1
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Chaves LF, Meyers AC, Hodo CL, Sanders JP, Curtis-Robles R, Hamer GL, Hamer SA. Trypanosoma cruzi infection in dogs along the US-Mexico border: R 0 changes with vector species composition. Epidemics 2023; 45:100723. [PMID: 37935075 DOI: 10.1016/j.epidem.2023.100723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Revised: 07/05/2023] [Accepted: 10/26/2023] [Indexed: 11/09/2023] Open
Abstract
Infection with Trypanosoma cruzi, etiological agent of Chagas disease, is common in US government working dogs along the US-Mexico border. This 3145 km long border comprises four states: Texas (TX), New Mexico (NM), Arizona (AZ) and California (CA) with diverse ecosystems and several triatomine (a.k.a., kissing bug) species, primary vectors of T. cruzi in this region. The kissing bug (Heteroptera: Reduviidae) community ranging from CA to TX includes Triatoma protracta (Uhler), Triatoma recurva (Stål) and Triatoma rubida (Uhler) and becomes dominated by Triatoma gerstaeckeri Stål in TX. Here, we ask if T. cruzi infection dynamics in dogs varies along this border region, potentially reflecting changes in vector species and their vectorial capacity. Using reversible catalytic models of infection, where seropositivity can be lost, we estimated an R0 (Estimate ± S.E.) of 1.192 ± 0.084 for TX and NM. In contrast, seropositivity decayed to zero as dogs aged in AZ and CA. These results suggest that dogs are likely infected by T. cruzi during their training in western TX, with a force of infection large enough for keeping R0 above 1, i.e., the disease endemically established, in TX and NM. In AZ and CA, a lower force of infection, probably associated with different vector species communities and associated vectorial capacity and/or different lineages of T. cruzi, results in dogs decreasing their seropositivity with age.
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Affiliation(s)
- Luis Fernando Chaves
- Department of Environmental and Occupational Health, School of Public Health, Indiana University, Bloomington IN 47405, USA.
| | - Alyssa C Meyers
- Department of Veterinary Integrative Bioscienes, School of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, TX 77843, USA; Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI 48109, USA
| | - Carolyn L Hodo
- Department of Veterinary Integrative Bioscienes, School of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, TX 77843, USA; Department of Comparative Medicine, Keeling Center for Comparative Medicine and Research, The University of Texas MD Anderson Cancer Center, Bastrop, TX 78602, USA
| | - John P Sanders
- Office of Health Security, US Department of Homeland Security, Washington, DC 20528, USA
| | - Rachel Curtis-Robles
- Department of Veterinary Integrative Bioscienes, School of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, TX 77843, USA
| | - Gabriel L Hamer
- Department of Entomology, Texas A&M University, College Station, TX 77843, USA
| | - Sarah A Hamer
- Department of Veterinary Integrative Bioscienes, School of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, TX 77843, USA
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2
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Bustamante JM, White BE, Wilkerson GK, Hodo CL, Auckland LD, Wang W, McCain S, Hamer SA, Saunders AB, Tarleton RL. Frequency Variation and Dose Modification of Benznidazole Administration for the Treatment of Trypanosoma cruzi Infection in Mice, Dogs, and Nonhuman Primates. Antimicrob Agents Chemother 2023; 67:e0013223. [PMID: 37039666 PMCID: PMC10190575 DOI: 10.1128/aac.00132-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 03/22/2023] [Indexed: 04/12/2023] Open
Abstract
Trypanosoma cruzi naturally infects a broad range of mammalian species and frequently results in the pathology that has been most extensively characterized in human Chagas disease. Currently employed treatment regimens fail to achieve parasitological cure of T. cruzi infection in the majority of cases. In this study, we have extended our previous investigations of more effective, higher dose, intermittent administration protocols using the FDA-approved drug benznidazole (BNZ), in experimentally infected mice and in naturally infected dogs and nonhuman primates (NHP). Collectively, these studies demonstrate that twice-weekly administration of BNZ for more than 4 months at doses that are ~2.5-fold that of previously used daily dosing protocols, provided the best chance to obtain parasitological cure. Dosing less frequently or for shorter time periods was less dependable in all species. Prior treatment using an ineffective dosing regimen in NHPs did not prevent the attainment of parasitological cure with an intensified BNZ dosing protocol. Furthermore, parasites isolated after a failed BNZ treatment showed nearly identical susceptibility to BNZ as those obtained prior to treatment, confirming the low risk of induction of drug resistance with BNZ and the ability to adjust the treatment protocol when an initial regimen fails. These results provide guidance for the use of BNZ as an effective treatment for T. cruzi infection and encourage its wider use, minimally in high value dogs and at-risk NHP, but also potentially in humans, until better options are available.
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Affiliation(s)
- Juan M. Bustamante
- Center for Tropical and Emerging Global Diseases, University of Georgia, Athens, Georgia, USA
| | - Brooke E. White
- Center for Tropical and Emerging Global Diseases, University of Georgia, Athens, Georgia, USA
| | - Gregory K. Wilkerson
- MD Anderson Cancer Center, Michale E. Keeling Center for Comparative Medicine and Research, Bastrop, Texas, USA
| | - Carolyn L. Hodo
- Department of Veterinary Integrative Biosciences, School of Veterinary Medicine and Biomedical Research, Texas A&M University, College Station, Texas, USA
| | - Lisa D. Auckland
- Department of Veterinary Integrative Biosciences, School of Veterinary Medicine and Biomedical Research, Texas A&M University, College Station, Texas, USA
| | - Wei Wang
- Center for Tropical and Emerging Global Diseases, University of Georgia, Athens, Georgia, USA
| | | | - Sarah A. Hamer
- Department of Veterinary Integrative Biosciences, School of Veterinary Medicine and Biomedical Research, Texas A&M University, College Station, Texas, USA
| | - Ashley B. Saunders
- Department of Small Animal Clinical Sciences, School of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, Texas, USA
| | - Rick L. Tarleton
- Center for Tropical and Emerging Global Diseases, University of Georgia, Athens, Georgia, USA
- Department of Cellular Biology, University of Georgia, Athens, Georgia, USA
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3
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Tarleton RL. Effective drug discovery in Chagas disease. Trends Parasitol 2023; 39:423-431. [PMID: 37024318 DOI: 10.1016/j.pt.2023.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 03/17/2023] [Accepted: 03/17/2023] [Indexed: 04/07/2023]
Abstract
The Chagas field has gone >50 years without tangible progress toward new therapies. My colleagues and I have recently reported on a benzoxaborole compound that achieves consistent parasitological cure in experimentally infected mice and in naturally infected non-human primates (NHPs). While these results do not assure success in human clinical trials, they significantly de-risk this process and form a strong justification for such trials. Highly effective drug discovery depends on a solid understanding of host and parasite biology and excellent knowledge in designing and validating chemical entities. This opinion piece seeks to provide perspectives on the process that led to the discovery of AN15368, with the hope that this will facilitate the discovery of additional clinical candidates for Chagas disease.
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Affiliation(s)
- Rick L Tarleton
- Center for Tropical and Emerging Global Diseases, University of Georgia, Athens, GA 30602, USA.
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4
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Bustamante JM, White BE, Wilkerson GK, Hodo CL, Auckland LD, Wang W, McCain S, Hamer SA, Saunders AB, Tarleton RL. Frequency variation and dose modification of benznidazole administration for the treatment of Trypanosoma cruzi infection in mice, dogs and non-human primates. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.02.01.526739. [PMID: 36778432 PMCID: PMC9915573 DOI: 10.1101/2023.02.01.526739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 04/21/2023]
Abstract
Trypanosoma cruzi naturally infects a broad range of mammalian species and frequently results in the pathology that has been most extensively characterized in human Chagas disease. Currently employed treatment regimens fail to achieve parasitological cure of T. cruzi infection in the majority of cases. In this study, we have extended our previous investigations of more effective, higher dose, intermittent administration protocols using the FDA-approved drug benznidazole (BNZ), in experimentally infected mice and in naturally infected dogs and non-human primates (NHP). Collectively these studies demonstrate that twice-weekly administration of BNZ for more than 4 months at doses that are ∼2.5-fold that of previously used daily dosing protocols, provided the best chance to obtain parasitological cure. Dosing less frequently or for shorter time periods was less dependable in all species. Prior treatment using an ineffective dosing regimen in NHPs did not prevent the attainment of parasitological cure with an intensified BNZ dosing protocol. Furthermore, parasites isolated after a failed BNZ treatment showed nearly identical susceptibility to BNZ as those obtained prior to treatment, confirming the low risk of induction of drug resistance with BNZ and the ability to adjust the treatment protocol when an initial regimen fails. These results provide guidance for the use of BNZ as an effective treatment for T. cruzi infection and encourage its wider use, minimally in high value dogs and at-risk NHP, but also potentially in humans, until better options are available.
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Affiliation(s)
- Juan M Bustamante
- Center for Tropical and Emerging Global Diseases, University of Georgia, Athens, Georgia, USA
| | - Brooke E White
- Center for Tropical and Emerging Global Diseases, University of Georgia, Athens, Georgia, USA
| | - Gregory K Wilkerson
- MD Anderson Cancer Center, Michale E. Keeling Center for Comparative Medicine and Research, Bastrop, Texas, USA
| | - Carolyn L Hodo
- Department of Veterinary Integrative Biosciences, School of Veterinary Medicine and Biomedical Research, Texas A&M University, College Station, Texas, USA
| | - Lisa D Auckland
- Department of Veterinary Integrative Biosciences, School of Veterinary Medicine and Biomedical Research, Texas A&M University, College Station, Texas, USA
| | - Wei Wang
- Center for Tropical and Emerging Global Diseases, University of Georgia, Athens, Georgia, USA
| | | | - Sarah A Hamer
- Department of Veterinary Integrative Biosciences, School of Veterinary Medicine and Biomedical Research, Texas A&M University, College Station, Texas, USA
| | - Ashley B Saunders
- Department of Small Animal Clinical Sciences, School of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, Texas, USA
| | - Rick L Tarleton
- Center for Tropical and Emerging Global Diseases, University of Georgia, Athens, Georgia, USA
- Department of Cellular Biology, University of Georgia, Athens, Georgia, USA
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Mixed T Helper1/T Helper2/T Cytotoxic Profile in Subjects with Chronic Chagas Disease with Hypersensitivity Reactions to Benznidazole. Microbiol Spectr 2022; 10:e0135722. [PMID: 35938810 PMCID: PMC9430713 DOI: 10.1128/spectrum.01357-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Dermatitis is the most common adverse event during treatment with benznidazole in chronic Chagas disease and is probably mediated by T cells. A set of molecules representative of the different type IV hypersensitivity reactions was evaluated in the circulation and skin biopsies of Trypanosoma cruzi-infected subjects presenting dermatitis during benznidazole administration. Through cytometric bead assays and enzyme-linked immunosorbent assay capture techniques, the serum levels of cytokines, chemokines, proapoptotic molecules, and mediators of the activation and migration of eosinophils and T cells were measured in subjects infected with Trypanosoma cruzi who exhibited skin adverse events (n = 22) and compared with those without adverse events (n = 37) during benznidazole therapy. Serum levels of interleukin- 5 (IL-5), soluble Fas cell surface death receptor ligand (FAS-L), and interferon γ-induced protein (IP-10) significantly increased at 7 to 30 days posttreatment with benznidazole and decreased thereafter in subjects with dermatitis but not in those without dermatitis. Circulating eotaxin levels were lower in subjects with dermatitis than in those without. Two patterns emerged in the skin biopsies: a T helper 1/T cytotoxic profile and a T helper 2/T cytotoxic profile with the presence of CD4+ and CD8+ T cells. Increased low-density lipoprotein (LDL), glutamic-oxaloacetic transaminase (GOT), uremia, and T cell activation emerged as risk factors for the development of dermatitis during benznidazole administration. These results support a delayed-type hypersensitivity reaction to benznidazole, involving CD4+ and CD8+ T cells and eosinophils, and a mixed cytokine profile. This study provides new insights for better management of adverse drug reactions to benznidazole. IMPORTANCE This study identified the risk factors for the development of adverse reactions to benznidazole and identified a set molecule to monitor the appearance of these reactions. This knowledge might improve the safety of benznidazole administration.
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6
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Pérez-Molina JA, Crespillo-Andújar C, Bosch-Nicolau P, Molina I. Trypanocidal treatment of Chagas disease. ACTA ACUST UNITED AC 2021; 39:458-470. [PMID: 34736749 DOI: 10.1016/j.eimce.2020.04.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 04/18/2020] [Indexed: 11/24/2022]
Abstract
Chagas disease is a neglected parasitosis caused by the protozoan parasite Trypanosoma cruzi. This infection is present in most Latin American countries, although, due to migratory movements, it is a growing cause for concern in non-endemic countries. The only two drugs currently available for its treatment-benznidazole and nifurtimox-were marketed 50 years ago. While they are very effective for acute and recent infection, and for the prevention of maternofoetal transmission, their efficacy declines in people who have chronic infection, especially those older than 18 years of age. In the presence of visceral involvement, parasiticidal treatment is of little or no value. The safety profile of both drugs is far from ideal, with frequent adverse events and high rates of drug discontinuation, mainly in adults. So far, new drugs and new strategies have not been shown to improve the results of the current nitroimidazoles, although the results are promising. In this review, we focus on the aspects that allow clinicians to make the best use of currently available drugs. In addition, we discuss new therapeutic options and ongoing research in the field.
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Affiliation(s)
- Jose A Pérez-Molina
- National Referral Centre for Tropical Diseases, Infectious Diseases Department, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Madrid, Spain.
| | - Clara Crespillo-Andújar
- National Referral Centre for Tropical Diseases, Infectious Diseases Department, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Madrid, Spain
| | - Pau Bosch-Nicolau
- Tropical Medicine Unit, Department of Infectious Diseases, Vall d'Hebron University Hospital, PROSICS Barcelona, Barcelona, Spain
| | - Israel Molina
- Tropical Medicine Unit, Department of Infectious Diseases, Vall d'Hebron University Hospital, PROSICS Barcelona, Barcelona, Spain; Instituto René Rachou-FIOCRUZ Minas, Chagas Disease Research Group, Belo Horizonte, MG, Brazil
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7
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Perin L, Pinto L, Balthazar Nardotto GH, da Silva Fonseca K, Oliveira Paiva B, Fernanda Rodrigues Bastos Mendes T, Molina I, Correa-Oliveira R, Melo de Abreu Vieira P, Martins Carneiro C. Population pharmacokinetics and biodistribution of benznidazole in mice. J Antimicrob Chemother 2021; 75:2213-2221. [PMID: 32356873 DOI: 10.1093/jac/dkaa130] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 03/03/2020] [Accepted: 03/12/2020] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVES To evaluate the population pharmacokinetics of different benznidazole treatment regimens and the drug's biodistribution in mice. METHODS Two hundred mice were divided into five groups according to benznidazole dosing regimens: (1) 100 mg/kg/day for 20 days; (2) 100 mg/kg/day for 40 days; (3) 200 mg/kg/day for 20 days; (4) 40 mg/kg/day for 20 days; or (5) 40 mg/kg/day for 40 days. The mice were euthanized and blood, heart, liver, colon and brain were collected. Samples were prepared by liquid-liquid extraction and analysed by HPLC-diode-array detection. The pharmacokinetic analysis of benznidazole was evaluated via non-linear mixed-effects modelling using the NONMEN program. RESULTS Our results demonstrate that mouse weight allometrically influences benznidazole clearance; the AUC curve and the highest plasma concentration are dose proportional; benznidazole does not influence its own metabolism; its tissue distribution is limited; and the standard treatment regimen for Chagas' disease in mice (100 mg/kg/day for 20 days) is inadequate from a pharmacokinetic standpoint, as are the other regimens tested in this study (100 mg/kg/day for 40 days, 200 mg/kg/day for 20 days and 40 mg/kg/day for 20 or 40 days). CONCLUSIONS Benznidazole reformulations that allow better tissue penetration and plasma and tissue exposure should be evaluated to enable higher cure rates in both animals and patients. The population pharmacokinetic model developed here can allow optimization of the dosing regimen of benznidazole to treat experimental Chagas' disease. Determining appropriate treatment regimens in animals allows translation of these to clinical studies.
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Affiliation(s)
- Luísa Perin
- Laboratory of Immunopathology, Nucleus of Biological Sciences Research, Federal University of Ouro Preto, Ouro Preto, Minas Gerais, Brazil
| | - Leonardo Pinto
- Laboratory of Immunopathology, Nucleus of Biological Sciences Research, Federal University of Ouro Preto, Ouro Preto, Minas Gerais, Brazil
| | - Glauco Henrique Balthazar Nardotto
- Laboratory of Clinical Pharmacokinetics, Department of Clinical, Toxicological and Bromatological Analyses, Faculty of Pharmaceutical Sciences of Ribeirão Preto, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Kátia da Silva Fonseca
- Laboratory of Immunopathology, Nucleus of Biological Sciences Research, Federal University of Ouro Preto, Ouro Preto, Minas Gerais, Brazil
| | - Beatriz Oliveira Paiva
- Laboratory of Immunopathology, Nucleus of Biological Sciences Research, Federal University of Ouro Preto, Ouro Preto, Minas Gerais, Brazil
| | | | - Israel Molina
- Laboratory of Immunopathology, Nucleus of Biological Sciences Research, Federal University of Ouro Preto, Ouro Preto, Minas Gerais, Brazil.,Tropical Medicine and International Health Unit, Department of Infectious Diseases, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain, PROSICS Barcelona
| | - Rodrigo Correa-Oliveira
- Laboratory of Immunopathology, Nucleus of Biological Sciences Research, Federal University of Ouro Preto, Ouro Preto, Minas Gerais, Brazil.,Laboratory of Cellular and Molecular Immunology, René Rachou Research Center, Oswaldo Cruz Foundation, Belo Horizonte, Minas Gerais, Brazil
| | - Paula Melo de Abreu Vieira
- Laboratory of Immunopathology, Nucleus of Biological Sciences Research, Federal University of Ouro Preto, Ouro Preto, Minas Gerais, Brazil.,Laboratory of Morphopathology, Department of Biological Sciences, Nucleus of Biological Sciences Research, Institute of Exact and Biological Sciences, Federal University of Ouro Preto, Ouro Preto, Minas Gerais, Brazil
| | - Cláudia Martins Carneiro
- Laboratory of Immunopathology, Nucleus of Biological Sciences Research, Federal University of Ouro Preto, Ouro Preto, Minas Gerais, Brazil.,Department of Clinical Analysis, School of Pharmacy, Federal University of Ouro Preto, Ouro Preto, Minas Gerais, Brazil
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8
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Fonseca KDS, Perin L, de Paiva NCN, da Silva BC, Duarte THC, Marques FDS, Costa GDP, Molina I, Correa-Oliveira R, Vieira PMDA, Carneiro CM. Benznidazole Treatment: Time- and Dose-Dependence Varies with the Trypanosoma cruzi Strain. Pathogens 2021; 10:729. [PMID: 34207764 PMCID: PMC8229751 DOI: 10.3390/pathogens10060729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Revised: 05/13/2021] [Accepted: 05/13/2021] [Indexed: 12/02/2022] Open
Abstract
As the development of new drugs for Chagas disease is not a priority due to its neglected disease status, an option for increasing treatment adherence is to explore alternative treatment regimens, which may decrease the incidence of side effects. Therefore, we evaluated the efficacy of different therapeutic schemes with benznidazole (BNZ) on the acute and chronic phases of the disease, using mice infected with strains that have different BNZ susceptibilities. Our results show that the groups of animals infected by VL-10 strain, when treated in the chronic phase with a lower dose of BNZ for a longer period of time (40 mg/kg/day for 40 days) presented better treatment efficacy than with the standard protocol (100 mg/kg/day for 20 days) although the best result in the treatment of the animals infected by the VL-10 strain was with100 mg/kg/day for 40 days. In the acute infection by the Y and VL-10 strains of T. cruzi, the treatment with a standard dose, but with a longer time of treatment (100 mg/kg/day for 40 days) presented the best results. Given these data, our results indicate that for BNZ, the theory of dose and time proportionality does not apply to the phases of infection.
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Affiliation(s)
- Kátia da Silva Fonseca
- Laboratory of Immunopathology, Nucleus of Biological Sciences Research, Federal University of Ouro Preto, Ouro Preto 35400-000, Brazil; (K.d.S.F.); (L.P.); (N.C.N.d.P.); (B.C.d.S.); (G.d.P.C.); (I.M.); (R.C.-O.); (P.M.d.A.V.)
| | - Luísa Perin
- Laboratory of Immunopathology, Nucleus of Biological Sciences Research, Federal University of Ouro Preto, Ouro Preto 35400-000, Brazil; (K.d.S.F.); (L.P.); (N.C.N.d.P.); (B.C.d.S.); (G.d.P.C.); (I.M.); (R.C.-O.); (P.M.d.A.V.)
| | - Nívia Carolina Nogueira de Paiva
- Laboratory of Immunopathology, Nucleus of Biological Sciences Research, Federal University of Ouro Preto, Ouro Preto 35400-000, Brazil; (K.d.S.F.); (L.P.); (N.C.N.d.P.); (B.C.d.S.); (G.d.P.C.); (I.M.); (R.C.-O.); (P.M.d.A.V.)
| | - Beatriz Cristiane da Silva
- Laboratory of Immunopathology, Nucleus of Biological Sciences Research, Federal University of Ouro Preto, Ouro Preto 35400-000, Brazil; (K.d.S.F.); (L.P.); (N.C.N.d.P.); (B.C.d.S.); (G.d.P.C.); (I.M.); (R.C.-O.); (P.M.d.A.V.)
| | - Thays Helena Chaves Duarte
- Laboratory of Morphopathology, Department of Biological Sciences, Nucleus of Biological Sciences Research, Institute of Exact and Biological Sciences, Federal University of Ouro Preto, Ouro Preto 35400-000, Brazil; (T.H.C.D.); (F.d.S.M.)
| | - Flávia de Souza Marques
- Laboratory of Morphopathology, Department of Biological Sciences, Nucleus of Biological Sciences Research, Institute of Exact and Biological Sciences, Federal University of Ouro Preto, Ouro Preto 35400-000, Brazil; (T.H.C.D.); (F.d.S.M.)
| | - Guilherme de Paula Costa
- Laboratory of Immunopathology, Nucleus of Biological Sciences Research, Federal University of Ouro Preto, Ouro Preto 35400-000, Brazil; (K.d.S.F.); (L.P.); (N.C.N.d.P.); (B.C.d.S.); (G.d.P.C.); (I.M.); (R.C.-O.); (P.M.d.A.V.)
| | - Israel Molina
- Laboratory of Immunopathology, Nucleus of Biological Sciences Research, Federal University of Ouro Preto, Ouro Preto 35400-000, Brazil; (K.d.S.F.); (L.P.); (N.C.N.d.P.); (B.C.d.S.); (G.d.P.C.); (I.M.); (R.C.-O.); (P.M.d.A.V.)
- Tropical Medicine and International Health Unit, Department of Infectious Diseases, Vall d’Hebron University Hospital, Universitat Autònoma de Barcelona, PROSICS Barcelona, 08035 Barcelona, Spain
| | - Rodrigo Correa-Oliveira
- Laboratory of Immunopathology, Nucleus of Biological Sciences Research, Federal University of Ouro Preto, Ouro Preto 35400-000, Brazil; (K.d.S.F.); (L.P.); (N.C.N.d.P.); (B.C.d.S.); (G.d.P.C.); (I.M.); (R.C.-O.); (P.M.d.A.V.)
- Laboratory of Cellular and Molecular Immunology, René Rachou Research Center, Oswaldo Cruz Foundation, Belo Horizonte 30190-002, Brazil
| | - Paula Melo de Abreu Vieira
- Laboratory of Immunopathology, Nucleus of Biological Sciences Research, Federal University of Ouro Preto, Ouro Preto 35400-000, Brazil; (K.d.S.F.); (L.P.); (N.C.N.d.P.); (B.C.d.S.); (G.d.P.C.); (I.M.); (R.C.-O.); (P.M.d.A.V.)
- Laboratory of Morphopathology, Department of Biological Sciences, Nucleus of Biological Sciences Research, Institute of Exact and Biological Sciences, Federal University of Ouro Preto, Ouro Preto 35400-000, Brazil; (T.H.C.D.); (F.d.S.M.)
| | - Cláudia Martins Carneiro
- Laboratory of Immunopathology, Nucleus of Biological Sciences Research, Federal University of Ouro Preto, Ouro Preto 35400-000, Brazil; (K.d.S.F.); (L.P.); (N.C.N.d.P.); (B.C.d.S.); (G.d.P.C.); (I.M.); (R.C.-O.); (P.M.d.A.V.)
- Department of Clinical Analysis, School of Pharmacy, Federal University of Ouro Preto, Ouro Preto 35400-000, Brazil
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9
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Castro Eiro MD, Natale MA, Alvarez MG, Shen H, Viotti R, Lococo B, Bua J, Nuñez M, Bertocchi GL, Albareda MC, Cesar G, Tarleton RL, Laucella SA. Reduced Trypanosoma cruzi-specific humoral response and enhanced T cell immunity after treatment interruption with benznidazole in chronic Chagas disease. J Antimicrob Chemother 2021; 76:1580-1592. [PMID: 33693664 PMCID: PMC8600036 DOI: 10.1093/jac/dkab054] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 02/08/2021] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Interruption of benznidazole therapy due to the appearance of adverse effects, which is presumed to lead to treatment failure, is a major drawback in the treatment of chronic Chagas disease. METHODS Trypanosoma cruzi-specific humoral and T cell responses, T cell phenotype and parasite load were measured to compare the outcome in 33 subjects with chronic Chagas disease treated with an incomplete benznidazole regimen and 58 subjects treated with the complete regimen, during a median follow-up period of 48 months. RESULTS Both treatment regimens induced a reduction in the T. cruzi-specific antibody levels and similar rates of treatment failure when evaluated using quantitative PCR. Regardless of the regimen, polyfunctional CD4+ T cells increased in the subjects, with successful treatment outcome defined as a decrease of T. cruzi-specific antibodies. Regardless of the serological outcome, naive and central memory T cells increased after both regimens. A decrease in CD4+ HLA-DR+ T cells was associated with successful treatment in both regimens. The cytokine profiles of subjects with successful treatment showed fewer inflammatory mediators than those of the untreated T. cruzi-infected subjects. High levels of T cells expressing IL-7 receptor and low levels of CD8+ T cells expressing the programmed cell death protein 1 at baseline were associated with successful treatment following benznidazole interruption. CONCLUSIONS These findings challenge the notion that treatment failure is the sole potential outcome of an incomplete benznidazole regimen and support the need for further assessment of the treatment protocols for chronic Chagas disease.
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Affiliation(s)
- Melisa D Castro Eiro
- Instituto Nacional de Parasitología “Dr. Mario Fatala Chaben”, Buenos Aires, Argentina
| | - María A Natale
- Instituto Nacional de Parasitología “Dr. Mario Fatala Chaben”, Buenos Aires, Argentina
| | - María G Alvarez
- Hospital Interzonal General de Agudos Eva Perón, Buenos Aires, Argentina
| | - Huifeng Shen
- Center for Tropical and Emerging Global Diseases, University of Georgia, Athens, GA, USA
| | - Rodolfo Viotti
- Hospital Interzonal General de Agudos Eva Perón, Buenos Aires, Argentina
| | - Bruno Lococo
- Hospital Interzonal General de Agudos Eva Perón, Buenos Aires, Argentina
| | - Jacqueline Bua
- Instituto Nacional de Parasitología “Dr. Mario Fatala Chaben”, Buenos Aires, Argentina
| | - Myriam Nuñez
- Departmento de Físicomatemática, Facultad de Farmacia y Bioquímica, Universidad de Buenos Aires, Buenos Aires, Argentina
| | | | - María C Albareda
- Instituto Nacional de Parasitología “Dr. Mario Fatala Chaben”, Buenos Aires, Argentina
| | - Gonzalo Cesar
- Instituto Nacional de Parasitología “Dr. Mario Fatala Chaben”, Buenos Aires, Argentina
| | - Rick L Tarleton
- Center for Tropical and Emerging Global Diseases, University of Georgia, Athens, GA, USA
| | - Susana A Laucella
- Instituto Nacional de Parasitología “Dr. Mario Fatala Chaben”, Buenos Aires, Argentina
- Hospital Interzonal General de Agudos Eva Perón, Buenos Aires, Argentina
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Torrico F, Gascón J, Barreira F, Blum B, Almeida IC, Alonso-Vega C, Barboza T, Bilbe G, Correia E, Garcia W, Ortiz L, Parrado R, Ramirez JC, Ribeiro I, Strub-Wourgaft N, Vaillant M, Sosa-Estani S. New regimens of benznidazole monotherapy and in combination with fosravuconazole for treatment of Chagas disease (BENDITA): a phase 2, double-blind, randomised trial. THE LANCET. INFECTIOUS DISEASES 2021; 21:1129-1140. [PMID: 33836161 DOI: 10.1016/s1473-3099(20)30844-6] [Citation(s) in RCA: 90] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 09/10/2020] [Accepted: 10/14/2020] [Indexed: 01/06/2023]
Abstract
BACKGROUND Current treatment for Chagas disease with the only available drugs, benznidazole or nifurtimox, has substantial limitations, including long treatment duration and safety and tolerability concerns. We aimed to evaluate the efficacy and safety of new benznidazole monotherapy regimens and combinations with fosravuconazole, in the treatment of Chagas disease. METHODS We did a double-blind, double-dummy, phase 2, multicentre, randomised trial in three outpatient units in Bolivia. Adults aged 18-50 years with chronic indeterminate Chagas disease, confirmed by serological testing and positive qualitative PCR results, were randomly assigned (1:1:1:1:1:1:1) to one of seven treatment groups using a balanced block randomisation scheme with an interactive response system. Participants were assigned to benznidazole 300 mg daily for 8 weeks, 4 weeks, or 2 weeks, benznidazole 150 mg daily for 4 weeks, benznidazole 150 mg daily for 4 weeks plus fosravuconazole, benznidazole 300 mg once per week for 8 weeks plus fosravuconazole, or placebo, with a 12-month follow-up period. The primary endpoints were sustained parasitological clearance at 6 months, defined as persistent negative qualitative PCR results from end of treatment, and incidence and severity of treatment-emergent adverse events, serious adverse events, and adverse events leading to treatment discontinuation. Primary efficacy analysis was based on the intention-to-treat and per-protocol populations and secondary efficacy analyses on the per-protocol population. Safety analyses were based on the as-treated population. Recruitment is now closed. This trial is registered with ClinicalTrials.gov, NCT03378661. FINDINGS Between Nov 30, 2016, and July 27, 2017, we screened 518 patients, and 210 were enrolled and randomised. 30 patients (14%) were assigned to each treatment group. All 210 randomised patients were included in the intention-to-treat population, and 190 (90%) were included in the per-protocol population. In the intention-to-treat analysis, only one (3%) of 30 patients in the placebo group had sustained parasitological clearance at 6 months of follow-up. Sustained parasitological clearance at 6 months was observed in 25 (89%) of 28 patients receiving benznidazole 300 mg daily for 8 weeks (rate difference vs placebo 86% [95% CI 73-99]), 25 (89%) of 28 receiving benznidazole 300 mg daily for 4 weeks (86% [73-99]), 24 (83%) of 29 receiving benznidazole 300 mg daily for 2 weeks (79% [64-95]), 25 (83%) of 30 receiving benznidazole 150 mg daily for 4 weeks (80% [65-95]), 23 (85%) of 28 receiving benznidazole 150 mg daily for 4 weeks plus fosravuconazole (82% [67-97]), and 24 (83%) of 29 receiving benznidazole 300 mg weekly for 8 weeks plus fosravuconazole (79% [64-95]; p<0·0001 for all group comparisons with placebo). Six patients (3%) had ten serious adverse events (leukopenia [n=3], neutropenia [n=2], pyrexia, maculopapular rash, acute cholecystitis, biliary polyp, and breast cancer), eight had 12 severe adverse events (defined as interfering substantially with the patient's usual functions; elevated alanine aminotransferase [n=4], elevated gamma-glutamyltransferase [n=2], elevated aspartate aminotransferase [n=1], neutropenia [n=3], leukopenia [n=1], and breast cancer [n=1]), and 15 (7%) had adverse events that led to treatment discontinuation (most of these were in the groups who received benznidazole 300 mg daily for 8 weeks, benznidazole 300 mg once per week for 8 weeks plus fosravuconazole, and benznidazole 150 mg daily for 4 weeks plus fosravuconazole). No adverse events leading to treatment discontinuation were observed in patients treated with benznidazole 300 mg daily for 2 weeks or placebo. There were no treatment-related deaths. INTERPRETATION Benznidazole induced effective antiparasitic response, regardless of treatment duration, dose, or combination with fosravuconazole, and was well tolerated in adult patients with chronic Chagas disease. Shorter or reduced regimens of benznidazole could substantially improve treatment tolerability and accessibility, but further studies are needed to confirm these results. FUNDING Drugs for Neglected Diseases initiative (DNDi). TRANSLATION For the Spanish translation of the abstract see Supplementary Materials section.
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Affiliation(s)
- Faustino Torrico
- Fundación Ciencia y Estudios Aplicados para el Desarrollo en Salud y Medio Ambiente (CEADES), Cochabamba, Bolivia; Universidad Mayor de San Simón, Cochabamba, Bolivia
| | - Joaquim Gascón
- Barcelona Institute for Global Health, Barcelona, Spain; Universitat de Barcelona, Barcelona, Spain
| | | | | | | | - Cristina Alonso-Vega
- Barcelona Institute for Global Health, Barcelona, Spain; DNDi Latin America, Rio de Janeiro, Brazil
| | | | - Graeme Bilbe
- Drugs for Neglected Diseases initiative (DNDi), Geneva, Switzerland
| | | | - Wilson Garcia
- Fundación Ciencia y Estudios Aplicados para el Desarrollo en Salud y Medio Ambiente (CEADES), Cochabamba, Bolivia
| | - Lourdes Ortiz
- Fundación Ciencia y Estudios Aplicados para el Desarrollo en Salud y Medio Ambiente (CEADES), Cochabamba, Bolivia; Juan Misael Saracho Autonomous University, Tarija, Bolivia
| | - Rudy Parrado
- Universidad Mayor de San Simón, Cochabamba, Bolivia
| | - Juan Carlos Ramirez
- Instituto Nacional de Parasitología "Dr Mario Fatala Chaben" (INP-ANLIS), Buenos Aires, Argentina
| | - Isabela Ribeiro
- Drugs for Neglected Diseases initiative (DNDi), Geneva, Switzerland
| | | | | | - Sergio Sosa-Estani
- DNDi Latin America, Rio de Janeiro, Brazil; Epidemiology and Public Health Research Centre, CONICET, Buenos Aires, Argentina.
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Vallejo M, Reyes PP, Martinez Garcia M, Gonzalez Garay AG. Trypanocidal drugs for late-stage, symptomatic Chagas disease (Trypanosoma cruzi infection). Cochrane Database Syst Rev 2020; 12:CD004102. [PMID: 33305846 PMCID: PMC8103997 DOI: 10.1002/14651858.cd004102.pub3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND People with Chagas disease may develop progressive and lethal heart conditions. Drugs to eliminate the parasite Trypanosoma cruzi (T cruzi) currently carry limited therapeutic value and are used in the early stages of the disease. Extending the use of these drugs to treat chronic chagasic cardiomyopathy (CCC) has also been proposed. OBJECTIVES To assess the benefits and harms of nitrofurans and trypanocidal drugs for treating late-stage, symptomatic Chagas disease and CCC in terms of blood parasite reduction or clearance, mortality, adverse effects, and quality of life. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and LILACS databases on 12 November 2019. We also searched two clinical trials registers, ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP), on 3 December 2019. SELECTION CRITERIA We included randomised controlled trials (RCTs) assessing trypanocidal drugs versus placebo or no treatment for late-stage, symptomatic Chagas disease and CCC. DATA COLLECTION AND ANALYSIS We conducted the reporting of the review according the standard Cochrane methods. Two review authors independently retrieved articles, performed data extraction, and assessed risk of bias. Any disagreements were resolved by a third review author. We contacted study authors for additional information. MAIN RESULTS We included two studies in this review update. One RCT randomly assigned 26 participants to benznidazole 5 mg/kg/day; 27 participants to nifurtimox 5 mg/kg/day; and 24 participants to placebo for 30 days. The second RCT, newly included in this update, randomised 1431 participants to benznidazole 300 mg/day for 40 to 80 days and 1423 participants to placebo. We also identified one ongoing study. Benznidazole compared to placebo At five-year follow-up, low quality of the evidence suggests that there may be a benefit of benznidazole when compared to placebo for clearance or reduction of antibody titres (risk ratio (RR) 1.25, 95% confidence interval (CI) 1.14 to 1.37; 1 trial; 1896 participants). We are uncertain about the effects of benznidazole for the clearance of parasitaemia demonstrated by negative xenodiagnosis, blood culture, and/or molecular assays due to very limited evidence. Low quality of the evidence suggests that when compared to placebo, benznidazole may make little to no difference in the risk of heart failure (RR 0.89, 95% CI 0.69 to 1.14; 1 trial; 2854 participants) and ventricular tachycardia (RR 0.80, 95% CI 0.51 to 1.26; 1 trial; 2854 participants). We found moderate quality of the evidence that adverse events increase with benznidazole when compared to placebo (RR 2.52, 95% CI 2.09 to 3.03; 1 trial; 2854 participants). Adverse effects were observed in 23.9% of patients in the benznidazole group compared to 9.5% in the placebo group. The most frequent adverse effects were: cutaneous rash, gastrointestinal symptoms, and peripheral polyneuropathy. No data were available for the outcomes of pathological demonstration of tissue parasites and quality of life. Nifurtimox compared to placebo Data were only available for this comparison for the outcome clearance or reduction of antibody titres, and we are uncertain about the effect due to very limited evidence. Regarding adverse events, one RCT mentioned in a general manner that nifurtimox caused intense adverse events, without any quantification. AUTHORS' CONCLUSIONS There is insufficient evidence to support the efficacy of the trypanocidal drugs benznidazole and nifurtimox for late-stage, symptomatic Chagas disease and CCC.
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Affiliation(s)
- Maite Vallejo
- Instituto Nacional de Cardiología Ignacio Chávez, Juan Badiano No. 1. Col. Seccion XVI, Tlalpan, Mexico
| | - Pedro Pa Reyes
- Instituto Nacional de Cardiología Ignacio Chávez, Juan Badiano No. 1. Col. Seccion XVI, Tlalpan, Mexico
| | - Mireya Martinez Garcia
- Sociomedical Research Unit, Instituto Nacional de Cardiologia, Ignacio Chavez, Mexico City, Mexico
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Cafferata ML, Toscani MA, Althabe F, Belizán JM, Bergel E, Berrueta M, Capparelli EV, Ciganda Á, Danesi E, Dumonteil E, Gibbons L, Gulayin PE, Herrera C, Momper JD, Rossi S, Shaffer JG, Schijman AG, Sosa-Estani S, Stella CB, Klein K, Buekens P. Short-course Benznidazole treatment to reduce Trypanosoma cruzi parasitic load in women of reproductive age (BETTY): a non-inferiority randomized controlled trial study protocol. Reprod Health 2020; 17:128. [PMID: 32831069 PMCID: PMC7446054 DOI: 10.1186/s12978-020-00972-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 08/03/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Retrospective observational studies suggest that transmission of Trypanosoma cruzi does not occur in treated women when pregnant later in life. The level of parasitemia is a known risk factor for congenital transmission. Benznidazole (BZN) is the drug of choice for preconceptional treatment to reduce parasitic load. The fear of treatment-related side effects limits the implementation of the Argentine guideline recommending BZN 60d/300 mg (or equivalent) treatment of T. cruzi seropositive women during the postpartum period to prevent transmission in a future pregnancy. A short and low dose BZN treatment might reduce major side effects and increase compliance, but its efficacy to reduce T. cruzi parasitic load compared to the standard 60d/300 mg course is not yet established. Clinical trials testing alternative BZN courses among women of reproductive age are urgently needed. METHODS AND DESIGN We are proposing to perform a double-blinded, non-inferiority randomized controlled trial comparing a short low dose 30-day treatment with BZN 150 mg/day (30d/150 mg) vs. BZN 60d/300 mg. We will recruit not previously treated T. cruzi seropositive women with a live birth during the postpartum period in Argentina, randomize them at 6 months postpartum, and follow them up with the following specific aims: Specific aim 1: to measure the effect of BZN 30d/150 mg compared to 60d/300 mg preconceptional treatment on parasitic load measured by the frequency of positive Polymerase Chain Reaction (PCR) (primary outcome) and by real-time quantitative PCR (qPCR), immediately and 10 months after treatment. Specific aim 2: to measure the frequency of serious adverse events and/or any adverse event leading to treatment interruption. TRIAL REGISTRATION ClinicalTrials.gov . Identifier: NCT03672487 . Registered 14 September 2018.
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Affiliation(s)
- María L Cafferata
- Instituto de Efectividad Clinica y Sanitaria (IECS), Buenos Aires, Argentina.
- Unidad de Investigación Clínica y Epidemiológica Montevideo (UNICEM), Montevideo, Uruguay.
| | - María A Toscani
- Instituto de Efectividad Clinica y Sanitaria (IECS), Buenos Aires, Argentina
| | - Fernando Althabe
- Maternal and Perinatal Health. UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research (SRH), World Health Organization, Geneva, Switzerland
| | - Jose M Belizán
- Instituto de Efectividad Clinica y Sanitaria (IECS), Buenos Aires, Argentina
| | - Eduardo Bergel
- Instituto de Efectividad Clinica y Sanitaria (IECS), Buenos Aires, Argentina
| | - Mabel Berrueta
- Instituto de Efectividad Clinica y Sanitaria (IECS), Buenos Aires, Argentina
| | - Edmund V Capparelli
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego (UCSD), San Diego, USA
- Schools of Medicine, University of California, San Diego (UCSD), San Diego, USA
| | - Álvaro Ciganda
- Instituto de Efectividad Clinica y Sanitaria (IECS), Buenos Aires, Argentina
- Unidad de Investigación Clínica y Epidemiológica Montevideo (UNICEM), Montevideo, Uruguay
| | - Emmaria Danesi
- Centro Nacional de Diagnóstico e Investigación en Endemoepidemias (CeNDIE) ANLIS Dr. C. G. Malbrán, Buenos Aires, Argentina
| | - Eric Dumonteil
- School of Public Health and Tropical Medicine, Tulane University, New Orleans, USA
| | - Luz Gibbons
- Instituto de Efectividad Clinica y Sanitaria (IECS), Buenos Aires, Argentina
| | - Pablo E Gulayin
- Instituto de Efectividad Clinica y Sanitaria (IECS), Buenos Aires, Argentina
| | - Claudia Herrera
- School of Public Health and Tropical Medicine, Tulane University, New Orleans, USA
| | - Jeremiah D Momper
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego (UCSD), San Diego, USA
| | - Steven Rossi
- Schools of Medicine, University of California, San Diego (UCSD), San Diego, USA
| | - Jeffrey G Shaffer
- School of Public Health and Tropical Medicine, Tulane University, New Orleans, USA
| | - Alejandro G Schijman
- Laboratorio de Biología Molecular de la Enfermedad de Chagas (LaBMECh), Instituto de Investigaciones en Ingeniería Genética y Biología Molecular "Dr. Héctor Torres" (INGEBI), Buenos Aires, Argentina
| | - Sergio Sosa-Estani
- Drugs for Neglected Diseases initiative - Latin America (DNDi), Rio de Janeiro, Brazil
- Centro de Investigaciones en Epidemiología y Salud Pública (CIESP-IECS), Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Buenos Aires, Argentina
| | - Candela B Stella
- Instituto de Efectividad Clinica y Sanitaria (IECS), Buenos Aires, Argentina
| | - Karen Klein
- Instituto de Efectividad Clinica y Sanitaria (IECS), Buenos Aires, Argentina
| | - Pierre Buekens
- School of Public Health and Tropical Medicine, Tulane University, New Orleans, USA
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New Scheme of Intermittent Benznidazole Administration in Patients Chronically Infected with Trypanosoma cruzi: Clinical, Parasitological, and Serological Assessment after Three Years of Follow-Up. Antimicrob Agents Chemother 2020; 64:AAC.00439-20. [PMID: 32571827 DOI: 10.1128/aac.00439-20] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 06/18/2020] [Indexed: 02/07/2023] Open
Abstract
In a pilot study, we showed that the intermittent administration of benznidazole in chronic Chagas disease patients resulted in a low rate of treatment suspension and therapeutic failure, as assessed by quantitative PCR (qPCR) at the end of treatment. Here, a 3-year posttreatment follow-up study of the same cohort of patients is presented. The treatment scheme consisted of 12 doses of benznidazole at 5 mg/kg of body weight/day in two daily doses every 5 days. Parasite load, Trypanosoma cruzi-specific antibodies, and serum chemokine levels were measured prior to treatment and after a median follow-up of 36 months posttreatment by DNA minicircle kinetoplastid and nuclear DNA satellite sequence qPCR methods, conventional serological techniques, a Luminex-based assay with recombinant T. cruzi proteins, and a cytometric bead array. At the end of follow-up, 14 of 17 (82%) patients had negative qPCR findings, whereas three of 17 (18%) had detectable nonquantifiable findings by at least one of the qPCR techniques. A decline in parasite-specific antibodies at 12 months posttreatment was confirmed by conventional serological tests and the Luminex assays. Monocyte chemoattractant protein 1 levels increased after treatment, whereas monokine induced by gamma interferon levels decreased. New posttreatment electrocardiographic abnormalities were observed in only one patient who had cardiomyopathy prior to treatment. Together, these data strengthen our previous findings by showing that the intermittent administration of benznidazole results in a low rate of treatment suspension, with treatment efficacy comparable to that of a daily dose of 5 mg/kg for 60 days.
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Pérez-Molina JA, Crespillo-Andújar C, Bosch-Nicolau P, Molina I. Trypanocidal treatment of Chagas disease. Enferm Infecc Microbiol Clin 2020; 39:S0213-005X(20)30193-2. [PMID: 32527494 DOI: 10.1016/j.eimc.2020.04.011] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 04/02/2020] [Accepted: 04/18/2020] [Indexed: 01/16/2023]
Abstract
Chagas disease is a neglected parasitosis caused by the protozoan parasite Trypanosoma cruzi. This infection is present in most Latin American countries, although, due to migratory movements, it is a growing cause for concern in non-endemic countries. The only two drugs currently available for its treatment-benznidazole and nifurtimox-were marketed 50 years ago. While they are very effective for acute and recent infection, and for the prevention of maternofoetal transmission, their efficacy declines in people who have chronic infection, especially those older than 18 years of age. In the presence of visceral involvement, parasiticidal treatment is of little or no value. The safety profile of both drugs is far from ideal, with frequent adverse events and high rates of drug discontinuation, mainly in adults. So far, new drugs and new strategies have not been shown to improve the results of the current nitroimidazoles, although the results are promising. In this review, we focus on the aspects that allow clinicians to make the best use of currently available drugs. In addition, we discuss new therapeutic options and ongoing research in the field.
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Affiliation(s)
- Jose A Pérez-Molina
- National Referral Centre for Tropical Diseases, Infectious Diseases Department, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Madrid, Spain.
| | - Clara Crespillo-Andújar
- National Referral Centre for Tropical Diseases, Infectious Diseases Department, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Madrid, Spain
| | - Pau Bosch-Nicolau
- Tropical Medicine Unit, Department of Infectious Diseases, Vall d'Hebron University Hospital, PROSICS Barcelona, Barcelona, Spain
| | - Israel Molina
- Tropical Medicine Unit, Department of Infectious Diseases, Vall d'Hebron University Hospital, PROSICS Barcelona, Barcelona, Spain; Instituto René Rachou-FIOCRUZ Minas, Chagas Disease Research Group, Belo Horizonte, MG, Brazil
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15
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Molina-Morant D, Fernández ML, Bosch-Nicolau P, Sulleiro E, Bangher M, Salvador F, Sanchez-Montalva A, Ribeiro ALP, de Paula AMB, Eloi S, Correa-Oliveira R, Villar JC, Sosa-Estani S, Molina I. Efficacy and safety assessment of different dosage of benznidazol for the treatment of Chagas disease in chronic phase in adults (MULTIBENZ study): study protocol for a multicenter randomized Phase II non-inferiority clinical trial. Trials 2020; 21:328. [PMID: 32293523 PMCID: PMC7158046 DOI: 10.1186/s13063-020-4226-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 03/03/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Chagas disease (CD) continues to be a neglected infectious disease with one of the largest burdens globally. Despite the modest cure rates in adult chronic patients and its safety profile, benznidazole (BNZ) is still the drug of choice. Its current recommended dose is based on nonrandomized studies, and efficacy and safety of the optimal dose of BNZ have been scarcely analyzed in clinical trials. METHODS/DESIGN MULTIBENZ is a phase II, randomized, noninferiority, double-blind, multicenter international clinical trial. A total of 240 patients with Trypanosoma CD in the chronic phase will be recruited in four different countries (Argentina, Brazil, Colombia, and Spain). Patients will be randomized to receive BNZ 150 mg/day for 60 days, 400 mg/day for 15 days, or 300 mg/day for 60 days (comparator arm). The primary outcome is the efficacy of three different BNZ therapeutic schemes in terms of dose and duration. Efficacy will be assessed according to the proportion of patients with sustained parasitic load suppression in peripheral blood measured by polymerase chain reaction. The secondary outcomes are related to pharmacokinetics and drug tolerability. The follow-up will be 12 months from randomization to end of study participation. Recruitment was started in April 2018. CONCLUSION This is a clinical trial conducted for the assessment of different dose schemes of BNZ compared with the standard treatment regimen for the treatment of CD in the chronic phase. MULTIBENZ may help to clarify which is the most adequate BNZ regimen in terms of efficacy and safety, predicated on sustained parasitic load suppression in peripheral blood. TRIAL REGISTRATION ClinicalTrials.gov, NCT03191162. Registered on 19 June 2017.
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Affiliation(s)
- D Molina-Morant
- Infectious Diseases Department, Vall d'Hebron University Hospital, PROSICS Barcelona, Universitat Autònoma de Barcelona, P° Vall d'Hebron 119, Edifici Mediterrània, VHIR, 08035, Barcelona, Spain
| | - M L Fernández
- Departamento de Clínica, Patología y Tratamiento, Instituto Nacional de Parasitología Dr. Mario Fatala Chaben, Ministerio de Salud y Desarrollo Social, Buenos Aires, Argentina
| | - P Bosch-Nicolau
- Infectious Diseases Department, Vall d'Hebron University Hospital, PROSICS Barcelona, Universitat Autònoma de Barcelona, P° Vall d'Hebron 119, Edifici Mediterrània, VHIR, 08035, Barcelona, Spain
| | - E Sulleiro
- Microbiology Department, Vall d'Hebron University Hospital, PROSICS Barcelona, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - M Bangher
- Instituto de Cardiología de Corrientes Juana Francisca Cabral (Argentina), Corrientes, Argentina
| | - F Salvador
- Infectious Diseases Department, Vall d'Hebron University Hospital, PROSICS Barcelona, Universitat Autònoma de Barcelona, P° Vall d'Hebron 119, Edifici Mediterrània, VHIR, 08035, Barcelona, Spain
| | - A Sanchez-Montalva
- Infectious Diseases Department, Vall d'Hebron University Hospital, PROSICS Barcelona, Universitat Autònoma de Barcelona, P° Vall d'Hebron 119, Edifici Mediterrània, VHIR, 08035, Barcelona, Spain
| | - A L P Ribeiro
- Programa de Pós-graduação Infectologia e Medicina Tropical, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - A M B de Paula
- Laboratory of Health Science, Postgraduate Program in Health Sciences, Universidade Estadual de Montes Claros (Unimontes), Montes Claros, MG, Brazil
| | - S Eloi
- Programa de Pós-graduação em Patologia, Departamento de Propedêutica Complementar, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
- Faculdade de Medicina da Universidade José do Rosário Vellano, Belo Horizonte, Brazil
| | - R Correa-Oliveira
- René Rachou Institute, Oswaldo Cruz Foundation, Belo Horizonte, Brazil
| | - J C Villar
- Faculty of Health Sciences, Universidad Autónoma de Bucaramanga and Research Department, Bucaramanga, Colombia
- Fundación Cardioinfantil - Instituto de Cardiología, Bogotá, Colombia
| | - S Sosa-Estani
- Chagas Clinical Program, Drugs for Neglected Disease initiative (DNDi), Geneva, Switzerland
- Epidemiology and Public Health Research Center, CONICET, Buenos Aires, Argentina
| | - I Molina
- Infectious Diseases Department, Vall d'Hebron University Hospital, PROSICS Barcelona, Universitat Autònoma de Barcelona, P° Vall d'Hebron 119, Edifici Mediterrània, VHIR, 08035, Barcelona, Spain.
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16
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Sulleiro E, Silgado A, Serre-Delcor N, Salvador F, Tavares de Oliveira M, Moure Z, Sao-Aviles A, Oliveira I, Treviño B, Goterris L, Sánchez-Montalvá A, Pou D, Molina I, Pumarola T. Usefulness of real-time PCR during follow-up of patients treated with Benznidazole for chronic Chagas disease: Experience in two referral centers in Barcelona. PLoS Negl Trop Dis 2020; 14:e0008067. [PMID: 32069287 PMCID: PMC7048293 DOI: 10.1371/journal.pntd.0008067] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 02/28/2020] [Accepted: 01/15/2020] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Antitrypanosomal treatment with Benznidazole (BZ) or Nifurtimox may be recommended for patients with chronic Chagas disease (CD) to reduce the onset or progression of symptoms. However, such treatment has limited efficacy and high level of toxic effects. In addition, the current cure biomarker (serology conversion) precludes any treatment assessment unless a prolonged follow-up is arranged. PCR is thus the most useful, alternative surrogate marker for evaluating responses to treatment. The aim of this study is to describe the usefulness of real-time PCR in monitoring BZ treatment within a large cohort of chronic CD cases in Barcelona. METHODOLOGY/PRINCIPAL FINDINGS A total of 370 chronic CD patients were monitored with real-time PCR post-BZ treatment. The median follow-up was 4 years (IQR 2.2-5.3y), with a median of 3 clinical visits (IQR 2-4). Only 8 patients (2.2%) presented with at least one incident of positive real-time PCR after treatment and were therefore considered as treatment failure. Four of those failure patients had completed full course treatment, whereas the remaining cases had defaulted with a statistical difference between both groups (p = 0.02). Half of the failure patients had undergone less than 4 years of follow-up monitoring all presented with parasitemia before treatment. CONCLUSIONS/SIGNIFICANCE BZ treatment failure was highly infrequent in our cohort. BZ discontinuation was a risk factor for positive real-time PCR results during clinical follow-up. Regular testing with real-time PCR during follow-up allows for early detection of treatment failure in patients with chronic CD.
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Affiliation(s)
- Elena Sulleiro
- Department of Microbiology, Vall d’Hebron University Hospital, Universitat Autònoma de Barcelona PROSICS, Barcelona, Spain
| | - Aroa Silgado
- Department of Microbiology, Vall d’Hebron University Hospital, Universitat Autònoma de Barcelona PROSICS, Barcelona, Spain
| | - Núria Serre-Delcor
- Tropical Medicine Unit Vall d´Hebron-Drassanes, Universitat Autònoma de Barcelona PROSICS, Barcelona, Spain
| | - Fernando Salvador
- Department of Infectious Diseases, Universitat Autònoma de Barcelona, Vall d’Hebron University Hospital, PROSICS, Barcelona, Spain
| | - Maykon Tavares de Oliveira
- Departamento de Clínica médica, Unidade de Cardiologia, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, São Paulo, Brazil
| | - Zaira Moure
- Department of Microbiology, Vall d’Hebron University Hospital, Universitat Autònoma de Barcelona PROSICS, Barcelona, Spain
| | - Augusto Sao-Aviles
- Department of Infectious Diseases, Universitat Autònoma de Barcelona, Vall d’Hebron University Hospital, PROSICS, Barcelona, Spain
| | - Inés Oliveira
- Tropical Medicine Unit Vall d´Hebron-Drassanes, Universitat Autònoma de Barcelona PROSICS, Barcelona, Spain
| | - Begoña Treviño
- Tropical Medicine Unit Vall d´Hebron-Drassanes, Universitat Autònoma de Barcelona PROSICS, Barcelona, Spain
| | - Lidia Goterris
- Department of Microbiology, Vall d’Hebron University Hospital, Universitat Autònoma de Barcelona PROSICS, Barcelona, Spain
| | - Adrián Sánchez-Montalvá
- Department of Infectious Diseases, Universitat Autònoma de Barcelona, Vall d’Hebron University Hospital, PROSICS, Barcelona, Spain
| | - Diana Pou
- Tropical Medicine Unit Vall d´Hebron-Drassanes, Universitat Autònoma de Barcelona PROSICS, Barcelona, Spain
| | - Israel Molina
- Department of Infectious Diseases, Universitat Autònoma de Barcelona, Vall d’Hebron University Hospital, PROSICS, Barcelona, Spain
| | - Tomàs Pumarola
- Department of Microbiology, Vall d’Hebron University Hospital, Universitat Autònoma de Barcelona PROSICS, Barcelona, Spain
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Perin L, Fonseca KDS, de Carvalho TV, Carvalho LM, Madeira JV, Medeiros LDF, Molina I, Correa-Oliveira R, Carneiro CM, Vieira PMDA. Low-dose of benznidazole promotes therapeutic cure in experimental chronic Chagas' disease with absence of parasitism in blood, heart and colon. Exp Parasitol 2020; 210:107834. [PMID: 31978394 DOI: 10.1016/j.exppara.2020.107834] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 01/13/2020] [Accepted: 01/14/2020] [Indexed: 10/25/2022]
Abstract
Studies suggest that the dose of the standard benznidazole (BNZ) treatment regimen might be too high. We investigated the efficacy of BNZ 20 and 40 mg/kg/day compared with standard dose (100 mg/kg/day) to induce cure in mice infected with Trypanosoma cruzi Y strain in the acute and chronic phases of Chagas' disease. Our findings indicate that an experimental treatment with a BNZ low-dose (40 mg/kg/day) is similarly effective as the usual dose in the chronic mice model (100% of cure). In addition, the treatment in the chronic model of Chagas' disease presented better results than the acute model and colon appears to be a key tissue when it comes to evaluating treatment efficacy compared to blood and heart. Therefore, our data suggest the reconsideration of the current therapy, mainly in the chronic phase of the disease.
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Affiliation(s)
- Luísa Perin
- Laboratory of Immunopathology, Nucleus of Biological Sciences Research, Federal University of Ouro Preto, Ouro Preto, Minas Gerais, Brazil.
| | - Kátia da Silva Fonseca
- Laboratory of Immunopathology, Nucleus of Biological Sciences Research, Federal University of Ouro Preto, Ouro Preto, Minas Gerais, Brazil
| | - Thaís Vieira de Carvalho
- Laboratory of Morphopathology, Department of Biological Sciences, Nucleus of Biological Sciences Research, Institute of Exact and Biological Sciences, Federal University of Ouro Preto, Ouro Preto, Minas Gerais, Brazil
| | - Lívia Mendes Carvalho
- Laboratory of Morphopathology, Department of Biological Sciences, Nucleus of Biological Sciences Research, Institute of Exact and Biological Sciences, Federal University of Ouro Preto, Ouro Preto, Minas Gerais, Brazil
| | - João Vitor Madeira
- Laboratory of Immunopathology, Nucleus of Biological Sciences Research, Federal University of Ouro Preto, Ouro Preto, Minas Gerais, Brazil
| | - Luciana da Fonseca Medeiros
- Laboratory of Immunopathology, Nucleus of Biological Sciences Research, Federal University of Ouro Preto, Ouro Preto, Minas Gerais, Brazil
| | - Israel Molina
- Laboratory of Immunopathology, Nucleus of Biological Sciences Research, Federal University of Ouro Preto, Ouro Preto, Minas Gerais, Brazil; Tropical Medicine and International Health Unit, Department of Infectious Diseases, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, PROSICS Barcelona, Barcelona, Spain
| | - Rodrigo Correa-Oliveira
- Laboratory of Immunopathology, Nucleus of Biological Sciences Research, Federal University of Ouro Preto, Ouro Preto, Minas Gerais, Brazil; Laboratory of Cellular and Molecular Immunology, René Rachou Research Center, Oswaldo Cruz Foundation, Belo Horizonte, Minas Gerais, Brazil
| | - Cláudia Martins Carneiro
- Laboratory of Immunopathology, Nucleus of Biological Sciences Research, Federal University of Ouro Preto, Ouro Preto, Minas Gerais, Brazil; Department of Clinical Analysis, School of Pharmacy, Federal University of Ouro Preto, Ouro Preto, Minas Gerais, Brazil
| | - Paula Melo de Abreu Vieira
- Laboratory of Immunopathology, Nucleus of Biological Sciences Research, Federal University of Ouro Preto, Ouro Preto, Minas Gerais, Brazil; Laboratory of Morphopathology, Department of Biological Sciences, Nucleus of Biological Sciences Research, Institute of Exact and Biological Sciences, Federal University of Ouro Preto, Ouro Preto, Minas Gerais, Brazil.
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Molina I, Perin L, Aviles AS, de Abreu Vieira PM, da Silva Fonseca K, Cunha LM, Carneiro CM. The effect of benznidazole dose among the efficacy outcome in the murine animal model. A quantitative integration of the literature. Acta Trop 2020; 201:105218. [PMID: 31610148 DOI: 10.1016/j.actatropica.2019.105218] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 09/06/2019] [Accepted: 10/10/2019] [Indexed: 12/17/2022]
Abstract
Despite more than 100 years since it was firstly described Chagas disease, only two drugs are available to treat Chagas disease: Nifurtimox launched by Bayer in 1965 and benznidazole launched by Roche in 1971. Drug discovery initiatives have been looking for new compounds as an alternative to these old drugs. Although new platforms have been used with the latest technologies, a critical step on that process still relies on the in vivo model. Unfortunately, to date, available animal models have limited predictive value and there is no standardization. With the aim to better understand the role of benznidazole, the current standard of care of Chagas disease, we performed this review. We intend to analyze the influence of the experimental design of the most used animal model, the murine model, in the assessment of the efficacy endpoint.
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Affiliation(s)
- Israel Molina
- Tropical Medicine Unit, Infectious Disease Department. PROSICS (International Health Program of the Catalan Health Institute), Hospital Universitario Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain; Laboratório de Imunopatologia, Núcleo de Pesquisas em Ciências Biológicas, Instituto de Ciências Exatas e Biológicas, Universidade Federal de Ouro Preto, Ouro Preto, MG, Brazil.
| | - Luisa Perin
- Laboratório de Imunopatologia, Núcleo de Pesquisas em Ciências Biológicas, Instituto de Ciências Exatas e Biológicas, Universidade Federal de Ouro Preto, Ouro Preto, MG, Brazil
| | - Augusto Sao Aviles
- Tropical Medicine Unit, Infectious Disease Department. PROSICS (International Health Program of the Catalan Health Institute), Hospital Universitario Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Paula Melo de Abreu Vieira
- Laboratório de Imunopatologia, Núcleo de Pesquisas em Ciências Biológicas, Instituto de Ciências Exatas e Biológicas, Universidade Federal de Ouro Preto, Ouro Preto, MG, Brazil; Laboratório de Morfopatologia, Departamento de Ciências Biológicas, Núcleo de Pesquisas em Ciências Biológicas, Instituto de Ciências Exatas e Biológicas, Universidade Federal de Ouro Preto, Ouro Preto, Minas Gerais, Brazil
| | - Katia da Silva Fonseca
- Laboratório de Imunopatologia, Núcleo de Pesquisas em Ciências Biológicas, Instituto de Ciências Exatas e Biológicas, Universidade Federal de Ouro Preto, Ouro Preto, MG, Brazil
| | - Lucas Maciel Cunha
- Laboratório de Imunopatologia, Núcleo de Pesquisas em Ciências Biológicas, Instituto de Ciências Exatas e Biológicas, Universidade Federal de Ouro Preto, Ouro Preto, MG, Brazil
| | - Claudia M Carneiro
- Laboratório de Imunopatologia, Núcleo de Pesquisas em Ciências Biológicas, Instituto de Ciências Exatas e Biológicas, Universidade Federal de Ouro Preto, Ouro Preto, MG, Brazil
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Barrett MP, Kyle DE, Sibley LD, Radke JB, Tarleton RL. Protozoan persister-like cells and drug treatment failure. Nat Rev Microbiol 2019; 17:607-620. [PMID: 31444481 PMCID: PMC7024564 DOI: 10.1038/s41579-019-0238-x] [Citation(s) in RCA: 81] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2019] [Indexed: 01/01/2023]
Abstract
Antimicrobial treatment failure threatens our ability to control infections. In addition to antimicrobial resistance, treatment failures are increasingly understood to derive from cells that survive drug treatment without selection of genetically heritable mutations. Parasitic protozoa, such as Plasmodium species that cause malaria, Toxoplasma gondii and kinetoplastid protozoa, including Trypanosoma cruzi and Leishmania spp., cause millions of deaths globally. These organisms can evolve drug resistance and they also exhibit phenotypic diversity, including the formation of quiescent or dormant forms that contribute to the establishment of long-term infections that are refractory to drug treatment, which we refer to as 'persister-like cells'. In this Review, we discuss protozoan persister-like cells that have been linked to persistent infections and discuss their impact on therapeutic outcomes following drug treatment.
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Affiliation(s)
- Michael P Barrett
- Wellcome Centre for Integrative Parasitology, Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK.
| | - Dennis E Kyle
- Center for Tropical and Emerging Global Diseases, University of Georgia, Athens, GA, USA
| | - L David Sibley
- Department of Molecular Microbiology, Washington University School of Medicine, St Louis, MO, USA
| | - Joshua B Radke
- Department of Molecular Microbiology, Washington University School of Medicine, St Louis, MO, USA
| | - Rick L Tarleton
- Center for Tropical and Emerging Global Diseases, University of Georgia, Athens, GA, USA
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Sartor P, Colaianni I, Cardinal MV, Bua J, Freilij H, Gürtler RE. Improving access to Chagas disease diagnosis and etiologic treatment in remote rural communities of the Argentine Chaco through strengthened primary health care and broad social participation. PLoS Negl Trop Dis 2017; 11:e0005336. [PMID: 28192425 PMCID: PMC5325580 DOI: 10.1371/journal.pntd.0005336] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2016] [Revised: 02/24/2017] [Accepted: 01/18/2017] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Rural populations in the Gran Chaco region have large prevalence rates of Trypanosoma cruzi infection and very limited access to diagnosis and treatment. We implemented an innovative strategy to bridge these gaps in 13 rural villages of Pampa del Indio held under sustained vector surveillance and control. METHODOLOGY The non-randomized treatment program included participatory workshops, capacity strengthening of local health personnel, serodiagnosis, qualitative and quantitative PCRs, a 60-day treatment course with benznidazole and follow-up. Parents and healthcare agents were instructed on drug administration and early detection and notification of adverse drug-related reactions (ADR). Healthcare agents monitored medication adherence and ADRs at village level. PRINCIPAL FINDINGS The seroprevalence of T. cruzi infection was 24.1% among 395 residents up to 18 years of age examined. Serodiagnostic (70%) and treatment coverage (82%) largely exceeded local historical levels. Sixty-six (85%) of 78 eligible patients completed treatment with 97% medication adherence. ADRs occurred in 32% of patients, but most were mild and manageable. Four patients showing severe or moderate ADRs required treatment withdrawal. T. cruzi DNA was detected by qPCR in 47 (76%) patients before treatment, and persistently occurred in only one patient over 20-180 days posttreatment. CONCLUSIONS AND SIGNIFICANCE Our results demonstrate that diagnosis and treatment of T. cruzi infection in remote, impoverished rural areas can be effectively addressed through strengthened primary healthcare attention and broad social participation with adequate external support. This strategy secured high treatment coverage and adherence; effectively managed ADRs, and provided early evidence of positive therapeutic responses.
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Affiliation(s)
- Paula Sartor
- Universidad de Buenos Aires, Consejo Nacional de Investigaciones Científicas y Técnicas, Instituto de Ecología, Genética y Evolución de Buenos Aires (IEGEBA), Facultad de Ciencias Exactas y Naturales, Buenos Aires, Argentina.,Dirección de Epidemiología, Ministerio de Salud de la Provincia del Chaco, Chaco, Argentina.,Programa Nacional de Chagas, Ministerio de Salud de la Nación, Buenos Aires, Argentina
| | - Ivana Colaianni
- Universidad de Buenos Aires, Consejo Nacional de Investigaciones Científicas y Técnicas, Instituto de Ecología, Genética y Evolución de Buenos Aires (IEGEBA), Facultad de Ciencias Exactas y Naturales, Buenos Aires, Argentina.,Hospital Santojanni, Buenos Aires, Argentina
| | - M Victoria Cardinal
- Universidad de Buenos Aires, Consejo Nacional de Investigaciones Científicas y Técnicas, Instituto de Ecología, Genética y Evolución de Buenos Aires (IEGEBA), Facultad de Ciencias Exactas y Naturales, Buenos Aires, Argentina
| | - Jacqueline Bua
- Instituto Nacional de Parasitología "Dr. M. Fatala Chaben", ANLIS C.G. Malbrán, Buenos Aires, Argentina
| | - Héctor Freilij
- Programa Nacional de Chagas, Ministerio de Salud de la Nación, Buenos Aires, Argentina
| | - Ricardo E Gürtler
- Universidad de Buenos Aires, Consejo Nacional de Investigaciones Científicas y Técnicas, Instituto de Ecología, Genética y Evolución de Buenos Aires (IEGEBA), Facultad de Ciencias Exactas y Naturales, Buenos Aires, Argentina
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Murcia L, Carrilero B, Ferrer F, Roig M, Franco F, Segovia M. Success of benznidazole chemotherapy in chronic Trypanosoma cruzi-infected patients with a sustained negative PCR result. Eur J Clin Microbiol Infect Dis 2016; 35:1819-1827. [DOI: 10.1007/s10096-016-2733-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Accepted: 07/13/2016] [Indexed: 12/24/2022]
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Bermudez J, Davies C, Simonazzi A, Pablo Real J, Palma S. Current drug therapy and pharmaceutical challenges for Chagas disease. Acta Trop 2016; 156:1-16. [PMID: 26747009 DOI: 10.1016/j.actatropica.2015.12.017] [Citation(s) in RCA: 161] [Impact Index Per Article: 20.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2015] [Revised: 12/23/2015] [Accepted: 12/25/2015] [Indexed: 12/11/2022]
Abstract
One of the most significant health problems in the American continent in terms of human health, and socioeconomic impact is Chagas disease, caused by the protozoan parasite Trypanosoma cruzi. Infection was originally transmitted by reduviid insects, congenitally from mother to fetus, and by oral ingestion in sylvatic/rural environments, but blood transfusions, organ transplants, laboratory accidents, and sharing of contaminated syringes also contribute to modern day transmission. Likewise, Chagas disease used to be endemic from Northern Mexico to Argentina, but migrations have earned it global. The parasite has a complex life cycle, infecting different species, and invading a variety of cells - including muscle and nerve cells of the heart and gastrointestinal tract - in the mammalian host. Human infection outcome is a potentially fatal cardiomyopathy, and gastrointestinal tract lesions. In absence of a vaccine, vector control and treatment of patients are the only tools to control the disease. Unfortunately, the only drugs now available for Chagas' disease, Nifurtimox and Benznidazole, are relatively toxic for adult patients, and require prolonged administration. Benznidazole is the first choice for Chagas disease treatment due to its lower side effects than Nifurtimox. However, different strategies are being sought to overcome Benznidazole's toxicity including shorter or intermittent administration schedules-either alone or in combination with other drugs. In addition, a long list of compounds has shown trypanocidal activity, ranging from natural products to specially designed molecules, re-purposing drugs commercialized to treat other maladies, and homeopathy. In the present review, we will briefly summarize the upturns of current treatment of Chagas disease, discuss the increment on research and scientific publications about this topic, and give an overview of the state-of-the-art research aiming to produce an alternative medication to treat T. cruzi infection.
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IL18 Gene Variants Influence the Susceptibility to Chagas Disease. PLoS Negl Trop Dis 2016; 10:e0004583. [PMID: 27027876 PMCID: PMC4814063 DOI: 10.1371/journal.pntd.0004583] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2015] [Accepted: 03/07/2016] [Indexed: 12/14/2022] Open
Abstract
Chagas disease is a parasitic disorder caused by the infection with the flagellated protozoan Trypanosoma cruzi. According to the World Health Organization, more than six million people are currently infected in endemic regions. Genetic factors have been proposed to influence predisposition to infection and development of severe clinical phenotypes like chronic Chagas cardiomyopathy (CCC). Interleukin 18 (IL18) encodes a proinflammatory cytokine that has been proposed to be involved in controlling T. cruzi infection. In this study, we analyzed the possible role of six IL18 gene variants (rs5744258, rs360722, rs2043055, rs187238, rs1946518 and rs360719), which cover most of the variation within the locus, in the susceptibility to infection by T. cruzi and/or CCC. In total, 1,171 individuals from a Colombian region endemic for Chagas disease, classified as seronegative (n = 595), seropositive asymptomatic (n = 175) and CCC (n = 401), were genotyped using TaqMan probes. Significant associations with T. cruzi infection were observed when comparing seronegative and seropositive individuals for rs187238 (P = 2.18E-03, OR = 0.77), rs360719 (P = 1.49E-03, OR = 0.76), rs2043055 (P = 2.52E-03, OR = 1.29), and rs1946518 (P = 0.0162, OR = 1.22). However, dependence analyses suggested that the association was mainly driven by the polymorphism rs360719. This variant is located within the promoter region of the IL18 gene, and it has been described that it creates a binding site for the transcription factor OCT-1 affecting IL-18 expression levels. In addition, no evidence of association was observed between any of the analyzed IL18 gene polymorphisms and the development of CCC. In summary, our data suggest that genetic variation within the promoter region of IL18 is directly involved in the susceptibility to infection by T. cruzi, which provides novel insight into disease pathophysiology and adds new perspectives to achieve a more effective disease control.
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Sexual transmission of Trypanosoma cruzi in murine model. Exp Parasitol 2015; 162:1-6. [PMID: 26724377 DOI: 10.1016/j.exppara.2015.12.017] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Revised: 12/03/2015] [Accepted: 12/22/2015] [Indexed: 11/21/2022]
Abstract
Trypanosoma cruzi is mainly transmitted by blood-sucking triatomines, but other routes also have epidemiological importance, such as blood transfusion and congenital transmission. Although the possibility of sexual transmission of T. cruzi has been suggested since its discovery, few studies have been published on this subject. We investigated acquisition of T. cruzi by sexual intercourse in an experimental murine model. Male and female mice in the chronic phase of Chagas disease were mated with naive partners. Parasitological, serological and molecular tests demonstrated the parasites in tissues and blood of partners. These results confirm the sexual transmission of T. cruzi in mice.
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New Scheme of Intermittent Benznidazole Administration in Patients Chronically Infected with Trypanosoma cruzi: a Pilot Short-Term Follow-Up Study with Adult Patients. Antimicrob Agents Chemother 2015; 60:833-7. [PMID: 26596935 DOI: 10.1128/aac.00745-15] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2015] [Accepted: 11/15/2015] [Indexed: 11/20/2022] Open
Abstract
There is a clinical need to test new schemes of benznidazole administration that are expected to be at least as effective as the current therapeutic scheme but safer. This study assessed a new scheme of benznidazole administration in chronic Chagas disease patients. A pilot study with intermittent doses of benznidazole at 5 mg/kg/day in two daily doses every 5 days for a total of 60 days was designed. The main criterion of response was the comparison of quantitative PCR (qPCR) findings prior to and 1 week after the end of treatment. The safety profile was assessed by the rate of suspensions and severity of adverse effects. Twenty patients were analyzed for safety, while qPCR was tested for 17 of them. The average age was 43 ± 7.9 years; 55% were female. Sixty-five percent of treated subjects showed detectable qPCR results prior to treatment of 1.45 (0.63 to 2.81) and 2.1 (1.18 to 2.78) parasitic equivalents per milliliter of blood (par.eq/ml) for kinetoplastic DNA (kDNA) qPCR and nuclear repetitive sequence satellite DNA (SatDNA) qPCR, respectively. One patient showed detectable PCR at the end of treatment (1/17), corresponding to 6% treatment failure, compared with 11/17 (65%) patients pretreatment (P = 0.01). Adverse effects were present in 10/20 (50%) patients, but in only one case was treatment suspended. Eight patients showed mild adverse effects, whereas moderate reactions with increased liver enzymes were observed in two patients. The main accomplishment of this pilot study is the promising low rate of treatment suspension. Intermittent administration of benznidazole emerges a new potential therapeutic scheme, the efficacy of which should be confirmed by long-term assessment posttreatment.
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Santamaria C, Chatelain E, Jackson Y, Miao Q, Ward BJ, Chappuis F, Ndao M. Serum biomarkers predictive of cure in Chagas disease patients after nifurtimox treatment. BMC Infect Dis 2014; 14:302. [PMID: 24894358 PMCID: PMC4059459 DOI: 10.1186/1471-2334-14-302] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Accepted: 05/28/2014] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Chagas disease (CD), caused by the protozoan Trypanosoma cruzi, remains an important public health issue in many Central and South American countries, as well as non-endemic areas with high rates of immigration from these countries. Existing treatment options for CD are limited and often unsatisfactory. Moreover the lack of post-treatment tests of cure limits the development of new drugs. To address this issue, we sought to identify serum biomarkers following nifurtimox (Nfx) treatment that could be used as an early test of cure and/or markers of a therapeutic response. METHODS Human sera from Chagas patients pre- and post-treatment with Nfx (n = 37) were compared to samples from healthy subjects (n = 37) using a range of proteomic and immunologic techniques. Biomarker peaks with the best discriminatory power were further characterized. RESULTS Using serum samples (n = 111), we validated the presence of five key biomarkers identified in our previous study, namely human apolipoprotein A-I (APOA1) and specific fragments thereof and one fragment of human fibronectin (FN1). In chagasic serum samples all biomarkers except full-length APOA1 were upregulated. These five biomarkers returned to normal in 43% (16/37) of the patients treated with Nfx at three years after treatment. CONCLUSIONS The normalization of biomarker patterns strongly associated with CD suggests that these markers can be used to identify patients in whom Nfx treatment is successful. We believe that these are the first biomarkers predictive of cure in CD patients.
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Affiliation(s)
| | | | | | | | | | | | - Momar Ndao
- National Reference Center for Parasitology, Research Institute of the McGill University Health Centre, Department of Medicine, Division of Infectious Diseases, Montreal General Hospital, 1650 Cedar Ave,, Room R3-137, Montreal, Quebec H3G 1A4, Canada.
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Bustamante JM, Craft JM, Crowe BD, Ketchie SA, Tarleton RL. New, combined, and reduced dosing treatment protocols cure Trypanosoma cruzi infection in mice. J Infect Dis 2013; 209:150-62. [PMID: 23945371 DOI: 10.1093/infdis/jit420] [Citation(s) in RCA: 107] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
The development of treatment protocols with reduced toxicity and equivalent or improved efficacy for Trypanosoma cruzi infection is a priority. We tested the effectiveness of benznidazole (BZ), nifurtimox (NFX), other prospective drugs in intermittent and combined treatment protocols to cure T. cruzi infection initiated with susceptible and drug-resistant parasite strains. A 40-day course of BZ, NFX, or the oxaborale AN4169 cured 100% of mice, whereas posaconazole (POS), and NTLA-1 (a nitro-triazole) cured approximately 90% and 20% of mice, respectively. Reducing the overall dosage of BZ or NFX by using an intermittent (once every 5 days) schedule or combining 5 daily doses of POS with 7 intermittent doses of BZ also provided approximately 100% cure. T. cruzi strains resistant to BZ were also found to be resistant to other drugs (POS), and extending the time of treatment or combining drugs did not increase cure rates with these isolates. Thus, dosing schedules for anti-T. cruzi compounds should be determined empirically, and compounds targeting different pathways may be combined to yield effective therapies with reduced toxicity. This work also suggests that standard treatment protocols using BZ and NFX may be significantly overdosing patients, perhaps contributing to the adverse events.
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