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Paccoud O, Desnos-Ollivier M, Persat F, Demar M, Boukris-Sitbon K, Bellanger AP, Bonhomme J, Bonnal C, Botterel F, Bougnoux ME, Brun S, Cassaing S, Cateau E, Chouaki T, Cornet M, Dannaoui E, Desbois-Nogard N, Durieux MF, Favennec L, Fekkar A, Gabriel F, Gangneux JP, Guitard J, Hasseine L, Huguenin A, Le Gal S, Letscher-Bru V, Mahinc C, Morio F, Nicolas M, Poirier P, Ranque S, Roosen G, Rouges C, Roux AL, Sasso M, Alanio A, Lortholary O, Lanternier F. Features of cryptococcosis among 652 HIV-seronegative individuals in France: a cross-sectional observational study (2005-2020). Clin Microbiol Infect 2024; 30:937-944. [PMID: 38556212 DOI: 10.1016/j.cmi.2024.03.031] [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: 12/08/2023] [Revised: 02/20/2024] [Accepted: 03/24/2024] [Indexed: 04/02/2024]
Abstract
OBJECTIVES We aimed to describe features and outcomes of cryptococcosis among HIV-seronegative individuals in a large surveillance network for cryptococcosis in France. METHODS We included incident cases of cryptococcosis in HIV-seronegative individuals from 2005 to 2020. We compared patient characteristics, disease presentations, cryptococcal antigen results, and induction antifungal treatments according to underlying disease. We examined factors associated with 90-day mortality. Among patients with disseminated infections, we investigated whether receipt of flucytosine and polyene combination was associated with lower mortality. RESULTS Among 652 individuals, 209 (32.1%) had malignancy, 130 (19.9%) were solid-organ transplant recipients, 204 (31.3%) had other immunocompromising conditions, and 109 (16.7%) had no reported underlying factor. The commonest presentations were disseminated infections (63.3%, 413/652) and isolated pulmonary infections (25.3%, 165/652). Solid-organ transplant patients were most likely to have disseminated infections and a positive serum cryptococcal antigen result. Patients with malignancy were older and less likely to receive a flucytosine-containing regimen for disseminated infections than others (58.7%, 78/133 vs. 73.2%, 194/265; p 0.029). The crude 90-day case-fatality ratio was 27.2% (95% CI, 23.5%-31.1%). Age ≥60 years (aOR: 2.75 [1.78-4.26]; p < 0.001), meningitis/fungaemia (aOR: 4.79 [1.80-12.7]; p 0.002), and malignancy (aOR: 2.4 [1.14-5.07]; p 0.02) were associated with higher 90-day mortality. Receipt of flucytosine and polyene combination was associated with lower 90-day mortality (aOR: 0.40 [0.23-0.71]; p 0.002) in multivariable analysis and inverse probability of treatment weighted analysis (aOR: 0.45 [0.25-0.80]; p 0.006). DISCUSSION HIV-seronegative individuals with cryptococcosis comprise a wide range of underlying conditions with different presentations and outcomes, requiring a tailored approach to diagnosis and management.
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Affiliation(s)
- Olivier Paccoud
- Université Paris Cité, Department of Infectious Diseases and Tropical Medicine, Necker - Enfants Malades University Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), IHU Imagine, 75014 Paris, France.
| | - Marie Desnos-Ollivier
- Mycology Department, Institut Pasteur, Université Paris Cité, National Reference Center for Invasive Mycoses and Antifungals, Mycology Translational Research Group, France
| | - Florence Persat
- UR3738 Centre pour l'lnnovation en Cancérologie de Lyon, Team Inflammation and Immunity of the Respiratory Epithelium, Claude Bernard University-Lyon 1, 69495 Pierre Bénite, France; Department of Medical Mycology and Parasitology, Institute of Infectious Agents, Croix-Rousse Hospital, Hospices Civils de Lyon, 69004 Lyon, France
| | - Magalie Demar
- Laboratoire Hospitalo-Universitaire de Parasito-Mycologie, Centre hospitalier de Cayenne Guyane, Cayenne, France
| | - Karine Boukris-Sitbon
- Mycology Department, Institut Pasteur, Université Paris Cité, National Reference Center for Invasive Mycoses and Antifungals, Mycology Translational Research Group, France
| | - Anne-Pauline Bellanger
- CHU de Besançon, Laboratoire de Parasitologie-Mycologie, UMR Chrono-Environnement/CNRS 6249, F-25000, Besançon, France
| | - Julie Bonhomme
- Laboratoire de Parasitologie-Mycologie, CHU de Caen, ToxEMAC-ABTE, Unicaen Université Normandie, Caen, France
| | - Christine Bonnal
- Laboratory of Parasitology-Mycology, Bichat-Claude Bernard University Hospital, AP-HP, 75018 Paris, France
| | - Françoise Botterel
- Unité de Parasitologie - Mycologie, Département des agents infectieux, AP-HP, Dynamyc research Unit, UPEC, France
| | - Marie-Elisabeth Bougnoux
- Unité de Parasitologie-Mycologie, Service de Microbiologie Clinique, Hôpital Necker-Enfants-Malades, AP-HP, Paris, France; Institut Pasteur, Université Paris Cité, INRAE USC2019, Unité Biologie et Pathogénicité Fongiques, Paris, France
| | - Sophie Brun
- Parasitology-Mycology Department, Avicenne Hospital, AP-HP, Bobigny, France
| | - Sophie Cassaing
- Department of Parasitology and Mycology, Toulouse University Hospital, Restore-FLAMES, Toulouse III University, France
| | - Estelle Cateau
- Laboratoire de Parasitologie-Mycologie - CHU de Poitiers, Ecologie et Biologie des Interactions UMR CNRS 7267, France
| | - Taieb Chouaki
- Service de Parasitologie Mycologie Médicales, CHU Amiens Picardie 80054, Amiens, France; Inserm U1285, Univ. Lille, CNRS, UMR 8576 - UGSF - Unité de Glycobiologie Structurale et Fonctionnelle, F-59000 Lille, France
| | - Muriel Cornet
- Université Grenoble Alpes, CNRS, UMR 5525, CHU Grenoble Alpes, VetAgro Sup, Grenoble INP, TIMC, 38000 Grenoble, France
| | - Eric Dannaoui
- Mycology Department, Institut Pasteur, Université Paris Cité, National Reference Center for Invasive Mycoses and Antifungals, Mycology Translational Research Group, France; Unité de Parasitologie-Mycologie, Service de Microbiologie Clinique, Hôpital Necker-Enfants-Malades, AP-HP, Paris, France
| | - Nicole Desbois-Nogard
- Laboratoire de Parasitologie-Mycologie, Centre Hospitalier Universitaire de Martinique, Fort-de-France, Martinique, France
| | | | - Loïc Favennec
- French National Cryptosporidiosis Reference Center, CHU de Rouen, Rouen, Normandie, France; EA 7510, UFR Santé, University of Rouen Normandy, Rouen, France
| | - Arnaud Fekkar
- AP-HP, Groupe Hospitalier La Pitié-Salpêtrière, Parasitologie Mycologie, F-75013, Paris, France; Sorbonne Université, Inserm, CNRS, Centre d'Immunologie et des Maladies Infectieuses, Cimi-Paris, F-75013, Paris, France
| | - Frederic Gabriel
- Laboratoire de Parasitologie-Mycologie, CHU de Bordeaux, F-33000 Bordeaux, France
| | - Jean-Pierre Gangneux
- Université de Rennes, CHU Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail) - UMR_S 1085, Laboratory of Parasitology and Medical Mycology, European Confederation of Medical Mycology (ECMM) Excellence Center, Centre National de Référence Aspergilloses Chroniques, Rennes Teaching Hospital, F-35000 Rennes, France
| | - Juliette Guitard
- Sorbonne Université, Inserm, Centre de Recherche Saint-Antoine, CRSA, AP-HP, Hôpital Saint-Antoine, Service de Parasitologie-Mycologie, Paris, France
| | - Lilia Hasseine
- Parasitologie - Mycologie, Hôpital de l'Archet, CHU Nice, Nice, Provence-Alpes-Côte d'Azur, France
| | - Antoine Huguenin
- Université de Reims Champagne Ardenne, ESCAPE EA7510, Laboratoire de Parasitologie-Mycologie, Pôle de Biologie Pathologie, CHU de Reims, Rue du Général Koening, Reims, France
| | - Solène Le Gal
- CHU de Brest, Laboratoire de Parasitologie-Mycologie, Univ Brest, Univ Angers, Infections Respiratoires Fongiques, F-29200, Brest, France
| | - Valérie Letscher-Bru
- Laboratoire de Parasitologie et Mycologie Médicale, Les Hôpitaux Universitaires de Strasbourg, Institut de Parasitologie et Pathologie Tropicale, UR7292 Dynamique des interactions hôte pathogène, Fédération de Médecine Translationnelle, Université de Strasbourg, Strasbourg, France
| | - Caroline Mahinc
- Centre Hospitalier Universitaire de Saint Etienne, Service de Parasitologie Mycologie, Saint Etienne, France
| | - Florent Morio
- Nantes Université, CHU Nantes, Cibles et Médicaments des Infections et de l'Immunité, UR1155, Nantes, France
| | - Muriel Nicolas
- Laboratoire de Parasitologie-Mycologie, Centre Hospitalier Universitaire de Guadeloupe, Pointe-à-Pitre, Guadeloupe, France
| | - Philippe Poirier
- Université Clermont Auvergne, Inserm, 3IHP, Centre Hospitalier Universitaire Clermont-Ferrand, Service de Parasitologie-Mycologie, Clermont-Ferrand, France
| | - Stéphane Ranque
- Aix-Marseille Université, IHU Méditerranée Infection, AP-HM, IRD, SSA, VITROME, 13005 Marseille, France
| | | | - Célia Rouges
- Laboratoire de Parasitologie-Mycologie, Centre Hospitalier Universitaire Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Anne-Laure Roux
- Université Paris-Saclay, UVSQ, Inserm, Infection et Inflammation, Montigny-Le-Bretonneux, France; AP-HP, GHU Paris Saclay, Hôpital Ambroise Paré, Microbiology Department, Boulogne-Billancourt, France
| | - Milène Sasso
- Laboratoire de Parasitologie-Mycologie, CHU Nîmes & Université de Montpellier, CNRS, IRD, MiVEGEC, Montpellier, France
| | - Alexandre Alanio
- Mycology Department, Institut Pasteur, Université Paris Cité, National Reference Center for Invasive Mycoses and Antifungals, Mycology Translational Research Group, France; Laboratoire de Parasitologie-Mycologie, AP-HP, Hôpital Saint-Louis, F-75010 Paris, France
| | - Olivier Lortholary
- Université Paris Cité, Department of Infectious Diseases and Tropical Medicine, Necker - Enfants Malades University Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), IHU Imagine, 75014 Paris, France; Mycology Department, Institut Pasteur, Université Paris Cité, National Reference Center for Invasive Mycoses and Antifungals, Mycology Translational Research Group, France
| | - Fanny Lanternier
- Université Paris Cité, Department of Infectious Diseases and Tropical Medicine, Necker - Enfants Malades University Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), IHU Imagine, 75014 Paris, France; Mycology Department, Institut Pasteur, Université Paris Cité, National Reference Center for Invasive Mycoses and Antifungals, Mycology Translational Research Group, France
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Liu MZ, Dai XH, Zeng MT, Chen EQ. Clinical treatment of cryptococcal meningitis: an evidence-based review on the emerging clinical data. J Neurol 2024; 271:2960-2979. [PMID: 38289535 DOI: 10.1007/s00415-024-12193-8] [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: 11/10/2023] [Revised: 01/07/2024] [Accepted: 01/13/2024] [Indexed: 05/30/2024]
Abstract
Cryptococcal meningitis (CM) is a fatal fungal central nervous system (CNS) infection caused by Cryptococcus infecting the meninges and/or brain parenchyma, with fever, headache, neck stiffness, and visual disturbances as the primary clinical manifestations. Immunocompromised individuals with human immunodeficiency virus (HIV) infection or who have undergone organ transplantation, as well as immunocompetent people can both be susceptible to CM. Without treatment, patients with CM may have a mortality rate of up to 100% after hospital admission. Even after receiving therapy, CM patients may still suffer from problems such as difficulty to cure, poor prognosis, and high mortality. Therefore, timely and effective treatment is essential to improve the mortality and prognosis of CM patients. Currently, the clinical outcomes of CM are frequently unsatisfactory due to limited drug choices, severe adverse reactions, drug resistance, etc. Here, we review the research progress of CM treatment strategies and discuss the suitable options for managing CM, hoping to provide a reference for physicians to select the most appropriate treatment regimens for CM patients.
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Affiliation(s)
- Mao-Zhu Liu
- Center of Infectious Diseases, West China Hospital, Sichuan University, No.37 Guo Xue Xiang, Wuhou District, Chengdu, 610041, China
- Department of Pharmacy, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Xin-Hua Dai
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Ming-Tang Zeng
- Department of Pharmacy, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - En-Qiang Chen
- Center of Infectious Diseases, West China Hospital, Sichuan University, No.37 Guo Xue Xiang, Wuhou District, Chengdu, 610041, China.
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Kouamou V, Makadzange AT. Simplified regimens for AIDS-related cryptococcal meningitis - improving its access in Africa. AIDS 2023; 37:2253-2257. [PMID: 37877282 DOI: 10.1097/qad.0000000000003699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2023]
Affiliation(s)
- Vinie Kouamou
- Charles River Medical Group
- Unit of Internal Medicine, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare, Zimbabwe
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Paccoud O, Shuping L, Mashau R, Greene G, Quan V, Meiring S, Govender NP. Impact of prior cryptococcal antigen screening on in-hospital mortality in cryptococcal meningitis or fungaemia among HIV-seropositive individuals in South Africa: a cross-sectional observational study. Clin Microbiol Infect 2023; 29:1063-1069. [PMID: 37086780 DOI: 10.1016/j.cmi.2023.04.016] [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: 02/08/2023] [Revised: 04/11/2023] [Accepted: 04/15/2023] [Indexed: 04/24/2023]
Abstract
OBJECTIVES We investigated whether patients with cryptococcal meningitis (CM) or fungaemia detected through South Africa's laboratory cryptococcal antigen (CrAg) screening programme had better outcomes than those presenting directly to the hospital. METHODS We compared 14-day in-hospital case-fatality ratios of HIV-seropositive individuals with CD4 counts below 100 cells/μL and laboratory-confirmed CM/fungaemia from 2017-2021, with or without evidence of a positive blood CrAg test within 14 days prior to diagnosis. We evaluated whether the impact of prior CrAg screening on mortality varied according to the study period (pre-COVID-19: before March 2020 vs. COVID-19: after March 2020). RESULTS Overall, 24.5% (830/3390) of patients had a prior positive CrAg test within 14 days of diagnosis. CrAg-screened patients were less likely to have an altered mental status at baseline than non-CrAg-screened patients (38.1% [296/776] vs. 42.6% [1010/2372], p = 0.03), and had a lower crude 14-day case-fatality ratio (24.7% [205/830] vs. 28.3% [724/2560]; OR, 0.83 [95% CI, 0.69-0.99]; p = 0.045). Previous CrAg screening was associated with a greater reduction in the crude 14-day mortality during the COVID-19 period (OR, 0.64 [0.47-0.87]; p = 0.005) compared with before (OR, 0.95 [0.76-1.19]; p = 0.68). After adjustment, previous CrAg screening within 14 days was associated with increased survival only during the COVID-19 period (adjusted OR, 0.70 [0.51-0.96]; p = 0.03). DISCUSSION Previous CrAg screening was associated with a survival benefit in patients hospitalized with CM/fungaemia during the COVID-19 period, with fewer patients having an altered mental status at baseline, suggesting that these patients may have been diagnosed with cryptococcosis earlier.
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Affiliation(s)
- Olivier Paccoud
- Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses, National Institute for Communicable Diseases, A Division of the National Health Laboratory Service, Johannesburg, South Africa; Université Paris Cité, Necker-Pasteur Center for Infectious Diseases and Tropical Medicine, Hospital Necker-Enfants Maladies, Assistance Publique-Hopitaux de Paris, Paris, France
| | - Liliwe Shuping
- Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses, National Institute for Communicable Diseases, A Division of the National Health Laboratory Service, Johannesburg, South Africa
| | - Rudzani Mashau
- Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses, National Institute for Communicable Diseases, A Division of the National Health Laboratory Service, Johannesburg, South Africa
| | - Greg Greene
- Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses, National Institute for Communicable Diseases, A Division of the National Health Laboratory Service, Johannesburg, South Africa
| | - Vanessa Quan
- Division of Public Health Surveillance and Response, National Institute for Communicable Diseases, A Division of the National Health Laboratory Service, Johannesburg, South Africa
| | - Susan Meiring
- Division of Public Health Surveillance and Response, National Institute for Communicable Diseases, A Division of the National Health Laboratory Service, Johannesburg, South Africa; School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Nelesh P Govender
- Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses, National Institute for Communicable Diseases, A Division of the National Health Laboratory Service, Johannesburg, South Africa; School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Institute of Infection and Immunity, St George's University of London, London, UK; Medical Research Council Centre for Medical Mycology, University of Exeter, Exeter, UK; Division of Medical Microbiology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
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Sprute R, Duda S, Liekweg A, Simon M, Cornely OA. The silent flucytosine shortage in Europe - not a distant problem. THE LANCET REGIONAL HEALTH. EUROPE 2023; 30:100658. [PMID: 37293188 PMCID: PMC10245318 DOI: 10.1016/j.lanepe.2023.100658] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 05/17/2023] [Indexed: 06/10/2023]
Affiliation(s)
- Rosanne Sprute
- Faculty of Medicine and University Hospital Cologne, Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, Cologne, Germany
- Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD) and Excellence Center for Medical Mycology (ECMM), University of Cologne, Cologne, Germany
- German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany
| | - Seraina Duda
- Hospital Pharmacy, University Hospital Cologne, Germany
| | | | - Michaela Simon
- Institute for Medical Microbiology, Immunology, and Hygiene, University Hospital Cologne and Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Oliver A. Cornely
- Faculty of Medicine and University Hospital Cologne, Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, Cologne, Germany
- Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD) and Excellence Center for Medical Mycology (ECMM), University of Cologne, Cologne, Germany
- German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany
- Faculty of Medicine and University Hospital Cologne, Clinical Trials Centre Cologne (ZKS Köln), University of Cologne, Cologne, Germany
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John LL, Thomson DD, Bicanic T, Hoenigl M, Brown AJ, Harrison TS, Bignell EM. Heightened Efficacy of Anidulafungin When Used in Combination with Manogepix or 5-Flucytosine against Candida auris In Vitro. Antimicrob Agents Chemother 2023; 67:e0164522. [PMID: 37162367 PMCID: PMC10269148 DOI: 10.1128/aac.01645-22] [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: 12/14/2022] [Accepted: 03/20/2023] [Indexed: 05/11/2023] Open
Abstract
Candida auris is an emerging, multidrug-resistant fungal pathogen that causes refractory colonization and life-threatening, invasive nosocomial infections. The high proportion of C. auris isolates that display antifungal resistance severely limits treatment options. Combination therapies provide a possible strategy by which to enhance antifungal efficacy and prevent the emergence of further resistance. Therefore, we examined drug combinations using antifungals that are already in clinical use or are undergoing clinical trials. Using checkerboard assays, we screened combinations of 5-flucytosine and manogepix (the active form of the novel antifungal drug fosmanogepix) with anidulafungin, amphotericin B, or voriconazole against drug resistant and susceptible C. auris isolates from clades I and III. Fractional inhibitory concentration indices (FICI values) of 0.28 to 0.75 and 0.36 to 1.02 were observed for combinations of anidulafungin with manogepix or 5-flucytosine, respectively, indicating synergistic activity. The high potency of these anidulafungin combinations was confirmed using live-cell microfluidics-assisted imaging of the fungal growth. In summary, combinations of anidulafungin with manogepix or 5-flucytosine show great potential against both resistant and susceptible C. auris isolates.
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Affiliation(s)
- Larissa L.H. John
- Medical Research Council Centre for Medical Mycology, University of Exeter, Geoffrey Pope Building, Stocker Road, Exeter, United Kingdom
| | - Darren D. Thomson
- Medical Research Council Centre for Medical Mycology, University of Exeter, Geoffrey Pope Building, Stocker Road, Exeter, United Kingdom
| | - Tihana Bicanic
- Medical Research Council Centre for Medical Mycology, University of Exeter, Geoffrey Pope Building, Stocker Road, Exeter, United Kingdom
- Institute of Infection and Immunity, St George’s University of London, Cranmer Terrace, London, United Kingdom
- Clinical Academic Group in Infection and Immunity, St George’s University Hospitals NHS Foundation Trust, Cranmer Terrace, London, United Kingdom
| | - Martin Hoenigl
- Division of Infectious Diseases, Medical University of Graz, Austria
- BioTechMed, Graz, Austria
- Translational Medical Mycology Research Unit, ECMM Excellence Center for Medical Mycology, Medical University of Graz, Graz, Austria
| | - Alistair J.P. Brown
- Medical Research Council Centre for Medical Mycology, University of Exeter, Geoffrey Pope Building, Stocker Road, Exeter, United Kingdom
| | - Thomas S. Harrison
- Medical Research Council Centre for Medical Mycology, University of Exeter, Geoffrey Pope Building, Stocker Road, Exeter, United Kingdom
- Institute of Infection and Immunity, St George’s University of London, Cranmer Terrace, London, United Kingdom
- Clinical Academic Group in Infection and Immunity, St George’s University Hospitals NHS Foundation Trust, Cranmer Terrace, London, United Kingdom
| | - Elaine M. Bignell
- Medical Research Council Centre for Medical Mycology, University of Exeter, Geoffrey Pope Building, Stocker Road, Exeter, United Kingdom
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Osborn MR, Spec A, Mazi PB. Management of HIV-Associated Cryptococcal Meningitis. CURRENT FUNGAL INFECTION REPORTS 2023. [DOI: 10.1007/s12281-023-00458-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
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Harrison TS, Lawrence DS, Mwandumba HC, Boulware DR, Hosseinipour MC, Lortholary O, Meintjes G, Mosepele M, Jarvis JN. How Applicable Is the Single-Dose AMBITION Regimen for Human Immunodeficiency Virus-Associated Cryptococcal Meningitis to High-Income Settings? Clin Infect Dis 2023; 76:944-949. [PMID: 36166405 PMCID: PMC9989135 DOI: 10.1093/cid/ciac792] [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: 07/01/2022] [Revised: 09/05/2022] [Accepted: 09/23/2022] [Indexed: 11/12/2022] Open
Abstract
The AmBisome Therapy Induction Optimization (AMBITION-cm) trial, conducted in eastern and southern Africa, showed that a single, high dose (10 mg/kg) of liposomal amphotericin B, given with an oral backbone of fluconazole and flucytosine, was noninferior to the World Health Organization (WHO)-recommended regimen of 7 days of amphotericin B deoxycholate plus flucytosine for treatment of human immunodeficiency virus (HIV)-associated cryptococcal meningitis and has been incorporated into WHO treatment guidelines. We believe that the trial also has important implications for the treatment of HIV-associated cryptococcal meningitis in high-income settings. We advance the arguments, supported by evidence where available, that the AMBITION-cm trial regimen is likely to be as fungicidal as the currently recommended 14-day liposomal amphotericin-based treatments, better tolerated with fewer adverse effects, and confer significant economic and practical benefits and, therefore, should be included as a treatment option in guidance for HIV-associated cryptococcal treatment in high-income settings.
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Affiliation(s)
- Thomas S Harrison
- Institute of Infection and Immunity, St George's University London, London, United Kingdom
- Clinical Academic Group in Infection and Immunity, St George's University Hospitals NHS Foundation Trust, London, United Kingdom
- Medical Research Council Centre for Medical Mycology, University of Exeter, Exeter, United Kingdom
| | - David S Lawrence
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Henry C Mwandumba
- Clinical Sciences Department, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
- Malawi-Liverpool-Wellcome Clinical Research Programme, Blantyre, Malawi
- Department of Medicine, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - David R Boulware
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Mina C Hosseinipour
- Lilongwe Medical Relief Trust (University of North Carolina Project), Lilongwe, Malawi
- Department of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Olivier Lortholary
- Institut Pasteur, National Center for Scientific Research, Molecular Mycology Unit and National Reference Center for Invasive Mycoses and Antifungals, Unités Mixtes de Recherche 2000, Paris, France
- Université de Paris-Cité, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, Hôpital Necker Enfants Malades, Assistance Publique–Hôpitaux de Paris, IHU Imagine, Paris, France
| | - Graeme Meintjes
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Mosepele Mosepele
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- Department of Internal Medicine, University of Botswana, Gaborone, Botswana
| | - Joseph N Jarvis
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
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Wake RM, Molloy SF, Jarvis JN, Harrison TS, Govender NP. Cryptococcal Antigenemia in Advanced Human Immunodeficiency Virus Disease: Pathophysiology, Epidemiology, and Clinical Implications. Clin Infect Dis 2023; 76:764-770. [PMID: 35986670 PMCID: PMC9938740 DOI: 10.1093/cid/ciac675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 08/11/2022] [Accepted: 08/17/2022] [Indexed: 11/14/2022] Open
Abstract
Cryptococcal antigen (CrAg) is detectable in blood prior to the onset of symptomatic cryptococcal meningitis (CM), a leading cause of death among people with advanced human immunodeficiency virus (HIV) disease globally. Highly sensitive assays can detect CrAg in blood, and screening people with HIV with low CD4 counts, followed by preemptive antifungal treatment, is recommended and widely implemented as part of a global strategy to prevent CM and end cryptococcal-related deaths. Cryptococcal antigenemia encompasses a spectrum of conditions from preclinical asymptomatic infection (cerebrospinal fluid [CSF] CrAg-negative) through subclinical (CSF CrAg-positive without overt meningism) to clinical symptomatic cryptococcal disease, usually manifesting as CM. In this review, we summarize current understanding of the pathophysiology, risk factors for, and clinical implications of cryptococcal antigenemia within this spectrum. We also provide an update on global prevalence, recommended screening and treatment strategies, and future considerations for improving outcomes among patients with cryptococcal antigenemia.
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Affiliation(s)
- Rachel M Wake
- Institute for Infection and Immunity, St George’s University of London, London, United Kingdom
- Clinical Academic Group in Infection and Immunity, St George’s University Hospitals National Health Service Foundation Trust, London, United Kingdom
| | - Síle F Molloy
- Institute for Infection and Immunity, St George’s University of London, London, United Kingdom
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Joseph N Jarvis
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Thomas S Harrison
- Institute for Infection and Immunity, St George’s University of London, London, United Kingdom
- Clinical Academic Group in Infection and Immunity, St George’s University Hospitals National Health Service Foundation Trust, London, United Kingdom
- MRC Centre for Medical Mycology, University of Exeter, Exeter, United Kingdom
| | - Nelesh P Govender
- Institute for Infection and Immunity, St George’s University of London, London, United Kingdom
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- MRC Centre for Medical Mycology, University of Exeter, Exeter, United Kingdom
- Division of the National Health Laboratory Service, Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses, National Institute for Communicable Diseases, Johannesburg, South Africa
- Division of Medical Microbiology, University of Cape Town, Cape Town, South Africa
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Zhao H, Cheng J, Zhou L, Luo Y, Zhu R, Jiang Y, Wang X, Zhu L. Induction therapy with high dose fluconazole plus flucytosine for human immunodeficiency virus‐uninfected cryptococcal meningitis patients: Feasible or not? Mycoses 2022; 66:59-68. [PMID: 36111370 PMCID: PMC10087831 DOI: 10.1111/myc.13528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 09/05/2022] [Accepted: 09/09/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Cryptococcal meningitis (CM) is increasingly recognised in human immunodeficiency virus (HIV)-uninfected patients with high mortality. The efficacy and safety profiles of induction therapy with high-dose fluconazole plus flucytosine remain unclear. METHODS HIV-uninfected CM patients who received high-dose fluconazole (800 mg/d) for initial therapy in Huashan Hospital were included in this retrospective study from January 2013 to December 2018. Efficacy and safety of initial therapy, clinical outcomes and risk factors were evaluated. RESULTS Twenty-seven (71.1%) patients who received high-dose fluconazole with flucytosine combination therapy and 11 (28.9%) having fluconazole alone for induction therapy were included. With a median duration of 42 days (IQR, 28-86), the successful response rate of initial therapy was 76.3% (29/38), while adverse drug reactions occurred in 14 patients (36.8%). The rate of persistently positive cerebrospinal fluid (CSF) culture results was 30.6% at 2 weeks, which was significantly associated with CSF CrAg titre >1:1280 (OR 9.56; 95% CI 1.40-103.65; p = .010) and CSF culture of Cryptococcus >3.9 log10 CFU/ml (OR 19.20; 95% CI 1.60-920.54; p = .011), and decreased to 8.6% at 4 weeks. One-year mortality was 15.8% (6/38), and low serum albumin (35 g/L) was found as an independent risk factor for 1-year mortality (HR 6.31; 95% CI 1.150-34.632; p = .034). CONCLUSIONS Induction therapy with high-dose fluconazole (800 mg/d), combined with flucytosine, effectively treated HIV-uninfected CM and was well tolerated. Long-term fluconazole treatment with continued monitoring is beneficial for patients with persistent infection.
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Affiliation(s)
- Hua‐Zhen Zhao
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, National Medical Center for Infectious Diseases, Huashan Hospital Fudan University Shanghai China
| | - Jia‐Hui Cheng
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, National Medical Center for Infectious Diseases, Huashan Hospital Fudan University Shanghai China
| | - Ling‐Hong Zhou
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, National Medical Center for Infectious Diseases, Huashan Hospital Fudan University Shanghai China
| | - Yu Luo
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, National Medical Center for Infectious Diseases, Huashan Hospital Fudan University Shanghai China
| | - Rong‐Sheng Zhu
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, National Medical Center for Infectious Diseases, Huashan Hospital Fudan University Shanghai China
| | - Ying‐Kui Jiang
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, National Medical Center for Infectious Diseases, Huashan Hospital Fudan University Shanghai China
| | - Xuan Wang
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, National Medical Center for Infectious Diseases, Huashan Hospital Fudan University Shanghai China
| | - Li‐Ping Zhu
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, National Medical Center for Infectious Diseases, Huashan Hospital Fudan University Shanghai China
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Temfack E, Lortholary O. Access to flucytosine for the treatment of HIV-associated cryptococcal meningitis in Africa. THE LANCET. INFECTIOUS DISEASES 2022; 22:1262-1264. [PMID: 35750066 DOI: 10.1016/s1473-3099(22)00315-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 05/06/2022] [Indexed: 06/15/2023]
Affiliation(s)
- Elvis Temfack
- Africa Centers for Disease Control and Prevention, Addis Ababa, Ethiopia; National Public Health Laboratory, Yaoundé, Cameroon.
| | - Olivier Lortholary
- Molecular Mycology Unit, Institut Pasteur of Paris, Paris, France; Department of Infectious and Tropical Diseases, University of Paris Cité, Paris, France; Department of Infectious and Tropical Diseases, Necker Hospital, Paris, France
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Affiliation(s)
- Diego R Falci
- Pontificia Universidade Católica do Rio Grande do Sul, Porto Alegre, Brazil
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