Antifungal Combinations for Treatment of Cryptococcal Meningitis in Africa

Duration of systemic antifungal therapy for patients with invasive fungal diseases: A reassessment

Invasive fungal diseases are associated with significant morbidity and mortality, especially among immunocompromised patients, and often prompt for rapid and aggressive treatment aiming cure. Due to the expanding magnitude of patients burdened by chronic immunosuppression and affected by fungal diseases, the diversity of clinical settings has risen. This often results in prolonged therapy (induction, consolidation and maintenance) associated with potentially severe side effects, and clinicians face the challenging decisions of when and how to stop anti-fungal therapy. Adequate duration of therapy is poorly defined, hampered by the lack of dedicated trials to the question, the heterogeneity of cases (type of fungal pathogen, localization of infection, underlying host conditions) and various confounding factors that may influence the clinical response (e.g. persistence vs recovery of immunosuppression, impact of surgery). In this review, we aim to evaluate the existing data underlying the guidelines and recommendations of treatment duration for the most frequent invasive fungal diseases (cryptococcal meningitis, Pneumocystis pneumonia, invasive aspergillosis, invasive candidiasis and mucormycosis), as well as specific localizations of deep-seated diseases (osteo-articular or central nervous system diseases and endocarditis) and emerging considerations and strategies.

Personalised risk-prediction tools for cryptococcal meningitis mortality to guide treatment stratification in sub-Saharan Africa: a prognostic modelling study based on pooled analysis of two randomised controlled trials

BACKGROUND

Cryptococcal meningitis is a major driver of global HIV-related mortality, and validated approaches to stratify mortality risk could help to target effective treatment strategies. We aimed to develop and validate models to predict risk of all-cause mortality in people with HIV-associated cryptococcal meningitis in sub-Saharan African countries.

METHODS

For this prediction modelling study, we pooled individual-level data from the ACTA (ISRCTN45035509) and AMBITION-cm (ISRCTN72509687) randomised controlled trials. Data in ACTA were collected between Feb 12, 2013, and Jan 10, 2017, and data in AMBITION-cm were collected between Jan 31, 2018, and June 11, 2021. Adults aged 18 years or older with a first episode of HIV-associated cryptococcal meningitis were recruited to both trials. Exclusion criteria included pregnancy or lactation; receipt of high-dose anti-fungal treatment doses before screening; and contraindications to trial medication. Participants were recruited from nine hospitals across Cameroon, Malawi, Tanzania, and Zambia in ACTA and eight hospitals across Botswana, Malawi, South Africa, Uganda, and Zimbabwe in AMBITION-cm. We developed two primary multivariable logistic-regression models for the primary outcome of 2-week mortality: a basic model for use in a resource-limited setting that contained only candidate predictors that are routinely, programmatically obtained at hospital admission and a research model for which all predefined candidate predictors were considered for inclusion. We used internal-external cross-validation to evaluate model performance across countries within the development cohort (ie, data from all countries except Malawi participants in AMBITION-cm), before validation of discrimination, calibration, and net benefit in held-out data from Malawi.

FINDINGS

We included 674 eligible participants from ACTA and 814 from AMBITION-cm in the pooled analysis (total sample size 1488). 1263 participants were included in model development, with 225 from the Malawi site in AMBITION-cm held out for validation. 222 (17·6%) of 1263 participants in the development set and 21 (9·3%) of 225 participants in the validation set met the primary model outcome of 2-week mortality. We retained five predictors in the basic model and seven in the research model. Predictors in both models were Glasgow Coma Scale score, Eastern Cooperative Oncology Group performance status, haemoglobin, blood neutrophil count, and treatment. Additional predictors in the research model were cerebrospinal fluid opening pressure and log10 cerebrospinal fluid quantitative cryptococcal culture. Discrimination was relatively consistent between study sites for both models (pooled C statistic 0·75 [95% CI 0·68-0·82] for the basic model and 0·78 [0·75-0·82] for the research model), but calibration was more heterogeneous (pooled calibration slope 0·87 [95% CI 0·57 to 1·17] and 0·83 [0·69 to 0·97], pooled calibration in the large 0·00 [-0·54 to 0·55] and -0·02 [-0·46 to 0·42], for the basic and research models, respectively). In held-out validation, discrimination of both models was slightly higher than estimates from internal-external cross-validation (C statistic 0·78 [95% CI 0·70-0·87] in the basic model and 0·85 [0·79-0·92] in the research model). Calibration assessment suggested overestimation of risk, particularly in the high-risk range: calibration slope 1·04 (95% CI 0·54 to 1·55), calibration in the large -0·55 (-1·02 to -0·07). When comparing single, high-dose liposomal amphotericin B plus 14 days of flucytosine plus fluconazole with 1 week of amphotericin B plus flucytosine in AMBITION-cm, hazard ratios were 0·50 (95% CI 0·26-0·97) in the low-risk stratum and 0·96 (0·67-1·37) in the high-risk stratum for the basic model, and 0·61 (0·31-1·18) in the low-risk stratum and 1·03 (0·72-1·47) in the high-risk stratum for the research model.

INTERPRETATION

Both models accurately predicted 2-week mortality in people with HIV and have the potential to be incorporated into future treatment-stratification approaches in low-income and middle-income countries.

FUNDING

National Institute for Health Research.

Management, Outcomes, and Predictors of Mortality of Cryptococcus Infection in Patients Without HIV: A Multicenter Study in 46 Hospitals in Australia and New Zealand

BACKGROUND

Limited data exist regarding outcomes of cryptococcosis in patients without human immunodeficiency virus (HIV), and few studies have compared outcomes of Cryptococcus gattii versus Cryptococcus neoformans infection.

METHODS

We conducted a retrospective study in 46 Australian and New Zealand hospitals to determine the outcomes of cryptococcosis in patients without HIV diagnosed between 2015 and 2019 and compared outcomes of C. gattii versus C. neoformans infections. Multivariable analysis identified predictors of mortality within 1 year.

RESULTS

Of 426 patients, 1-year all-cause mortality was 21%. Cryptococcus gattii infection was associated with lower mortality than C. neoformans (adjusted odds ratio [OR], 0.47; 95% confidence interval [CI], .23-.95), while severe neurological symptoms at presentation were the strongest predictor of death (adjusted OR, 8.46; 95% CI, 2.99-23.98). Almost all (99.5%) patients with central nervous system (CNS) infection received induction antifungal therapy versus 27.7% with isolated pulmonary cryptococcosis. The most common regimen in CNS disease was liposomal amphotericin B with flucytosine (93.8%; mean duration, 31 ± 13 days). Among patients with CNS cryptococcosis, C. gattii infection was associated with higher risk of immune reconstitution inflammatory response (C-IRIS) than C. neoformans (21% versus 3%, P < .001). Nineteen patients received amphotericin B-based re-induction therapy for suspected relapse, but none had microbiological relapse. Serum cryptococcal antigen positivity and lung imaging abnormalities resolved slowly (resolution at 1 year in 25% and 34% of patients, respectively).

CONCLUSIONS

Compared with C. neoformans, C. gattii infection demonstrated lower mortality but higher C-IRIS risk in CNS infection. Severe neurological symptoms were the strongest predictor of mortality.

Induction Treatment for HIV-Associated Cryptococcal Meningitis: Where Have We Been and Where Are We Going?

Cryptococcal meningitis remains a leading cause of morbidity and mortality among individuals with HIV/AIDS, particularly in resource-limited settings. Treatment begins with induction therapy followed by consolidation and maintenance. Evidence related to induction therapy has evolved significantly over the past decade. Current treatment relies primarily on three antifungal agents: amphotericin B, flucytosine, and fluconazole, each with distinct mechanisms of action and limitations. The World Health Organization's 2022 guidelines for induction therapy recommend a single high dose of liposomal amphotericin B combined with 14 days of flucytosine and fluconazole. The 2010 IDSA guidelines for induction therapy recommend amphotericin B deoxycholate and flucytosine for two weeks. The U.S. CDC/NIH/IDSA/HIVMA joint guidelines and the ECCM/ISHAM/ASM joint guidelines list both options, but the recommendation varies by setting resources (e.g., resource-limited vs. other). The newer treatment approaches (single high-dose liposomal amphotericin B) that are supported by trials such as AMBITION-cryptococcal meningitis have limited adoption in high-resource settings, with recent studies showing that only 14% of North American infectious disease providers have utilized the regimen. Adjunctive medications, such as dexamethasone, tamoxifen, and sertraline, have proven ineffective or harmful in clinical trials. This review underscores the ongoing challenges in cryptococcal meningitis treatment and the need for continued research to improve patient outcomes, tracing the evolution from past monotherapy approaches to current combination strategies while exploring future directions.

Availability and cost of antifungal therapy in Vietnam: A 5-year retrospective study

Access to antifungal agents for the treatment of invasive fungal infections (IFIs) varies significantly between countries. Limited access or high cost may contribute to the burden of IFIs. We aimed to investigate the availability and cost of antifungal treatment for IFIs in Vietnam. Procurement data from 2018 to 2022 was collected from the Drug Administration of Vietnam website. We calculated the cost per defined daily dose (DDD) and identified the manufacturing countries. We explored the pharmacotherapy cost of the four major IFIs if first-line agents were used in accordance with the Vietnam 2021 antifungal prescribing guideline. We also estimated the treatment expenditure in 2020 based on the estimated disease burden previously published and suggested cost-saving measures. At least 57.6 million USD was spent on 15.5 million DDD of antifungals in 5 years. Seven systemic antifungal agents were available in Vietnam. Caspofungin and micafungin were the least used but most expensive, whereas fluconazole and itraconazole were the most consumed but cheapest antifungals. Vietnam manufactured 70% of azole antifungals and relied on imports for the remaining antifungals consumed. We estimated the first-line pharmacological treatment for the estimated cases of four IFIs in 2020 to cost at least 209.1 million USD, which exceeded the actual spend in 2020. We discovered that antifungal agents for IFIs impose a substantial economic burden on Vietnam's healthcare system. We highlight the need for cost-effectiveness studies of expensive first-line medications. Efforts to mitigate this economic burden should include antifungal stewardship, prevention of IFIs, and sourcing from cost-effective manufacturers.

Use of sequential lateral flow assays to diagnose cryptococcal infection among people living with HIV in Monrovia, Liberia

Cryptococcal meningitis is one of the top causes of morbidity and mortality in people living with HIV/AIDS. In high prevalence regions, current recommendations are to screen individuals with blood CD4+ T cell counts less than 200 cells/µl for serum cryptococcal antigen (CrAg) and then preemptively treat those who test positive for presumed cryptococcosis. However, in many low-resource settings, including Monrovia, Liberia, flow cytometric CD4 assays are not readily available. We tested subjects with known HIV infection using a lateral flow assay (LFA), which provides a semi-quantitative determination of whether the blood CD4+ T cell count is ≤200 cells/µl. Subjects with counts ≤200 cells/µl were then tested with an LFA that detects CrAg. Of the 500 HIV+ subjects tested, 201 (40.2%) had blood CD4+ T cell count ≤200. Of those, 82/201 (40.7%) were serum CrAg+. Subjects who were serum CrAg+ were more likely to have a Glasgow Coma Score <15, whereas subjects who were CrAg- were more likely to be HIV-2+. Lumbar punctures were performed on 61 serum CrAg+ subjects; 30/61 (49.2%) subjects were cerebrospinal fluid CrAg+. Thus, sequential point-of-care testing enabled the diagnosis of cryptococcosis in HIV+ individuals with blood CD4 T cell counts ≤200 cells/µl. As diagnostic testing informs life-saving therapies, it is imperative that these assays are made readily available in resource-poor settings.

Relative Contribution of Pharmacokinetics and Immune Signatures to Clinical Outcomes in Patients With HIV-associated Cryptococcal Meningitis

Background

Host immune responses to HIV-associated cryptococcal meningitis are critical in disease outcome. Their interaction with antifungal drug exposure is poorly understood. This study explored associations between immune biomarkers, antifungal drug exposure, and clinical outcomes in HIV-associated cryptococcal meningitis.

Methods

We analyzed serial plasma and cerebrospinal fluid immune biomarkers from 64 participants recruited from the AMBITION-cm trial. We estimated individual-level exposure to amphotericin B, flucytosine, and fluconazole. Associations between immune biomarkers, pharmacokinetic parameters, and clinical outcomes were evaluated.

Results

An inflammatory cerebrospinal fluid response, characterized by coordination between tumor necrosis factor-α, granulocyte colony-stimulating factor, and interleukin-7 signaling, was linked to low fungal burden, low intracranial pressure, and survival. However, the value of specific immune biomarkers did not predict EFA or mortality. Exposure to amphotericin B was significantly associated with EFA.

Conclusions

Favorable clinical outcomes from HIV-associated cryptococcal meningitis are associated with coordinated inflammatory and cytotoxic responses in the central nervous system. Antifungal drug exposure was the dominant predictor of EFA.

Cryptococcosis

Cryptococcosis is an invasive fungal infection caused by yeasts of the genus Cryptococcus that causes a significant global burden of disease in both immunocompromised and immunocompetent individuals. Over the past several decades, diagnosis and management of cryptococcal disease have moved to focus on rapid, reliable, and cost-effective care delivery, with the advent of new antigen detection assays and novel antifungal treatment strategies.

Comparison of Early Fungicidal Activity and Mortality Between Daily Liposomal Amphotericin B and Daily Amphotericin B Deoxycholate for Cryptococcal Meningitis

BACKGROUND

Limited data exist on the antifungal activity of daily liposomal amphotericin B with flucytosine induction regimens for cryptococcal meningitis, which are recommended in high-income countries. Liposomal amphotericin B monotherapy at 3 mg/kg previously failed to meet noninferiority criteria compared to amphotericin B deoxycholate in its registrational clinical trial. We aimed to compare the quantitative antifungal activity and mortality between daily amphotericin B deoxycholate and daily liposomal amphotericin B among persons with human immunodeficiency virus (HIV)-related cryptococcal meningitis receiving adjunctive flucytosine 100 mg/kg/day.

METHODS

We analyzed data from 3 clinical studies involving participants with HIV-associated cryptococcal meningitis receiving either daily liposomal amphotericin B at 3 mg/kg/day with flucytosine (n = 94) or amphotericin B deoxycholate at 0.7-1.0 mg/kg/day with flucytosine (n = 404) as induction therapy. We compared participant baseline characteristics, cerebrospinal fluid (CSF) early fungicidal activity (EFA), and 10-week mortality.

RESULTS

We included 498 participants in this analysis, of whom 201 had available EFA data (n = 46 liposomal amphotericin B; n = 155 amphotericin B deoxycholate). Overall, there is no statistical evidence that the antifungal activity of liposomal amphotericin B (mean EFA, 0.495 [95% confidence interval {CI}, .355-.634] log10 colony-forming units [CFU]/mL/day) differ from amphotericin B deoxycholate (mean EFA, 0.402 [95% CI, .360-.445] log10 CFU/mL) (P = .13). Mortality at 10 weeks trended lower for liposomal amphotericin B (28.2%) versus amphotericin B deoxycholate (34.6%) but was not statistically different when adjusting for baseline characteristics (adjusted hazard ratio, 0.74 [95% CI, .44-1.25]; P = .26).

CONCLUSIONS

Daily liposomal amphotericin B induction demonstrated a similar rate of CSF fungal clearance and 10-week mortality as amphotericin B deoxycholate when combined with flucytosine for the treatment of HIV-associated cryptococcal meningitis.

Analysis of intracranial lesions in patients with HIV-associated cryptococcal meningitis

Background

Intracranial imaging abnormalities are commonly observed in patients suffering from HIV-associated cryptococcal meningitis, both before and during the treatment period. This study aims to analyze the prevalence, origins, radiological characteristics, treatments, and prognosis of intracranial lesions in patients with HIV-associated cryptococcal meningitis, thereby providing references for future clinical decision-making.

Methods

The clinical data of patients diagnosed with HIV-associated cryptococcal meningitis and admitted to the Shanghai Public Health Clinical Centre between 2013 and 2019 were collected. Logistic regression analysis was subsequently conducted to identify potential risk factors associated with the development of intracranial lesions in this patient group.

Results

Of 211 patients analyzed, 64.5% (136/211) had intracranial lesions during treatment and follow-up. Initial cranial imaging showed 60% had lesions pre-treatment. Throughout treatment, 32.7% (52/159) developed new or worsened lesions. Mortality rates at 2 weeks, 8 weeks, and 2 years for those with detected lesions were 3%, 7.6%, and 13.2%, respectively. Lesions were primarily caused by Cryptococcus (70.5%) and Mycobacterium (24.3%). Lacunar infarcts, especially in the basal ganglia, were the most common type. Patients aged 50 years or older, and those presenting with altered mental status upon admission, were found to be more likely to have intracranial lesions at baseline, with adjusted odds ratios of 5.364 (95% CI: 1.468-19.591, P=0.011) and 7.970 (95% CI: 2.241-28.337, P=0.001), respectively. Patients with lesion progression showed higher levels of IFN-γ, IL-4, IL-5, IL-6, IL-1Ra, IL-1β, GM-CSF, Eotaxin, and Basic FGF in cerebrospinal fluid after four weeks of treatment.

Conclusion

Intracranial lesions in HIV-associated cryptococcal meningitis patients are mostly due to Cryptococcus and Mycobacterium infections. They often appear as lacunar infarcts, predominantly in the basal ganglia, and can worsen with treatment initiation, possibly due to higher baseline cytokine levels in cerebrospinal fluid.

Neurocognitive Impairment Among Cryptococcal Meningitis Survivors in Uganda, a Prospective Cohort Study

Background

Neurocognitive impairment in HIV-associated cryptococcal meningitis survivors remains poorly characterized. We sought to identify risk factors associated with sustained neurocognitive impairment.

Methods

Cryptococcal meningitis survivors from the ASTRO-CM trial underwent neurocognitive assessment at 12 weeks. A composite quantitative neurocognitive performance score (QNPZ-8) was calculated as a mean of 8 independent z-scores. Participants were classified by QNPZ-8 score as having mild (QNPZ-8 ≥-1), moderate (-2 < QNPZ-8 < -1), or severe (QNPZ-8 ≤-2) impairment compared with the reference cohort of HIV-negative Ugandan adults. We compared differences in baseline demographics and clinical and laboratory variables by impairment categories.

Results

One hundred fifty-two participants completed ≥5 of the 8 neuropsychological tests and were included in the analysis. Overall, 37% (57/152) exhibited mild (QNPZ-8 ≥-1), 37% (56/152) moderate (-2 < QNPZ-8 < -1), and 26% (39/152) severe impairment (QNPZ-8 ≤-2). The overall mean QNPZ-8 score (SD) of -1.4 (0.82) denoted moderate neurocognitive impairment at 12 weeks. At baseline, lower weight (P = .03), Glasgow Coma Scale score <15 (P = .03), and education ≤7 years (P < .001) were more frequently observed among those with severe neurocognitive impairment at 12 weeks. Education ≤7 years (odds ratio, 6.13; 95% CI, 2.96-12.68; P < .001) and Glasgow Coma Scale score <15 (odds ratio, 2.61; 95% CI, 1.23-5.57; P = .013) were associated with moderate or severe neurocognitive impairment.

Conclusions

Neurocognitive impairment is prevalent at 12 weeks post-treatment in HIV-associated cryptococcal meningitis. Education level and Glasgow Coma Scale score <15 are associated with worse neurocognitive performance. Our findings underscore the need to further evaluate the impact of cryptococcal meningitis on neurocognitive outcomes.

Causes of HIV-related CNS infection in Cameroon, Malawi, and Tanzania: epidemiological findings from the DREAMM HIV-related CNS implementation study

BACKGROUND

CNS infections cause approximately a third of HIV-related deaths. The Driving Reduced AIDS-Associated Meningo-encephalitis Mortality DREAMM study aimed to prospectively diagnose the aetiology of HIV-related CNS infection in five public hospitals in Cameroon, Malawi, and Tanzania.

METHODS

DREAMM was a multicentre, hybrid type-2 implementation science project. Adults (aged ≥18 years) presenting with a first episode of suspected CNS infection, who were HIV seropositive or willing to have an HIV test, were eligible for recruitment. Following implementation of the DREAMM model of care, we measured the prevalence of cryptococcal meningitis, tuberculous meningitis, bacterial meningitis, and cerebral toxoplasmosis and did a χ2 test to assess whether prevalence differed between countries. We also reported disease-specific mortality and Toxoplasma gondii seroprevalence.

FINDINGS

Of 356 participants with suspected CNS infection analysed at baseline, 269 (76%) were diagnosed as having a CNS infection. Of these, 202 (75%) had a confirmed diagnosis. Between Cameroon, Malawi, and Tanzania, the prevalence of the four main types of CNS infection differed (cryptococcal meningitis p=0·0014, bacterial meningitis p=0·0043, CNS tuberculosis p<0·0001, and toxoplasmosis p<0·0001). Cryptococcal meningitis (148 [55%] of 269) was the leading cause overall. The next most common causes were CNS tuberculosis in Tanzania (29 [29%] of 99) and bacterial meningitis in Malawi (15 [19%] of 80). In Cameroon, cerebral toxoplasmosis (39 [43%] of 90) was the leading cause followed by cryptococcal meningitis (36 [40%] of 90). For cryptococcal meningitis, all-cause 2-week mortality was 23% (34 of 147) and all-cause 10-week mortality was 45% (66 of 146).

INTERPRETATION

Within the study population, the aetiology of HIV-related CNS infection varied substantially between Malawi, Cameroon, and Tanzania. Additional prospective epidemiological data are needed to inform HIV programmes. 2-week cryptococcal meningitis mortality outcomes were similar to those of clinical trials. However, new interventions are urgently needed to sustain mortality reductions following hospital discharge.

FUNDING

European and Developing Countries Clinical Trials Partnership and French Agency for Research on AIDS and Viral Hepatitis.

TRANSLATIONS

For the French and Portuguese translations of the abstract see Supplementary Materials section.

AIDS-related mycoses: advances, challenges, and future directions

Fungal infections are a major contributor to mortality for people with HIV/AIDS. Recently, researchers, clinicians, industry experts, and policymakers convened for the triennial AIDS-Related Mycoses Meeting to address critical gaps in the management of AIDS-related mycoses. Delegates highlighted several scientifically driven milestones that have significantly reduced fungal-related deaths, and the need to address outstanding challenges in diagnosis, treatment, and research.

Impact of cerebrospinal fluid leukocyte infiltration and activated neuroimmune mediators on survival with HIV-associated cryptococcal meningitis

INTRODUCTION

Cryptococcal meningitis remains a prominent cause of death in persons with advanced HIV disease. CSF leukocyte infiltration predicts survival at 18 weeks; however, how CSF immune response relates to CSF leukocyte infiltration is unknown.

METHODS

We enrolled 401 adults with HIV-associated cryptococcal meningitis in Uganda who received amphotericin and fluconazole induction therapy. We assessed the association of CSF leukocytes, chemokine, and cytokine responses with 18-week survival.

RESULTS

Participants with CSF leukocytes ≥50/microliter had a higher probability of 18-week survival compared with those with ≤50 cells/microliter (68% (52/77 vs. 52% (151/292); Hazard Ratio = 1.63, 95% confidence interval 1.14-2.23; p = 0.008). Survival was also associated with higher expression of T helper (Th)-1, Th17 cytokines, and immune regulatory elements. CSF levels of Programmed Death-1 Ligand, CXCL10, and Interleukin (IL)-2 independently predicted survival. In multivariate analysis, CSF leukocytes were inversely associated with CSF fungal burden and positively associated with CSF protein and immune parameters (interferon-gamma (IFN-γ), IL-17A, tumor necrosis factor alpha (TNF)-α, and circulating CD4+ and CD8+ T cells).

CONCLUSION

18-week survival after diagnosis of cryptococcal meningitis was associated with higher CSF leukocytes at baseline with greater T helper 1 (IFN-γ, IL-2 and TNF-α cytokines), T helper 17 (IL-17A cytokine) and CXCR3+ T cell (CXCL10 chemokine) responses. These results highlight the interdependent contribution of soluble and cellular immune responses in predicting survival and may support potential pathways for adjunctive immune therapy in HIV-associated cryptococcal meningitis.

Fungal positivity and other laboratory parameters in HIV- and non-HIV-related cryptococcal meningitis patients upon antifungal treatment

The association between fungal positivity in cerebral spinal fluid (CSF) and other laboratory parameters in cryptococcal meningitis (CM) with or without HIV infection is unclear. India ink staining and culture were used to detect the Cryptococcus in the CSF during the treatment course. Hematology analysis and chemistry analysis of CSF were also performed. Flow cytometry was used to analyze the T lymphocyte subsets in the blood. The positivity of the culture reduced significantly faster than that of the ink staining in both HIV and non-HIV patients between treatment time points. The total protein in the CSF of the HIV-related patients was significantly lower than in the non-HIV-related patients at all time points of treatment (p = 0.009, 0.012, 0.001, and 0.037, respectively). The lactate dehydrogenase (LDH) in the CSF of the HIV-related patients at admission was significantly lower than in the non-HIV-related patients (p = 0.017). There were significant differences in glucose and LDH levels between different time points of treatment (p = 0.000 and 0.016, respectively) in the non-HIV-related patients. For Cryptococcus detection in CSF, the culture method appeared to be more sensitive and reliable than the ink staining method. HIV-related CM patients showed certain hematologic and CSF chemistry features which may help guide the management of patients.

[Neuromeningeal cryptoccosis in an HIV-negative patient in Bamako, Mali]

Introduction/Rationale

Neuromeningeal cryptococcosis (NMC) is a common fungal infection in immunocompromised patients with HIV infection. Its rarity outside HIV/AIDS requires a systematic search for other immunosuppressive factors and a differential diagnosis. We report a case of NMC in an immunocompetent patient admitted to the Point G University Hospital Center in Bamako, Mali.

Case description

The patient presented with fever (39.3°C), general deterioration, Glasgow Coma Scale score of 10/15 without motor deficits, neck stiffness, and helmet-like headache unresponsive to analgesics. The patient had a CD4 count of 932 cells/mm3. No other immunosuppressive conditions were noted. The diagnosis of NMC was confirmed based on clinical and microbiologic findings. The patient was successfully treated in Bamako using an alternative protocol with fluconazole, a more accessible, less expensive treatment with fewer side effects compared to amphotericin B.

Discussion/Conclusion

The occurrence of cryptococcosis in an immunocompetent host is rare. However, it can occur in the absence of predisposing factors. Fluconazole is an effective alternative therapy.

The evolution of HIV-associated cryptococcal meningitis in Uganda from 2010 to 2022

Given extensive improvements in access to antiretroviral therapy (ART) over the past 12 years, the HIV and cryptococcal meningitis landscapes have dramatically changed since 2010. We sought to evaluate changes in clinical presentation and clinical outcomes of people presenting with HIV-associated cryptococcal meningitis between 2010 and 2022 in Uganda. We analyzed three prospective cohorts of HIV-infected Ugandans with cryptococcal meningitis during 2010-2012, 2013-2017, and 2018-2022. We summarized baseline demographics, clinical characteristics at presentation, and 2-week and 16-week mortality. Overall, 2022 persons had confirmed cryptococcal meningitis between 2010 and 2022. In the most recent 2018-2022 cohort, 48% presented as ART-naïve, and the median CD4 cell count was 26 cells/µl. Participants in the 2018-2022 cohort had the lowest cerebrospinal fluid (CSF) opening pressure (median 22 cmH2O) and the highest percentage with sterile CSF quantitative cultures (21%) compared with earlier cohorts (P < .001 for both), signifying a less severely ill population presenting with cryptococcal meningitis. Two-week mortality was lowest among participants with cryptococcal meningitis enrolled in a clinical trial in the 2018-2022 cohort at 13% compared to 26% in both 2010-2012 and 2013-2017 (P < .001). While AIDS-related deaths have dramatically declined over the past 12 years, cryptococcosis persists, presenting challenges to HIV program implementation. Two-week mortality has improved in the most recent cohort, likely due to the establishment of cryptococcal screening programs, better supportive care including scheduled lumbar punctures, and the availability of flucytosine-an essential component of antifungal therapy.

Case studies of health economic analyses informing pharmaceutical health technology assessments for essential medicine selection and public-sector guidelines in South Africa

BACKGROUND

Constrained resources under universal health coverage (UHC) necessitate a balance between medication costs and essential health system requirements. Policymakers practice priority-setting, as either implicit or explicit rationing, embedded in evidence-informed decision-making processes to guide funding decisions. Health technology assessment (HTA) is a method that may assist explicit evidence-informed priority setting. South Africa developed an official HTA methods guide in 2022, however before this, commissioning and performing economic evaluations was not standardized.

METHODS

We conducted a descriptive collective case study to explore the impact of economic analyses on the selection of, and access to, essential medicines in South Africa. Four cases were purposefully selected, and both official information and secondary data, including media reports, were reviewed. Data elements were extracted and organized in a matrix. Cases were reported narratively with a positivist epistemological approach, presenting the authors' reflections.

RESULTS

We found economic analyses that reflected methodologies described in the HTA guide: international reference pricing, cost-minimization, cost-effectiveness, cost-utility, and budget impact analyses. Economic analyses informing the 'resource-use' domain in the GRADE evidence-to-decision framework supported decision-making, influenced market-shaping with price reductions of interventions through benchmarking (fosfomycin, flucytosine), improved equitable access nationally (flucytosine), and prioritized a defined patient group in a justifiable and transparent manner (bortezomib).

CONCLUSION

A standardized HTA evaluation process guided by a nationally accepted framework is necessary for evidence-informed decision-making. Economic analyses (cost-effectiveness, affordability, and resource use) should be consistently included when making decisions on new interventions.

Utility of handheld non-mydriatic fundoscopy in a case of bilateral, reversible vision loss in an advanced HIV patient with cryptococcal meningitis in Sub-Saharan Africa

Cryptococcal meningitis is a fungal infection that is typically caused by Cryptococcus neoformans and most commonly seen in severely immunosuppressed patient. This disease causes severe neurologic disease due to elevated intracranial pressures. In this case report, we describe a patient with newly diagnosed HIV presenting to the hospital with cryptococcal meningitis complicated by sudden vision loss. We highlight the role of prompt diagnosis and treatment in the reversal of vision loss, with subsequent monitoring using a handheld, non-mydriatic fundus imaging device.

Reassessment of the role of combination antifungal therapy in the current era

PURPOSE OF REVIEW

Given the high mortality and morbidity associated with invasive fungal diseases (IFDs), the use of combination antifungal therapies is often considered despite the dearth of data. This review aims to summarize the current state of literature of combination antifungal therapies, discussing the potential roles of newer antifungal combinations and key considerations for their clinical use.

RECENT FINDINGS

In infections other than cryptococcal meningitis or in the setting of empirical treatment for suspected azole-resistant Aspergillus infections, the utility of the combination antifungal approaches remains controversial given the paucity of well designed randomized controlled trials. Data on potential combined antifungal treatments have been primarily limited to in-vitro studies, animal models, case reports and/or observational studies. With availability of novel antifungal agents (e.g. ibrexafungerp, fosmanogepix), combination therapy to treat mould infections should be re-visited. A phase 2 clinical trial of ibrexafungerp combined with voriconazole to treat invasive pulmonary aspergillosis is on-going.

SUMMARY

There is a need to investigate the use of combination antifungal agents. This includes delineating the indication of these combined antifungal therapies and determining how to use them most appropriately in the clinical setting.

Sclareolide as Antifungal Strategy Against Cryptococcus neoformans: Unveiling Its Mechanisms of Action

Cryptococcal infection commonly begins as an opportunistic infection in humans, however, this can escalate to a systemic or life-threatening form in immunocompromised individuals. Here, we aim to identify novel antifungal molecules from plants resources. Sclareolide, a phytochemical classified as a sesquiterpene lactone, was assessed against Cryptococcus neoformans H99. Sclareolide exhibited promising antifungal properties with a minimum inhibitory concentration (MIC) of 16 µg/mL. Additionally, the C. neoformans growth rate was significantly affected by sclareolide treatment in a concentration-dependent manner, as observed through a time killing assay, with a significant reduction at MIC × 8 compared to the control by 48 h. To elucidate the underlying mechanisms of sclareolide antifungal activity, fluorescence-based methods were employed. Propidium iodide (PI) accumulation assay indicated a reduction in C. neoformans membrane integrity, with values as low as 6.62 ± 0.18% after treatment. Moreover, sclareolide at MIC × 4 and MIC × 8 significantly increased the production of reactive oxygen species (ROS) and reduced the mitochondrial membrane potential (MMP), suggesting oxidative stress and mitochondrial dysfunction in C. neoformans. Sclareolide did not induce caspase-dependent apoptosis, suggesting a non-apoptotic mechanism. Further, a checkerboard experiment was performed to assess potential synergistic interaction with Amphotericin B, however, no synergism was observed. Moving on, sclareolide at 128 µg/mL did not exhibit toxicity in Galleria mellonella, further supporting its potential as a safe antifungal agent. These findings suggest that the antifungal activity of sclareolide against C. neoformans is mediated by oxidative stress. Further in vivo and pharmacokinetic studies are recommended to explore the potential of sclareolide as a prototype for the development of novel anti-cryptococcal therapies.

The pathobiology of human fungal infections

Human fungal infections are a historically neglected area of disease research, yet they cause more than 1.5 million deaths every year. Our understanding of the pathophysiology of these infections has increased considerably over the past decade, through major insights into both the host and pathogen factors that contribute to the phenotype and severity of these diseases. Recent studies are revealing multiple mechanisms by which fungi modify and manipulate the host, escape immune surveillance and generate complex comorbidities. Although the emergence of fungal strains that are less susceptible to antifungal drugs or that rapidly evolve drug resistance is posing new threats, greater understanding of immune mechanisms and host susceptibility factors is beginning to offer novel immunotherapeutic options for the future. In this Review, we provide a broad and comprehensive overview of the pathobiology of human fungal infections, focusing specifically on pathogens that can cause invasive life-threatening infections, highlighting recent discoveries from the pathogen, host and clinical perspectives. We conclude by discussing key future challenges including antifungal drug resistance, the emergence of new pathogens and new developments in modern medicine that are promoting susceptibility to infection.

CAF to the Rescue! Potential and Challenges of Combination Antifungal Therapy for Reducing Morbidity and Mortality in Hospitalized Patients With Serious Fungal Infections

The global burden of invasive fungal disease is substantial and escalating. Combination antifungal therapy (CAF) may improve patient outcomes by reducing development of resistance, improving drug penetration and rate of fungal clearance, and allowing for lower and less toxic antifungal drug doses; yet, increased cost, antagonism, drug-drug interactions, and toxicity are concerns. Clinical practice guidelines recommend antifungal monotherapy, rather than CAF, for most invasive fungal diseases due to a lack of comparative randomized clinical trials. An examination of the existing body of CAF research should frame new hypotheses and determine priorities for future CAF clinical trials. We performed a systematic review of CAF clinical studies for invasive candidiasis, cryptococcosis, invasive aspergillosis, and mucormycosis. Additionally, we summarized findings from animal models of CAF and assessed laboratory methods available to evaluate CAF efficacy. Future CAF trials should be prioritized according to animal models showing improved survival and observational clinical data supporting efficacy and safety.

Machine learning-based prognostic prediction for hospitalized HIV/AIDS patients with cryptococcus infection in Guangxi, China

OBJECTIVE

To develop and validate a machine learning model for predicting mortality-associated prognostic factors in order to reduce in-hospital mortality rates among HIV/AIDS patients with Cryptococcus infection in Guangxi, China.

METHODS

This retrospective prognostic study included HIV/AIDS patients with cryptococcosis in the Fourth People's Hospital of Nanning from October 2011 to June 2019. Clinical features were extracted and used to train ten machine learning models, including Logistic Regression, KNN, DT, RF, Adaboost, Xgboost, LightGBM, Catboost, SVM, and NBM, to predict the outcome of HIV patients with cryptococcosis infection. The sensitivity, specificity, AUC, and F1 value were applied to assess model performance in both the testing and training sets. The optimal model was selected and interpreted.

RESULTS

A total of 396 patients were included in the study. The average in-hospital mortality of HIV/AIDS patients with cryptococcosis was 12.9% from 2012 to 2019. After feature screening, 20 clinical features were selected for model construction, accounting for 93.8%, including ART, Electrolyte disorder, Anemia, and 17 laboratory tests. The RF model (AUC 0.9787, Sensitivity 0.9535, Specificity 0.8889, F1 0.7455) and the SVM model (AUC 0.9286, Sensitivity 0.7907, Specificity 0.9786, F1 0.8293) had excellent performance. The SHAP analysis showed that the primary risk factors for prognosis prediction were identified as BUN/CREA, Electrolyte disorder, NEUT%, Urea, and IBIL.

CONCLUSIONS

RF and SVM machine learning models have shown promising predictive abilities for the prognosis of hospitalized HIV/AIDS patients with cryptococcosis, which can aid clinical assessment and treatment decisions for patient prognosis.

Azole Combinations and Multi-Targeting Drugs That Synergistically Inhibit Candidozyma auris

Limited antifungal treatment options and drug resistance require innovative approaches to effectively combat fungal infections. Combination therapy is a promising strategy that addresses these pressing issues by concurrently targeting multiple cellular sites. The drug targets usually selected for combination therapy are from different cellular pathways with the goals of increasing treatment options and reducing development of resistance. However, some circumstances can prevent the implementation of combination therapy in clinical practice. These could include the increased risk of adverse effects, drug interactions, and even the promotion of drug resistance. Furthermore, robust clinical evidence supporting the superiority of combination therapy over monotherapy is limited and underscores the need for further research. Despite these challenges, synergies detected with different antifungal classes, such as the azoles and echinocandins, suggest that treatment strategies can be optimized by better understanding the underlying mechanisms. This review provides an overview of multi-targeting combination strategies with a primary focus on Candidozyma auris infections.

Antifungal susceptibility and multilocus sequence typing (MLST) of Cryptococcus neoformans complex from HIV-associated cryptococcal meningitis patients in Manaus, Amazonas, Brazil

Cryptococcus neoformans is primarily responsible for cases of cryptococcal meningitis in individuals with HIV/AIDS. This study evaluated the susceptibility of C. neoformans obtained from individuals with cryptococcal meningitis associated with HIV/AIDS in Manaus, Amazonas, Brazil, against the action of the antifungals amphotericin B, flucytosine, fluconazole, itraconazole and posaconazole and analyzed it using Multilocus Sequence Typing (MLST) in order to identify the Sequence Types (STs). We analyzed 30 isolates of C. neoformans, from 24 HIV/AIDS patients diagnosed with cryptococcosis from 2017 to 2019 in a reference hospital, in addition to 3 environmental isolates: 1 isolate obtained in the home of a patient and 2 isolates obtained from neighboring homes of patients. 86.6% (n = 26/30) of the clinical isolates were identified as C. neoformans VNI ST93, 6.6% (n = 2/30) as C. neoformans VNI ST5, 3.3% (n = 1/30) as C. neoformans VNI ST32 and 3.3% (n = 1/30) as C. neoformans VNB ST232. The environmental isolates were identified as C. neoformans VNI ST93 (n = 3/3). 96.6% (n = 29/30) isolates were sensitive to amphotericin B, though there was variation in the MIC. 60% (n = 18/30) presented a MIC above the proposed epidemiological cutoff values for one or more antifungals. All environmental isolates were sensitive to the tested antifungals. The MLST showed that there is an important relationship between C. neoformans VNI ST93 and individuals with HIV/AIDS, including in the environmental isolates analyzed. C. neoformans VNB ST232 was observed for the first time in Amazonas. Amphotericin B was proven to be the best drug, but fluconazole and posaconazole also showed relevant action.

Bioavailability of a novel sustained-release pellet formulation of 5-flucytosine in healthy-fed participants for use in patients with cryptococcal meningitis

Cryptococcal meningoencephalitis (CM) is an opportunistic fungal infection and a major cause of death among people living with human immunodeficiency virus in sub-Saharan Africa. 5-flucytosine (5-FC) is a unique, brain-permeable antifungal agent used to reduce mortality from CM and to prevent disease in individuals carrying cryptococcal antigen. 5-FC has a short plasma half-life, requiring 6-hourly oral dosing with an immediate-release (IR) formulation, a significant challenge in hospital and outpatient settings, risking a lack of compliance. We recently reported the relative bioavailability in fasting conditions of a sustained release (SR) oral pellet formulation of 5-FC. In this phase I study, we assessed the safety and pharmacokinetic profiles of the new 5-FC SR formulation in a single dose (2 × 3000 mg), relative to 5-FC IR tablets (Ancotil®; 1500 mg b.i.d.) in healthy participants in fed conditions. This randomized, two-period crossover study was conducted in South Africa to confirm the dose of the identified 5-FC SR formulation for a twice-daily 5-FC regimen in patients. Thirty-six healthy participants were included. All treatments were well tolerated and no serious adverse event was reported. Cmax and AUC(0-t) for the SR formulation (49.2 ± 10.49 μg/mL and 640.4 ± 126.4 h.μg/mL, respectively) were significantly higher than for the IR formulation (36.8 ± 7.61 μg/mL and 456.6 ± 72.8 h.μg/mL, respectively). A physiological based pharmacokinetic model (PBPK) predicted that under fasting conditions, 6000 mg SR pellets would show a good overlap with the IR product (3000 mg b.i.d), thus 6000 mg SR 5-FC b.i.d. in fasting conditions is recommended.

Characteristics of HIV-associated cryptococcal meningitis in a tertiary Chilean hospital: An observational retrospective study

BACKGROUND

Central nervous system opportunistic infections can be the first presentation of an HIV infection. Our aim is to describe clinical and laboratory characteristics of HIV-associated Cryptococcal Meningitis (CM), in-hospital outcomes and analyze associations of these parameters with adverse outcomes.

METHODS

Observational study of local cohort of HIV-associated cryptococcal meningitis in a high complexity tertiary urban hospital in Santiago, Chile. Descriptive analysis through chart review of all episodes of HIV-associated CM in adults, from 1995 to 2019. Inclusion criteria were confirmed CM with cerebrospinal fluid culture or India ink in the appropriate clinical context and HIV diagnosis. We selected relevant variables that have been described as predictors of adverse outcomes in the literature and explore associations in our cohort.

RESULTS

There were 37 HIV associated CM cases, occurring from 2000 to 2019. Majority were men (86 %) with a median age of 35 years. CM was the first HIV manifestation in 32 %. Opening pressure was measured in 10 % of patients at admission. Most CSF parameters were mildly altered, and two patients presented with completely normal CSF findings. Most patients -94,4 %- suffered adverse events secondary to antifungal therapy. Despite of recommendations against their use, steroids were frequently prescribed. Mortality was 18,9 %, and was associated with older age, and more days of headache prior to admission.

CONCLUSIONS

CM clinical presentation and CSF characteristics are variable at presentation, which can lead to delayed diagnosis. Inappropriate use of corticosteroids, antifungal toxicity and suboptimal management of elevated intracranial pressure are key aspects to improve.

Global guideline for the diagnosis and management of cryptococcosis: an initiative of the ECMM and ISHAM in cooperation with the ASM

Cryptococcosis is a major worldwide disseminated invasive fungal infection. Cryptococcosis, particularly in its most lethal manifestation of cryptococcal meningitis, accounts for substantial mortality and morbidity. The breadth of the clinical cryptococcosis syndromes, the different patient types at-risk and affected, and the vastly disparate resource settings where clinicians practice pose a complex array of challenges. Expert contributors from diverse regions of the world have collated data, reviewed the evidence, and provided insightful guideline recommendations for health practitioners across the globe. This guideline offers updated practical guidance and implementable recommendations on the clinical approaches, screening, diagnosis, management, and follow-up care of a patient with cryptococcosis and serves as a comprehensive synthesis of current evidence on cryptococcosis. This Review seeks to facilitate optimal clinical decision making on cryptococcosis and addresses the myriad of clinical complications by incorporating data from historical and contemporary clinical trials. This guideline is grounded on a set of core management principles, while acknowledging the practical challenges of antifungal access and resource limitations faced by many clinicians and patients. More than 70 societies internationally have endorsed the content, structure, evidence, recommendation, and pragmatic wisdom of this global cryptococcosis guideline to inform clinicians about the past, present, and future of care for a patient with cryptococcosis.

Efficacy of Liposomal Nystatin in a Rabbit Model of Cryptococcal Meningitis

Cryptococcal meningitis (CM) causes significant global morbidity and mortality. Current therapeutic strategies rely on deoxycholated or liposomal forms of the polyene amphotericin B. Nystatin is also a polyene with broad-spectrum antimicrobial activity. Treatment with systemic nystatin has been limited by toxicity, which is a consistent challenge with polyene therapeutics. One mechanism to improve the toxicity is usage of a liposomal form of the active agent. Previous data from a murine candidemia model indicated that liposomal nystatin may be an effective antifungal drug formulation. Since the rabbit model of CM is a highly predictive preclinical system for evaluating antifungal therapeutics, we tested the effectiveness of two doses of daily liposomal nystatin, 3 and 8 mg/kg in the rabbit model of CM. Treatment with liposomal nystatin in this model did not reduce the fungal burden in the cerebrospinal fluid. A subsequent clinical trial also did not find activity in a human population. These data indicate that liposomal nystatin in the current form and at the tested dosages is not an effective therapy for CM. The data provide further evidence for the predictive power of the rabbit model of CM as a vital preclinical system for testing novel antifungal therapeutics for CM.

All hands on Dec: Treating cryptococcosis with dectin decorated liposomes loaded with antifungals

Systemic cryptococcosis is often fatal even with the current antifungal therapy and there is no vaccine available. Induction therapy with amphotericin B (AmB) is essential for its treatment, which can be either in the form of AmB deoxycholate at 1 mg/kg/day for 7 days or a single dose of liposomal AmB (AmB-LLs) at 10 mg/kg, both in combination with flucytosine. AmB is highly toxic and it is imperative to further increase its efficacy without increasing its toxicity. Previously, we developed a targeted antifungal drug delivery system (DectiSome) that uses liposomes decorated with host-pathogen receptor dectins to target AmB to fungal cells. Here, we showed that a single dose of Dectin-2 coated liposomal AmB, relative to AmB-LLs, reduced fungal burden and prolonged animal survival in the murine model of systemic cryptococcosis. Our results demonstrate that DectiSomes are a promising antifungal delivery system that could improve cryptococcosis therapy in the future.

Epidemiology of cryptococcal meningitis and fluconazole heteroresistance in Cryptococcus neoformans isolates from a teaching hospital in southwestern China

Cryptococcal meningitis (CM), a common and serious opportunistic infection mostly caused by Cryptococcus neoformans, is primarily treated with fluconazole. Nevertheless, Cryptococcus neoformans strains that undergo repeated exposure to azoles can gradually acquire heteroresistance to fluconazole. The management of this specific CM infection poses a substantial challenge. Determining a globally accepted definition for fluconazole heteroresistance and developing effective and prompt methods for identifying heteroresistance is of utmost importance. We collected data on the clinical and epidemiological characteristics of patients diagnosed with CM. All the available Cryptococcus neoformans strains isolated from these patients were collected and subjected to antifungal susceptibility testing and evaluation of fluconazole heteroresistance. AIDS was present in 40.5% of the patients, whereas 24.1% did not have any underlying diseases. Patients with chronic diseases or impaired immune systems are susceptible to infection by Cryptococcus neoformans, a fungus that frequently (39.6%, 19/48) shows heteroresistance to fluconazole, as confirmed by population analysis profile (PAP).IMPORTANCEFluconazole heteroresistance poses a significant threat to the efficacy of fluconazole in treating cryptococcal meningitis (CM). Unfortunately, the standard broth microdilution method often misses the subtle percentages of subpopulations exhibiting heteroresistance. While the population analysis profile (PAP) method is esteemed as the gold standard, its time-consuming and labor-intensive nature makes it impractical for routine clinical use. In contrast, the Kirby-Bauer (KB) disk diffusion method offers a simple and effective screening solution. Our study highlights the value of KB over PAP and minimum inhibitory concentration (MIC) by demonstrating that when adjusting the inoculum concentration to 1.0 McFarland and subjecting samples to a 72-hour incubation period at 35°C, the KB method closely mirrors the outcomes of the PAP approach in detecting fluconazole heteroresistance. This optimization of the KB method not only enhances assay efficiency but also provides a blueprint for developing a timely and effective strategy for identifying heteroresistance.

Mid-Upper Arm Circumference Is a Strong Predictor of Mortality Among Ugandan Adults With HIV-Associated Cryptococcal Meningitis: A Prospective Cohort Study

Background

Mortality among adults diagnosed with HIV-associated cryptococcal meningitis remains high (24%-40%). We hypothesized that nutritional state, as measured by mid-upper arm circumference (MUAC), is a potentially modifiable risk factor for mortality.

Methods

Ugandan adults hospitalized with HIV-associated cryptococcal meningitis had MUAC measurements performed at baseline. We compared MUAC measurements with baseline clinical and demographic variables and investigated associations with survival using Cox regression.

Results

Of 433 participants enrolled, 41% were female, the median CD4 T-cell count (interquartile range [IQR]) was 15 (6-41) cells/μL, and 37% were antiretroviral therapy naïve. The median MUAC (IQR) was 24 (22-26) cm, the median weight (IQR) was 53 (50-60) kg, and MUAC correlated with weight (Pearson r = 0.6; P < .001). Overall, 46% (200/433) died during the 18-week follow-up. Participants in the lowest MUAC quartile (≤22 cm) had the highest mortality: 39% (46/118) at 2 weeks and 62% (73/118) at 18 weeks. A baseline MUAC ≤22 cm was associated with an 82% increased risk of 18-week mortality as compared with participants with an MUAC >22 cm (unadjusted hazard ratio, 1.82; 95% CI, 1.36-2.42; P < .001). Following adjustment for antiretroviral therapy status, CD4 count, hemoglobin, amphotericin dose, and tuberculosis status, the adjusted hazard ratio was 1.84 (95% CI, 1.27-2.65; P < .001). As a continuous variable, 18-week mortality was reduced by 10% for every 1-cm increase in MUAC. CSF Th17 immune responses were positively associated with MUAC quartile.

Conclusions

MUAC measurement is a simple bedside tool that can identify adults with HIV-associated cryptococcal meningitis at high risk for mortality for whom an enhanced bundle of care, including nutritional supplementation, should be further investigated.

Cryptococcosis-a systematic review to inform the World Health Organization Fungal Priority Pathogens List

Cryptococcosis causes a high burden of disease worldwide. This systematic review summarizes the literature on Cryptococcus neoformans and C. gattii infections to inform the World Health Organization's first Fungal Priority Pathogen List. PubMed and Web of Science were used to identify studies reporting on annual incidence, mortality, morbidity, antifungal resistance, preventability, and distribution/emergence in the past 10 years. Mortality rates due to C. neoformans were 41%-61%. Complications included acute renal impairment, raised intracranial pressure needing shunts, and blindness. There was moderate evidence of reduced susceptibility (MIC range 16-32 mg/l) of C. neoformans to fluconazole, itraconazole, ketoconazole, voriconazole, and amphotericin B. Cryptococcus gattii infections comprised 11%-33% of all cases of invasive cryptococcosis globally. The mortality rates were 10%-23% for central nervous system (CNS) and pulmonary infections, and ∼43% for bloodstream infections. Complications described included neurological sequelae (17%-27% in C. gattii infections) and immune reconstitution inflammatory syndrome. MICs were generally low for amphotericin B (MICs: 0.25-0.5 mg/l), 5-flucytosine (MIC range: 0.5-2 mg/l), itraconazole, posaconazole, and voriconazole (MIC range: 0.06-0.5 mg/l). There is a need for increased surveillance of disease phenotype and outcome, long-term disability, and drug susceptibility to inform robust estimates of disease burden.

Integrated management of cryptococcal meningitis and concurrent opportunistic infections to improve outcomes in advanced HIV disease: a randomised strategy trial

Background

Mortality associated with HIV-associated cryptococcal meningitis remains high even in the context of clinical trials (24-45% at 10 weeks); mortality at 12-months is up to 78% in resource limited settings. Co-prevalent tuberculosis (TB) is common and preventable, and likely contributes to poor patient outcomes. Innovative strategies to increase TB preventative therapy (TPT) provision and uptake within this high-risk group are needed.

Protocol

The IMPROVE trial (Integrated management of cryptococcal meningitis and concurrent opportunistic infections to improve outcomes in advanced HIV disease) is a nested open label, two arm, randomised controlled strategy trial to evaluate the safety (adverse events) and feasibility (adherence and tolerability) of two ultra-short course TPT strategies, in the context of recent diagnosis and treatment for cryptococcal meningitis. We will enrol 205 adults with HIV-associated cryptococcal meningitis from three hospitals in Uganda. Participants will be randomised to either inpatient initiation (early) or outpatient initiation (standard, week 6) of 1HP (one month of isoniazid and rifapentine). Participant follow-up is to include TB screening, 1HP pill counts and tolerability reviews on alternate weeks until week-18. The trial primary endpoint is TB-disease free 1HP treatment completion at 18-weeks, secondary endpoints: 1HP treatment completion, 1HP discontinuation, grade ≥3 adverse events and serious adverse events, drug-induced liver injury, incident active TB, 18-week survival; rifapentine, fluconazole and dolutegravir concentrations will be measured with intensive sampling in a pharmacokinetic sub-study of 15 eligible participants.

Discussion

The IMPROVE trial will provide preliminary safety and feasibility data to inform 1HP TPT strategies for adults with advanced HIV disease and cryptococcal meningitis. The potential impact of demonstrating that inpatient initiation of 1HP TPT is safe and feasible amongst this high-risk subpopulation with advanced HIV disease, would be to expand the range of clinical encounters in which clinicians can feasibly provide 1HP, and therefore increase the reach of TPT as a preventative intervention.

ISRCTN registration

ISRCTN18437550 (05/11/2021).

HIV-associated disseminated cryptococcosis-An unusual clinical and diagnostic picture with successful cure by single dose liposomal amphotericin B treatment

BACKGROUND

Cryptococcosis is an invasive, opportunistic fungal infection seen especially in human immunodeficiency virus (HIV) infected patients. Cryptococcal meningitis (CM) is the second leading cause of mortality in HIV patients. We report a case of disseminated cryptococcosis presenting with altered mental status in a newly diagnosed HIV infection.

METHODS AND RESULTS

A 50-year-old with a short history of altered mental sensorium and a history of low-grade fever and weight loss for few months presented at a tertiary care hospital in North India. He was detected positive for HIV-1. Cryptococcal antigen (CRAG) was positive in Cerebrospinal fluid (CSF), and negative in serum. The fungal culture in CSF was sterile while the fungal blood culture grew Cryptococcus neoformans. The patient was treated with single high-dose Liposomal Amphotericin B (LAmB) therapy followed by Fluconazole and Flucytosine for the next two weeks followed by fluconazole daily for consolidation and maintenance therapy. Antiretroviral therapy (ART) was started 4 weeks after induction therapy. After 6 months, the patient is doing fine.

CONCLUSION

Single dose LAmB along with the backbone of fluconazole and flucytosine appears promising in disseminated cryptococcal infection in HIV-infected individuals.

Infectious Diseases Physician Management of Cryptococcal Meningitis in North America-Is Single High-Dose Liposomal Amphotericin B Being Used?

Background

Several recent randomized trials have been conducted in resource-limited settings for cryptococcal meningitis that have rapidly innovated international guidelines. The 2010 Infectious Diseases Society of America (IDSA) cryptococcal meningitis guideline has not been updated with recent trials. The 2022 AMBITION-cm trial found that a single 10-mg/kg dose of liposomal amphotericin B plus daily flucytosine and fluconazole for 2 weeks was noninferior to 1 week of amphotericin B deoxycholate with flucytosine. It is unknown whether physicians in high-resource settings are using this regimen or more traditional regimens.

Methods

We developed an electronic survey in June 2023 to better understand whether physician members of the IDSA Emerging Infections Network (EIN) and Mycoses Study Group Education and Research Consortium (MSG-ERC) had used the AMBITION-cm induction regimen, would use the regimen in hypothetical clinical scenarios, and what perceived barriers to use existed.

Results

A total of 242 of 561 (43%) physicians responded to the survey, of whom 205 provided care for persons with cryptococcal meningitis in the last year. Overall, 29 (14%) had used the AMBITION-cm regimen, and 176 (86%) had not. In various hypothetical clinical scenarios, only ∼10% of 209 respondents selected the AMBITION-cm regimen as preferred. Perceived barriers to uptake included the applicability of trials performed in low-resource settings to high-resource settings, that the regimen is not recommended in the 2010 IDSA guidelines, and the applicability to persons without HIV.

Conclusions

Most respondents had not used the single-dose liposomal amphotericin B regimen, but the regimen is being used. Further study of this regimen in other patient populations and settings is necessary.

Clinical treatment of cryptococcal meningitis: an evidence-based review on the emerging clinical data

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.

Impact of Cerebrospinal Fluid Leukocyte Infiltration and Neuroimmmune Mediators on Survival with HIV-Associated Cryptococcal Meningitis

Introduction

Cryptococcal meningitis remains a prominent cause of death in persons with advanced HIV disease. CSF leukocyte infiltration predicts survival at 18 weeks; however, how CSF immune response relates to CSF leukocyte infiltration is unknown.

Methods

We enrolled 401 adults with HIV-associated cryptococcal meningitis in Uganda who received amphotericin and fluconazole induction therapy. We assessed the association of CSF leukocytes, chemokine, and cytokine responses with 18-week survival.

Results

Participants with CSF leukocytes ≥50/μL, had higher probability 68% (52/77) of 18-week survival compared with 52% (151/292) 18-week survival in those with ≤50 cells/μL (Hazard Ratio=1.63, 95% confidence intervals 1.14-2.23; p=0.008). Survival was also associated with higher expression of T helper (Th)-1, Th17 cytokines, and immune regulatory elements. CSF levels of Programmed Death-1 Ligand, CXCL10, and Interleukin (IL)-2 independently predicted survival. In multivariate analysis, CSF leukocytes were inversely associated with CSF fungal burden and positively associated with CSF protein, interferon-gamma (IFN-γ), IL-17A, tumor necrosis factor (TNF)-α, and peripheral blood CD4+ and CD8+ T cells expression.

Conclusion

18-week survival after diagnosis of cryptococcal meningitis was associated with higher CSF leukocytes at baseline with greater T helper 1 (IFN-γ, IL-2 and TNF-α cytokines), T helper 17 (IL-17A cytokine) and CXCR3+ T cell (CXCL10 chemokine) responses. These results highlight the interdependent contribution of soluble and cellular immune responses in predicting survival with HIV-associated cryptococcal meningitis.

Poor long-term outcomes despite improved hospital survival for patients with cryptococcal meningitis in rural, Northern Uganda

BACKGROUND

Cryptococcal meningitis (CM) remains a major cause of death among people living with HIV in rural sub-Saharan Africa. We previously reported that a CM diagnosis and treatment program (CM-DTP) improved hospital survival for CM patients in rural, northern Uganda. This study aimed to evaluate the impact on long-term survival.

METHODS

We conducted a retrospective study at Lira Regional Referral Hospital in Uganda evaluating long-term survival (≥1 year) of CM patients diagnosed after CM-DTP initiation (February 2017-September 2021). We compared with a baseline historical group of CM patients before CM-DTP implementation (January 2015-February 2017). Using Cox proportional hazards models, we assessed time-to-death in these groups, adjusting for confounders.

RESULTS

We identified 318 CM patients, 105 in the Historical Group, and 213 in the CM-DTP Group. The Historical Group had a higher 30-day mortality of 78.5% compared to 42.2% in the CM-DTP Group. The overall survival rate for the CM-DTP group at three years was 25.6%. Attendance at follow-up visits (HR:0.13, 95% CI: [0.03-0.53], p <0.001), ART adherence (HR:0.27, 95% CI: [0.10-0.71], p = 0.008), and fluconazole adherence: (HR:0.03, 95% CI: [0.01-0.13], p <0.001), weight >50kg (HR:0.54, 95% CI: [0.35-0.84], p = 0.006), and performance of therapeutic lumbar punctures (HR:0.42, 95% CI: [0.24-0.71], p = 0.001), were associated with lower risk of death. Altered mentation was associated with increased death risk (HR: 1.63, 95% CI: 1.10-2.42, p = 0.016).

CONCLUSION

Long-term survival of CM patients improved after the initiation of the CM-DTP. Despite this improved survival, long-term outcomes remained sub-optimal, suggesting that further work is needed to enhance long-term survival.

Funding for research on cryptococcal disease: an analysis based on the G-finder report

Members of the genus Cryptococcus are the causative agents of cryptococcal meningitis, a disease mainly associated with HIV-induced immunosuppression. Patients with cryptococcal meningitis are at a serious risk of death. Most patients suffering from cryptococcosis belong to neglected populations. With reduced support for research, new therapies are unlikely to emerge. In this essay, we used the Policy Cures/G-finder platform as a reference database for funding research on cryptococcal disease. Funding for cryptococcal research started being tracked by G-finder in 2013 and has continued to appear in the annual reports ever since. In total, 15 institutions were reported as major funders for research on cryptococcal disease over the years. The US National Institutes of Health (NIH) was the main funder, followed by the UK's Wellcome Trust. The annual analysis suggested slow yearly growth in funding from 2013 to 2021. The development of new tools to prevent and fight cryptococcal disease is urgent but requires improved funding.

Cryptococcosis and Cryptococcal Meningitis: A Narrative Review and the Up-to-Date Management Approach

Cryptococcosis is a fungal infectious disease that enormously impacts human health worldwide. Cryptococcal meningitis is the most severe disease caused by the fungus Cryptococcus, and can lead to death, if left untreated. Many patients develop resistance and progress to death even after treatment. It requires a prolonged treatment course in people with AIDS. This narrative review provides an evidence-based summary of the current treatment modalities and future trial options, including newer ones, namely, 18B7, T-2307, VT-1598, AR12, manogepix, and miltefosine. This review also evaluated the management and empiric treatment of cryptococcus meningitis. The disease can easily evade diagnosis with subacute presentation. Despite the severity of the disease, treatment options for cryptococcosis remain limited, and more research is needed.

Analysis of the relationship between drug susceptibility of Cryptococcus neoformans isolates and mortality in HIV-negative cryptococcal meningitis

OBJECTIVES

The relationship between antifungal susceptibility and mortality of cryptococcal meningitis (CM) in HIV-negative patients is poorly understood.

METHODS

We conducted a retrospective analysis of 1-year follow-up of 200 HIV-negative CM patients with an initial cerebrospinal fluid (CSF) culture for Cryptococcus neoformans. According to the cut-off values of minimum inhibitory concentration (MIC), two groups of five antifungal agents were classified: amphotericin B (AmB), ≤0.5 µg/mL, >0.5 µg/mL; 5-flucytosine (5-FC), ≤4 µg/mL, >4 µg/mL; fluconazole (FLU), ≤4 µg/mL, >4 µg/mL; itraconazole (ITR), ≤0.125 µg/mL, >0.125 µg/mL; and voriconazole (VOR), <0.25 µg/mL, ≥0.25 µg/mL. Comparisons were performed to analyse clinical features, laboratory, modified Rankin Scale (mRS) scores, and CSF findings under different prognosis outcomes in 1-year.

RESULTS

All of Cryptococcus neoformans isolates were sensitive to AmB and VOR, most of them were sensitive to 5-FC and FLU (95.5% and 90.5%, respectively) while only 55.0% of them were susceptible to ITR. Minimum inhibitory concentrations of ITR and VOR were significantly related to baseline mRS scores. All-cause mortality was not significantly related to MICs in Cryptococcus neoformans strains. The combination of actual antifungal agents and two groups of the MICs values for antifungal agents had no significant effects on all-cause mortality.

CONCLUSION

Most Cryptococcus neoformans isolates were sensitive to AmB, VOR, 5-FC, and FLU. Because of the small number of deaths, we are not able to comment on whether MIC is associated with mortality of CM in HIV-negative patients.

Development and validation of quantitative PCR assays for HIV-associated cryptococcal meningitis in sub-Saharan Africa: a diagnostic accuracy study

BACKGROUND

HIV-associated cryptococcal meningitis is the second leading cause of AIDS-related deaths, with a 10-week mortality rate of 25-30%. Fungal load assessed by colony-forming unit (CFU) counts is used as a prognostic marker and to monitor response to treatment in research studies. PCR-based assessment of fungal load could be quicker and less labour-intensive. We sought to design, optimise, and validate quantitative PCR (qPCR) assays for the detection, identification, and quantification of Cryptococcus infections in patients with cryptococcal meningitis in sub-Saharan Africa.

METHODS

We developed and validated species-specific qPCR assays based on DNA amplification of QSP1 (QSP1A specific to Cryptococcus neoformans, QSP1B/C specific to Cryptococcus deneoformans, and QSP1D specific to Cryptococcus gattii species) and a pan-Cryptococcus assay based on a multicopy 28S rRNA gene. This was a longitudinal study that validated the designed assays on cerebrospinal fluid (CSF) of 209 patients with cryptococcal meningitis at baseline (day 0) and during anti-fungal therapy (day 7 and day 14), from the AMBITION-cm trial in Botswana and Malawi (2018-21). Eligible patients were aged 18 years or older and presenting with a first case of cryptococcal meningitis.

FINDINGS

When compared with quantitative cryptococcal culture as the reference, the sensitivity of the 28S rRNA was 98·2% (95% CI 95·1-99·5) and of the QSP1 assay was 90·4% (85·2-94·0) in CSF at day 0. Quantification of the fungal load with QSP1 and 28S rRNA qPCR correlated with quantitative cryptococcal culture (R2=0·73 and R2=0·78, respectively). Both Botswana and Malawi had a predominant C neoformans prevalence of 67% (95% CI 55-75) and 68% (57-73), respectively, and lower C gattii rates of 21% (14-31) and 8% (4-14), respectively. We identified ten patients that, after 14 days of treatment, harboured viable but non-culturable yeasts based on QSP1 RNA detection (without any positive CFU in CSF culture).

INTERPRETATION

QSP1 and 28S rRNA assays are useful in identifying Cryptococcus species. qPCR results correlate well with baseline quantitative cryptococcal culture and show a similar decline in fungal load during induction therapy. These assays could be a faster alternative to quantitative cryptococcal culture to determine fungal load clearance. The clinical implications of the possible detection of viable but non-culturable cells in CSF during induction therapy remain unclear.

FUNDING

European and Developing Countries Clinical Trials Partnership; Swedish International Development Cooperation Agency; Wellcome Trust/UK Medical Research Council/UKAID Joint Global Health Trials; and UK National Institute for Health Research.

Prevalence, treatment, and factors associated with cryptococcal meningitis post introduction of integrase inhibitors antiretroviral based regimens among People Living with HIV in Tanzania

OBJECTIVE

This study aimed to assess the prevalence of Cryptococcal Meningitis (CM), treatment practice, and the associated factors post-introduction of Tenofovir Lamivudine and Dolutegravir (TLD) regimen among People Living with HIV (PLHIV) in Tanzania.

METHODS

This was an analytical cross-sectional study, and the data was collected retrospectively in three public regional referral hospitals (RRHs) in Dar es Salaam, Tanzania. A total of 405 files of the PLHIV admitted in the medical wards on the TLD regimen from January 2019 to December 2022 were reviewed. The collected information includes the patient's demographic characteristics, Cryptococcal status, CD4 level at the time of CM diagnosis, status of using ART, CM treatment approach, and outcome. Data was analyzed using SPSS software version 23.

RESULTS

Out of 405 patients, the majority 267(65.9%) were female, 224(55.3%) were aged between 36-55 years, and 293(72.3%) were married. ART defaulters were found to be 37(9.1%). The prevalence of CM was found to be 48(11.9%), out of which 42(87.5%) received fluconazole alone. ART defaulter and marital status significantly (p-value < 0.05) were associated with those who tested CM positive.

CONCLUSION

The study found the prevalence of CM among PLHIV to be significantly high and the majority were treated with fluconazole alone. ART defaulters and marital status were significantly associated with one being CM positive. Responsible authorities and stakeholders should enforce guideline adherence and PLHIV should be encouraged on medication adherence.

Antifungal Resistance in Cryptococcal Infections

Antifungal therapy, especially with the azoles, could promote the incidence of less susceptible isolates of Cryptococcus neoformans and C. gattii species complexes (SC), mostly in developing countries. Given that these species affect mostly the immunocompromised host, the infections are severe and difficult to treat. This review encompasses the following topics: 1. infecting species and their virulence, 2. treatment, 3. antifungal susceptibility methods and available categorical endpoints, 4. genetic mechanisms of resistance, 5. clinical resistance, 6. fluconazole minimal inhibitory concentrations (MICs), clinical outcome, 7. environmental influences, and 8. the relevance of host factors, including pharmacokinetic/pharmacodynamic (PK/PD) parameters, in predicting the clinical outcome to therapy. As of now, epidemiologic cutoff endpoints (ECVs/ECOFFs) are the most reliable antifungal resistance detectors for these species, as only one clinical breakpoint (amphotericin B and C. neoformans VNI) is available.

Interplay between acetylation and ubiquitination of imitation switch chromatin remodeler Isw1 confers multidrug resistance in Cryptococcus neoformans

Cryptococcus neoformans poses a threat to human health, but anticryptococcal therapy is hampered by the emergence of drug resistance, whose underlying mechanisms remain poorly understood. Herein, we discovered that Isw1, an imitation switch chromatin remodeling ATPase, functions as a master modulator of genes responsible for in vivo and in vitro multidrug resistance in C. neoformans. Cells with the disrupted ISW1 gene exhibited profound resistance to multiple antifungal drugs. Mass spectrometry analysis revealed that Isw1 is both acetylated and ubiquitinated, suggesting that an interplay between these two modification events exists to govern Isw1 function. Mutagenesis studies of acetylation and ubiquitination sites revealed that the acetylation status of Isw1K97 coordinates with its ubiquitination processes at Isw1K113 and Isw1K441 through modulating the interaction between Isw1 and Cdc4, an E3 ligase. Additionally, clinical isolates of C. neoformans overexpressing the degradation-resistant ISW1K97Q allele showed impaired drug-resistant phenotypes. Collectively, our studies revealed a sophisticated acetylation-Isw1-ubiquitination regulation axis that controls multidrug resistance in C. neoformans.