegetation in the reexamination of echocardiogram supported the diagnosis of FE. INTERVENTIONS The patient was given antifungal therapy with fluconazol. The INR increased dramatically on the 9th day of antifungal treatment, and subcutaneous bruising occurred at the intravenous infusion site. The antagonist of vitamin K1 was used and warfarin was reduced to a smaller dosage. The antifungal agent was replaced with caspofungin. OUTCOMES Her speech improved significantly, and the muscle strength of her paralyzed side reached the Medical Research Council scale of grade IV. She continued to receive caspofungin for antifungal treatment with relatively stable INR and waited for heart valve surgery. LESSONS The choice of antifungal agents is often a big challenge for FE patients, especially when they need warfarin for anticoagulation. It is better to administer a low dose of warfarin while carefully monitoring the INR or choose the antifungal drugs with little or no effect on warfarin.
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Affiliation(s)
- Xiaoxia Zhu
- Department of Cardiology, The Second Affiliated Hospital of Anhui Medical University
| | - Shugang Cao
- Department of Neurology, The Affiliated Hefei Hospital of Anhui Medical University, Hefei, Anhui, P.R. China
| | - Mingwu Xia
- Department of Neurology, The Affiliated Hefei Hospital of Anhui Medical University, Hefei, Anhui, P.R. China
| | - Chandong Ding
- Department of Cardiology, The Second Affiliated Hospital of Anhui Medical University
| | - Rongfeng Wang
- Department of Neurology, The Affiliated Hefei Hospital of Anhui Medical University, Hefei, Anhui, P.R. China
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12
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Prakash C, Fan B, Ke A, Le K, Yang H. Physiologically based pharmacokinetic modeling and simulation to predict drug-drug interactions of ivosidenib with CYP3A perpetrators in patients with acute myeloid leukemia. Cancer Chemother Pharmacol 2020; 86:619-632. [PMID: 32978634 DOI: 10.1007/s00280-020-04148-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 09/10/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE Develop a physiologically based pharmacokinetic (PBPK) model of ivosidenib using in vitro and clinical PK data from healthy participants (HPs), refine it with clinical data on ivosidenib co-administered with itraconazole, and develop a model for patients with acute myeloid leukemia (AML) and apply it to predict ivosidenib drug-drug interactions (DDI). METHODS An HP PBPK model was developed in Simcyp Population-Based Simulator (version 15.1), with the CYP3A4 component refined based on a clinical DDI study. A separate model accounting for the reduced apparent oral clearance in patients with AML was used to assess the DDI potential of ivosidenib as the victim of CYP3A perpetrators. RESULTS For a single 250 mg ivosidenib dose, the HP model predicted geometric mean ratios of 2.14 (plasma area under concentration-time curve, to infinity [AUC0-∞]) and 1.04 (maximum plasma concentration [Cmax]) with the strong CYP3A4 inhibitor, itraconazole, within 1.26-fold of the observed values (2.69 and 1.0, respectively). The AML model reasonably predicted the observed ivosidenib concentration-time profiles across all dose levels in patients. Predicted ivosidenib geometric mean steady-state AUC0-∞ and Cmax ratios were 3.23 and 2.26 with ketoconazole, and 1.90 and 1.52 with fluconazole, respectively. Co-administration of the strong CYP3A4 inducer, rifampin, predicted a greater DDI effect on a single dose of ivosidenib than on multiple doses (AUC ratios 0.35 and 0.67, Cmax ratios 0.91 and 0.81, respectively). CONCLUSION Potentially clinically relevant DDI effects with CYP3A4 inducers and moderate and strong inhibitors co-administered with ivosidenib were predicted. Considering the challenges of conducting clinical DDI studies in patients, this PBPK approach is valuable in ivosidenib DDI risk assessment and management.
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Affiliation(s)
| | - Bin Fan
- Agios Pharmaceuticals, Inc., Cambridge, MA, USA
| | - Alice Ke
- Certara UK Limited, Sheffield, UK
| | - Kha Le
- Agios Pharmaceuticals, Inc., Cambridge, MA, USA
| | - Hua Yang
- Agios Pharmaceuticals, Inc., Cambridge, MA, USA
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13
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Gonzalez D, Laughon MM, Smith PB, Ge S, Ambalavanan N, Atz A, Sokol GM, Hornik CD, Stewart D, Mundakel G, Poindexter BB, Gaedigk R, Mills M, Cohen‐Wolkowiez M, Martz K, Hornik CP. Population pharmacokinetics of sildenafil in extremely premature infants. Br J Clin Pharmacol 2019; 85:2824-2837. [PMID: 31475367 PMCID: PMC6955411 DOI: 10.1111/bcp.14111] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 08/06/2019] [Accepted: 08/22/2019] [Indexed: 11/30/2022] Open
Abstract
AIMS To characterize the population pharmacokinetics (PK) of sildenafil and its active metabolite, N-desmethyl sildenafil (DMS), in premature infants. METHODS We performed a multicentre, open-label trial to characterize the PK of sildenafil in infants ≤28 weeks gestation and < 365 postnatal days (cohort 1) or < 32 weeks gestation and 3-42 postnatal days (cohort 2). In cohort 1, we obtained PK samples from infants receiving sildenafil as ordered per the local standard of care (intravenous [IV] or enteral). In cohort 2, we administered a single IV dose of sildenafil and performed PK sampling. We performed a population PK analysis and dose-exposure simulations using the software NONMEM®. RESULTS We enrolled 34 infants (cohort 1 n = 25; cohort 2 n = 9) and collected 109 plasma PK samples. Sildenafil was given enterally (0.42-2.09 mg/kg) in 24 infants in cohort 1 and via IV (0.125 or 0.25 mg/kg) in all infants in cohort 2. A 2-compartment PK model for sildenafil and 1-compartment model for DMS, with presystemic conversion of sildenafil to DMS, characterized the data well. Coadministration of fluconazole (n = 4), a CYP3A inhibitor, resulted in an estimated 59% decrease in sildenafil clearance. IV doses of 0.125, 0.5 and 1 mg/kg every 8 hours (in the absence of fluconazole) resulted in steady-state maximum sildenafil concentrations that were generally within the range of those reported to inhibit phosphodiesterase type 5 activity in vitro. CONCLUSIONS We successfully characterized the PK of sildenafil and DMS in premature infants and applied the model to inform dosing for a follow-up, phase II study.
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MESH Headings
- Administration, Oral
- Cohort Studies
- Cytochrome P-450 CYP3A/blood
- Cytochrome P-450 CYP3A/genetics
- Fluconazole/administration & dosage
- Fluconazole/pharmacokinetics
- Gestational Age
- Humans
- Hypertension, Pulmonary/blood
- Hypertension, Pulmonary/drug therapy
- Infant
- Infant, Newborn
- Infant, Premature/blood
- Infant, Premature, Diseases/blood
- Infant, Premature, Diseases/drug therapy
- Injections, Intravenous
- Models, Biological
- Phosphodiesterase 5 Inhibitors/administration & dosage
- Phosphodiesterase 5 Inhibitors/blood
- Phosphodiesterase 5 Inhibitors/pharmacokinetics
- Phosphodiesterase 5 Inhibitors/therapeutic use
- Sildenafil Citrate/administration & dosage
- Sildenafil Citrate/blood
- Sildenafil Citrate/pharmacokinetics
- Sildenafil Citrate/therapeutic use
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Affiliation(s)
- Daniel Gonzalez
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of PharmacyThe University of North Carolina at Chapel HillChapel HillNCUSA
| | - Matthew M. Laughon
- Department of Pediatrics, School of MedicineThe University of North Carolina at Chapel HillChapel HillNCUSA
| | - P. Brian Smith
- Department of PediatricsDuke University School of MedicineDurhamNCUSA
- Duke Clinical Research InstituteDurhamNCUSA
| | - Shufan Ge
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of PharmacyThe University of North Carolina at Chapel HillChapel HillNCUSA
| | - Namasivayam Ambalavanan
- Division of Neonatology, School of MedicineUniversity of Alabama at BirminghamBirminghamALUSA
| | - Andrew Atz
- Department of PediatricsMedical University of South Carolina Children's HospitalCharlestonSCUSA
| | - Gregory M. Sokol
- Section of Neonatal‐Perinatal MedicineIndiana University School of MedicineIndianapolisINUSA
| | - Chi D. Hornik
- Department of PediatricsDuke University School of MedicineDurhamNCUSA
- Duke Clinical Research InstituteDurhamNCUSA
- Department of PharmacyDuke University Medical CenterDurhamNCUSA
| | - Dan Stewart
- University of Louisville Norton Children's HospitalLouisvilleKYUSA
| | - Gratias Mundakel
- Kings County Hospital Center/SUNY Downstate Medical CenterBrooklynNYUSA
| | | | - Roger Gaedigk
- Department of Clinical Pharmacology, Toxicology & Therapeutic Innovation, Children's Mercy‐Kansas CityUniversity of Missouri‐Kansas City School of MedicineKansas CityMOUSA
| | - Mary Mills
- Duke Clinical Research InstituteDurhamNCUSA
| | - Michael Cohen‐Wolkowiez
- Department of PediatricsDuke University School of MedicineDurhamNCUSA
- Duke Clinical Research InstituteDurhamNCUSA
| | | | - Christoph P. Hornik
- Department of PediatricsDuke University School of MedicineDurhamNCUSA
- Duke Clinical Research InstituteDurhamNCUSA
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14
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Gupta AK, Stec N, Bamimore MA, Foley KA, Shear NH, Piguet V. The efficacy and safety of pulse vs. continuous therapy for dermatophyte toenail onychomycosis. J Eur Acad Dermatol Venereol 2019; 34:580-588. [PMID: 31746067 DOI: 10.1111/jdv.16101] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 11/11/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Onychomycosis is a chronic, fungal infection of the nails. Complete cure remains challenging, but oral antifungal medications have been successful in managing the fungus for a significant proportion of patients. Treatment with these drugs can be continuous or intermittent, albeit the evidence on their relative efficacies remains unclear. OBJECTIVE To determine the relative effectiveness and safety of pulse versus continuous administration, of three common oral therapies for dermatophyte onychomycosis, by conducting multiple-treatment meta-analysis. METHODS This systematic review and network meta-analysis compared the efficacy (as per mycological cure) and adverse event rates of three oral antifungal medications in the treatment of dermatophyte toenail onychomycosis, namely terbinafine, itraconazole and fluconazole. A total of 30 studies were included in the systematic review, while 22 were included in the network meta-analysis. RESULTS The likelihood of mycological cure was not significantly different between continuous and pulse regimens for each of terbinafine and itraconazole. Use of continuous terbinafine for 24 weeks - but not 12 weeks - was significantly more likely to result in mycological cure than continuous itraconazole for 12 weeks or weekly fluconazole for 9-12 months. Rank probabilities demonstrated that 24-week continuous treatment of terbinafine was the most effective. There were no significant differences in the likelihood of adverse events between any continuous and pulse regimens of terbinafine, itraconazole and fluconazole. Drug treatments were similar to placebo in terms of their likelihood of producing adverse events. CONCLUSION More knowledge about the fungal life cycle and drugs' pharmacokinetics in nail and plasma could further explain the relative efficacy and safety of the pulse and continuous treatment regimens. Our results indicate that in the treatment of dermatophyte toenail onychomycosis, the continuous and pulse regimens for terbinafine and itraconazole have similar efficacies and rates of adverse events.
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Affiliation(s)
- A K Gupta
- Mediprobe Research Inc., London, ON, Canada
- Division of Dermatology, Department of Medicine, University of Toronto School of Medicine, Toronto, ON, Canada
| | - N Stec
- Mediprobe Research Inc., London, ON, Canada
| | | | - K A Foley
- Mediprobe Research Inc., London, ON, Canada
| | - N H Shear
- Division of Dermatology, Department of Medicine, University of Toronto School of Medicine, Toronto, ON, Canada
- Division of Dermatology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - V Piguet
- Division of Dermatology, Department of Medicine, University of Toronto School of Medicine, Toronto, ON, Canada
- Division of Dermatology, Women's College Hospital, Toronto, ON, Canada
- Division of Infection and Immunity, Cardiff University School of Medicine, Cardiff, UK
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15
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Fujioka K, Nagai T, Kinoshita Y, Urushihara M, Hamasaki Y, Shishido S, Kagami S. Successful treatment with voriconazole combined with amphotericin B-liposome for fluconazole-resistant pulmonary cryptococcosis after renal transplantation. CEN Case Rep 2019; 8:261-265. [PMID: 31161376 DOI: 10.1007/s13730-019-00403-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 05/23/2019] [Indexed: 11/26/2022] Open
Abstract
Cryptococcosis is an invasive fungal infection that is common among organ transplant recipients, and it is challenging to treat among these patients because of their immunocompromised status. Fluconazole (FLCZ) is recommended as a first-line treatment modality for pulmonary cryptococcosis in organ transplant recipients. However, cases of FLCZ resistance among Cryptococcus neoformans isolates have been reported from the Asia Pacific region. Previous studies have reported the efficacy of voriconazole (VRCZ) in patients with FLCZ-resistant fungal infections. Herein, we report a case of FLCZ-resistant pulmonary cryptococcosis after renal transplantation that was successfully treated with VRCZ combined with amphotericin B-liposome (L-AMB). The patient was a-23-year-old woman who underwent living-donor kidney transplantation at age 20 years. She has attended our hospital since before for mental retardation, epilepsy, and dilated cardiomyopathy. At age 23 years, she presented to our hospital with fever and cough. She was diagnosed with pulmonary cryptococcosis based on positive-serum cryptococcal antigen. Chest radiography showed bilateral consolidations. Fosfluconazole (F-FLCZ) was administered, and her condition improved. However, she developed cough and fever again on day 60 of hospitalization. Cryptococcosis recurrence was suspected due to the high degree of cryptococcal antigen titers showed (1:2048) taken on the same day. Therefore, L-AMB was added, and F-FLCZ was substituted with VRCZ. Her condition improved, but L-AMB was discontinued due to hyponatremia, hypokalemia, and elevated serum creatinine. This indicates that VRCZ caused the remission. She was discharged after 6 months of admission. In conclusion, this case shows the efficacy of VRCZ combined with L-AMB for refractory pulmonary cryptococcosis.
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Affiliation(s)
- Keisuke Fujioka
- Department of Pediatrics, Institute of Biochemical Sciences, Tokushima University Graduate School, Kuramoto-cho 3-18-15, Tokushima, Tokushima, 770-8503, Japan.
| | - Takashi Nagai
- Department of Pediatrics, Institute of Biochemical Sciences, Tokushima University Graduate School, Kuramoto-cho 3-18-15, Tokushima, Tokushima, 770-8503, Japan
| | - Yukiko Kinoshita
- Department of Pediatrics, Institute of Biochemical Sciences, Tokushima University Graduate School, Kuramoto-cho 3-18-15, Tokushima, Tokushima, 770-8503, Japan
| | - Maki Urushihara
- Department of Pediatrics, Institute of Biochemical Sciences, Tokushima University Graduate School, Kuramoto-cho 3-18-15, Tokushima, Tokushima, 770-8503, Japan
| | - Yuko Hamasaki
- Department of Pediatric Nephrology, Faculty of Medicine, Toho University, Tokyo, Japan
| | - Seiichiro Shishido
- Department of Pediatric Nephrology, Faculty of Medicine, Toho University, Tokyo, Japan
| | - Shoji Kagami
- Department of Pediatrics, Institute of Biochemical Sciences, Tokushima University Graduate School, Kuramoto-cho 3-18-15, Tokushima, Tokushima, 770-8503, Japan
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16
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Stone NR, Rhodes J, Fisher MC, Mfinanga S, Kivuyo S, Rugemalila J, Segal ES, Needleman L, Molloy SF, Kwon-Chung J, Harrison TS, Hope W, Berman J, Bicanic T. Dynamic ploidy changes drive fluconazole resistance in human cryptococcal meningitis. J Clin Invest 2019; 129:999-1014. [PMID: 30688656 PMCID: PMC6391087 DOI: 10.1172/jci124516] [Citation(s) in RCA: 93] [Impact Index Per Article: 18.6] [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: 08/31/2018] [Accepted: 11/30/2018] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Cryptococcal meningitis (CM) causes an estimated 180,000 deaths annually, predominantly in sub-Saharan Africa, where most patients receive fluconazole (FLC) monotherapy. While relapse after FLC monotherapy with resistant strains is frequently observed, the mechanisms and impact of emergence of FLC resistance in human CM are poorly understood. Heteroresistance (HetR) - a resistant subpopulation within a susceptible strain - is a recently described phenomenon in Cryptococcus neoformans (Cn) and Cryptococcus gattii (Cg), the significance of which has not previously been studied in humans. METHODS A cohort of 20 patients with HIV-associated CM in Tanzania was prospectively observed during therapy with either FLC monotherapy or in combination with flucytosine (5FC). Total and resistant subpopulations of Cryptococcus spp. were quantified directly from patient cerebrospinal fluid (CSF). Stored isolates underwent whole genome sequencing and phenotypic characterization. RESULTS Heteroresistance was detectable in Cryptococcus spp. in the CSF of all patients at baseline (i.e., prior to initiation of therapy). During FLC monotherapy, the proportion of resistant colonies in the CSF increased during the first 2 weeks of treatment. In contrast, no resistant subpopulation was detectable in CSF by day 14 in those receiving a combination of FLC and 5FC. Genomic analysis revealed high rates of aneuploidy in heteroresistant colonies as well as in relapse isolates, with chromosome 1 (Chr1) disomy predominating. This is apparently due to the presence on Chr1 of ERG11, which is the FLC drug target, and AFR1, which encodes a drug efflux pump. In vitro efflux levels positively correlated with the level of heteroresistance. CONCLUSION Our findings demonstrate for what we believe is the first time the presence and emergence of aneuploidy-driven FLC heteroresistance in human CM, association of efflux levels with heteroresistance, and the successful suppression of heteroresistance with 5FC/FLC combination therapy. FUNDING This work was supported by the Wellcome Trust Strategic Award for Medical Mycology and Fungal Immunology 097377/Z/11/Z and the Daniel Turnberg Travel Fellowship.
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Affiliation(s)
- Neil R.H. Stone
- Centre for Global Health, Institute for Infection and Immunity, St. George’s, University of London, United Kingdom
| | - Johanna Rhodes
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, United Kingdom
| | - Matthew C. Fisher
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, United Kingdom
| | - Sayoki Mfinanga
- National Institute of Medical Research, Dar es Salaam, Tanzania
- Liverpool School of Tropical Medicine, United Kingdom
| | - Sokoine Kivuyo
- National Institute of Medical Research, Dar es Salaam, Tanzania
| | | | - Ella Shtifman Segal
- School of Molecular Cell Biology and Biotechnology, Tel Aviv University, Israel
| | - Leor Needleman
- School of Molecular Cell Biology and Biotechnology, Tel Aviv University, Israel
| | - 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
| | - William Hope
- Institute of Translational Medicine, University of Liverpool, United Kingdom
| | - Judith Berman
- School of Molecular Cell Biology and Biotechnology, Tel Aviv University, Israel
| | - Tihana Bicanic
- Centre for Global Health, Institute for Infection and Immunity, St. George’s, University of London, United Kingdom
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Bérard A, Sheehy O, Zhao JP, Gorgui J, Bernatsky S, de Moura CS, Abrahamowicz M. Associations between low- and high-dose oral fluconazole and pregnancy outcomes: 3 nested case-control studies. CMAJ 2019; 191:E179-E187. [PMID: 30782643 PMCID: PMC6379167 DOI: 10.1503/cmaj.180963] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/22/2019] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND While topical azoles are the first-line treatment for fungal infections, oral fluconazole is frequently used during pregnancy. We aimed to assess the effect of exposure to low and high doses of fluconazole during pregnancy on the occurrence of spontaneous abortions, major congenital malformations and stillbirths. METHODS Within the Quebec Pregnancy Cohort (1998-2015), we identified women exposed to low- (≤ 150 mg) and high-dose (> 150 mg) fluconazole, and women who were not exposed. For each case of spontaneous abortion or stillbirth, up to 5 controls were randomly selected using an incidence density sampling method matched on gestational age at diagnosis of spontaneous abortion or stillbirth (index date) and the year of the last menstrual period. For cases of major congenital malformation, we considered all liveborn babies as controls. Generalized estimation equation models were used to analyze the 3 main outcomes separately. RESULTS Within a cohort of 441 949 pregnancies, 320 868 pregnancies were included in the analyses of spontaneous abortions, 226 599 of major congenital malformations and 7832 of stillbirths. Most (69.5%) women exposed to fluconazole in pregnancy received the common single therapeutic dose of 150 mg (low dose); the remainder received a dose of > 150 mg (high dose). Use of oral fluconazole during early pregnancy was associated with an increased risk of spontaneous abortion compared with no exposure (adjusted odds ratio [OR] for 345 cases exposed to low-dose treatment 2.23, 95% confidence interval [CI] 1.96-2.54; adjusted OR for 249 cases exposed to high-dose treatment 3.20, 95% CI 2.73-3.75). Exposure to fluconazole during the first trimester did not increase the risk of overall major congenital malformations; however, exposure to a high dose during the first trimester was associated with an increased risk of cardiac septal closure anomalies (adjusted OR 1.81, 95% CI 1.04-3.14; 13 exposed cases) compared with no exposure. No association was found between exposure to fluconazole during pregnancy and the risk of stillbirth. INTERPRETATION Any maternal exposure to fluconazole during pregnancy may increase risk of spontaneous abortion and doses higher than 150 mg during the first trimester may increase risk of cardiac septal closure anomalies.
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Affiliation(s)
- Anick Bérard
- Research Centre (Bérard, Sheehy, Zhao, Gorgui), CHU Sainte-Justine; Faculty of Pharmacy (Bérard, Gorgui), University of Montreal; Faculty of Medicine (Bernatsky, Moura), McGill University; Faculty of Medicine, Department of Clinical Epidemiology (Abrahamowicz), McGill University, Montréal, Que.
| | - Odile Sheehy
- Research Centre (Bérard, Sheehy, Zhao, Gorgui), CHU Sainte-Justine; Faculty of Pharmacy (Bérard, Gorgui), University of Montreal; Faculty of Medicine (Bernatsky, Moura), McGill University; Faculty of Medicine, Department of Clinical Epidemiology (Abrahamowicz), McGill University, Montréal, Que
| | - Jin-Ping Zhao
- Research Centre (Bérard, Sheehy, Zhao, Gorgui), CHU Sainte-Justine; Faculty of Pharmacy (Bérard, Gorgui), University of Montreal; Faculty of Medicine (Bernatsky, Moura), McGill University; Faculty of Medicine, Department of Clinical Epidemiology (Abrahamowicz), McGill University, Montréal, Que
| | - Jessica Gorgui
- Research Centre (Bérard, Sheehy, Zhao, Gorgui), CHU Sainte-Justine; Faculty of Pharmacy (Bérard, Gorgui), University of Montreal; Faculty of Medicine (Bernatsky, Moura), McGill University; Faculty of Medicine, Department of Clinical Epidemiology (Abrahamowicz), McGill University, Montréal, Que
| | - Sasha Bernatsky
- Research Centre (Bérard, Sheehy, Zhao, Gorgui), CHU Sainte-Justine; Faculty of Pharmacy (Bérard, Gorgui), University of Montreal; Faculty of Medicine (Bernatsky, Moura), McGill University; Faculty of Medicine, Department of Clinical Epidemiology (Abrahamowicz), McGill University, Montréal, Que
| | - Cristiano Soares de Moura
- Research Centre (Bérard, Sheehy, Zhao, Gorgui), CHU Sainte-Justine; Faculty of Pharmacy (Bérard, Gorgui), University of Montreal; Faculty of Medicine (Bernatsky, Moura), McGill University; Faculty of Medicine, Department of Clinical Epidemiology (Abrahamowicz), McGill University, Montréal, Que
| | - Michal Abrahamowicz
- Research Centre (Bérard, Sheehy, Zhao, Gorgui), CHU Sainte-Justine; Faculty of Pharmacy (Bérard, Gorgui), University of Montreal; Faculty of Medicine (Bernatsky, Moura), McGill University; Faculty of Medicine, Department of Clinical Epidemiology (Abrahamowicz), McGill University, Montréal, Que
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18
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Autmizguine J, Smith PB, Prather K, Bendel C, Natarajan G, Bidegain M, Kaufman DA, Burchfield DJ, Ross AS, Pandit P, Schell WA, Gao J, Benjamin DK. Effect of fluconazole prophylaxis on Candida fluconazole susceptibility in premature infants. J Antimicrob Chemother 2018; 73:3482-3487. [PMID: 30247579 PMCID: PMC6927883 DOI: 10.1093/jac/dky353] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 08/06/2018] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVES Extremely premature infants are at high risk of developing invasive candidiasis; fluconazole prophylaxis is safe and effective for reducing invasive candidiasis in this population but further study is needed. We sought to better understand the effect of prophylactic fluconazole on a selection of fluconazole-resistant Candida species. METHODS We evaluated the susceptibility to fluconazole of Candida isolates from premature infants (<750 g birth weight) enrolled in a multicentre, randomized, placebo-controlled trial of fluconazole prophylaxis. Candida species were isolated through surveillance cultures at baseline (study day 0-7), period 1 (study day 8-28) and period 2 (study day 29-49). Fluconazole MICs were determined for all Candida isolates. RESULTS Three hundred and sixty-one infants received fluconazole (n = 188) or placebo (n = 173). After the baseline period, Candida colonization was significantly lower in the fluconazole group compared with placebo during periods 1 (5% versus 27%; P < 0.001) and 2 (3% versus 27%; P < 0.001). After the baseline period, two infants (1%) were colonized with at least one fluconazole-resistant Candida in each group. Median fluconazole MIC was similar in both treatment groups at baseline and period 1. However, in period 2, median MIC was higher in the fluconazole group compared with placebo (1.00 versus 0.50 mg/L, P = 0.01). There was no emergence of resistance observed and no patients developed invasive candidiasis with a resistant Candida isolate. CONCLUSIONS Fluconazole prophylaxis decreased Candida albicans and 'non-albicans' Candida colonization and was associated with a slightly higher fluconazole MIC for colonizing Candida isolates.
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Affiliation(s)
- Julie Autmizguine
- Department of Pharmacology and Physiology, Université de Montréal, Montreal, Canada
- Department of Pediatrics, Université de Montréal, Montréal, Canada
- Research Center, CHU Ste-Justine, Montréal, Canada
| | - P Brian Smith
- Department of Pediatrics, Duke University, Durham, NC, USA
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - Kristi Prather
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | | | | | | | | | | | - Ashley S Ross
- University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Paresh Pandit
- Children’s Hospital of Philadelphia at Vitua West Jersey Hospital Voorhees, Voorhees, NJ, USA
| | - Wiley A Schell
- Department of Medicine, Duke University, Durham, NC, USA
| | - Jamie Gao
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - Daniel K Benjamin
- Department of Pediatrics, Duke University, Durham, NC, USA
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
- Corresponding author. Duke University Medical Center, Duke Clinical Research Institute, 2400 Pratt Street, Durham, NC 27705, USA. Tel:+1-919-668-7081; Fax: +1-919-668-7058; E-mail:
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19
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Lawrence DS, Youssouf N, Molloy SLF, Alanio A, Alufandika M, Boulware DR, Boyer-Chammard T, Chen T, Dromer F, Hlupeni A, Hope W, Hosseinipour MC, Kanyama C, Lortholary O, Loyse A, Meya DB, Mosepele M, Muzoora C, Mwandumba HC, Ndhlovu CE, Niessen L, Schutz C, Stott KE, Wang D, Lalloo DG, Meintjes G, Jaffar S, Harrison TS, Jarvis JN. AMBIsome Therapy Induction OptimisatioN (AMBITION): High Dose AmBisome for Cryptococcal Meningitis Induction Therapy in sub-Saharan Africa: Study Protocol for a Phase 3 Randomised Controlled Non-Inferiority Trial. Trials 2018; 19:649. [PMID: 30470259 PMCID: PMC6251219 DOI: 10.1186/s13063-018-3026-4] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [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: 08/16/2018] [Accepted: 10/29/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cryptococcal meningitis (CM) is a major cause of mortality in HIV programmes in Africa despite increasing access to antiretroviral therapy (ART). Mortality is driven in part by limited availability of amphotericin-based treatment, drug-induced toxicities of amphotericin B deoxycholate and prolonged hospital admissions. A single, high-dose of liposomal amphotericin (L-AmB, Ambisome) on a fluconazole backbone has been reported as non-inferior to 14 days of standard dose L-AmB in reducing fungal burden. This trial examines whether single, high-dose L-AmB given with high-dose fluconazole and flucytosine is non-inferior to a seven-day course of amphotericin B deoxycholate plus flucytosine (the current World Health Organization [WHO] recommended treatment regimen). METHODS An open-label phase III randomised controlled non-inferiority trial conducted in five countries in sub-Saharan Africa: Botswana, Malawi, South Africa, Uganda and Zimbabwe. The trial will compare CM induction therapy with (1) a single dose (10 mg/kg) of L-AmB given with 14 days of fluconazole (1200 mg/day) and flucytosine (100 mg/kg/day) to (2) seven days amphotericin B deoxycholate (1 mg/kg/day) given alongside seven days of flucytosine (100 mg/kg/day) followed by seven days of fluconazole (1200 mg/day). The primary endpoint is all-cause mortality at ten weeks with a non-inferiority margin of 10% and 90% power. Secondary endpoints are early fungicidal activity, proportion of grade III/IV adverse events, pharmacokinetic parameters and pharmacokinetic/pharmacodynamic associations, health service costs, all-cause mortality within the first two and four weeks, all-cause mortality within the first ten weeks (superiority analysis) and rates of CM relapse, immune reconstitution inflammatory syndrome and disability at ten weeks. A total of 850 patients aged ≥ 18 years with a first episode of HIV-associated CM will be enrolled (425 randomised to each arm). All patients will be followed for 16 weeks. All patients will receive consolidation therapy with fluconazole 800 mg/day to complete ten weeks of treatment, followed by fluconazole maintenance and ART as per local guidance. DISCUSSION A safe, sustainable and easy to administer regimen of L-AmB that is non-inferior to seven days of daily amphotericin B deoxycholate therapy may reduce the number of adverse events seen in patients treated with amphotericin B deoxycholate and shorten hospital admissions, providing a highly favourable and implementable alternative to the current WHO recommended first-line treatment. TRIAL REGISTRATION ISRCTN, ISRCTN72509687 . Registered on 13 July 2017.
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Affiliation(s)
- David S. Lawrence
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Nabila Youssouf
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Síle L. F. Molloy
- Research Centre for Infection and Immunity, St George’s University of London, London, UK
| | - Alexandre Alanio
- Molecular Mycology Unit and National Reference Centre for Invasive Mycoses, Institut Pasteur, Paris, France
| | - Melanie Alufandika
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi
| | - David R. Boulware
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
- Department of Medicine, University of Minnesota, Minneapolis, MN USA
| | - Timothée Boyer-Chammard
- Molecular Mycology Unit and National Reference Centre for Invasive Mycoses, Institut Pasteur, Paris, France
| | - Tao Chen
- Department of Clinical Sciences and International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Francoise Dromer
- Molecular Mycology Unit and National Reference Centre for Invasive Mycoses, Institut Pasteur, Paris, France
| | - Admire Hlupeni
- Department of Medicine, University of Zimbabwe College of Health Sciences, Parirenyatwa Hospital, Harare, Zimbabwe
| | - William Hope
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | | | - Cecilia Kanyama
- Lilongwe Medical Relief Trust (UNC Project), Lilongwe, Malawi
| | - Oliver Lortholary
- Molecular Mycology Unit and National Reference Centre for Invasive Mycoses, Institut Pasteur, Paris, France
| | - Angela Loyse
- Research Centre for Infection and Immunity, St George’s University of London, London, UK
| | - David B. Meya
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Mosepele Mosepele
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
- Department of Internal Medicine, University of Botswana, Gaborone, Botswana
| | - Conrad Muzoora
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Henry C. Mwandumba
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi
- Department of Clinical Sciences and International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Chiratidzo E. Ndhlovu
- Department of Medicine, University of Zimbabwe College of Health Sciences, Parirenyatwa Hospital, Harare, Zimbabwe
| | - Louis Niessen
- Department of Clinical Sciences and International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Charlotte Schutz
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, and Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Katharine E. Stott
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Duolao Wang
- Department of Clinical Sciences and International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - David G. Lalloo
- Department of Clinical Sciences and International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Graeme Meintjes
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, and Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Shabbar Jaffar
- Department of Clinical Sciences and International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Thomas S. Harrison
- Research Centre for Infection and Immunity, St George’s University of London, London, UK
| | - Joseph N. Jarvis
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
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20
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Fida M, Saraceno R, Gjylametaj N, Dervishi O, Barbullushi A, Kellici S, Vasili E. Eumycetoma pedis in an Albanian farmer. Cutis 2018; 102:E13-E15. [PMID: 30566558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Affiliation(s)
- Monika Fida
- Department of Dermatology, University of Medicine, Tirana, Albania
| | - Rosita Saraceno
- Department of Dermatology, University of Rome Tor Vergata, Italy
| | | | - Orjana Dervishi
- Laboratory Department, University of Medicine, Tirana, Albania
| | | | - Suela Kellici
- Faculty of Pharmacy, University of Medicine, Tirana, Albania
| | - Ermira Vasili
- Department of Dermatology, University of Medicine, Tirana, Albania
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El-Housiny S, Shams Eldeen MA, El-Attar YA, Salem HA, Attia D, Bendas ER, El-Nabarawi MA. Fluconazole-loaded solid lipid nanoparticles topical gel for treatment of pityriasis versicolor: formulation and clinical study. Drug Deliv 2018; 25:78-90. [PMID: 29239242 PMCID: PMC6058711 DOI: 10.1080/10717544.2017.1413444] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Accepted: 12/01/2017] [Indexed: 11/04/2022] Open
Abstract
Solid lipid nanoparticles (SLNs) are very potential formulations for topical delivery of antifungal drugs. Hence, the purpose of this research was to formulate the well-known antifungal agent Fluconazole (FLZ)-loaded SLNs topical gel to improve its efficiency for treatment of Pityriasis Versicolor (PV). FLZ-SLNs were prepared by modified high shear homogenization and ultrasonication method using different concentration of solid lipid (Compritol 888 ATO, Precirol ATO5) and surfactant (Cremophor RH40, Poloxamer 407). The physicochemical properties and the in vitro release study for all FLZ-SLNs were investigated. Furthermore, the optimized FLZ-SLN formula was incorporated into gel using Carpobol 934. A randomized controlled clinical trial (RCT) of potential batches was carried out on 30 well diagnosed PV patients comparing to market product Candistan® 1% cream. Follow up was done for 4 weeks by clinical and KOH examinations. The results showed that FlZ-SLNs were almost spherical shape having colloidal sizes with no aggregation. The drug entrapment efficiency ranged from 55.49% to 83.04%. The zeta potential values lie between -21 and -33 mV presenting good stability. FLZ showed prolonged in vitro release from SLNs dispersion and its Carbapol gel following Higuchi order equation. Clinical studies registered significant improvement (p < .05) in therapeutic response (1.4-fold; healing%, 4-fold; complete eradication) in terms of clinical cure and mycological cure rate from PV against marketed cream. Findings of the study suggest that the developed FLZ loaded SLNs topical gels have superior significant fast therapeutic index in treatment of PV over commercially available Candistan® cream.
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Affiliation(s)
- Shaimaa El-Housiny
- Department of Pharmaceutics and Industrial Pharmacy, Faculty of Pharmacy, Modern University for Technology and InformationCairoEgypt
| | | | - Yasmina Ahmed El-Attar
- Department of Dermatology and venereology, Faculty of Medicine, Tanat UniversityTantaEgypt
| | - Hoda A. Salem
- Department of Clinical Pharmacy, Faculty of Pharmacy, Al-Azhar UniversityCairoEgypt
| | - Dalia Attia
- Department of Pharmaceutics and Industrial Pharmacy, Faculty of Pharmacy, The British University in Egypt (BUE)CairoEgypt
| | - Ehab R. Bendas
- Department of Pharmaceutics and Industrial Pharmacy, Faculty of Pharmaceutical Sciences and Pharmaceutical Industries, Future University in EgyptCairoEgypt
| | - Mohamed A. El-Nabarawi
- Department of Pharmaceutics and Industrial Pharmacy, Faculty of Pharmacy, Cairo UniversityCairoEgypt
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22
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Molloy SF, Bradley J, Karunaharan N, Mputu M, Stone N, Phulusa J, Chawinga C, Gaskell K, Segula D, Ming D, Peirse M, Chanda D, Lakhi S, Loyse A, Kanyama C, Heyderman RS, Harrison TS. Effect of oral fluconazole 1200 mg/day on QT interval in African adults with HIV-associated cryptococcal meningitis. AIDS 2018; 32:2259-2261. [PMID: 30102652 PMCID: PMC6150187 DOI: 10.1097/qad.0000000000001961] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 06/27/2018] [Indexed: 11/25/2022]
Abstract
: We assessed the effect of fluconazole 1200 mg/day on the QT interval in cryptococcal meningitis patients. Mean corrected QT (QTc) change from baseline to day 7 was 10.1 ms (IQR: -28 to 46 ms) in the fluconazole treatment group and -12.6 ms (IQR: -39 to 13.5 ms) in those not taking fluconazole (P = 0.04). No significant increase in QTc measurements over 500 ms was observed with fluconazole. Nevertheless, it remains important to correct any electrolyte imbalance and avoid concomitant drugs that may increase QTc.
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Affiliation(s)
- Síle F. Molloy
- Centre for Global Health, Institute for Infection and Immunity, St George's University of London
- Joint first authors
| | - John Bradley
- MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
- Joint first authors
| | - Natasha Karunaharan
- Centre for Global Health, Institute for Infection and Immunity, St George's University of London
| | - Muhammad Mputu
- University Teaching Hospital, Lusaka, Zambia
- University of Zambia School of Medicine, Lusaka, Zambia
| | - Neil Stone
- Centre for Global Health, Institute for Infection and Immunity, St George's University of London
| | - Jacob Phulusa
- University of North Carolina Project–Malawi, Kamuzu Central Hospital, Lilongwe
| | - Chimwemwe Chawinga
- University of North Carolina Project–Malawi, Kamuzu Central Hospital, Lilongwe
| | - Kate Gaskell
- Malawi–Liverpool–Wellcome Trust Clinical Research Programme, College of Medicine, University of Malawi, Malawi
| | - Dalitso Segula
- Malawi–Liverpool–Wellcome Trust Clinical Research Programme, College of Medicine, University of Malawi, Malawi
| | - Damien Ming
- Malawi–Liverpool–Wellcome Trust Clinical Research Programme, College of Medicine, University of Malawi, Malawi
| | - Mary Peirse
- Malawi–Liverpool–Wellcome Trust Clinical Research Programme, College of Medicine, University of Malawi, Malawi
| | - Duncan Chanda
- University Teaching Hospital, Lusaka, Zambia
- University of Zambia School of Medicine, Lusaka, Zambia
| | | | - Angela Loyse
- Centre for Global Health, Institute for Infection and Immunity, St George's University of London
| | - Cecilia Kanyama
- University of North Carolina Project–Malawi, Kamuzu Central Hospital, Lilongwe
| | - Robert S. Heyderman
- Malawi–Liverpool–Wellcome Trust Clinical Research Programme, College of Medicine, University of Malawi, Malawi
- University College London, London, UK
| | - Thomas S. Harrison
- Centre for Global Health, Institute for Infection and Immunity, St George's University of London
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Abstract
BACKGROUND This review adds to a series of reviews looking at primary medical management options for patients with chronic rhinosinusitis.Chronic rhinosinusitis is common and characterised by inflammation of the lining of the nose and paranasal sinuses leading to nasal blockage, nasal discharge, facial pressure/pain and loss of sense of smell. The condition can occur with or without nasal polyps. Antifungals have been suggested as a treatment for chronic rhinosinusitis. OBJECTIVES To assess the effects of systemic and topical antifungal agents in patients with chronic rhinosinusitis, including those with allergic fungal rhinosinusitis (AFRS) and, if possible, AFRS exclusively. SEARCH METHODS The Cochrane ENT Information Specialist searched the Cochrane ENT Trials Register; Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid Embase; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 17 November 2017. SELECTION CRITERIA Randomised controlled trials (RCTs) with at least a two-week follow-up period comparing topical or systemic antifungals with (a) placebo, (b) no treatment, (c) other pharmacological interventions or (d) a different antifungal agent. We did not include post-surgical antifungal use. DATA COLLECTION AND ANALYSIS We used the standard Cochrane methodological procedures. Our primary outcomes were disease-specific health-related quality of life (HRQL), patient-reported disease severity and the significant adverse effects of hepatic toxicity (systemic antifungals). Secondary outcomes included general HRQL, endoscopic nasal polyp score, computerised tomography (CT) scan score and the adverse effects of gastrointestinal disturbance (systemic antifungals) and epistaxis, headache or local discomfort (topical antifungals). We used GRADE to assess the quality of the evidence for each outcome; this is indicated in italics. MAIN RESULTS We included eight studies (490 adult participants). The presence of nasal polyps on examination was an inclusion criterion in three studies, an exclusion criterion in one study and the remaining studies included a mixed population. No studies specifically investigated the effect of antifungals in patients with AFRS.Topical antifungal treatment versus placebo or no interventionWe included seven studies (437 participants) that used amphotericin B (six studies; 383 participants) and one that used fluconazole (54 participants). Different delivery methods, volumes and concentrations were used.Four studies reported disease-specific health-related quality of life using a range of instruments. We did not meta-analyse the results due to differences in the instruments used, and measurement and reporting methods. At the end of treatment (one to six months) none of the studies reported statistically significant differences between the groups (low-quality evidence - we are uncertain about the result).Two studies reported disease severity using patient-reported symptom scores. Meta-analysis was not possible. At the end of treatment (8 to 13 weeks) one study showed no difference and the second found that patients in the placebo group had less severe symptoms (very low-quality evidence - we are very uncertain about the result).In terms of adverse effects, topical antifungals may lead to more local irritation compared with placebo (risk ratio (RR) 2.29, 95% confidence interval (CI) 0.61 to 8.62; 312 participants; 5 studies; low-quality evidence) but little or no difference in epistaxis (RR 0.97, 95% CI 0.14 to 6.63; 225 participants; 4 studies, low-quality evidence) or headache (RR 1.26, 95% CI 0.60 to 2.63; 195 participants; 3 studies; very low-quality evidence).None of the studies found a difference in generic health-related quality of life (one study) or endoscopic score (five studies) between the treatment groups. Three studies investigated CT scan; two found no difference between the groups and one found a significant decrease in the mean percentage of air space occluded, favouring the antifungal group.Systemic antifungal treatment versus placebo or no treatmentOne study (53 participants) comparing terbinafine tablets against placebo reported that there may be little or no difference between the groups in disease-specific health-related quality of life or disease severity score (both low-quality evidence). Systemic antifungals may lead to more hepatic toxicity events (RR 3.35, 95% CI 0.14 to 78.60) but fewer gastrointestinal disturbances (RR 0.37, 95% CI 0.04 to 3.36), compared to placebo, although the evidence was of low quality.This study did not find a difference in CT scan score between the groups. Generic health-related quality of life and endoscopic score were not measured.Other comparisonsWe found no studies that compared antifungal agents against other treatments for chronic rhinosinusitis. AUTHORS' CONCLUSIONS Due to the very low quality of the evidence, it is uncertain whether or not the use of topical or systemic antifungals has an impact on patient outcomes in adults with chronic rhinosinusitis compared with placebo or no treatment. Studies including specific subgroups (i.e. AFRS) are lacking.
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Affiliation(s)
- Karen Head
- Nuffield Department of Surgical Sciences, University of OxfordCochrane ENTUK Cochrane Centre, Summertown Pavilion18 ‐ 24 Middle WayOxfordUK
| | - Steve Sharp
- National Institute for Health and Care ExcellenceLevel 1A, City TowerPiccadilly PlazaManchesterUKM1 4BT
| | | | - Claire Hopkins
- Guy's HospitalENT DepartmentGerat Maze PondLondonUKSE1 9RT
| | - Carl Philpott
- Norwich Medical School, University of East AngliaDepartment of MedicineNorwichUKNR4 7TJ
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24
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Abstract
Cryptococcal meningiti s causes 15% of AIDS-related deaths globally. Screening and preemptive treatment for cryptococcal antigen (CrAg) in the blood of persons with advanced HIV/AIDS reduces mortality. National and international HIV guidelines recommend CrAg screening; however, implementation studies and evaluations of how to integrate CrAg screening programs into existing HIV care infrastructure are lacking.During a CrAg screening program in Kampala, Uganda, we interviewed 15 health care workers (2 coordinating research nurses and 13 clinic personnel) from 6 HIV clinics between March and April 2017, to identify barriers to implementation as well as facilitating factors for program success. The interviews were coded and themes compiled.We found key factors for successful implementation of a CrAg screening program were: adequate supplies of fluconazole and CrAg lateral flow assay (LFA) point-of-care tests, timely patient follow-up, and quick turnaround time of laboratory results. Although both CrAg LFA kits and fluconazole are on the national formulary, stockouts are common, affecting patient care. The CrAg screening recommendation by national HIV guidelines remains integral to the success of the program, as overburdened clinics are otherwise reluctant to adopt additional screening. Collaboration with Ministries of Health for support with enforcing national guidelines, and procuring supplies is paramount to a successful CrAg screening program.Development of a CrAg screening and treatment program within the HIV clinic infrastructure has a number of barriers. Education and training of clinic staff, along with partnership with the Ministry of Health to ensure adequate supplies, facilitated the program.
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Affiliation(s)
- Sarah M. Lofgren
- Department of Medicine, University of Minnesota, Minneapolis, MN
| | | | - David B. Meya
- Department of Medicine, University of Minnesota, Minneapolis, MN
- Infectious Diseases Institute
- School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
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25
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Abstract
BACKGROUND There remains uncertainty about the optimum timing of antiretroviral therapy (ART) initiation in HIV-positive people with cryptococcal meningitis. This uncertainty is the result of conflicting data on the mortality risk and occurrence of immune reconstitution inflammatory syndrome (IRIS) when ART is initiated less than four weeks after cryptococcal meningitis treatment is commenced. OBJECTIVES To compare the outcomes of early initiation of ART (less than four weeks after starting antifungal treatment) versus delayed initiation of ART (four weeks or more after starting antifungal treatment) in HIV-positive people with concurrent cryptococcal meningitis. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and Embase for trials published between 1 January 1980 and 7 August 2017. We additionally searched international trial registries, including ClinicalTrials.gov and WHO International Clinical Trials Registry Platform (ICTRP), and conference abstracts from the International AIDS Society (IAS) and the Conference on Retroviruses and Opportunistic Infections (CROI) for ongoing or unpublished studies between 2015 and 2017. We reviewed reference lists of included studies to identify additional studies. SELECTION CRITERIA We included randomized controlled trials (RCTs) that compared early versus delayed ART initiation in HIV-positive people with cryptococcal meningitis. Children, adults, and adolescents from any setting were eligible for inclusion. DATA COLLECTION AND ANALYSIS Two review authors independently applied the inclusion criteria and extracted data. We presented dichotomous outcomes as risk ratios (RR) with 95% confidence intervals (CIs). We presented time-to-death data as hazard ratios with 95% CIs. We assessed the certainty of the evidence using the GRADE approach. MAIN RESULTS Four trials including 294 adult participants met the inclusion criteria of this review. Participants were predominantly from low- and middle-income countries. Two trials treated cryptococcal meningitis with amphotericin B and fluconazole; a third trial used fluconazole monotherapy; and the fourth trial did not specify the antifungal used.Early ART initiation may increase all-cause mortality compared to delayed ART initiation (RR 1.42, 95% CI 1.02 to 1.97; 294 participants, 4 trials; low-certainty evidence). Early ART initiation may reduce relapse of cryptococcal meningitis compared to delayed ART initiation (RR 0.27, 95% CI 0.07 to 1.04; 205 participants, 2 trials, low-certainty evidence). We are uncertain whether early ART initiation increases or reduces cryptococcal IRIS events compared to delayed ART initiation (RR 3.56, 95% CI 0.51 to 25.02; 205 participants, 2 trials; I2 = 54%; very low-certainty evidence). We are uncertain if early ART initiation increases or reduces virological suppression at six months compared to delayed ART initiation (RR 0.93, 95% CI 0.72 to 1.22; 205 participants, 2 trials; I2 statistic = 0%; very low-certainty evidence).We were unable to pool results related to rate of fungal clearance for the two trials that reported this outcome; individual trial results indicated that there was no difference in cerebrospinal fluid fungal clearance between trial arms. Similarly, we were unable to pool results on adverse events for the trials reporting on this outcome; individual trial results indicated no difference in the occurrence of grade 3 to 5 adverse events between trial arms.Three of the four included trials had an overall low or unclear risk of bias related to the primary outcome of all-cause mortality. However, we assessed one trial as at high risk of bias due to selective outcome reporting and other bias. This, in addition to the few clinical events and imprecision of effect estimates, led to downgrading of the evidence to low or very low certainty. AUTHORS' CONCLUSIONS The results of this review are relevant to HIV-positive adults with cryptococcal meningitis in low- and middle-income countries. These data suggest a higher risk of mortality among people who initiate ART within four weeks of cryptococcal meningitis diagnosis. However, it is unclear if this higher mortality risk is related to cryptococcal meningitis-IRIS.
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Affiliation(s)
- Ingrid Eshun‐Wilson
- Stellenbosch UniversityCentre for Evidence Based Health Care, Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health SciencesFrancie van Zyl Drive, Tygerberg, 7505, ParowCape TownWestern CapeSouth Africa7505
| | - Mbah P Okwen
- Yaoundé Central HospitalCentre for the Development of Best Practices in Health (CDBPH)YaoundéCameroon
| | - Marty Richardson
- Liverpool School of Tropical MedicineCochrane Infectious Diseases GroupPembroke PlaceLiverpoolUKL3 5QA
| | - Tihana Bicanic
- St George's University of LondonInstitute of Infection and ImmunityLondonUK
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Sung J, Perez IE, Feinstein A, Stein DK. A case report of purulent pericarditis caused by Candida albicans: Delayed complication forty-years after esophageal surgery. Medicine (Baltimore) 2018; 97:e11286. [PMID: 29995762 PMCID: PMC6076085 DOI: 10.1097/md.0000000000011286] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Candida pericarditis is a rare condition with high mortality. Risk factors include thoracic surgery and immunosuppression. We report a case of candida pericarditis which developed forty-years after esophageal reconstruction surgery. PATIENT CONCERNS A 42-year-old female presented with nausea, abdominal discomfort, and chest pain, and was found to have a cardiac tamponade secondary to candida pericarditis. Her notable risk factor was colonic interposition done during her infancy for esophageal atresia. DIAGNOSES The patient underwent emergent pericardial window where 500cc of purulent fluid was drained. The pericardial fluid culture grew Candida albicans. INTERVENTIONS Esophagram did not show any visible leak and the patient improved with surgical drainage and antifungal treatment with Caspofungin. Caspofungin was continued intravenously for a total of four weeks and was switched to fluconazole. OUTCOMES An Echocardiogram performed one month after pericardial window revealed trivial pericardial effusion. Serum beta-D-glucan at the time was negative. LESSONS This report highlights that candida pericarditis infection could occur as a late complication of colonic interposition. We also demonstrate the utility of using an echinocandin in treating this entity.
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27
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Abstract
This pharmacoepidemiology study uses Swedish and Norwegian registry data to investigate associations between fluconazole use during pregnancy and subsequent stillbirth and neonatal death.
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Affiliation(s)
- Björn Pasternak
- Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Viktor Wintzell
- Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Kari Furu
- Department of Pharmacoepidemiology, Norwegian Institute of Public Health, Oslo, Norway
| | - Anders Engeland
- Department of Pharmacoepidemiology, Norwegian Institute of Public Health, Oslo, Norway
| | - Martin Neovius
- Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Olof Stephansson
- Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
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Liang SE, Cohen DE, Rieder EA. Proximal Subungual Onychomycosis in the Immunocompetent: A Case Report and Review of the Literature. J Drugs Dermatol 2018; 17:475-478. [PMID: 29601625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Proximal subungual onychomycosis (PSO), which predominantly involves the nail plate from the proximal nail fold, is the rarest form of onychomycosis. Classically associated with an immunocompromised state, PSO is an uncommon diagnosis in individuals without immunodeficiency. We present a case of a healthy 51-year-old man, who presented with a three-month history of white discoloration of multiple toenails. Physical examination revealed white, opaque patches on the proximal third nail plates of multiple toenails. The affected digits also demonstrated proximal onycholysis, subungual debris, and mild paronychia. Laboratory examinations, including routine serologic studies as well as human immunodeficiency virus and antinuclear antibodies, were within normal limits. Proximal nail fragments of the left hallux showed sections of dystrophic nail plate with mounds of parakeratosis, collections of neutrophils, and hyphae that highlighted with periodic acid-Schiff staining. The patient was diagnosed with PSO and tinea pedis bilaterally and treated with oral fluconazole with gradual improvement. This case of PSO highlights the potential for its rare occurrence in a healthy host. However, the clinical presentation of PSO should trigger an evaluation for possible immunodeficiency. <p><em>J Drugs Dermatol. 2018;17(4):475-478.</em></p>.
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29
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Molloy SF, Kanyama C, Heyderman RS, Loyse A, Kouanfack C, Chanda D, Mfinanga S, Temfack E, Lakhi S, Lesikari S, Chan AK, Stone N, Kalata N, Karunaharan N, Gaskell K, Peirse M, Ellis J, Chawinga C, Lontsi S, Ndong JG, Bright P, Lupiya D, Chen T, Bradley J, Adams J, van der Horst C, van Oosterhout JJ, Sini V, Mapoure YN, Mwaba P, Bicanic T, Lalloo DG, Wang D, Hosseinipour MC, Lortholary O, Jaffar S, Harrison TS. Antifungal Combinations for Treatment of Cryptococcal Meningitis in Africa. N Engl J Med 2018. [PMID: 29539274 DOI: 10.1056/nejmoa1710922] [Citation(s) in RCA: 252] [Impact Index Per Article: 42.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Cryptococcal meningitis accounts for more than 100,000 human immunodeficiency virus (HIV)-related deaths per year. We tested two treatment strategies that could be more sustainable in Africa than the standard of 2 weeks of amphotericin B plus flucytosine and more effective than the widely used fluconazole monotherapy. METHODS We randomly assigned HIV-infected adults with cryptococcal meningitis to receive an oral regimen (fluconazole [1200 mg per day] plus flucytosine [100 mg per kilogram of body weight per day] for 2 weeks), 1 week of amphotericin B (1 mg per kilogram per day), or 2 weeks of amphotericin B (1 mg per kilogram per day). Each patient assigned to receive amphotericin B was also randomly assigned to receive fluconazole or flucytosine as a partner drug. After induction treatment, all the patients received fluconazole consolidation therapy and were followed to 10 weeks. RESULTS A total of 721 patients underwent randomization. Mortality in the oral-regimen, 1-week amphotericin B, and 2-week amphotericin B groups was 18.2% (41 of 225), 21.9% (49 of 224), and 21.4% (49 of 229), respectively, at 2 weeks and was 35.1% (79 of 225), 36.2% (81 of 224), and 39.7% (91 of 229), respectively, at 10 weeks. The upper limit of the one-sided 97.5% confidence interval for the difference in 2-week mortality was 4.2 percentage points for the oral-regimen group versus the 2-week amphotericin B groups and 8.1 percentage points for the 1-week amphotericin B groups versus the 2-week amphotericin B groups, both of which were below the predefined 10-percentage-point noninferiority margin. As a partner drug with amphotericin B, flucytosine was superior to fluconazole (71 deaths [31.1%] vs. 101 deaths [45.0%]; hazard ratio for death at 10 weeks, 0.62; 95% confidence interval [CI], 0.45 to 0.84; P=0.002). One week of amphotericin B plus flucytosine was associated with the lowest 10-week mortality (24.2%; 95% CI, 16.2 to 32.1). Side effects, such as severe anemia, were more frequent with 2 weeks than with 1 week of amphotericin B or with the oral regimen. CONCLUSIONS One week of amphotericin B plus flucytosine and 2 weeks of fluconazole plus flucytosine were effective as induction therapy for cryptococcal meningitis in resource-limited settings. (ACTA Current Controlled Trials number, ISRCTN45035509 .).
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Affiliation(s)
- Síle F Molloy
- From the Centre for Global Health, Institute for Infection and Immunity, St. George's University of London (S.F.M., A.L., N.S., N. Karunaharan, J.A., T.B., T.S.H.), University College London (R.S.H.), and the MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine (J.B.), London, and Liverpool School of Tropical Medicine, Liverpool (T.C., D.G.L., D.W., S.J.) - all in the United Kingdom; the University of North Carolina Project-Malawi, Kamuzu Central Hospital, Lilongwe (C. Kanyama, C.C., C.H., M.C.H.), Malawi-Liverpool-Wellcome Trust Clinical Research Programme (R.S.H., N. Kalata, K.G., M.P., J.E.) and the College of Medicine, University of Malawi (R.S.H., N. Kalata, K.G., M.P., J.E., J.J.O.), Blantyre, and Dignitas International, Zomba Central Hospital, Zomba (A.K.C., P.B., D.L., J.J.O.) - all in Malawi; University of Dschang, Dschang (C. Kouanfack), Hôpital Central Yaoundé/Site Agence Nationale de Recherche sur le Sida (ANRS) Cameroun, Yaoundé (C. Kouanfack, S. Lontsi, J.-G.N., V.S.), and Douala General Hospital (E.T., Y.N.M.) and University of Douala (Y.N.M.), Douala - all in Cameroon; the Institute for Medical Research and Training (D.C., N.S., N. Karunaharan, P.B.), University Teaching Hospital (D.C., S. Lakhi, N.S., N. Karunaharan, P.B.), and the Department of Internal Medicine and Directorate of Research and Postgraduate Studies, Lusaka Apex Medical University (P.M.), Lusaka, Zambia; the National Institute for Medical Research, Muhimbili Medical Research Centre, Dar Es Salaam, Tanzania (S.M., S. Lesikari); Institut Pasteur, Molecular Mycology Unit (E.T., O.L.), and Paris Descartes University, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, IHU Imagine, Assistance Publique-Hôpitaux de Paris (O.L.), Paris; the Division of Infectious Diseases, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto (A.K.C.); and the University of North Carolina, Chapel Hill (C.H., M.C.H.)
| | - Cecilia Kanyama
- From the Centre for Global Health, Institute for Infection and Immunity, St. George's University of London (S.F.M., A.L., N.S., N. Karunaharan, J.A., T.B., T.S.H.), University College London (R.S.H.), and the MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine (J.B.), London, and Liverpool School of Tropical Medicine, Liverpool (T.C., D.G.L., D.W., S.J.) - all in the United Kingdom; the University of North Carolina Project-Malawi, Kamuzu Central Hospital, Lilongwe (C. Kanyama, C.C., C.H., M.C.H.), Malawi-Liverpool-Wellcome Trust Clinical Research Programme (R.S.H., N. Kalata, K.G., M.P., J.E.) and the College of Medicine, University of Malawi (R.S.H., N. Kalata, K.G., M.P., J.E., J.J.O.), Blantyre, and Dignitas International, Zomba Central Hospital, Zomba (A.K.C., P.B., D.L., J.J.O.) - all in Malawi; University of Dschang, Dschang (C. Kouanfack), Hôpital Central Yaoundé/Site Agence Nationale de Recherche sur le Sida (ANRS) Cameroun, Yaoundé (C. Kouanfack, S. Lontsi, J.-G.N., V.S.), and Douala General Hospital (E.T., Y.N.M.) and University of Douala (Y.N.M.), Douala - all in Cameroon; the Institute for Medical Research and Training (D.C., N.S., N. Karunaharan, P.B.), University Teaching Hospital (D.C., S. Lakhi, N.S., N. Karunaharan, P.B.), and the Department of Internal Medicine and Directorate of Research and Postgraduate Studies, Lusaka Apex Medical University (P.M.), Lusaka, Zambia; the National Institute for Medical Research, Muhimbili Medical Research Centre, Dar Es Salaam, Tanzania (S.M., S. Lesikari); Institut Pasteur, Molecular Mycology Unit (E.T., O.L.), and Paris Descartes University, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, IHU Imagine, Assistance Publique-Hôpitaux de Paris (O.L.), Paris; the Division of Infectious Diseases, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto (A.K.C.); and the University of North Carolina, Chapel Hill (C.H., M.C.H.)
| | - Robert S Heyderman
- From the Centre for Global Health, Institute for Infection and Immunity, St. George's University of London (S.F.M., A.L., N.S., N. Karunaharan, J.A., T.B., T.S.H.), University College London (R.S.H.), and the MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine (J.B.), London, and Liverpool School of Tropical Medicine, Liverpool (T.C., D.G.L., D.W., S.J.) - all in the United Kingdom; the University of North Carolina Project-Malawi, Kamuzu Central Hospital, Lilongwe (C. Kanyama, C.C., C.H., M.C.H.), Malawi-Liverpool-Wellcome Trust Clinical Research Programme (R.S.H., N. Kalata, K.G., M.P., J.E.) and the College of Medicine, University of Malawi (R.S.H., N. Kalata, K.G., M.P., J.E., J.J.O.), Blantyre, and Dignitas International, Zomba Central Hospital, Zomba (A.K.C., P.B., D.L., J.J.O.) - all in Malawi; University of Dschang, Dschang (C. Kouanfack), Hôpital Central Yaoundé/Site Agence Nationale de Recherche sur le Sida (ANRS) Cameroun, Yaoundé (C. Kouanfack, S. Lontsi, J.-G.N., V.S.), and Douala General Hospital (E.T., Y.N.M.) and University of Douala (Y.N.M.), Douala - all in Cameroon; the Institute for Medical Research and Training (D.C., N.S., N. Karunaharan, P.B.), University Teaching Hospital (D.C., S. Lakhi, N.S., N. Karunaharan, P.B.), and the Department of Internal Medicine and Directorate of Research and Postgraduate Studies, Lusaka Apex Medical University (P.M.), Lusaka, Zambia; the National Institute for Medical Research, Muhimbili Medical Research Centre, Dar Es Salaam, Tanzania (S.M., S. Lesikari); Institut Pasteur, Molecular Mycology Unit (E.T., O.L.), and Paris Descartes University, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, IHU Imagine, Assistance Publique-Hôpitaux de Paris (O.L.), Paris; the Division of Infectious Diseases, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto (A.K.C.); and the University of North Carolina, Chapel Hill (C.H., M.C.H.)
| | - Angela Loyse
- From the Centre for Global Health, Institute for Infection and Immunity, St. George's University of London (S.F.M., A.L., N.S., N. Karunaharan, J.A., T.B., T.S.H.), University College London (R.S.H.), and the MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine (J.B.), London, and Liverpool School of Tropical Medicine, Liverpool (T.C., D.G.L., D.W., S.J.) - all in the United Kingdom; the University of North Carolina Project-Malawi, Kamuzu Central Hospital, Lilongwe (C. Kanyama, C.C., C.H., M.C.H.), Malawi-Liverpool-Wellcome Trust Clinical Research Programme (R.S.H., N. Kalata, K.G., M.P., J.E.) and the College of Medicine, University of Malawi (R.S.H., N. Kalata, K.G., M.P., J.E., J.J.O.), Blantyre, and Dignitas International, Zomba Central Hospital, Zomba (A.K.C., P.B., D.L., J.J.O.) - all in Malawi; University of Dschang, Dschang (C. Kouanfack), Hôpital Central Yaoundé/Site Agence Nationale de Recherche sur le Sida (ANRS) Cameroun, Yaoundé (C. Kouanfack, S. Lontsi, J.-G.N., V.S.), and Douala General Hospital (E.T., Y.N.M.) and University of Douala (Y.N.M.), Douala - all in Cameroon; the Institute for Medical Research and Training (D.C., N.S., N. Karunaharan, P.B.), University Teaching Hospital (D.C., S. Lakhi, N.S., N. Karunaharan, P.B.), and the Department of Internal Medicine and Directorate of Research and Postgraduate Studies, Lusaka Apex Medical University (P.M.), Lusaka, Zambia; the National Institute for Medical Research, Muhimbili Medical Research Centre, Dar Es Salaam, Tanzania (S.M., S. Lesikari); Institut Pasteur, Molecular Mycology Unit (E.T., O.L.), and Paris Descartes University, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, IHU Imagine, Assistance Publique-Hôpitaux de Paris (O.L.), Paris; the Division of Infectious Diseases, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto (A.K.C.); and the University of North Carolina, Chapel Hill (C.H., M.C.H.)
| | - Charles Kouanfack
- From the Centre for Global Health, Institute for Infection and Immunity, St. George's University of London (S.F.M., A.L., N.S., N. Karunaharan, J.A., T.B., T.S.H.), University College London (R.S.H.), and the MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine (J.B.), London, and Liverpool School of Tropical Medicine, Liverpool (T.C., D.G.L., D.W., S.J.) - all in the United Kingdom; the University of North Carolina Project-Malawi, Kamuzu Central Hospital, Lilongwe (C. Kanyama, C.C., C.H., M.C.H.), Malawi-Liverpool-Wellcome Trust Clinical Research Programme (R.S.H., N. Kalata, K.G., M.P., J.E.) and the College of Medicine, University of Malawi (R.S.H., N. Kalata, K.G., M.P., J.E., J.J.O.), Blantyre, and Dignitas International, Zomba Central Hospital, Zomba (A.K.C., P.B., D.L., J.J.O.) - all in Malawi; University of Dschang, Dschang (C. Kouanfack), Hôpital Central Yaoundé/Site Agence Nationale de Recherche sur le Sida (ANRS) Cameroun, Yaoundé (C. Kouanfack, S. Lontsi, J.-G.N., V.S.), and Douala General Hospital (E.T., Y.N.M.) and University of Douala (Y.N.M.), Douala - all in Cameroon; the Institute for Medical Research and Training (D.C., N.S., N. Karunaharan, P.B.), University Teaching Hospital (D.C., S. Lakhi, N.S., N. Karunaharan, P.B.), and the Department of Internal Medicine and Directorate of Research and Postgraduate Studies, Lusaka Apex Medical University (P.M.), Lusaka, Zambia; the National Institute for Medical Research, Muhimbili Medical Research Centre, Dar Es Salaam, Tanzania (S.M., S. Lesikari); Institut Pasteur, Molecular Mycology Unit (E.T., O.L.), and Paris Descartes University, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, IHU Imagine, Assistance Publique-Hôpitaux de Paris (O.L.), Paris; the Division of Infectious Diseases, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto (A.K.C.); and the University of North Carolina, Chapel Hill (C.H., M.C.H.)
| | - Duncan Chanda
- From the Centre for Global Health, Institute for Infection and Immunity, St. George's University of London (S.F.M., A.L., N.S., N. Karunaharan, J.A., T.B., T.S.H.), University College London (R.S.H.), and the MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine (J.B.), London, and Liverpool School of Tropical Medicine, Liverpool (T.C., D.G.L., D.W., S.J.) - all in the United Kingdom; the University of North Carolina Project-Malawi, Kamuzu Central Hospital, Lilongwe (C. Kanyama, C.C., C.H., M.C.H.), Malawi-Liverpool-Wellcome Trust Clinical Research Programme (R.S.H., N. Kalata, K.G., M.P., J.E.) and the College of Medicine, University of Malawi (R.S.H., N. Kalata, K.G., M.P., J.E., J.J.O.), Blantyre, and Dignitas International, Zomba Central Hospital, Zomba (A.K.C., P.B., D.L., J.J.O.) - all in Malawi; University of Dschang, Dschang (C. Kouanfack), Hôpital Central Yaoundé/Site Agence Nationale de Recherche sur le Sida (ANRS) Cameroun, Yaoundé (C. Kouanfack, S. Lontsi, J.-G.N., V.S.), and Douala General Hospital (E.T., Y.N.M.) and University of Douala (Y.N.M.), Douala - all in Cameroon; the Institute for Medical Research and Training (D.C., N.S., N. Karunaharan, P.B.), University Teaching Hospital (D.C., S. Lakhi, N.S., N. Karunaharan, P.B.), and the Department of Internal Medicine and Directorate of Research and Postgraduate Studies, Lusaka Apex Medical University (P.M.), Lusaka, Zambia; the National Institute for Medical Research, Muhimbili Medical Research Centre, Dar Es Salaam, Tanzania (S.M., S. Lesikari); Institut Pasteur, Molecular Mycology Unit (E.T., O.L.), and Paris Descartes University, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, IHU Imagine, Assistance Publique-Hôpitaux de Paris (O.L.), Paris; the Division of Infectious Diseases, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto (A.K.C.); and the University of North Carolina, Chapel Hill (C.H., M.C.H.)
| | - Sayoki Mfinanga
- From the Centre for Global Health, Institute for Infection and Immunity, St. George's University of London (S.F.M., A.L., N.S., N. Karunaharan, J.A., T.B., T.S.H.), University College London (R.S.H.), and the MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine (J.B.), London, and Liverpool School of Tropical Medicine, Liverpool (T.C., D.G.L., D.W., S.J.) - all in the United Kingdom; the University of North Carolina Project-Malawi, Kamuzu Central Hospital, Lilongwe (C. Kanyama, C.C., C.H., M.C.H.), Malawi-Liverpool-Wellcome Trust Clinical Research Programme (R.S.H., N. Kalata, K.G., M.P., J.E.) and the College of Medicine, University of Malawi (R.S.H., N. Kalata, K.G., M.P., J.E., J.J.O.), Blantyre, and Dignitas International, Zomba Central Hospital, Zomba (A.K.C., P.B., D.L., J.J.O.) - all in Malawi; University of Dschang, Dschang (C. Kouanfack), Hôpital Central Yaoundé/Site Agence Nationale de Recherche sur le Sida (ANRS) Cameroun, Yaoundé (C. Kouanfack, S. Lontsi, J.-G.N., V.S.), and Douala General Hospital (E.T., Y.N.M.) and University of Douala (Y.N.M.), Douala - all in Cameroon; the Institute for Medical Research and Training (D.C., N.S., N. Karunaharan, P.B.), University Teaching Hospital (D.C., S. Lakhi, N.S., N. Karunaharan, P.B.), and the Department of Internal Medicine and Directorate of Research and Postgraduate Studies, Lusaka Apex Medical University (P.M.), Lusaka, Zambia; the National Institute for Medical Research, Muhimbili Medical Research Centre, Dar Es Salaam, Tanzania (S.M., S. Lesikari); Institut Pasteur, Molecular Mycology Unit (E.T., O.L.), and Paris Descartes University, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, IHU Imagine, Assistance Publique-Hôpitaux de Paris (O.L.), Paris; the Division of Infectious Diseases, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto (A.K.C.); and the University of North Carolina, Chapel Hill (C.H., M.C.H.)
| | - Elvis Temfack
- From the Centre for Global Health, Institute for Infection and Immunity, St. George's University of London (S.F.M., A.L., N.S., N. Karunaharan, J.A., T.B., T.S.H.), University College London (R.S.H.), and the MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine (J.B.), London, and Liverpool School of Tropical Medicine, Liverpool (T.C., D.G.L., D.W., S.J.) - all in the United Kingdom; the University of North Carolina Project-Malawi, Kamuzu Central Hospital, Lilongwe (C. Kanyama, C.C., C.H., M.C.H.), Malawi-Liverpool-Wellcome Trust Clinical Research Programme (R.S.H., N. Kalata, K.G., M.P., J.E.) and the College of Medicine, University of Malawi (R.S.H., N. Kalata, K.G., M.P., J.E., J.J.O.), Blantyre, and Dignitas International, Zomba Central Hospital, Zomba (A.K.C., P.B., D.L., J.J.O.) - all in Malawi; University of Dschang, Dschang (C. Kouanfack), Hôpital Central Yaoundé/Site Agence Nationale de Recherche sur le Sida (ANRS) Cameroun, Yaoundé (C. Kouanfack, S. Lontsi, J.-G.N., V.S.), and Douala General Hospital (E.T., Y.N.M.) and University of Douala (Y.N.M.), Douala - all in Cameroon; the Institute for Medical Research and Training (D.C., N.S., N. Karunaharan, P.B.), University Teaching Hospital (D.C., S. Lakhi, N.S., N. Karunaharan, P.B.), and the Department of Internal Medicine and Directorate of Research and Postgraduate Studies, Lusaka Apex Medical University (P.M.), Lusaka, Zambia; the National Institute for Medical Research, Muhimbili Medical Research Centre, Dar Es Salaam, Tanzania (S.M., S. Lesikari); Institut Pasteur, Molecular Mycology Unit (E.T., O.L.), and Paris Descartes University, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, IHU Imagine, Assistance Publique-Hôpitaux de Paris (O.L.), Paris; the Division of Infectious Diseases, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto (A.K.C.); and the University of North Carolina, Chapel Hill (C.H., M.C.H.)
| | - Shabir Lakhi
- From the Centre for Global Health, Institute for Infection and Immunity, St. George's University of London (S.F.M., A.L., N.S., N. Karunaharan, J.A., T.B., T.S.H.), University College London (R.S.H.), and the MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine (J.B.), London, and Liverpool School of Tropical Medicine, Liverpool (T.C., D.G.L., D.W., S.J.) - all in the United Kingdom; the University of North Carolina Project-Malawi, Kamuzu Central Hospital, Lilongwe (C. Kanyama, C.C., C.H., M.C.H.), Malawi-Liverpool-Wellcome Trust Clinical Research Programme (R.S.H., N. Kalata, K.G., M.P., J.E.) and the College of Medicine, University of Malawi (R.S.H., N. Kalata, K.G., M.P., J.E., J.J.O.), Blantyre, and Dignitas International, Zomba Central Hospital, Zomba (A.K.C., P.B., D.L., J.J.O.) - all in Malawi; University of Dschang, Dschang (C. Kouanfack), Hôpital Central Yaoundé/Site Agence Nationale de Recherche sur le Sida (ANRS) Cameroun, Yaoundé (C. Kouanfack, S. Lontsi, J.-G.N., V.S.), and Douala General Hospital (E.T., Y.N.M.) and University of Douala (Y.N.M.), Douala - all in Cameroon; the Institute for Medical Research and Training (D.C., N.S., N. Karunaharan, P.B.), University Teaching Hospital (D.C., S. Lakhi, N.S., N. Karunaharan, P.B.), and the Department of Internal Medicine and Directorate of Research and Postgraduate Studies, Lusaka Apex Medical University (P.M.), Lusaka, Zambia; the National Institute for Medical Research, Muhimbili Medical Research Centre, Dar Es Salaam, Tanzania (S.M., S. Lesikari); Institut Pasteur, Molecular Mycology Unit (E.T., O.L.), and Paris Descartes University, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, IHU Imagine, Assistance Publique-Hôpitaux de Paris (O.L.), Paris; the Division of Infectious Diseases, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto (A.K.C.); and the University of North Carolina, Chapel Hill (C.H., M.C.H.)
| | - Sokoine Lesikari
- From the Centre for Global Health, Institute for Infection and Immunity, St. George's University of London (S.F.M., A.L., N.S., N. Karunaharan, J.A., T.B., T.S.H.), University College London (R.S.H.), and the MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine (J.B.), London, and Liverpool School of Tropical Medicine, Liverpool (T.C., D.G.L., D.W., S.J.) - all in the United Kingdom; the University of North Carolina Project-Malawi, Kamuzu Central Hospital, Lilongwe (C. Kanyama, C.C., C.H., M.C.H.), Malawi-Liverpool-Wellcome Trust Clinical Research Programme (R.S.H., N. Kalata, K.G., M.P., J.E.) and the College of Medicine, University of Malawi (R.S.H., N. Kalata, K.G., M.P., J.E., J.J.O.), Blantyre, and Dignitas International, Zomba Central Hospital, Zomba (A.K.C., P.B., D.L., J.J.O.) - all in Malawi; University of Dschang, Dschang (C. Kouanfack), Hôpital Central Yaoundé/Site Agence Nationale de Recherche sur le Sida (ANRS) Cameroun, Yaoundé (C. Kouanfack, S. Lontsi, J.-G.N., V.S.), and Douala General Hospital (E.T., Y.N.M.) and University of Douala (Y.N.M.), Douala - all in Cameroon; the Institute for Medical Research and Training (D.C., N.S., N. Karunaharan, P.B.), University Teaching Hospital (D.C., S. Lakhi, N.S., N. Karunaharan, P.B.), and the Department of Internal Medicine and Directorate of Research and Postgraduate Studies, Lusaka Apex Medical University (P.M.), Lusaka, Zambia; the National Institute for Medical Research, Muhimbili Medical Research Centre, Dar Es Salaam, Tanzania (S.M., S. Lesikari); Institut Pasteur, Molecular Mycology Unit (E.T., O.L.), and Paris Descartes University, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, IHU Imagine, Assistance Publique-Hôpitaux de Paris (O.L.), Paris; the Division of Infectious Diseases, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto (A.K.C.); and the University of North Carolina, Chapel Hill (C.H., M.C.H.)
| | - Adrienne K Chan
- From the Centre for Global Health, Institute for Infection and Immunity, St. George's University of London (S.F.M., A.L., N.S., N. Karunaharan, J.A., T.B., T.S.H.), University College London (R.S.H.), and the MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine (J.B.), London, and Liverpool School of Tropical Medicine, Liverpool (T.C., D.G.L., D.W., S.J.) - all in the United Kingdom; the University of North Carolina Project-Malawi, Kamuzu Central Hospital, Lilongwe (C. Kanyama, C.C., C.H., M.C.H.), Malawi-Liverpool-Wellcome Trust Clinical Research Programme (R.S.H., N. Kalata, K.G., M.P., J.E.) and the College of Medicine, University of Malawi (R.S.H., N. Kalata, K.G., M.P., J.E., J.J.O.), Blantyre, and Dignitas International, Zomba Central Hospital, Zomba (A.K.C., P.B., D.L., J.J.O.) - all in Malawi; University of Dschang, Dschang (C. Kouanfack), Hôpital Central Yaoundé/Site Agence Nationale de Recherche sur le Sida (ANRS) Cameroun, Yaoundé (C. Kouanfack, S. Lontsi, J.-G.N., V.S.), and Douala General Hospital (E.T., Y.N.M.) and University of Douala (Y.N.M.), Douala - all in Cameroon; the Institute for Medical Research and Training (D.C., N.S., N. Karunaharan, P.B.), University Teaching Hospital (D.C., S. Lakhi, N.S., N. Karunaharan, P.B.), and the Department of Internal Medicine and Directorate of Research and Postgraduate Studies, Lusaka Apex Medical University (P.M.), Lusaka, Zambia; the National Institute for Medical Research, Muhimbili Medical Research Centre, Dar Es Salaam, Tanzania (S.M., S. Lesikari); Institut Pasteur, Molecular Mycology Unit (E.T., O.L.), and Paris Descartes University, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, IHU Imagine, Assistance Publique-Hôpitaux de Paris (O.L.), Paris; the Division of Infectious Diseases, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto (A.K.C.); and the University of North Carolina, Chapel Hill (C.H., M.C.H.)
| | - Neil Stone
- From the Centre for Global Health, Institute for Infection and Immunity, St. George's University of London (S.F.M., A.L., N.S., N. Karunaharan, J.A., T.B., T.S.H.), University College London (R.S.H.), and the MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine (J.B.), London, and Liverpool School of Tropical Medicine, Liverpool (T.C., D.G.L., D.W., S.J.) - all in the United Kingdom; the University of North Carolina Project-Malawi, Kamuzu Central Hospital, Lilongwe (C. Kanyama, C.C., C.H., M.C.H.), Malawi-Liverpool-Wellcome Trust Clinical Research Programme (R.S.H., N. Kalata, K.G., M.P., J.E.) and the College of Medicine, University of Malawi (R.S.H., N. Kalata, K.G., M.P., J.E., J.J.O.), Blantyre, and Dignitas International, Zomba Central Hospital, Zomba (A.K.C., P.B., D.L., J.J.O.) - all in Malawi; University of Dschang, Dschang (C. Kouanfack), Hôpital Central Yaoundé/Site Agence Nationale de Recherche sur le Sida (ANRS) Cameroun, Yaoundé (C. Kouanfack, S. Lontsi, J.-G.N., V.S.), and Douala General Hospital (E.T., Y.N.M.) and University of Douala (Y.N.M.), Douala - all in Cameroon; the Institute for Medical Research and Training (D.C., N.S., N. Karunaharan, P.B.), University Teaching Hospital (D.C., S. Lakhi, N.S., N. Karunaharan, P.B.), and the Department of Internal Medicine and Directorate of Research and Postgraduate Studies, Lusaka Apex Medical University (P.M.), Lusaka, Zambia; the National Institute for Medical Research, Muhimbili Medical Research Centre, Dar Es Salaam, Tanzania (S.M., S. Lesikari); Institut Pasteur, Molecular Mycology Unit (E.T., O.L.), and Paris Descartes University, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, IHU Imagine, Assistance Publique-Hôpitaux de Paris (O.L.), Paris; the Division of Infectious Diseases, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto (A.K.C.); and the University of North Carolina, Chapel Hill (C.H., M.C.H.)
| | - Newton Kalata
- From the Centre for Global Health, Institute for Infection and Immunity, St. George's University of London (S.F.M., A.L., N.S., N. Karunaharan, J.A., T.B., T.S.H.), University College London (R.S.H.), and the MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine (J.B.), London, and Liverpool School of Tropical Medicine, Liverpool (T.C., D.G.L., D.W., S.J.) - all in the United Kingdom; the University of North Carolina Project-Malawi, Kamuzu Central Hospital, Lilongwe (C. Kanyama, C.C., C.H., M.C.H.), Malawi-Liverpool-Wellcome Trust Clinical Research Programme (R.S.H., N. Kalata, K.G., M.P., J.E.) and the College of Medicine, University of Malawi (R.S.H., N. Kalata, K.G., M.P., J.E., J.J.O.), Blantyre, and Dignitas International, Zomba Central Hospital, Zomba (A.K.C., P.B., D.L., J.J.O.) - all in Malawi; University of Dschang, Dschang (C. Kouanfack), Hôpital Central Yaoundé/Site Agence Nationale de Recherche sur le Sida (ANRS) Cameroun, Yaoundé (C. Kouanfack, S. Lontsi, J.-G.N., V.S.), and Douala General Hospital (E.T., Y.N.M.) and University of Douala (Y.N.M.), Douala - all in Cameroon; the Institute for Medical Research and Training (D.C., N.S., N. Karunaharan, P.B.), University Teaching Hospital (D.C., S. Lakhi, N.S., N. Karunaharan, P.B.), and the Department of Internal Medicine and Directorate of Research and Postgraduate Studies, Lusaka Apex Medical University (P.M.), Lusaka, Zambia; the National Institute for Medical Research, Muhimbili Medical Research Centre, Dar Es Salaam, Tanzania (S.M., S. Lesikari); Institut Pasteur, Molecular Mycology Unit (E.T., O.L.), and Paris Descartes University, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, IHU Imagine, Assistance Publique-Hôpitaux de Paris (O.L.), Paris; the Division of Infectious Diseases, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto (A.K.C.); and the University of North Carolina, Chapel Hill (C.H., M.C.H.)
| | - Natasha Karunaharan
- From the Centre for Global Health, Institute for Infection and Immunity, St. George's University of London (S.F.M., A.L., N.S., N. Karunaharan, J.A., T.B., T.S.H.), University College London (R.S.H.), and the MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine (J.B.), London, and Liverpool School of Tropical Medicine, Liverpool (T.C., D.G.L., D.W., S.J.) - all in the United Kingdom; the University of North Carolina Project-Malawi, Kamuzu Central Hospital, Lilongwe (C. Kanyama, C.C., C.H., M.C.H.), Malawi-Liverpool-Wellcome Trust Clinical Research Programme (R.S.H., N. Kalata, K.G., M.P., J.E.) and the College of Medicine, University of Malawi (R.S.H., N. Kalata, K.G., M.P., J.E., J.J.O.), Blantyre, and Dignitas International, Zomba Central Hospital, Zomba (A.K.C., P.B., D.L., J.J.O.) - all in Malawi; University of Dschang, Dschang (C. Kouanfack), Hôpital Central Yaoundé/Site Agence Nationale de Recherche sur le Sida (ANRS) Cameroun, Yaoundé (C. Kouanfack, S. Lontsi, J.-G.N., V.S.), and Douala General Hospital (E.T., Y.N.M.) and University of Douala (Y.N.M.), Douala - all in Cameroon; the Institute for Medical Research and Training (D.C., N.S., N. Karunaharan, P.B.), University Teaching Hospital (D.C., S. Lakhi, N.S., N. Karunaharan, P.B.), and the Department of Internal Medicine and Directorate of Research and Postgraduate Studies, Lusaka Apex Medical University (P.M.), Lusaka, Zambia; the National Institute for Medical Research, Muhimbili Medical Research Centre, Dar Es Salaam, Tanzania (S.M., S. Lesikari); Institut Pasteur, Molecular Mycology Unit (E.T., O.L.), and Paris Descartes University, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, IHU Imagine, Assistance Publique-Hôpitaux de Paris (O.L.), Paris; the Division of Infectious Diseases, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto (A.K.C.); and the University of North Carolina, Chapel Hill (C.H., M.C.H.)
| | - Kate Gaskell
- From the Centre for Global Health, Institute for Infection and Immunity, St. George's University of London (S.F.M., A.L., N.S., N. Karunaharan, J.A., T.B., T.S.H.), University College London (R.S.H.), and the MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine (J.B.), London, and Liverpool School of Tropical Medicine, Liverpool (T.C., D.G.L., D.W., S.J.) - all in the United Kingdom; the University of North Carolina Project-Malawi, Kamuzu Central Hospital, Lilongwe (C. Kanyama, C.C., C.H., M.C.H.), Malawi-Liverpool-Wellcome Trust Clinical Research Programme (R.S.H., N. Kalata, K.G., M.P., J.E.) and the College of Medicine, University of Malawi (R.S.H., N. Kalata, K.G., M.P., J.E., J.J.O.), Blantyre, and Dignitas International, Zomba Central Hospital, Zomba (A.K.C., P.B., D.L., J.J.O.) - all in Malawi; University of Dschang, Dschang (C. Kouanfack), Hôpital Central Yaoundé/Site Agence Nationale de Recherche sur le Sida (ANRS) Cameroun, Yaoundé (C. Kouanfack, S. Lontsi, J.-G.N., V.S.), and Douala General Hospital (E.T., Y.N.M.) and University of Douala (Y.N.M.), Douala - all in Cameroon; the Institute for Medical Research and Training (D.C., N.S., N. Karunaharan, P.B.), University Teaching Hospital (D.C., S. Lakhi, N.S., N. Karunaharan, P.B.), and the Department of Internal Medicine and Directorate of Research and Postgraduate Studies, Lusaka Apex Medical University (P.M.), Lusaka, Zambia; the National Institute for Medical Research, Muhimbili Medical Research Centre, Dar Es Salaam, Tanzania (S.M., S. Lesikari); Institut Pasteur, Molecular Mycology Unit (E.T., O.L.), and Paris Descartes University, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, IHU Imagine, Assistance Publique-Hôpitaux de Paris (O.L.), Paris; the Division of Infectious Diseases, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto (A.K.C.); and the University of North Carolina, Chapel Hill (C.H., M.C.H.)
| | - Mary Peirse
- From the Centre for Global Health, Institute for Infection and Immunity, St. George's University of London (S.F.M., A.L., N.S., N. Karunaharan, J.A., T.B., T.S.H.), University College London (R.S.H.), and the MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine (J.B.), London, and Liverpool School of Tropical Medicine, Liverpool (T.C., D.G.L., D.W., S.J.) - all in the United Kingdom; the University of North Carolina Project-Malawi, Kamuzu Central Hospital, Lilongwe (C. Kanyama, C.C., C.H., M.C.H.), Malawi-Liverpool-Wellcome Trust Clinical Research Programme (R.S.H., N. Kalata, K.G., M.P., J.E.) and the College of Medicine, University of Malawi (R.S.H., N. Kalata, K.G., M.P., J.E., J.J.O.), Blantyre, and Dignitas International, Zomba Central Hospital, Zomba (A.K.C., P.B., D.L., J.J.O.) - all in Malawi; University of Dschang, Dschang (C. Kouanfack), Hôpital Central Yaoundé/Site Agence Nationale de Recherche sur le Sida (ANRS) Cameroun, Yaoundé (C. Kouanfack, S. Lontsi, J.-G.N., V.S.), and Douala General Hospital (E.T., Y.N.M.) and University of Douala (Y.N.M.), Douala - all in Cameroon; the Institute for Medical Research and Training (D.C., N.S., N. Karunaharan, P.B.), University Teaching Hospital (D.C., S. Lakhi, N.S., N. Karunaharan, P.B.), and the Department of Internal Medicine and Directorate of Research and Postgraduate Studies, Lusaka Apex Medical University (P.M.), Lusaka, Zambia; the National Institute for Medical Research, Muhimbili Medical Research Centre, Dar Es Salaam, Tanzania (S.M., S. Lesikari); Institut Pasteur, Molecular Mycology Unit (E.T., O.L.), and Paris Descartes University, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, IHU Imagine, Assistance Publique-Hôpitaux de Paris (O.L.), Paris; the Division of Infectious Diseases, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto (A.K.C.); and the University of North Carolina, Chapel Hill (C.H., M.C.H.)
| | - Jayne Ellis
- From the Centre for Global Health, Institute for Infection and Immunity, St. George's University of London (S.F.M., A.L., N.S., N. Karunaharan, J.A., T.B., T.S.H.), University College London (R.S.H.), and the MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine (J.B.), London, and Liverpool School of Tropical Medicine, Liverpool (T.C., D.G.L., D.W., S.J.) - all in the United Kingdom; the University of North Carolina Project-Malawi, Kamuzu Central Hospital, Lilongwe (C. Kanyama, C.C., C.H., M.C.H.), Malawi-Liverpool-Wellcome Trust Clinical Research Programme (R.S.H., N. Kalata, K.G., M.P., J.E.) and the College of Medicine, University of Malawi (R.S.H., N. Kalata, K.G., M.P., J.E., J.J.O.), Blantyre, and Dignitas International, Zomba Central Hospital, Zomba (A.K.C., P.B., D.L., J.J.O.) - all in Malawi; University of Dschang, Dschang (C. Kouanfack), Hôpital Central Yaoundé/Site Agence Nationale de Recherche sur le Sida (ANRS) Cameroun, Yaoundé (C. Kouanfack, S. Lontsi, J.-G.N., V.S.), and Douala General Hospital (E.T., Y.N.M.) and University of Douala (Y.N.M.), Douala - all in Cameroon; the Institute for Medical Research and Training (D.C., N.S., N. Karunaharan, P.B.), University Teaching Hospital (D.C., S. Lakhi, N.S., N. Karunaharan, P.B.), and the Department of Internal Medicine and Directorate of Research and Postgraduate Studies, Lusaka Apex Medical University (P.M.), Lusaka, Zambia; the National Institute for Medical Research, Muhimbili Medical Research Centre, Dar Es Salaam, Tanzania (S.M., S. Lesikari); Institut Pasteur, Molecular Mycology Unit (E.T., O.L.), and Paris Descartes University, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, IHU Imagine, Assistance Publique-Hôpitaux de Paris (O.L.), Paris; the Division of Infectious Diseases, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto (A.K.C.); and the University of North Carolina, Chapel Hill (C.H., M.C.H.)
| | - Chimwemwe Chawinga
- From the Centre for Global Health, Institute for Infection and Immunity, St. George's University of London (S.F.M., A.L., N.S., N. Karunaharan, J.A., T.B., T.S.H.), University College London (R.S.H.), and the MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine (J.B.), London, and Liverpool School of Tropical Medicine, Liverpool (T.C., D.G.L., D.W., S.J.) - all in the United Kingdom; the University of North Carolina Project-Malawi, Kamuzu Central Hospital, Lilongwe (C. Kanyama, C.C., C.H., M.C.H.), Malawi-Liverpool-Wellcome Trust Clinical Research Programme (R.S.H., N. Kalata, K.G., M.P., J.E.) and the College of Medicine, University of Malawi (R.S.H., N. Kalata, K.G., M.P., J.E., J.J.O.), Blantyre, and Dignitas International, Zomba Central Hospital, Zomba (A.K.C., P.B., D.L., J.J.O.) - all in Malawi; University of Dschang, Dschang (C. Kouanfack), Hôpital Central Yaoundé/Site Agence Nationale de Recherche sur le Sida (ANRS) Cameroun, Yaoundé (C. Kouanfack, S. Lontsi, J.-G.N., V.S.), and Douala General Hospital (E.T., Y.N.M.) and University of Douala (Y.N.M.), Douala - all in Cameroon; the Institute for Medical Research and Training (D.C., N.S., N. Karunaharan, P.B.), University Teaching Hospital (D.C., S. Lakhi, N.S., N. Karunaharan, P.B.), and the Department of Internal Medicine and Directorate of Research and Postgraduate Studies, Lusaka Apex Medical University (P.M.), Lusaka, Zambia; the National Institute for Medical Research, Muhimbili Medical Research Centre, Dar Es Salaam, Tanzania (S.M., S. Lesikari); Institut Pasteur, Molecular Mycology Unit (E.T., O.L.), and Paris Descartes University, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, IHU Imagine, Assistance Publique-Hôpitaux de Paris (O.L.), Paris; the Division of Infectious Diseases, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto (A.K.C.); and the University of North Carolina, Chapel Hill (C.H., M.C.H.)
| | - Sandrine Lontsi
- From the Centre for Global Health, Institute for Infection and Immunity, St. George's University of London (S.F.M., A.L., N.S., N. Karunaharan, J.A., T.B., T.S.H.), University College London (R.S.H.), and the MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine (J.B.), London, and Liverpool School of Tropical Medicine, Liverpool (T.C., D.G.L., D.W., S.J.) - all in the United Kingdom; the University of North Carolina Project-Malawi, Kamuzu Central Hospital, Lilongwe (C. Kanyama, C.C., C.H., M.C.H.), Malawi-Liverpool-Wellcome Trust Clinical Research Programme (R.S.H., N. Kalata, K.G., M.P., J.E.) and the College of Medicine, University of Malawi (R.S.H., N. Kalata, K.G., M.P., J.E., J.J.O.), Blantyre, and Dignitas International, Zomba Central Hospital, Zomba (A.K.C., P.B., D.L., J.J.O.) - all in Malawi; University of Dschang, Dschang (C. Kouanfack), Hôpital Central Yaoundé/Site Agence Nationale de Recherche sur le Sida (ANRS) Cameroun, Yaoundé (C. Kouanfack, S. Lontsi, J.-G.N., V.S.), and Douala General Hospital (E.T., Y.N.M.) and University of Douala (Y.N.M.), Douala - all in Cameroon; the Institute for Medical Research and Training (D.C., N.S., N. Karunaharan, P.B.), University Teaching Hospital (D.C., S. Lakhi, N.S., N. Karunaharan, P.B.), and the Department of Internal Medicine and Directorate of Research and Postgraduate Studies, Lusaka Apex Medical University (P.M.), Lusaka, Zambia; the National Institute for Medical Research, Muhimbili Medical Research Centre, Dar Es Salaam, Tanzania (S.M., S. Lesikari); Institut Pasteur, Molecular Mycology Unit (E.T., O.L.), and Paris Descartes University, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, IHU Imagine, Assistance Publique-Hôpitaux de Paris (O.L.), Paris; the Division of Infectious Diseases, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto (A.K.C.); and the University of North Carolina, Chapel Hill (C.H., M.C.H.)
| | - Jean-Gilbert Ndong
- From the Centre for Global Health, Institute for Infection and Immunity, St. George's University of London (S.F.M., A.L., N.S., N. Karunaharan, J.A., T.B., T.S.H.), University College London (R.S.H.), and the MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine (J.B.), London, and Liverpool School of Tropical Medicine, Liverpool (T.C., D.G.L., D.W., S.J.) - all in the United Kingdom; the University of North Carolina Project-Malawi, Kamuzu Central Hospital, Lilongwe (C. Kanyama, C.C., C.H., M.C.H.), Malawi-Liverpool-Wellcome Trust Clinical Research Programme (R.S.H., N. Kalata, K.G., M.P., J.E.) and the College of Medicine, University of Malawi (R.S.H., N. Kalata, K.G., M.P., J.E., J.J.O.), Blantyre, and Dignitas International, Zomba Central Hospital, Zomba (A.K.C., P.B., D.L., J.J.O.) - all in Malawi; University of Dschang, Dschang (C. Kouanfack), Hôpital Central Yaoundé/Site Agence Nationale de Recherche sur le Sida (ANRS) Cameroun, Yaoundé (C. Kouanfack, S. Lontsi, J.-G.N., V.S.), and Douala General Hospital (E.T., Y.N.M.) and University of Douala (Y.N.M.), Douala - all in Cameroon; the Institute for Medical Research and Training (D.C., N.S., N. Karunaharan, P.B.), University Teaching Hospital (D.C., S. Lakhi, N.S., N. Karunaharan, P.B.), and the Department of Internal Medicine and Directorate of Research and Postgraduate Studies, Lusaka Apex Medical University (P.M.), Lusaka, Zambia; the National Institute for Medical Research, Muhimbili Medical Research Centre, Dar Es Salaam, Tanzania (S.M., S. Lesikari); Institut Pasteur, Molecular Mycology Unit (E.T., O.L.), and Paris Descartes University, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, IHU Imagine, Assistance Publique-Hôpitaux de Paris (O.L.), Paris; the Division of Infectious Diseases, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto (A.K.C.); and the University of North Carolina, Chapel Hill (C.H., M.C.H.)
| | - Philip Bright
- From the Centre for Global Health, Institute for Infection and Immunity, St. George's University of London (S.F.M., A.L., N.S., N. Karunaharan, J.A., T.B., T.S.H.), University College London (R.S.H.), and the MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine (J.B.), London, and Liverpool School of Tropical Medicine, Liverpool (T.C., D.G.L., D.W., S.J.) - all in the United Kingdom; the University of North Carolina Project-Malawi, Kamuzu Central Hospital, Lilongwe (C. Kanyama, C.C., C.H., M.C.H.), Malawi-Liverpool-Wellcome Trust Clinical Research Programme (R.S.H., N. Kalata, K.G., M.P., J.E.) and the College of Medicine, University of Malawi (R.S.H., N. Kalata, K.G., M.P., J.E., J.J.O.), Blantyre, and Dignitas International, Zomba Central Hospital, Zomba (A.K.C., P.B., D.L., J.J.O.) - all in Malawi; University of Dschang, Dschang (C. Kouanfack), Hôpital Central Yaoundé/Site Agence Nationale de Recherche sur le Sida (ANRS) Cameroun, Yaoundé (C. Kouanfack, S. Lontsi, J.-G.N., V.S.), and Douala General Hospital (E.T., Y.N.M.) and University of Douala (Y.N.M.), Douala - all in Cameroon; the Institute for Medical Research and Training (D.C., N.S., N. Karunaharan, P.B.), University Teaching Hospital (D.C., S. Lakhi, N.S., N. Karunaharan, P.B.), and the Department of Internal Medicine and Directorate of Research and Postgraduate Studies, Lusaka Apex Medical University (P.M.), Lusaka, Zambia; the National Institute for Medical Research, Muhimbili Medical Research Centre, Dar Es Salaam, Tanzania (S.M., S. Lesikari); Institut Pasteur, Molecular Mycology Unit (E.T., O.L.), and Paris Descartes University, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, IHU Imagine, Assistance Publique-Hôpitaux de Paris (O.L.), Paris; the Division of Infectious Diseases, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto (A.K.C.); and the University of North Carolina, Chapel Hill (C.H., M.C.H.)
| | - Duncan Lupiya
- From the Centre for Global Health, Institute for Infection and Immunity, St. George's University of London (S.F.M., A.L., N.S., N. Karunaharan, J.A., T.B., T.S.H.), University College London (R.S.H.), and the MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine (J.B.), London, and Liverpool School of Tropical Medicine, Liverpool (T.C., D.G.L., D.W., S.J.) - all in the United Kingdom; the University of North Carolina Project-Malawi, Kamuzu Central Hospital, Lilongwe (C. Kanyama, C.C., C.H., M.C.H.), Malawi-Liverpool-Wellcome Trust Clinical Research Programme (R.S.H., N. Kalata, K.G., M.P., J.E.) and the College of Medicine, University of Malawi (R.S.H., N. Kalata, K.G., M.P., J.E., J.J.O.), Blantyre, and Dignitas International, Zomba Central Hospital, Zomba (A.K.C., P.B., D.L., J.J.O.) - all in Malawi; University of Dschang, Dschang (C. Kouanfack), Hôpital Central Yaoundé/Site Agence Nationale de Recherche sur le Sida (ANRS) Cameroun, Yaoundé (C. Kouanfack, S. Lontsi, J.-G.N., V.S.), and Douala General Hospital (E.T., Y.N.M.) and University of Douala (Y.N.M.), Douala - all in Cameroon; the Institute for Medical Research and Training (D.C., N.S., N. Karunaharan, P.B.), University Teaching Hospital (D.C., S. Lakhi, N.S., N. Karunaharan, P.B.), and the Department of Internal Medicine and Directorate of Research and Postgraduate Studies, Lusaka Apex Medical University (P.M.), Lusaka, Zambia; the National Institute for Medical Research, Muhimbili Medical Research Centre, Dar Es Salaam, Tanzania (S.M., S. Lesikari); Institut Pasteur, Molecular Mycology Unit (E.T., O.L.), and Paris Descartes University, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, IHU Imagine, Assistance Publique-Hôpitaux de Paris (O.L.), Paris; the Division of Infectious Diseases, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto (A.K.C.); and the University of North Carolina, Chapel Hill (C.H., M.C.H.)
| | - Tao Chen
- From the Centre for Global Health, Institute for Infection and Immunity, St. George's University of London (S.F.M., A.L., N.S., N. Karunaharan, J.A., T.B., T.S.H.), University College London (R.S.H.), and the MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine (J.B.), London, and Liverpool School of Tropical Medicine, Liverpool (T.C., D.G.L., D.W., S.J.) - all in the United Kingdom; the University of North Carolina Project-Malawi, Kamuzu Central Hospital, Lilongwe (C. Kanyama, C.C., C.H., M.C.H.), Malawi-Liverpool-Wellcome Trust Clinical Research Programme (R.S.H., N. Kalata, K.G., M.P., J.E.) and the College of Medicine, University of Malawi (R.S.H., N. Kalata, K.G., M.P., J.E., J.J.O.), Blantyre, and Dignitas International, Zomba Central Hospital, Zomba (A.K.C., P.B., D.L., J.J.O.) - all in Malawi; University of Dschang, Dschang (C. Kouanfack), Hôpital Central Yaoundé/Site Agence Nationale de Recherche sur le Sida (ANRS) Cameroun, Yaoundé (C. Kouanfack, S. Lontsi, J.-G.N., V.S.), and Douala General Hospital (E.T., Y.N.M.) and University of Douala (Y.N.M.), Douala - all in Cameroon; the Institute for Medical Research and Training (D.C., N.S., N. Karunaharan, P.B.), University Teaching Hospital (D.C., S. Lakhi, N.S., N. Karunaharan, P.B.), and the Department of Internal Medicine and Directorate of Research and Postgraduate Studies, Lusaka Apex Medical University (P.M.), Lusaka, Zambia; the National Institute for Medical Research, Muhimbili Medical Research Centre, Dar Es Salaam, Tanzania (S.M., S. Lesikari); Institut Pasteur, Molecular Mycology Unit (E.T., O.L.), and Paris Descartes University, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, IHU Imagine, Assistance Publique-Hôpitaux de Paris (O.L.), Paris; the Division of Infectious Diseases, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto (A.K.C.); and the University of North Carolina, Chapel Hill (C.H., M.C.H.)
| | - John Bradley
- From the Centre for Global Health, Institute for Infection and Immunity, St. George's University of London (S.F.M., A.L., N.S., N. Karunaharan, J.A., T.B., T.S.H.), University College London (R.S.H.), and the MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine (J.B.), London, and Liverpool School of Tropical Medicine, Liverpool (T.C., D.G.L., D.W., S.J.) - all in the United Kingdom; the University of North Carolina Project-Malawi, Kamuzu Central Hospital, Lilongwe (C. Kanyama, C.C., C.H., M.C.H.), Malawi-Liverpool-Wellcome Trust Clinical Research Programme (R.S.H., N. Kalata, K.G., M.P., J.E.) and the College of Medicine, University of Malawi (R.S.H., N. Kalata, K.G., M.P., J.E., J.J.O.), Blantyre, and Dignitas International, Zomba Central Hospital, Zomba (A.K.C., P.B., D.L., J.J.O.) - all in Malawi; University of Dschang, Dschang (C. Kouanfack), Hôpital Central Yaoundé/Site Agence Nationale de Recherche sur le Sida (ANRS) Cameroun, Yaoundé (C. Kouanfack, S. Lontsi, J.-G.N., V.S.), and Douala General Hospital (E.T., Y.N.M.) and University of Douala (Y.N.M.), Douala - all in Cameroon; the Institute for Medical Research and Training (D.C., N.S., N. Karunaharan, P.B.), University Teaching Hospital (D.C., S. Lakhi, N.S., N. Karunaharan, P.B.), and the Department of Internal Medicine and Directorate of Research and Postgraduate Studies, Lusaka Apex Medical University (P.M.), Lusaka, Zambia; the National Institute for Medical Research, Muhimbili Medical Research Centre, Dar Es Salaam, Tanzania (S.M., S. Lesikari); Institut Pasteur, Molecular Mycology Unit (E.T., O.L.), and Paris Descartes University, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, IHU Imagine, Assistance Publique-Hôpitaux de Paris (O.L.), Paris; the Division of Infectious Diseases, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto (A.K.C.); and the University of North Carolina, Chapel Hill (C.H., M.C.H.)
| | - Jack Adams
- From the Centre for Global Health, Institute for Infection and Immunity, St. George's University of London (S.F.M., A.L., N.S., N. Karunaharan, J.A., T.B., T.S.H.), University College London (R.S.H.), and the MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine (J.B.), London, and Liverpool School of Tropical Medicine, Liverpool (T.C., D.G.L., D.W., S.J.) - all in the United Kingdom; the University of North Carolina Project-Malawi, Kamuzu Central Hospital, Lilongwe (C. Kanyama, C.C., C.H., M.C.H.), Malawi-Liverpool-Wellcome Trust Clinical Research Programme (R.S.H., N. Kalata, K.G., M.P., J.E.) and the College of Medicine, University of Malawi (R.S.H., N. Kalata, K.G., M.P., J.E., J.J.O.), Blantyre, and Dignitas International, Zomba Central Hospital, Zomba (A.K.C., P.B., D.L., J.J.O.) - all in Malawi; University of Dschang, Dschang (C. Kouanfack), Hôpital Central Yaoundé/Site Agence Nationale de Recherche sur le Sida (ANRS) Cameroun, Yaoundé (C. Kouanfack, S. Lontsi, J.-G.N., V.S.), and Douala General Hospital (E.T., Y.N.M.) and University of Douala (Y.N.M.), Douala - all in Cameroon; the Institute for Medical Research and Training (D.C., N.S., N. Karunaharan, P.B.), University Teaching Hospital (D.C., S. Lakhi, N.S., N. Karunaharan, P.B.), and the Department of Internal Medicine and Directorate of Research and Postgraduate Studies, Lusaka Apex Medical University (P.M.), Lusaka, Zambia; the National Institute for Medical Research, Muhimbili Medical Research Centre, Dar Es Salaam, Tanzania (S.M., S. Lesikari); Institut Pasteur, Molecular Mycology Unit (E.T., O.L.), and Paris Descartes University, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, IHU Imagine, Assistance Publique-Hôpitaux de Paris (O.L.), Paris; the Division of Infectious Diseases, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto (A.K.C.); and the University of North Carolina, Chapel Hill (C.H., M.C.H.)
| | - Charles van der Horst
- From the Centre for Global Health, Institute for Infection and Immunity, St. George's University of London (S.F.M., A.L., N.S., N. Karunaharan, J.A., T.B., T.S.H.), University College London (R.S.H.), and the MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine (J.B.), London, and Liverpool School of Tropical Medicine, Liverpool (T.C., D.G.L., D.W., S.J.) - all in the United Kingdom; the University of North Carolina Project-Malawi, Kamuzu Central Hospital, Lilongwe (C. Kanyama, C.C., C.H., M.C.H.), Malawi-Liverpool-Wellcome Trust Clinical Research Programme (R.S.H., N. Kalata, K.G., M.P., J.E.) and the College of Medicine, University of Malawi (R.S.H., N. Kalata, K.G., M.P., J.E., J.J.O.), Blantyre, and Dignitas International, Zomba Central Hospital, Zomba (A.K.C., P.B., D.L., J.J.O.) - all in Malawi; University of Dschang, Dschang (C. Kouanfack), Hôpital Central Yaoundé/Site Agence Nationale de Recherche sur le Sida (ANRS) Cameroun, Yaoundé (C. Kouanfack, S. Lontsi, J.-G.N., V.S.), and Douala General Hospital (E.T., Y.N.M.) and University of Douala (Y.N.M.), Douala - all in Cameroon; the Institute for Medical Research and Training (D.C., N.S., N. Karunaharan, P.B.), University Teaching Hospital (D.C., S. Lakhi, N.S., N. Karunaharan, P.B.), and the Department of Internal Medicine and Directorate of Research and Postgraduate Studies, Lusaka Apex Medical University (P.M.), Lusaka, Zambia; the National Institute for Medical Research, Muhimbili Medical Research Centre, Dar Es Salaam, Tanzania (S.M., S. Lesikari); Institut Pasteur, Molecular Mycology Unit (E.T., O.L.), and Paris Descartes University, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, IHU Imagine, Assistance Publique-Hôpitaux de Paris (O.L.), Paris; the Division of Infectious Diseases, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto (A.K.C.); and the University of North Carolina, Chapel Hill (C.H., M.C.H.)
| | - Joep J van Oosterhout
- From the Centre for Global Health, Institute for Infection and Immunity, St. George's University of London (S.F.M., A.L., N.S., N. Karunaharan, J.A., T.B., T.S.H.), University College London (R.S.H.), and the MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine (J.B.), London, and Liverpool School of Tropical Medicine, Liverpool (T.C., D.G.L., D.W., S.J.) - all in the United Kingdom; the University of North Carolina Project-Malawi, Kamuzu Central Hospital, Lilongwe (C. Kanyama, C.C., C.H., M.C.H.), Malawi-Liverpool-Wellcome Trust Clinical Research Programme (R.S.H., N. Kalata, K.G., M.P., J.E.) and the College of Medicine, University of Malawi (R.S.H., N. Kalata, K.G., M.P., J.E., J.J.O.), Blantyre, and Dignitas International, Zomba Central Hospital, Zomba (A.K.C., P.B., D.L., J.J.O.) - all in Malawi; University of Dschang, Dschang (C. Kouanfack), Hôpital Central Yaoundé/Site Agence Nationale de Recherche sur le Sida (ANRS) Cameroun, Yaoundé (C. Kouanfack, S. Lontsi, J.-G.N., V.S.), and Douala General Hospital (E.T., Y.N.M.) and University of Douala (Y.N.M.), Douala - all in Cameroon; the Institute for Medical Research and Training (D.C., N.S., N. Karunaharan, P.B.), University Teaching Hospital (D.C., S. Lakhi, N.S., N. Karunaharan, P.B.), and the Department of Internal Medicine and Directorate of Research and Postgraduate Studies, Lusaka Apex Medical University (P.M.), Lusaka, Zambia; the National Institute for Medical Research, Muhimbili Medical Research Centre, Dar Es Salaam, Tanzania (S.M., S. Lesikari); Institut Pasteur, Molecular Mycology Unit (E.T., O.L.), and Paris Descartes University, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, IHU Imagine, Assistance Publique-Hôpitaux de Paris (O.L.), Paris; the Division of Infectious Diseases, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto (A.K.C.); and the University of North Carolina, Chapel Hill (C.H., M.C.H.)
| | - Victor Sini
- From the Centre for Global Health, Institute for Infection and Immunity, St. George's University of London (S.F.M., A.L., N.S., N. Karunaharan, J.A., T.B., T.S.H.), University College London (R.S.H.), and the MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine (J.B.), London, and Liverpool School of Tropical Medicine, Liverpool (T.C., D.G.L., D.W., S.J.) - all in the United Kingdom; the University of North Carolina Project-Malawi, Kamuzu Central Hospital, Lilongwe (C. Kanyama, C.C., C.H., M.C.H.), Malawi-Liverpool-Wellcome Trust Clinical Research Programme (R.S.H., N. Kalata, K.G., M.P., J.E.) and the College of Medicine, University of Malawi (R.S.H., N. Kalata, K.G., M.P., J.E., J.J.O.), Blantyre, and Dignitas International, Zomba Central Hospital, Zomba (A.K.C., P.B., D.L., J.J.O.) - all in Malawi; University of Dschang, Dschang (C. Kouanfack), Hôpital Central Yaoundé/Site Agence Nationale de Recherche sur le Sida (ANRS) Cameroun, Yaoundé (C. Kouanfack, S. Lontsi, J.-G.N., V.S.), and Douala General Hospital (E.T., Y.N.M.) and University of Douala (Y.N.M.), Douala - all in Cameroon; the Institute for Medical Research and Training (D.C., N.S., N. Karunaharan, P.B.), University Teaching Hospital (D.C., S. Lakhi, N.S., N. Karunaharan, P.B.), and the Department of Internal Medicine and Directorate of Research and Postgraduate Studies, Lusaka Apex Medical University (P.M.), Lusaka, Zambia; the National Institute for Medical Research, Muhimbili Medical Research Centre, Dar Es Salaam, Tanzania (S.M., S. Lesikari); Institut Pasteur, Molecular Mycology Unit (E.T., O.L.), and Paris Descartes University, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, IHU Imagine, Assistance Publique-Hôpitaux de Paris (O.L.), Paris; the Division of Infectious Diseases, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto (A.K.C.); and the University of North Carolina, Chapel Hill (C.H., M.C.H.)
| | - Yacouba N Mapoure
- From the Centre for Global Health, Institute for Infection and Immunity, St. George's University of London (S.F.M., A.L., N.S., N. Karunaharan, J.A., T.B., T.S.H.), University College London (R.S.H.), and the MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine (J.B.), London, and Liverpool School of Tropical Medicine, Liverpool (T.C., D.G.L., D.W., S.J.) - all in the United Kingdom; the University of North Carolina Project-Malawi, Kamuzu Central Hospital, Lilongwe (C. Kanyama, C.C., C.H., M.C.H.), Malawi-Liverpool-Wellcome Trust Clinical Research Programme (R.S.H., N. Kalata, K.G., M.P., J.E.) and the College of Medicine, University of Malawi (R.S.H., N. Kalata, K.G., M.P., J.E., J.J.O.), Blantyre, and Dignitas International, Zomba Central Hospital, Zomba (A.K.C., P.B., D.L., J.J.O.) - all in Malawi; University of Dschang, Dschang (C. Kouanfack), Hôpital Central Yaoundé/Site Agence Nationale de Recherche sur le Sida (ANRS) Cameroun, Yaoundé (C. Kouanfack, S. Lontsi, J.-G.N., V.S.), and Douala General Hospital (E.T., Y.N.M.) and University of Douala (Y.N.M.), Douala - all in Cameroon; the Institute for Medical Research and Training (D.C., N.S., N. Karunaharan, P.B.), University Teaching Hospital (D.C., S. Lakhi, N.S., N. Karunaharan, P.B.), and the Department of Internal Medicine and Directorate of Research and Postgraduate Studies, Lusaka Apex Medical University (P.M.), Lusaka, Zambia; the National Institute for Medical Research, Muhimbili Medical Research Centre, Dar Es Salaam, Tanzania (S.M., S. Lesikari); Institut Pasteur, Molecular Mycology Unit (E.T., O.L.), and Paris Descartes University, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, IHU Imagine, Assistance Publique-Hôpitaux de Paris (O.L.), Paris; the Division of Infectious Diseases, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto (A.K.C.); and the University of North Carolina, Chapel Hill (C.H., M.C.H.)
| | - Peter Mwaba
- From the Centre for Global Health, Institute for Infection and Immunity, St. George's University of London (S.F.M., A.L., N.S., N. Karunaharan, J.A., T.B., T.S.H.), University College London (R.S.H.), and the MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine (J.B.), London, and Liverpool School of Tropical Medicine, Liverpool (T.C., D.G.L., D.W., S.J.) - all in the United Kingdom; the University of North Carolina Project-Malawi, Kamuzu Central Hospital, Lilongwe (C. Kanyama, C.C., C.H., M.C.H.), Malawi-Liverpool-Wellcome Trust Clinical Research Programme (R.S.H., N. Kalata, K.G., M.P., J.E.) and the College of Medicine, University of Malawi (R.S.H., N. Kalata, K.G., M.P., J.E., J.J.O.), Blantyre, and Dignitas International, Zomba Central Hospital, Zomba (A.K.C., P.B., D.L., J.J.O.) - all in Malawi; University of Dschang, Dschang (C. Kouanfack), Hôpital Central Yaoundé/Site Agence Nationale de Recherche sur le Sida (ANRS) Cameroun, Yaoundé (C. Kouanfack, S. Lontsi, J.-G.N., V.S.), and Douala General Hospital (E.T., Y.N.M.) and University of Douala (Y.N.M.), Douala - all in Cameroon; the Institute for Medical Research and Training (D.C., N.S., N. Karunaharan, P.B.), University Teaching Hospital (D.C., S. Lakhi, N.S., N. Karunaharan, P.B.), and the Department of Internal Medicine and Directorate of Research and Postgraduate Studies, Lusaka Apex Medical University (P.M.), Lusaka, Zambia; the National Institute for Medical Research, Muhimbili Medical Research Centre, Dar Es Salaam, Tanzania (S.M., S. Lesikari); Institut Pasteur, Molecular Mycology Unit (E.T., O.L.), and Paris Descartes University, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, IHU Imagine, Assistance Publique-Hôpitaux de Paris (O.L.), Paris; the Division of Infectious Diseases, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto (A.K.C.); and the University of North Carolina, Chapel Hill (C.H., M.C.H.)
| | - Tihana Bicanic
- From the Centre for Global Health, Institute for Infection and Immunity, St. George's University of London (S.F.M., A.L., N.S., N. Karunaharan, J.A., T.B., T.S.H.), University College London (R.S.H.), and the MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine (J.B.), London, and Liverpool School of Tropical Medicine, Liverpool (T.C., D.G.L., D.W., S.J.) - all in the United Kingdom; the University of North Carolina Project-Malawi, Kamuzu Central Hospital, Lilongwe (C. Kanyama, C.C., C.H., M.C.H.), Malawi-Liverpool-Wellcome Trust Clinical Research Programme (R.S.H., N. Kalata, K.G., M.P., J.E.) and the College of Medicine, University of Malawi (R.S.H., N. Kalata, K.G., M.P., J.E., J.J.O.), Blantyre, and Dignitas International, Zomba Central Hospital, Zomba (A.K.C., P.B., D.L., J.J.O.) - all in Malawi; University of Dschang, Dschang (C. Kouanfack), Hôpital Central Yaoundé/Site Agence Nationale de Recherche sur le Sida (ANRS) Cameroun, Yaoundé (C. Kouanfack, S. Lontsi, J.-G.N., V.S.), and Douala General Hospital (E.T., Y.N.M.) and University of Douala (Y.N.M.), Douala - all in Cameroon; the Institute for Medical Research and Training (D.C., N.S., N. Karunaharan, P.B.), University Teaching Hospital (D.C., S. Lakhi, N.S., N. Karunaharan, P.B.), and the Department of Internal Medicine and Directorate of Research and Postgraduate Studies, Lusaka Apex Medical University (P.M.), Lusaka, Zambia; the National Institute for Medical Research, Muhimbili Medical Research Centre, Dar Es Salaam, Tanzania (S.M., S. Lesikari); Institut Pasteur, Molecular Mycology Unit (E.T., O.L.), and Paris Descartes University, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, IHU Imagine, Assistance Publique-Hôpitaux de Paris (O.L.), Paris; the Division of Infectious Diseases, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto (A.K.C.); and the University of North Carolina, Chapel Hill (C.H., M.C.H.)
| | - David G Lalloo
- From the Centre for Global Health, Institute for Infection and Immunity, St. George's University of London (S.F.M., A.L., N.S., N. Karunaharan, J.A., T.B., T.S.H.), University College London (R.S.H.), and the MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine (J.B.), London, and Liverpool School of Tropical Medicine, Liverpool (T.C., D.G.L., D.W., S.J.) - all in the United Kingdom; the University of North Carolina Project-Malawi, Kamuzu Central Hospital, Lilongwe (C. Kanyama, C.C., C.H., M.C.H.), Malawi-Liverpool-Wellcome Trust Clinical Research Programme (R.S.H., N. Kalata, K.G., M.P., J.E.) and the College of Medicine, University of Malawi (R.S.H., N. Kalata, K.G., M.P., J.E., J.J.O.), Blantyre, and Dignitas International, Zomba Central Hospital, Zomba (A.K.C., P.B., D.L., J.J.O.) - all in Malawi; University of Dschang, Dschang (C. Kouanfack), Hôpital Central Yaoundé/Site Agence Nationale de Recherche sur le Sida (ANRS) Cameroun, Yaoundé (C. Kouanfack, S. Lontsi, J.-G.N., V.S.), and Douala General Hospital (E.T., Y.N.M.) and University of Douala (Y.N.M.), Douala - all in Cameroon; the Institute for Medical Research and Training (D.C., N.S., N. Karunaharan, P.B.), University Teaching Hospital (D.C., S. Lakhi, N.S., N. Karunaharan, P.B.), and the Department of Internal Medicine and Directorate of Research and Postgraduate Studies, Lusaka Apex Medical University (P.M.), Lusaka, Zambia; the National Institute for Medical Research, Muhimbili Medical Research Centre, Dar Es Salaam, Tanzania (S.M., S. Lesikari); Institut Pasteur, Molecular Mycology Unit (E.T., O.L.), and Paris Descartes University, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, IHU Imagine, Assistance Publique-Hôpitaux de Paris (O.L.), Paris; the Division of Infectious Diseases, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto (A.K.C.); and the University of North Carolina, Chapel Hill (C.H., M.C.H.)
| | - Duolao Wang
- From the Centre for Global Health, Institute for Infection and Immunity, St. George's University of London (S.F.M., A.L., N.S., N. Karunaharan, J.A., T.B., T.S.H.), University College London (R.S.H.), and the MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine (J.B.), London, and Liverpool School of Tropical Medicine, Liverpool (T.C., D.G.L., D.W., S.J.) - all in the United Kingdom; the University of North Carolina Project-Malawi, Kamuzu Central Hospital, Lilongwe (C. Kanyama, C.C., C.H., M.C.H.), Malawi-Liverpool-Wellcome Trust Clinical Research Programme (R.S.H., N. Kalata, K.G., M.P., J.E.) and the College of Medicine, University of Malawi (R.S.H., N. Kalata, K.G., M.P., J.E., J.J.O.), Blantyre, and Dignitas International, Zomba Central Hospital, Zomba (A.K.C., P.B., D.L., J.J.O.) - all in Malawi; University of Dschang, Dschang (C. Kouanfack), Hôpital Central Yaoundé/Site Agence Nationale de Recherche sur le Sida (ANRS) Cameroun, Yaoundé (C. Kouanfack, S. Lontsi, J.-G.N., V.S.), and Douala General Hospital (E.T., Y.N.M.) and University of Douala (Y.N.M.), Douala - all in Cameroon; the Institute for Medical Research and Training (D.C., N.S., N. Karunaharan, P.B.), University Teaching Hospital (D.C., S. Lakhi, N.S., N. Karunaharan, P.B.), and the Department of Internal Medicine and Directorate of Research and Postgraduate Studies, Lusaka Apex Medical University (P.M.), Lusaka, Zambia; the National Institute for Medical Research, Muhimbili Medical Research Centre, Dar Es Salaam, Tanzania (S.M., S. Lesikari); Institut Pasteur, Molecular Mycology Unit (E.T., O.L.), and Paris Descartes University, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, IHU Imagine, Assistance Publique-Hôpitaux de Paris (O.L.), Paris; the Division of Infectious Diseases, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto (A.K.C.); and the University of North Carolina, Chapel Hill (C.H., M.C.H.)
| | - Mina C Hosseinipour
- From the Centre for Global Health, Institute for Infection and Immunity, St. George's University of London (S.F.M., A.L., N.S., N. Karunaharan, J.A., T.B., T.S.H.), University College London (R.S.H.), and the MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine (J.B.), London, and Liverpool School of Tropical Medicine, Liverpool (T.C., D.G.L., D.W., S.J.) - all in the United Kingdom; the University of North Carolina Project-Malawi, Kamuzu Central Hospital, Lilongwe (C. Kanyama, C.C., C.H., M.C.H.), Malawi-Liverpool-Wellcome Trust Clinical Research Programme (R.S.H., N. Kalata, K.G., M.P., J.E.) and the College of Medicine, University of Malawi (R.S.H., N. Kalata, K.G., M.P., J.E., J.J.O.), Blantyre, and Dignitas International, Zomba Central Hospital, Zomba (A.K.C., P.B., D.L., J.J.O.) - all in Malawi; University of Dschang, Dschang (C. Kouanfack), Hôpital Central Yaoundé/Site Agence Nationale de Recherche sur le Sida (ANRS) Cameroun, Yaoundé (C. Kouanfack, S. Lontsi, J.-G.N., V.S.), and Douala General Hospital (E.T., Y.N.M.) and University of Douala (Y.N.M.), Douala - all in Cameroon; the Institute for Medical Research and Training (D.C., N.S., N. Karunaharan, P.B.), University Teaching Hospital (D.C., S. Lakhi, N.S., N. Karunaharan, P.B.), and the Department of Internal Medicine and Directorate of Research and Postgraduate Studies, Lusaka Apex Medical University (P.M.), Lusaka, Zambia; the National Institute for Medical Research, Muhimbili Medical Research Centre, Dar Es Salaam, Tanzania (S.M., S. Lesikari); Institut Pasteur, Molecular Mycology Unit (E.T., O.L.), and Paris Descartes University, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, IHU Imagine, Assistance Publique-Hôpitaux de Paris (O.L.), Paris; the Division of Infectious Diseases, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto (A.K.C.); and the University of North Carolina, Chapel Hill (C.H., M.C.H.)
| | - Olivier Lortholary
- From the Centre for Global Health, Institute for Infection and Immunity, St. George's University of London (S.F.M., A.L., N.S., N. Karunaharan, J.A., T.B., T.S.H.), University College London (R.S.H.), and the MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine (J.B.), London, and Liverpool School of Tropical Medicine, Liverpool (T.C., D.G.L., D.W., S.J.) - all in the United Kingdom; the University of North Carolina Project-Malawi, Kamuzu Central Hospital, Lilongwe (C. Kanyama, C.C., C.H., M.C.H.), Malawi-Liverpool-Wellcome Trust Clinical Research Programme (R.S.H., N. Kalata, K.G., M.P., J.E.) and the College of Medicine, University of Malawi (R.S.H., N. Kalata, K.G., M.P., J.E., J.J.O.), Blantyre, and Dignitas International, Zomba Central Hospital, Zomba (A.K.C., P.B., D.L., J.J.O.) - all in Malawi; University of Dschang, Dschang (C. Kouanfack), Hôpital Central Yaoundé/Site Agence Nationale de Recherche sur le Sida (ANRS) Cameroun, Yaoundé (C. Kouanfack, S. Lontsi, J.-G.N., V.S.), and Douala General Hospital (E.T., Y.N.M.) and University of Douala (Y.N.M.), Douala - all in Cameroon; the Institute for Medical Research and Training (D.C., N.S., N. Karunaharan, P.B.), University Teaching Hospital (D.C., S. Lakhi, N.S., N. Karunaharan, P.B.), and the Department of Internal Medicine and Directorate of Research and Postgraduate Studies, Lusaka Apex Medical University (P.M.), Lusaka, Zambia; the National Institute for Medical Research, Muhimbili Medical Research Centre, Dar Es Salaam, Tanzania (S.M., S. Lesikari); Institut Pasteur, Molecular Mycology Unit (E.T., O.L.), and Paris Descartes University, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, IHU Imagine, Assistance Publique-Hôpitaux de Paris (O.L.), Paris; the Division of Infectious Diseases, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto (A.K.C.); and the University of North Carolina, Chapel Hill (C.H., M.C.H.)
| | - Shabbar Jaffar
- From the Centre for Global Health, Institute for Infection and Immunity, St. George's University of London (S.F.M., A.L., N.S., N. Karunaharan, J.A., T.B., T.S.H.), University College London (R.S.H.), and the MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine (J.B.), London, and Liverpool School of Tropical Medicine, Liverpool (T.C., D.G.L., D.W., S.J.) - all in the United Kingdom; the University of North Carolina Project-Malawi, Kamuzu Central Hospital, Lilongwe (C. Kanyama, C.C., C.H., M.C.H.), Malawi-Liverpool-Wellcome Trust Clinical Research Programme (R.S.H., N. Kalata, K.G., M.P., J.E.) and the College of Medicine, University of Malawi (R.S.H., N. Kalata, K.G., M.P., J.E., J.J.O.), Blantyre, and Dignitas International, Zomba Central Hospital, Zomba (A.K.C., P.B., D.L., J.J.O.) - all in Malawi; University of Dschang, Dschang (C. Kouanfack), Hôpital Central Yaoundé/Site Agence Nationale de Recherche sur le Sida (ANRS) Cameroun, Yaoundé (C. Kouanfack, S. Lontsi, J.-G.N., V.S.), and Douala General Hospital (E.T., Y.N.M.) and University of Douala (Y.N.M.), Douala - all in Cameroon; the Institute for Medical Research and Training (D.C., N.S., N. Karunaharan, P.B.), University Teaching Hospital (D.C., S. Lakhi, N.S., N. Karunaharan, P.B.), and the Department of Internal Medicine and Directorate of Research and Postgraduate Studies, Lusaka Apex Medical University (P.M.), Lusaka, Zambia; the National Institute for Medical Research, Muhimbili Medical Research Centre, Dar Es Salaam, Tanzania (S.M., S. Lesikari); Institut Pasteur, Molecular Mycology Unit (E.T., O.L.), and Paris Descartes University, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, IHU Imagine, Assistance Publique-Hôpitaux de Paris (O.L.), Paris; the Division of Infectious Diseases, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto (A.K.C.); and the University of North Carolina, Chapel Hill (C.H., M.C.H.)
| | - Thomas S Harrison
- From the Centre for Global Health, Institute for Infection and Immunity, St. George's University of London (S.F.M., A.L., N.S., N. Karunaharan, J.A., T.B., T.S.H.), University College London (R.S.H.), and the MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine (J.B.), London, and Liverpool School of Tropical Medicine, Liverpool (T.C., D.G.L., D.W., S.J.) - all in the United Kingdom; the University of North Carolina Project-Malawi, Kamuzu Central Hospital, Lilongwe (C. Kanyama, C.C., C.H., M.C.H.), Malawi-Liverpool-Wellcome Trust Clinical Research Programme (R.S.H., N. Kalata, K.G., M.P., J.E.) and the College of Medicine, University of Malawi (R.S.H., N. Kalata, K.G., M.P., J.E., J.J.O.), Blantyre, and Dignitas International, Zomba Central Hospital, Zomba (A.K.C., P.B., D.L., J.J.O.) - all in Malawi; University of Dschang, Dschang (C. Kouanfack), Hôpital Central Yaoundé/Site Agence Nationale de Recherche sur le Sida (ANRS) Cameroun, Yaoundé (C. Kouanfack, S. Lontsi, J.-G.N., V.S.), and Douala General Hospital (E.T., Y.N.M.) and University of Douala (Y.N.M.), Douala - all in Cameroon; the Institute for Medical Research and Training (D.C., N.S., N. Karunaharan, P.B.), University Teaching Hospital (D.C., S. Lakhi, N.S., N. Karunaharan, P.B.), and the Department of Internal Medicine and Directorate of Research and Postgraduate Studies, Lusaka Apex Medical University (P.M.), Lusaka, Zambia; the National Institute for Medical Research, Muhimbili Medical Research Centre, Dar Es Salaam, Tanzania (S.M., S. Lesikari); Institut Pasteur, Molecular Mycology Unit (E.T., O.L.), and Paris Descartes University, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, IHU Imagine, Assistance Publique-Hôpitaux de Paris (O.L.), Paris; the Division of Infectious Diseases, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto (A.K.C.); and the University of North Carolina, Chapel Hill (C.H., M.C.H.)
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Chen D, Wan X, Kruger E, Chen C, Yue X, Wang L, Wu J. Cost-effectiveness of de-escalation from micafungin versus escalation from fluconazole for invasive candidiasis in China. J Med Econ 2018; 21:301-307. [PMID: 29303621 DOI: 10.1080/13696998.2017.1417312] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
AIMS Guidelines on treating invasive candidiasis recommend initial treatment with a broad-spectrum echinocandin (e.g. micafungin), then switching to fluconazole if isolates prove sensitive (de-escalation strategy). This study aimed to evaluate the cost-effectiveness of de-escalation from micafungin vs escalation from fluconazole from a Chinese public payers perspective. MATERIALS AND METHODS Cost-effectiveness was estimated using a decision analytic model, in which patients begin treatment with fluconazole 400 mg/day (escalation) or micafungin 100 mg/day (de-escalation). From Day 3, when susceptibility results are available, patients are treated with either fluconazole (if isolates are fluconazole-sensitive/dose-dependent) or micafungin (if isolates are resistant). The total duration of (appropriate) treatment is 14 days. Model inputs are early (Day 3) and end-of-treatment mortality rates, treatment success rates, and health resource utilization. Model outputs are costs of health resource utilization over 42 days, incremental cost per life-year, and incremental cost per quality-adjusted life-year (QALY) over a lifetime horizon. RESULTS In the base-case analysis, the de-escalation strategy was associated with longer survival and higher treatment success rates compared with escalation, at a lower overall cost (-¥1,154; -175 United States Dollars). Life-years and QALYs were also better with de-escalation. Thus, this strategy dominated the escalation strategy for all outcomes. In a probabilistic sensitivity analysis, 99% of 10,000 simulations were below the very cost-effective threshold (1 × gross domestic product). LIMITATIONS The main limitation of the study was the lack of real-world input data for clinical outcomes on treatment with micafungin in China; data from other countries were included in the model. CONCLUSION A de-escalation strategy is cost-saving from the Chinese public health payer perspective compared with escalation. It improves outcomes and reduces costs to the health system by reducing hospitalization, due to an increase in the proportion of patients receiving appropriate treatment.
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Affiliation(s)
- Dechang Chen
- a Department of Critical Care Medicine , Shanghai Ruijin Hospital affiliated to Jiaotong University, School of Medicine , Shanghai , PR China
| | - Xianyao Wan
- b Intensive Care Unit, The First Affiliated Hospital of Dalian Medical University , Dalian , PR China
| | | | - Can Chen
- d IMS Health China , Beijing , PR China
| | - Xiaomeng Yue
- e James L. Winkle College of Pharmacy , University of Cincinnati , OH , USA
| | - Liang Wang
- f Astellas Pharma China Inc , Beijing , PR China
| | - Jiuhong Wu
- g Pharmacy Department , The 306th Hospital of PLA , Beijing , PR China
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Francesconi VA, Francesconi F, Ramasawmy R, Romero GAS, Alecrim MDGC. Failure of fluconazole in treating cutaneous leishmaniasis caused by Leishmania guyanensis in the Brazilian Amazon: An open, nonrandomized phase 2 trial. PLoS Negl Trop Dis 2018; 12:e0006225. [PMID: 29481560 PMCID: PMC5854414 DOI: 10.1371/journal.pntd.0006225] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2017] [Revised: 03/15/2018] [Accepted: 01/09/2018] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND The treatment of Leishmaniasis caused by Leishmania (Viannia) guyanensis is based on a weak strength of evidence from very few clinical trials and some case series reports. Current treatment guidelines recommend pentamidine isethionate or meglumine antimoniate (Glucantime) as the first-line choices. Both are parenteral drugs with a low therapeutic indexes leading to a high risk of undesired effects. Imidazole derivatives interfere with the production of leishmanial ergosterol, an essential component of their membrane structure. One drug that has been studied in different clinical presentations of Leishmania is fluconazole, a hydrophilic bis-triazole, which is easily absorbed through the oral route with a low toxicity profile and is considered safe for children. This drug is readily available in poor countries with a reasonable cost making it a potential option for treating leishmaniasis. METHODS AND FINDINGS An adaptive nonrandomized clinical trial with sequential groups with dose escalation of oral fluconazole was designed to treat adult men with localized cutaneous leishmaniasis (LCL) in Manaus, Brazil. Eligible participants were patients with LCL with confirmed Leishmania guyanensis infection. RESULTS Twenty adult male patients were treated with 450 mg of fluconazole daily for 30 days. One patient (5%) was cured within 30 days of treatment. Of the 19 failures (95%), 13 developed a worsening of ulcers and six evolved lymphatic spreading of the disease. Planned dose escalation was suspended after the disappointing failure rate during the first stage of the trial. CONCLUSION/SIGNIFICANCE Oral fluconazole, at the dose of 450mg per day, was not efficacious against LCL caused by Leishmania guyanensis in adult men. TRIAL REGISTRATION Brazilian Clinical Trial Registration (ReBec)-RBR-8w292w; UTN number-1158-2421.
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Affiliation(s)
- Valeska Albuquerque Francesconi
- Department of Dermatology, Academic and Research Division at the Tropical Medicine Foundation - Dr Heitor Vieira Dourado, Manaus, Amazonas, Brazil
| | - Fabio Francesconi
- Department of Dermatology, Academic and Research Division at the Tropical Medicine Foundation - Dr Heitor Vieira Dourado, Manaus, Amazonas, Brazil
| | - Rajendranath Ramasawmy
- Department of Molecular Biology, Division of Immunogenetics, at the Tropical Medicine Foundation - Dr Heitor Vieira Dourado and Universidade Nilton Lins, Manaus, Amazonas, Brazil
| | | | - Maria das Graças Costa Alecrim
- Department of Infectology, Division of Malaria and Neglected Tropical Diseases at the Tropical Medicine Foundation - Dr Heitor Vieira Dourado, Manaus, Amazonas, Brazil
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Henriques M, Cerca N, Azeredo J, Oliveira R. Influence of Sub-Inhibitory Concentrations of Antimicrobial Agents on Biofilm Formation in Indwelling Medical Devices. Int J Artif Organs 2018; 28:1181-5. [PMID: 16353125 DOI: 10.1177/039139880502801116] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Biofilms of Staphylococcus epidermidis and Candida spp. are two of the most frequent factors of infections associated with the use of indwelling medical devices. Several strategies have been proposed and/or developed to prevent infection. The aim of this study was to compare the effect of sub-inhibitory concentrations of anti-microbial agents on biofilm formation. Biofilms of three strains of S. epidermidis and two of both Candida albicans and Candida dubliniensis were formed in the presence of three antibiotics and two antifungal agents respectively. Based on the control samples, the percentage of biofilm formation inhibition by the different agents was determined and compared. The results showed that the influence of the antibacterial and antifungal agents tested is strain dependent, with the effect of the different agents also varying among strains, even though they have the same mechanism of action.
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Affiliation(s)
- M Henriques
- Center of Biological Engineering, CEB, University of Minho, Campus de Gualtar, Braga, Portugal
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Kryukov AI, Kunel'skaya NL, Kunel'skaya VY, Ivoilov AY, Turovskiy AB, Shadrin GB, Machulin AI. [Otomycosis: the modern view of etiology and management]. Vestn Otorinolaringol 2018; 83:48-51. [PMID: 29488497 DOI: 10.17116/otorino201883148-51] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
This article deals with the modern approaches to the diagnostics and treatment of fungal ear infection depending on the localization of the inflammatory process and the species of the causative fungal agent with special reference to the factors underlying the development of otomycosis under the present-day conditions based on the results of the analysis of the studies carried out during the period from 2010 to 2014. The materials of the examination of 2152 patients who applied for the medical care to various clinical departments of the Institute and were found to present with chronic inflammatory ear pathology were available for the analysis. Fungal lesions were diagnosed in 495 (23%) patients with this condition. Fungal lesions of the external ear were the predominant form of pathology; they were documented in 331 (67%) patients. Fungal otitis media was diagnosed in 85 (17%) patients and fungal lesions of the postoperative cavity in 79 (16%) patients suffering from otomycosis. 65% of the patients presenting with external fungal otitis, 20% of those with fungal otitis media, and 95% of the patients with inflammation of the postoperative cavity were infected with mold fungi dominated by the genus Aspergillus spp. 79 (16%) patients suffering from otomycosis. In 35% of the patients presenting with fungal external otitis, 80% of those with fungal otitis media, and 5% of the patients with inflammation of the postoperative cavity of the middle ear, the causative agents of the disease were the fungi Candida spp. The authors describe the modern schemes for the treatment of otomycosis elaborated at the L.I. Sverzhevskiy Research Institute of Clinical Otorhinolaryngology.
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Affiliation(s)
- A I Kryukov
- Department of Otorhinolaryngology, N.I. Pirogov Russian National Research Medical University, Moscow, Russia, 117997; L.I. Sverzhevskiy Research Institute of Clinical Otorhinolaryngology, Moscow Health Department, Moscow, Russia, 117152
| | - N L Kunel'skaya
- Department of Otorhinolaryngology, N.I. Pirogov Russian National Research Medical University, Moscow, Russia, 117997; L.I. Sverzhevskiy Research Institute of Clinical Otorhinolaryngology, Moscow Health Department, Moscow, Russia, 117152
| | - V Ya Kunel'skaya
- L.I. Sverzhevskiy Research Institute of Clinical Otorhinolaryngology, Moscow Health Department, Moscow, Russia, 117152
| | - A Yu Ivoilov
- Department of Otorhinolaryngology, N.I. Pirogov Russian National Research Medical University, Moscow, Russia, 117997; L.I. Sverzhevskiy Research Institute of Clinical Otorhinolaryngology, Moscow Health Department, Moscow, Russia, 117152
| | - A B Turovskiy
- L.I. Sverzhevskiy Research Institute of Clinical Otorhinolaryngology, Moscow Health Department, Moscow, Russia, 117152
| | - G B Shadrin
- L.I. Sverzhevskiy Research Institute of Clinical Otorhinolaryngology, Moscow Health Department, Moscow, Russia, 117152
| | - A I Machulin
- L.I. Sverzhevskiy Research Institute of Clinical Otorhinolaryngology, Moscow Health Department, Moscow, Russia, 117152
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Pagès A, Iriart X, Molinier L, Georges B, Berry A, Massip P, Juillard-Condat B. Cost Effectiveness of Candida Polymerase Chain Reaction Detection and Empirical Antifungal Treatment among Patients with Suspected Fungal Peritonitis in the Intensive Care Unit. Value Health 2017; 20:1319-1328. [PMID: 29241891 DOI: 10.1016/j.jval.2017.06.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Revised: 06/01/2017] [Accepted: 06/18/2017] [Indexed: 06/07/2023]
Abstract
BACKGROUND Mortality from intra-abdominal candidiasis in intensive care units (ICUs) is high. It takes many days for peritoneal-fluid fungal culture to become positive, and the recommended empirical antifungal therapy involves excessive costs. Polymerase chain reaction (PCR) should produce results more rapidly than fungal culture. OBJECTIVES To perform a cost-effectiveness analysis of the combination of several diagnostic and therapeutic strategies to manage Candida peritonitis in non-neutropenic adult patients in ICUs. METHODS We constructed a decision tree model to evaluate the cost effectiveness. Cost and effectiveness were taken into account in a 1-year time horizon and from the French National Health Insurance perspective. Six strategies were compared: fluconazole or echinocandin as an empirical therapy, plus diagnosis by fungal culture or detection by PCR of all Candida species, or use of PCR to detect most fluconazole-resistant Candida species (i.e., Candida krusei and Candida glabrata). RESULTS The use of fluconazole empirical treatment and PCR to detect all Candida species is more cost effective than using fluconazole empirical treatment without PCR (incremental cost-effectiveness ratio of €40,055/quality-adjusted life-year). Empirical treatment with echinocandin plus PCR to detect C. krusei and C. glabrata is the most effective strategy, but has an incremental cost-effectiveness ratio of €93,776/quality-adjusted life-year. If the cost of echinocandin decreases, then strategies involving PCR plus empirical echinocandin become more cost-effective. CONCLUSIONS Detection by PCR of all Candida species and of most fluconazole-resistant Candida species could improve the cost-effectiveness of fluconazole and echinocandin given to non-neutropenic patients with suspected peritoneal candidiasis in ICUs.
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Affiliation(s)
| | - Xavier Iriart
- CHU de Toulouse, Laboratoire de parasitologie et mycologie, Toulouse, France; Inserm U1043/CNRS UMR5282/CPTP, UPS Université de Toulouse III, Toulouse, France
| | - Laurent Molinier
- CHU de Toulouse, Département d'Information Médicale, Toulouse, France; Inserm, UMR1027, UPS Université de Toulouse III, Toulouse, France
| | - Bernard Georges
- CHU de Toulouse, Réanimation Polyvalente, Hôpital Rangueil, Toulouse, France
| | - Antoine Berry
- CHU de Toulouse, Laboratoire de parasitologie et mycologie, Toulouse, France; Inserm U1043/CNRS UMR5282/CPTP, UPS Université de Toulouse III, Toulouse, France
| | - Patrice Massip
- CHU de Toulouse, Service des Maladies Infectieuses et Tropicales, Toulouse, France
| | - Blandine Juillard-Condat
- CHU de Toulouse, Pharmacie, Toulouse, France; Inserm, UMR1027, UPS Université de Toulouse III, Toulouse, France
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Saha H, Pal AK, Sahu NP, Saha RK, Goswami P. Effects of fluconazole based medicated feed on haemato-immunological responses and resistance of Labeo rohita against Saprolegnia parasitica. Fish Shellfish Immunol 2017; 71:346-352. [PMID: 28964864 DOI: 10.1016/j.fsi.2017.09.073] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Revised: 09/21/2017] [Accepted: 09/26/2017] [Indexed: 06/07/2023]
Abstract
Fluconazole (FLZ) is a new azole antifungal drug having no earlier record of its utilization for the treatment of fish diseases. A 55-days experiment was carried out to delineate the role of FLZ based medicated feed on haemato-immunological responses and prevention of fungal infection in Labeo rohita fingerlings. Three hundred and sixty fingerlings were randomly distributed into four experimental groups in triplicates. Four iso-caloric and iso-nitrogenous purified medicated feeds were prepared with 0, 100, 200 and 300 mg FLZ 100 g-1 feed. Haemato-immunological parameters like erythrocyte counts (EC), haemoglobulin (Hb), leucocyte counts (LC), packed cell volume (PCV), mean corpuscular haemoglobin (MCH), mean corpuscular volume (MCV), mean corpuscular haemoglobin concentration (MCHC), nitro-blue tetrazolium (NBT), albumin, globulin, total plasma protein were studied. The present study revealed that the continuous feeding of FLZ based feed for 15-30 days significantly (P < 0.05) increases the erythropoiesis, heme-synthesis, as well as the leucocytosis in rohu. However, all the doses exhibited equal protection from the infectious S. parasitica after 45 days of continuous feeding.
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Affiliation(s)
- Himadri Saha
- Division of Fish Nutrition, Biochemistry and Physiology, Central Institute of Fisheries Education, Mumbai, Maharashtra 400061, India; Department of Aquatic Health and Environment, College of Fisheries, CAU, Lembucherra, Agartala, Tripura 799210, India.
| | - Asim Kumar Pal
- Division of Fish Nutrition, Biochemistry and Physiology, Central Institute of Fisheries Education, Mumbai, Maharashtra 400061, India
| | - Narottam Prasad Sahu
- Division of Fish Nutrition, Biochemistry and Physiology, Central Institute of Fisheries Education, Mumbai, Maharashtra 400061, India.
| | - Ratan Kumar Saha
- Department of Aquatic Health and Environment, College of Fisheries, CAU, Lembucherra, Agartala, Tripura 799210, India
| | - Pritam Goswami
- Department of Aquatic Health and Environment, College of Fisheries, CAU, Lembucherra, Agartala, Tripura 799210, India
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Abstract
BACKGROUND Vulvovaginal candidiasis (VVC) is estimated to be the second most common form of infection after bacterial vaginosis. The ability of probiotics in maintaining and recovering the normal vaginal microbiota, and their potential ability to resist Candidas give rise to the concept of using probiotics for the treatment of VVC. OBJECTIVES To assess the effectiveness and safety of probiotics for the treatment of vulvovaginal candidiasis in non-pregnant women. SEARCH METHODS We searched the following databases to October 2017: Sexually Transmitted Infections Cochrane Review Group's Specialized Register, CENTRAL, MEDLINE, Embase and eight other databases. We searched in following international resources: World Health Organization International Clinical Trials Registry Platform, ClinicalTrials.gov, Web of Science and OpenGrey. We checked specialty journals, reference lists of published articles and conference proceedings. We collected information from pharmaceutical companies and experts in the field. SELECTION CRITERIA Randomized controlled trials (RCT) using probiotics, alone or as adjuvants to conventional antifungal drugs, to treat VVC in non-pregnant women. Trials recruiting women with recurrent VVC, coinfection with other vulvovaginal infections, diabetes mellitus, immunosuppressive disorders or taking immunosuppressant medication were ineligible for inclusion. Probiotics were included if they were made from single or multiple species and in any preparation type/dosage/route of administration. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for eligibility and quality and extracted data. We resolved any disagreements through consensus. The quality of the evidence was assessed using the GRADE approach. MAIN RESULTS Ten RCTs (1656 participants) met our inclusion criteria, and pharmaceutical industry funded none of these trials. All trials used probiotics as adjuvant therapy to antifungal drugs. Probiotics increased the rate of short-term clinical cure (risk ratio (RR) 1.14, 95% confidence interval (CI) 1.05 to 1.24, 695 participants, 5 studies, low quality evidence) and mycological cure (RR 1.06, 95% CI 1.02 to 1.10, 969 participants, 7 studies, low quality evidence) and decreased relapse rate at one month (RR 0.34, 95% CI 0.17 to 0.68, 388 participants, 3 studies, very low quality evidence). However, this effect did not translate into a higher frequency of long-term clinical cure (one month after treatment: RR 1.07, 95% CI 0.86 to 1.33, 172 participants, 1 study, very low quality evidence; three months after treatment: RR 1.30, 95% CI 1.00 to 1.70, 172 participants, one study, very low quality evidence) or mycological cure (one month after treatment: RR 1.26, 95% CI 0.93 to 1.71, 627 participants, 3 studies, very low quality evidence; three months after treatment: RR 1.16, 95% CI 1.00 to 1.35, 172 participants, one study, very low quality evidence). Probiotics use did not increase the frequency of serious (RR 0.80, 95% CI 0.22 to 2.94; 440 participants, 2 studies, low quality evidence). We found no eligible RCTs for outcomes as time to first relapse, need for additional treatment at the end of therapy, patient satisfaction and cost effectiveness. AUTHORS' CONCLUSIONS Low and very low quality evidence shows that, compared with conventional treatment, the use of probiotics as an adjuvant therapy could increases the rate of short-term clinical and mycological cure and decrease the relapse rate at one month but this did not translate into a higher frequency of long-term clinical or mycological cure. Probiotics use does not seem to increase the frequency of serious or non-serious adverse events. There is a need for well-designed RCTs with standardized methodologies, longer follow-up and larger sample size.
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Affiliation(s)
- Huan Yu Xie
- People's Hospital of Deyang CityDepartment of Obstetrics and GynecologyNo. 173, Tai Shan North RoadDeyangSichuanChina618000
| | - Dan Feng
- Cheng du Women & Children's Central HospitalDepartment of Obstetrics and GynecologyNo. 1617, Riyue AvenueChengduSichuanChina610091
| | - Dong Mei Wei
- West China Second University Hospital, West China Women's and Children's HospitalDepartment of Obstetrics and GynecologyNo. 17, Section Three, Ren Min Nan Lu AvenueChengduSichuanChina610041
| | - Ling Mei
- West China Second University Hospital, West China Women's and Children's HospitalDepartment of Obstetrics and GynecologyNo. 17, Section Three, Ren Min Nan Lu AvenueChengduSichuanChina610041
| | - Hui Chen
- West China Second University Hospital, West China Women's and Children's HospitalDepartment of Obstetrics and GynecologyNo. 17, Section Three, Ren Min Nan Lu AvenueChengduSichuanChina610041
| | - Xun Wang
- West China Second University Hospital, West China Women's and Children's HospitalDepartment of Obstetrics and GynecologyNo. 17, Section Three, Ren Min Nan Lu AvenueChengduSichuanChina610041
| | - Fang Fang
- West China Second University Hospital, Sichuan UniversityDepartment of Obstetrics and GynecologyNo. 17, Section Three, Ren Min Nan Lu AvenueChengduSichuanChina610041
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Rensen N, Gemke RJBJ, van Dalen EC, Rotteveel J, Kaspers GJL. Hypothalamic-pituitary-adrenal (HPA) axis suppression after treatment with glucocorticoid therapy for childhood acute lymphoblastic leukaemia. Cochrane Database Syst Rev 2017; 11:CD008727. [PMID: 29106702 PMCID: PMC6486149 DOI: 10.1002/14651858.cd008727.pub4] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Glucocorticoids play a major role in the treatment of acute lymphoblastic leukaemia (ALL). However, supraphysiological doses can suppress the hypothalamic-pituitary-adrenal (HPA) axis. HPA axis suppression resulting in reduced cortisol response may cause an impaired stress response and an inadequate host defence against infection, which remain a cause of morbidity and death. Suppression commonly occurs in the first days after cessation of glucocorticoid therapy, but the exact duration is unclear. This review is the second update of a previously published Cochrane review. OBJECTIVES To examine the occurrence and duration of HPA axis suppression after (each cycle of) glucocorticoid therapy for childhood ALL. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 11), MEDLINE/PubMed (from 1945 to December 2016), and Embase/Ovid (from 1980 to December 2016). In addition, we searched reference lists of relevant articles, conference proceedings (the International Society for Paediatric Oncology and the American Society of Clinical Oncology from 2005 up to and including 2016, and the American Society of Pediatric Hematology/Oncology from 2014 up to and including 2016), and ongoing trial databases (the International Standard Registered Clinical/Social Study Number (ISRCTN) register via http://www.controlled-trials.com, the National Institutes of Health (NIH) register via www.clinicaltrials.gov, and the International Clinical Trials Registry Platform (ICTRP) of the World Health Organization (WHO) via apps.who.int/trialsearch) on 27 December 2016. SELECTION CRITERIA All study designs, except case reports and patient series with fewer than 10 children, examining effects of glucocorticoid therapy for childhood ALL on HPA axis function. DATA COLLECTION AND ANALYSIS Two review authors independently performed study selection. One review author extracted data and assessed 'Risk of bias'; another review author checked this information. MAIN RESULTS We identified 10 studies (total of 298 children; we identified two studies for this update) including two randomised controlled trials (RCTs) that assessed adrenal function. None of the included studies assessed the HPA axis at the level of the hypothalamus, the pituitary, or both. Owing to substantial differences between studies, we could not pool results. All studies had risk of bias issues. Included studies demonstrated that adrenal insufficiency occurs in nearly all children during the first days after cessation of glucocorticoid treatment for childhood ALL. Most children recovered within a few weeks, but a small number of children had ongoing adrenal insufficiency lasting up to 34 weeks.Included studies evaluated several risk factors for (prolonged) adrenal insufficiency. First, three studies including two RCTs investigated the difference between prednisone and dexamethasone in terms of occurrence and duration of adrenal insufficiency. The RCTs found no differences between prednisone and dexamethasone arms. In the other (observational) study, children who received prednisone recovered earlier than children who received dexamethasone. Second, treatment with fluconazole appeared to prolong the duration of adrenal insufficiency, which was evaluated in two studies. One of these studies reported that the effect was present only when children received fluconazole at a dose higher than 10 mg/kg/d. Finally, two studies evaluated the presence of infection, stress episodes, or both, as a risk factor for adrenal insufficiency. In one of these studies (an RCT), trial authors found no relationship between the presence of infection/stress and adrenal insufficiency. The other study found that increased infection was associated with prolonged duration of adrenal insufficiency. AUTHORS' CONCLUSIONS We concluded that adrenal insufficiency commonly occurs in the first days after cessation of glucocorticoid therapy for childhood ALL, but the exact duration is unclear. No data were available on the levels of the hypothalamus and the pituitary; therefore, we could draw no conclusions regarding these outcomes. Clinicians may consider prescribing glucocorticoid replacement therapy during periods of serious stress in the first weeks after cessation of glucocorticoid therapy for childhood ALL to reduce the risk of life-threatening complications. However, additional high-quality research is needed to inform evidence-based guidelines for glucocorticoid replacement therapy.Special attention should be paid to patients receiving fluconazole therapy, and perhaps similar antifungal drugs, as these treatments may prolong the duration of adrenal insufficiency, especially when administered at a dose higher than 10 mg/kg/d.Finally, it would be relevant to investigate further the relationship between present infection/stress and adrenal insufficiency in a larger, separate study specially designed for this purpose.
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Affiliation(s)
- Niki Rensen
- VU University Medical CenterDepartment of Pediatrics, Division of Oncology/HematologyDe Boelelaan 1117AmsterdamNetherlands1081 HZ
| | - Reinoud JBJ Gemke
- VU University Medical CenterDepartment of Pediatrics, Division of General Pediatrics and other subspecialtiesPO Box 7057AmsterdamNetherlands1007 MB
| | - Elvira C van Dalen
- Emma Children's Hospital/Academic Medical CenterDepartment of Paediatric OncologyPO Box 22660 (room H4‐139)AmsterdamNetherlands1100 DD
| | - Joost Rotteveel
- VU University Medical CenterDepartment of Pediatrics, Division of EndocrinologyPO Box 7057AmsterdamNetherlands1007 MB
| | - Gertjan JL Kaspers
- VU University Medical CenterDepartment of Pediatrics, Division of Oncology/HematologyDe Boelelaan 1117AmsterdamNetherlands1081 HZ
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Semnani D, Afrashi M, Alihosseini F, Dehghan P, Maherolnaghsh M. Investigating the performance of drug delivery system of fluconazole made of nano-micro fibers coated on cotton/polyester fabric. J Mater Sci Mater Med 2017; 28:175. [PMID: 28956211 DOI: 10.1007/s10856-017-5957-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/2016] [Accepted: 08/03/2017] [Indexed: 06/07/2023]
Abstract
Polymer-based drug delivery systems are suitable to optimize the therapeutic properties of drugs and to render them safer, more effective and reliable. Long-term or repeated use of oral administration of fluconazole for treating chronic candidiasis in the patient and partially abandoned treatment lead to the resistant strains of the fungus Candida albicans and severity of the disease. In this study, the use of nanofibers and microfibers containing fluconazole for local drug delivery to increase the efficiencies and reduce the side effects caused by taking the drug was studied. Morphology, microstructure and chemical composition of PVA nanofibers containing fluconazole were characterized by scanning electron microscopy (SEM) and Fourier transform infrared spectroscopy (FTIR). As well as, the DSC test was indicated presence of fluconazole in PVA fibrous mats. The rate of drug release was investigated by UV-Vis spectrophotometery and swelling technique. SEM images showed that the nanofibers with uniform structure without beads were produced. The mechanical properties of the pristine PVA nanofiber and fibrous mat containing drug were evaluated. The release of fluconazole from PVA nanofibers in pH of 7.4 and at 37 °C was investigated. The results presented that the drug release rate is dependent on the morphology and structure of PVA nanofibers and could be adjusted in desired dosage. The presented products are applicable in the high production form for medical textile industry.
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Affiliation(s)
- Dariush Semnani
- Department of Textile Engineering, Isfahan University of Technology, Isfahan, Iran.
| | - Mehran Afrashi
- Department of Textile Engineering, Isfahan University of Technology, Isfahan, Iran
| | - Farzaneh Alihosseini
- Department of Textile Engineering, Isfahan University of Technology, Isfahan, Iran
| | - Parvin Dehghan
- Department of Parasitology and Mycology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mehrnoosh Maherolnaghsh
- Department of Parasitology and Mycology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
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Watt KM, Cohen-Wolkowiez M, Williams DC, Bonadonna DK, Cheifetz IM, Thakker D, Benjamin DK, Brouwer KL. Antifungal Extraction by the Extracorporeal Membrane Oxygenation Circuit. J Extra Corpor Technol 2017; 49:150-159. [PMID: 28979038 PMCID: PMC5621578] [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] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Accepted: 03/22/2017] [Indexed: 02/23/2023]
Abstract
Invasive candidiasis is common and often fatal in patients supported with extracorporeal membrane oxygenation (ECMO), and treatment relies on optimal antifungal dosing. The ECMO circuit can extract drug and decrease drug exposure, placing the patient at risk of therapeutic failure. This ex vivo study determined the extraction of antifungal drugs by the ECMO circuit. Fluconazole and micafungin were studied separately in three closed-loop circuit configurations to isolate the impact of the oxygenator, hemofilter, and tubing on circuit extraction. Each circuit was primed with human blood, and flow was set to 1 L/min. Drug was dosed to achieve therapeutic concentrations. Each antifungal was added to a separate tube of blood to serve as a control. Serial blood samples were collected over 24 hours and concentrations were quantified with a validated assay. Drug recovery was calculated at each time point: (C t /C i )*100, with C t and C i the concentrations at time = t and 1 minute, respectively. After 24 hours of recirculation, mean recovery of fluconazole in the ECMO circuit (95-98%) and controls (101%) was high. In contrast, mean recovery of micafungin was dependent on the time and circuit configuration. Recovery at 4 hours was only 46% when a hemofilter was in-line but was much higher when the hemofilter was removed (91%). By 24 hours, however, micafungin recovery was low in all circuit configurations (26-43%), regardless of the presence of a hemofilter, as well as in the controls (57%). In conclusion, these results suggest that micafungin is extracted by the ECMO circuit, which may result in decreased drug exposure in vivo.
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Affiliation(s)
- Kevin M. Watt
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina
| | - Michael Cohen-Wolkowiez
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Duane C. Williams
- Department of Pediatrics, Children's Hospital of Richmond, Richmond, Virginia; and
| | - Desiree K. Bonadonna
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina
- Perfusion Services, Duke University Medical Center, Durham, North Carolina
| | - Ira M. Cheifetz
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina
| | - Dhiren Thakker
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina
| | - Daniel K. Benjamin
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina
| | - Kim L.R. Brouwer
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina
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Affiliation(s)
- Tanvi Dev
- Department of Dermatology All India Institute of Medical Sciences New Delhi, India
| | - Himabindu Saginatham
- Department of Dermatology All India Institute of Medical Sciences New Delhi, India
| | - Gomathy Sethuraman
- Department of Dermatology All India Institute of Medical Sciences New Delhi, India
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Hatlen TJ, Murphy RA, Persichino JG. Necrotic ulcer on the thigh. Cutis 2017; 100:80-91. [PMID: 28961289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- Timothy J Hatlen
- Division of Infectious Diseases, Harbor-UCLA Medical Center, Torrance, California, USA
| | - Richard A Murphy
- Division of Infectious Diseases, Harbor-UCLA Medical Center, Torrance, California, USA
| | - Jon G Persichino
- Division of Infectious Diseases, Harbor-UCLA Medical Center, Torrance, California, USA
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Abstract
An 18-month-old neutered male labradoodle was treated with surgical debridement for maxillary osteomyelitis and sequestrum formation. Histopathologic findings of the necrotic bone were consistent with Cryptococcus subspecies, confirmed with latex agglutination serum titer testing. The patient responded to a combination of fluconazole and surgical debridement and was titer negative after 8 months of medical therapy. The patient never exhibited signs of systemic illness which is commonly reported with cryptococcosis. Cryptococcus subspecies infection in dogs in the Pacific Northwest is part of an ongoing outbreak in the region, first reported in 2001, and is associated with specific risk factors. This is the first published case of oral cryptococcosis from primary inoculation.
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Affiliation(s)
| | - Jean Battig
- 1 Animal Dental Clinic NW, Lake Oswego, OR, USA
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Soberón JR, Sgariglia MA, Pastoriza AC, Soruco EM, Jäger SN, Labadie GR, Sampietro DA, Vattuone MA. Antifungal activity and cytotoxicity of extracts and triterpenoid saponins obtained from the aerial parts of Anagallis arvensis L. J Ethnopharmacol 2017; 203:233-240. [PMID: 28389355 DOI: 10.1016/j.jep.2017.03.056] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Revised: 03/22/2017] [Accepted: 03/31/2017] [Indexed: 06/07/2023]
Abstract
ETHNOPHARMACOLOGICAL RELEVANCE Anagallis arvensis L. (Primulaceae) is used in argentinean northwestern traditional medicine to treat fungal infections. We are reporting the isolation and identification of compounds with antifungal activity against human pathogenic yeast Candida albicans, and toxicity evaluation. AIM OF THE STUDY to study the antifungal activity of extracts and purified compounds obtained form A. arvensis aerial parts, alone and in combinations with fluconazole (FLU), and to study the toxicity of the active compounds. MATERIALS AND METHODS Disk diffusion assays were used to perform an activity-guided isolation of antifungal compounds from the aerial parts of A. arvensis. Broth dilution checkerboard and viable cell count assays were employed to determine the effects of samples and combinations of FLU + samples against Candida albicans. The chemical structures of active compounds were elucidated by spectroscopic analysis. Genotoxic and haemolytic effects of the isolated compounds were determined. RESULTS Four triterpenoid saponins (1-4) were identified. Anagallisin C (AnC), exerted the highest inhibitory activity among the assayed compounds against C. albicans reference strain (ATCC 10231), with MIC-0 =1µg/mL. The Fractional Inhibitory Concentration Index (FICI=0.129) indicated a synergistic effect between AnC (0.125µg/mL) and FLU (0.031µg/mL) against C. albicans ATCC 10231. AnC inhibited C. albicans 12-99 FLU resistant strain (MIC-0 =1µg/mL), and the FICI=0.188 indicated a synergistic effect between AnC (0.125µg/mL) and fluconazole (16µg/mL). The combination AnC+ FLU exerted fungicidal activity against both C. albicans strains. AnC exerted inhibitory activity against C. albicans ATCC 10231 sessile cells (MIC50=0.5µg/mL and MIC80=1µg/mL) and against C. albicans 12-99 sessile cells (MIC50=0.75µg/mL and MIC80=1.25µg/mL). AnC exerted haemolytic effect against human red blood cells at 15µg/mL and did not exerted genotoxic effect on Bacillus subtilis rec strains. CONCLUSIONS The antifungal activity and lack of genotoxic effects of AnC give support to the traditional use of A. arvensis as antifungal and makes AnC a compound of interest to expand the available antifungal drugs.
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Affiliation(s)
- José R Soberón
- Cátedra de Fitoquímica, Instituto de Estudios Farmacológicos "Dr. A.R. Sampietro", Facultad de Bioquímica, Química y Farmacia, Universidad Nacional de Tucumán, Ayacucho 471, T4000INI San Miguel de Tucumán, Tucumán, Argentina; Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Godoy Cruz 2290, C1425FQB Ciudad Autónoma de Buenos Aires, Argentina.
| | - Melina A Sgariglia
- Cátedra de Fitoquímica, Instituto de Estudios Farmacológicos "Dr. A.R. Sampietro", Facultad de Bioquímica, Química y Farmacia, Universidad Nacional de Tucumán, Ayacucho 471, T4000INI San Miguel de Tucumán, Tucumán, Argentina; Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Godoy Cruz 2290, C1425FQB Ciudad Autónoma de Buenos Aires, Argentina
| | - Ana C Pastoriza
- Cátedra de Fitoquímica, Instituto de Estudios Farmacológicos "Dr. A.R. Sampietro", Facultad de Bioquímica, Química y Farmacia, Universidad Nacional de Tucumán, Ayacucho 471, T4000INI San Miguel de Tucumán, Tucumán, Argentina
| | - Estela M Soruco
- Cátedra de Fitoquímica, Instituto de Estudios Farmacológicos "Dr. A.R. Sampietro", Facultad de Bioquímica, Química y Farmacia, Universidad Nacional de Tucumán, Ayacucho 471, T4000INI San Miguel de Tucumán, Tucumán, Argentina
| | - Sebastián N Jäger
- Instituto de Química Rosario, UNR, CONICET, Suipacha 531, S2002LRK Rosario, Argentina
| | - Guillermo R Labadie
- Instituto de Química Rosario, UNR, CONICET, Suipacha 531, S2002LRK Rosario, Argentina; Facultad de Ciencias Bioquímicas y Farmacéuticas, Universidad Nacional de Rosario, Suipacha 531, S2002LRK Rosario, Argentina
| | - Diego A Sampietro
- Cátedra de Fitoquímica, Instituto de Estudios Farmacológicos "Dr. A.R. Sampietro", Facultad de Bioquímica, Química y Farmacia, Universidad Nacional de Tucumán, Ayacucho 471, T4000INI San Miguel de Tucumán, Tucumán, Argentina; Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Godoy Cruz 2290, C1425FQB Ciudad Autónoma de Buenos Aires, Argentina
| | - Marta A Vattuone
- Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Godoy Cruz 2290, C1425FQB Ciudad Autónoma de Buenos Aires, Argentina
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van Prehn J, Menke-van der Houven van Oordt CW, de Rooij ML, Meijer E, Bomers MK, van Dijk K. Hepatosplenic Candidiasis Without Prior Documented Candidemia: An Underrecognized Diagnosis? Oncologist 2017; 22:989-994. [PMID: 28469041 PMCID: PMC5553951 DOI: 10.1634/theoncologist.2017-0019] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Accepted: 02/16/2017] [Indexed: 11/27/2022] Open
Abstract
Hepatosplenic candidiasis (HSC) often occurs without prior documented candidemia. Underrecognized HSC can be mistaken for metastases and can have serious consequences for patients, especially when additional, inappropriate treatment, such as surgery and chemo‐ or immunotherapy, is initiated. To emphasize the importance of diagnosing HSC without prior documented candidemia, three illustrative cases and a review of the literature on HSC and candidemia are presented. Introduction. Patients with a history of chemotherapy or stem cell transplantation (SCT) and prolonged neutropenia are at risk for hepatic and/or splenic seeding of Candida. In our experience, hepatosplenic candidiasis (HSC) without documented candidemia often remains unrecognized. Case presentations. We describe three cases of HSC without documented candidemia and the challenges in establishing the diagnosis and adequately treating this condition. The first patient had a history of SCT for treatment of breast cancer and was scheduled for hemihepatectomy for suspected liver metastasis. A second opinion at our institute resulted in the diagnosis of hepatic candidiasis without prior documented candidemia, for which she was treated successfully with fluconazole. The second case demonstrates the limitations of (blood and tissue) cultures and the value of molecular methods to confirm the diagnosis. Case 3 illustrates treatment challenges, with ongoing dissemination and insufficient source control despite months of antifungal therapy, eventually resulting in a splenectomy. Literature review. A structured literature search was performed for articles describing any patient with HSC and documented blood culture results. Thirty articles were available for extraction of data on candidemia and HSC. Seventy percent (131/187) of patients with HSC did not have documented candidemia. The majority of HSC events were described in hematologic patients, although some cases were described in patients with solid tumors treated with SCT (n = 1) or chemotherapy and a history of leukopenia (n = 2). Current guidelines and practices for diagnosis and treatment are described. Conclusion. Clinicians should be aware that HSC most often occurs without documented candidemia. In case of persistent or unexplained fever or lesions in the liver and/or spleen, a history of neutropenia should place disseminated candidiasis in the differential diagnosis. HSC is not limited to hematological patients and may occur in patients with solid tumors treated with bone marrow‐suppressing chemotherapy or SCT. In the latter group, HSC as alternative diagnosis for hepatic metastasis should be considered when lesions are not typical for metastasis. This might prevent unnecessary surgery or inappropriate treatment. Implications for Practice. Timely diagnosis of hepatosplenic candidiasis (HSC) is challenging, but can prevent further complications and dissemination, and may even prevent unnecessary invasive procedures. Clinicians should realize that HSC often occurs without documented candidemia and that sensitivity of blood cultures for candidemia is limited. HSC is not strictly limited to hematologic patients and might also occur in patients with solid tumors treated with intensive chemotherapy or stem cell transplantation. Increased awareness for HSC in patients with any history of neutropenia is of importance to increase detection and prevent serious sequelae.
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Affiliation(s)
- Joffrey van Prehn
- Department of Medical Microbiology and Infection Control, VU University Medical Center, Amsterdam, The Netherlands
| | | | - Madelon L de Rooij
- Department of Internal Medicine, VU University Medical Center, Amsterdam, The Netherlands
| | - Ellen Meijer
- Department of Hematology, VU University Medical Center, Amsterdam, The Netherlands
| | - Marije K Bomers
- Department of Internal Medicine, VU University Medical Center, Amsterdam, The Netherlands
| | - Karin van Dijk
- Department of Medical Microbiology and Infection Control, VU University Medical Center, Amsterdam, The Netherlands
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Charpiat B, Tod M, Darnis B, Boulay G, Gagnieu MC, Mabrut JY. Respiratory depression related to multiple drug-drug interactions precipitated by a fluconazole loading dose in a patient treated with oxycodone. Eur J Clin Pharmacol 2017; 73:787-788. [PMID: 28280888 DOI: 10.1007/s00228-017-2215-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2016] [Accepted: 02/03/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Bruno Charpiat
- Pharmacie, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, 103, Grande Rue de la Croix-Rousse, 69317, Lyon Cedex 04, France.
- Pharmacie, Hôpital de la Croix-Rousse, 103 Grande rue de la Croix-Rousse, Groupement Hospitalier Nord, 69004, Lyon, France.
| | - Michel Tod
- Pharmacie, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, 103, Grande Rue de la Croix-Rousse, 69317, Lyon Cedex 04, France
| | - Benjamin Darnis
- Service de Chirurgie Générale, Digestive et de Transplantation Hépatique, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, 103, Grande Rue de la Croix-Rousse, 69317, Lyon Cedex 04, France
| | - Guillaume Boulay
- Service d'Anesthésie et de Réanimation, Hôpital de la Croix-Rousse, Groupement Hospitalier Nord, Hospices Civils de Lyon, 103, grande rue de la Croix-Rousse, 69317, Lyon Cedex 04, France
| | - Marie-Claude Gagnieu
- Unité de Pharmacologie, Hôpital Edouard Herriot, Hospices Civils de Lyon, 5 Place d'Arsonval, 69003, Lyon, France
| | - Jean-Yves Mabrut
- Service de Chirurgie Générale, Digestive et de Transplantation Hépatique, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, 103, Grande Rue de la Croix-Rousse, 69317, Lyon Cedex 04, France
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Charokopos A, Muhammad T, Surbhi S, Brateanu A. Weakness and pain in arms and legs · dark urine · history of vertebral osteomyelitis · Dx? J Fam Pract 2017; 66:170-173. [PMID: 28249055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Rhabdomyolysis is a serious complication of statin treatment. Both higher statin doses and pharmacokinetic factors can raise statin levels, leading to this serious usclerelated syndrome. Co-administration of statins with drugs that are strong inhibitors of cytochrome P450 (CYP) 3A4 (the main cytochrome P450 isoform that metabolizes most statins) can increase statin levels several fold. The trigger for our patient's statin-induced rhabdomyolysis was fluconazole, a known moderate inhibitor of CYP3A4, which is comparatively weaker than certain potent azoles like itraconazole or ketoconazole.
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Affiliation(s)
| | - Tariq Muhammad
- Department of Internal Medicine, Cleveland Clinic, Ohio, USA
| | - Sidana Surbhi
- Department of Internal Medicine, Cleveland Clinic, Ohio, USA
| | - Andrei Brateanu
- Department of Internal Medicine, Cleveland Clinic, Ohio, USA
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Gautam P, Light B, Purvis T. Stability of Two Antifungal Agents, Fluconazole and Miconazole, Compounded in HUMCO RECURA Topical Cream to Determine Beyond-Use Date. Int J Pharm Compd 2017; 21:154-159. [PMID: 28346211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
A novel compounding vehicle (RECURA) has previously been proven to penetrate the nail bed when compounded with the antifungal agent miconazole or fluconazole, providing for an effective treatment for onychomycosis. In this study, miconazole and fluconazole were compounded separately in RECURA compounding cream, and they were tested at different time points (0, 7, 14, 28, 45, 60, 90, and 180 days) to determine the beyond-use date of those formulations. The beyond-use date testing of both formulations (10% miconazole in RECURA and 10% fluconazole in RECURA) proved them to be physically, chemically, and microbiologically stable under International Conference of Harmonisation controlled room temperature (25°C ± 2°C/60% RH ±5%) for at least 180 days from the date of compounding. Stability-indicating analytical method validation was completed for the simultaneous determination of miconazole and fluconazole in RECURA base using high-performance liquid chromatography coupled with photodiode array detector prior to the study.
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Affiliation(s)
- Pradeep Gautam
- HUMCO Research and Development Laboratory, Austin, Texas.
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Patel PN, Sah P, Chandrashekar C, Vidyasagar S, Venkata Rao J, Tiwari M, Radhakrishnan R. Oral candidal speciation, virulence and antifungal susceptibility in type 2 diabetes mellitus. Diabetes Res Clin Pract 2017; 125:10-19. [PMID: 28131069 DOI: 10.1016/j.diabres.2017.01.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Revised: 12/17/2016] [Accepted: 01/06/2017] [Indexed: 11/21/2022]
Abstract
OBJECTIVES To determine the oral candidal carriage (OCC), activity of virulent factors and fluconazole susceptibility in subjects with type 2 diabetes mellitus (T2DM) and investigate their association with HbA1c measurements. MATERIALS AND METHODS A cross sectional study was conducted on 100 diabetics and 100 healthy volunteers. The virulence was assessed by measuring the phospholipase activity and proteolysis index. Fluconazole susceptibility was performed using the gradient diffusion method. The OCC, virulence factors and antifungal susceptibility were correlated with patients' HbA1c measurements. RESULTS The OCC and candidal density carriage was significantly higher in diabetics. Candida albicans (C. albicans) was the most frequently isolated species followed by Candida tropicalis (C. tropicalis). Relatively uncommon species, Candida lusitaniae (C. lusitaniae) and Candida lipolytica (C. lipolytica) were isolated from the diabetics. Prevalence of virulence factor, proteinase, was greater in diabetic group (p<0.05). Reduced fluconazole susceptibility was noted among the isolates from diabetics; however it was not statistically significant (p=0.593). Except one, all the susceptible-dose dependent and resistant isolates were Candida no-albicans (C. non-albicans). CONCLUSION C. albicans remains the predominant pathogen in diabetics, although other species are on the rise. Compared to control group, the isolated species from T2DM group had higher proteinase activity. Resistance to fluconazole was considerably greater among the C. non-albicans isolates from T2DM group. These findings warrant effective treatment modalities to reduce the occurrence of oropharyngeal candidiasis.
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Affiliation(s)
- Pratik N Patel
- Department of Oral Pathology and Microbiology, MCODS, Manipal, Manipal University, Karnataka, India
| | - Parul Sah
- Department of Oral Pathology and Microbiology, MCODS, Manipal, Manipal University, Karnataka, India
| | - Chetana Chandrashekar
- Department of Oral Pathology and Microbiology, MCODS, Manipal, Manipal University, Karnataka, India
| | - Sudha Vidyasagar
- Department of Medicine, KMC, Manipal, Manipal University, Karnataka, India
| | - J Venkata Rao
- Department of Pharmaceutical Biotechnology and Microbiology, MCOPS, Manipal, Manipal University, Karnataka, India
| | - Mradul Tiwari
- Department of Pharmaceutical Biotechnology and Microbiology, MCOPS, Manipal, Manipal University, Karnataka, India
| | - Raghu Radhakrishnan
- Department of Oral Pathology and Microbiology, MCODS, Manipal, Manipal University, Karnataka, India.
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Smith FL, Mercurio MG, Poligone B. Primary cutaneous cryptococcosis presenting as an extensive eroded plaque. Cutis 2017; 99:E16-E18. [PMID: 28398425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- Franki Lambert Smith
- Department of Dermatology, Rochester General Hospital Research Institute, New York, USA
| | - Mary Gail Mercurio
- Department of Dermatology, Rochester General Hospital Research Institute, New York, USA
| | - Brian Poligone
- Department of Dermatology, Rochester General Hospital Research Institute, New York, USA
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50
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Kriem S, Peretz A, Blum A. Lingua Villosa Nigra. Isr Med Assoc J 2017; 19:131. [PMID: 28457069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
MESH Headings
- Administration, Topical
- Aged, 80 and over
- Antifungal Agents/administration & dosage
- Candida albicans/isolation & purification
- Candidiasis, Oral/complications
- Candidiasis, Oral/diagnosis
- Candidiasis, Oral/drug therapy
- Candidiasis, Oral/physiopathology
- Female
- Fluconazole/administration & dosage
- Humans
- Tongue, Hairy/diagnosis
- Tongue, Hairy/drug therapy
- Tongue, Hairy/etiology
- Tongue, Hairy/physiopathology
- Treatment Outcome
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Affiliation(s)
- Suleiman Kriem
- Department of Medicine, Padeh Poria Medical Center, Tiberias, affiliated with Faculty of Medicine in the Galilee, Bar Ilan University, Safed, Israel
| | - Avi Peretz
- Department of Medicine, Padeh Poria Medical Center, Tiberias, affiliated with Faculty of Medicine in the Galilee, Bar Ilan University, Safed, Israel
| | - Arnon Blum
- Department of Medicine, Padeh Poria Medical Center, Tiberias, affiliated with Faculty of Medicine in the Galilee, Bar Ilan University, Safed, Israel
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