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Madadi AK, Sohn MJ. Advances in Intrathecal Nanoparticle Delivery: Targeting the Blood-Cerebrospinal Fluid Barrier for Enhanced CNS Drug Delivery. Pharmaceuticals (Basel) 2024; 17:1070. [PMID: 39204177 PMCID: PMC11357388 DOI: 10.3390/ph17081070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2024] [Revised: 08/02/2024] [Accepted: 08/13/2024] [Indexed: 09/03/2024] Open
Abstract
The blood-cerebrospinal fluid barrier (BCSFB) tightly regulates molecular exchanges between the bloodstream and cerebrospinal fluid (CSF), creating challenges for effective central nervous system (CNS) drug delivery. This review assesses intrathecal (IT) nanoparticle (NP) delivery systems that aim to enhance drug delivery by circumventing the BCSFB, complementing approaches that target the blood-brain barrier (BBB). Active pharmaceutical ingredients (APIs) face hurdles like restricted CNS distribution and rapid clearance, which diminish the efficacy of IT therapies. NPs can be engineered to extend drug circulation times, improve CNS penetration, and facilitate sustained release. This review discusses key pharmacokinetic (PK) parameters essential for the effectiveness of these systems. NPs can quickly traverse the subarachnoid space and remain within the leptomeninges for extended periods, often exceeding three weeks. Some designs enable deeper brain parenchyma penetration. Approximately 80% of NPs in the CSF are cleared through the perivascular glymphatic pathway, with microglia-mediated transport significantly contributing to their paravascular clearance. This review synthesizes recent progress in IT-NP delivery across the BCSFB, highlighting critical findings, ongoing challenges, and the therapeutic potential of surface modifications and targeted delivery strategies.
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Affiliation(s)
- Ahmad Khalid Madadi
- Department of Biomedical Science, Graduate School of Medicine, Inje University, 75, Bokji-ro, Busanjingu, Busan 47392, Republic of Korea;
| | - Moon-Jun Sohn
- Department of Biomedical Science, Graduate School of Medicine, Inje University, 75, Bokji-ro, Busanjingu, Busan 47392, Republic of Korea;
- Department of Neurosurgery, Neuroscience & Radiosurgery Hybrid Research Center, Inje University Ilsan Paik Hospital, College of Medicine, Juhwa-ro 170, Ilsanseo-gu, Goyang City 10380, Republic of Korea
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Wasserman S, Antilus-Sainte R, Abdelgawad N, Odjourian NM, Cristaldo M, Dougher M, Kaya F, Zimmerman M, Denti P, Gengenbacher M. Rifabutin central nervous system concentrations in a rabbit model of tuberculous meningitis. Antimicrob Agents Chemother 2024; 68:e0078324. [PMID: 39028192 PMCID: PMC11304741 DOI: 10.1128/aac.00783-24] [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: 05/28/2024] [Accepted: 07/02/2024] [Indexed: 07/20/2024] Open
Abstract
Tuberculous meningitis (TBM) has a high mortality, possibly due to suboptimal therapy. Drug exposure data of antituberculosis agents in the central nervous system (CNS) are required to develop more effective regimens. Rifabutin is a rifamycin equivalently potent to rifampin in human pulmonary tuberculosis. Here, we show that human-equivalent doses of rifabutin achieved potentially therapeutic exposure in relevant CNS tissues in a rabbit model of TBM, supporting further evaluation in clinical trials.
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Affiliation(s)
- Sean Wasserman
- Institute for Infection and Immunity, St. George’s, University of London, London, United Kingdom
- Center for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Noha Abdelgawad
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Narineh M. Odjourian
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, New Jersey, USA
| | - Melissa Cristaldo
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, New Jersey, USA
| | - Maureen Dougher
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, New Jersey, USA
| | - Firat Kaya
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, New Jersey, USA
| | - Matthew Zimmerman
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, New Jersey, USA
| | - Paolo Denti
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Martin Gengenbacher
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, New Jersey, USA
- Hackensack Meridian School of Medicine, Nutley, New Jersey, USA
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Chacko B, Chaudhry D, Peter JV, Khilnani GC, Saxena P, Sehgal IS, Ahuja K, Rodrigues C, Modi M, Jaiswal A, Jasiel GJ, Sahasrabudhe S, Bose P, Ahuja A, Suprapaneni V, Prajapat B, Manesh A, Chawla R, Guleria R. ISCCM Position Statement on the Approach to and Management of Critically Ill Patients with Tuberculosis. Indian J Crit Care Med 2024; 28:S67-S91. [PMID: 39234233 PMCID: PMC11369919 DOI: 10.5005/jp-journals-10071-24783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2024] [Accepted: 07/24/2024] [Indexed: 09/06/2024] Open
Abstract
Tuberculosis (TB) is an important cause of morbidity and mortality globally. About 3-4% of hospitalized TB patients require admission to the intensive care unit (ICU); the mortality in these patients is around 50-60%. There is limited literature on the evaluation and management of patients with TB who required ICU admission. The Indian Society of Critical Care Medicine (ISCCM) constituted a working group to develop a position paper that provides recommendations on the various aspects of TB in the ICU setting based on available evidence. Seven domains were identified including the categorization of TB in the critically ill, diagnostic workup, drug therapy, TB in the immunocompromised host, organ support, infection control, and post-TB sequelae. Forty-one questions pertaining to these domains were identified and evidence-based position statements were generated, where available, keeping in focus the critical care aspects. Where evidence was not available, the recommendations were based on consensus. This position paper guides the approach to and management of critically ill patients with TB. How to cite this article Chacko B, Chaudhry D, Peter JV, Khilnani G, Saxena P, Sehgal IS, et al. isccm Position Statement on the Approach to and Management of Critically Ill Patients with Tuberculosis. Indian J Crit Care Med 2024;28(S2):S67-S91.
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Affiliation(s)
- Binila Chacko
- Medical Intensive Care Unit, Christian Medical College, Vellore, Tamil Nadu, India
| | - Dhruva Chaudhry
- Department of Pulmonary and Critical Care Medicine, Pt BDS Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India
| | - John V Peter
- Medical Intensive Care Unit, Christian Medical College, Vellore, Tamil Nadu, India
| | - Gopi C Khilnani
- Department of Pulmonary, Critical Care and Sleep Medicine, PSRI Hospital, New Delhi, India
| | - Prashant Saxena
- Department of Pulmonary, Critical Care and Sleep Medicine, Fortis Hospital, Vasant Kung, New Delhi, India
| | - Inderpaul S Sehgal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, Punjab, India
| | - Kunal Ahuja
- Department of Pulmonary, Critical Care and Sleep Medicine, PSRI Hospital, New Delhi, India
| | - Camilla Rodrigues
- Department of Lab Medicine, Hinduja Hospital, Mumbai, Maharashtra, India
| | - Manish Modi
- Department of Neurology, Postgraduate Institute of Medical Education and Research, Chandigarh, Punjab, India
| | - Anand Jaiswal
- Deparment of Respiratory Diseases, Medanta Medicity, Gurugram, Haryana, India
| | - G Joel Jasiel
- Medical Intensive Care Unit, Christian Medical College, Vellore, Tamil Nadu, India
| | - Shrikant Sahasrabudhe
- Department of Critical Care Medicine and Pulmonology, KIMS Manavata Hospital, Nashik, Maharashtra, India
| | - Prithviraj Bose
- Medical Intensive Care Unit, Christian Medical College, Vellore, Tamil Nadu, India
| | - Aman Ahuja
- Department of Pulmonary and Critical Care Medicine, PGIMS, Rohtak, Haryana, India
| | - Vineela Suprapaneni
- Department of Pulmonary and Critical Care Medicine, PGIMS, Rohtak, Haryana, India
| | - Brijesh Prajapat
- Department of Pulmonary and Critical Care Medicine, Yashoda Group of Hospitals, Ghaziabad, Uttar Pradesh, India
| | - Abi Manesh
- Department of Infectious Diseases, Christian Medical College, Vellore, Tamil Nadu, India
| | - Rajesh Chawla
- Department of Respiratory Medicine, Critical Care and Sleep Medicine, Indraprastha Apollo Hospitals, New Delhi, India
| | - Randeep Guleria
- Institute of Internal Medicine and Respiratory and Sleep Medicine, Medanta Medical School, Gurugram, Haryana, India
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Gafar F, Yunivita V, Fregonese F, Apriani L, Aarnoutse RE, Ruslami R, Menzies D. Pharmacokinetics of standard versus high-dose rifampin for tuberculosis preventive treatment: A sub-study of the 2R 2 randomized controlled trial. Int J Antimicrob Agents 2024; 64:107197. [PMID: 38750674 DOI: 10.1016/j.ijantimicag.2024.107197] [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: 11/23/2023] [Revised: 03/18/2024] [Accepted: 05/06/2024] [Indexed: 06/09/2024]
Abstract
BACKGROUND Pharmacokinetic data of rifampin, when used for tuberculosis preventive treatment (TPT) are not available. We aimed to describe the pharmacokinetics of rifampin used for TPT, at standard and higher doses, and to assess predictors of rifampin exposure. METHODS A pharmacokinetic sub-study was performed in Bandung, Indonesia among participants in the 2R2 randomized trial, which compared TPT regimens of 2 months of high-dose rifampin at 20 mg/kg/day (2R20) and 30 mg/kg/day (2R30), with 4 months of standard-dose rifampin at 10 mg/kg/day (4R10) in adolescents and adults. Intensive pharmacokinetic sampling was performed after 2-8 weeks of treatment. Pharmacokinetic parameters were assessed non-compartmentally. Total exposure (AUC0-24) and peak concentration (Cmax) between arms were compared using one-way ANOVA and Tukey's post-hoc tests. Multivariable linear regression analyses were used to assess predictors of AUC0-24 and Cmax. RESULTS We enrolled 51 participants in this study. In the 4R10, 2R20, and 2R30 arms, the geometric mean AUC0-24 was 68.0, 186.8, and 289.9 h⋅mg/L, and Cmax was 18.4, 36.7, and 54.4 mg/L, respectively; high interindividual variabilities were observed. Compared with the 4R10 arm, AUC0-24 and Cmax were significantly higher in the 2R20 and 2R30 arms (P < 0.001). Drug doses, body weight, and female sex were predictors of higher rifampin AUC0-24 and Cmax (P < 0.05). AUC0-24 and Cmax values were much higher than those previously reported in persons with TB disease. CONCLUSIONS Doubling and tripling the rifampin dose led to three- and four-fold higher exposure compared to standard dose. Pharmacokinetic/pharmacodynamic modelling and simulations are warranted to support trials of shortening the duration of TPT regimens with high-dose rifampin.
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Affiliation(s)
- Fajri Gafar
- Respiratory Epidemiology and Clinical Research Unit, Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada; McGill International TB Centre, McGill University, Montreal, Quebec, Canada; Department of Biomedical Sciences, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Vycke Yunivita
- Department of Biomedical Sciences, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia; TB Working Group, Research Center for Care and Control of Infectious Diseases, Universitas Padjadjaran, Bandung, Indonesia
| | - Federica Fregonese
- Respiratory Epidemiology and Clinical Research Unit, Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada; McGill International TB Centre, McGill University, Montreal, Quebec, Canada
| | - Lika Apriani
- TB Working Group, Research Center for Care and Control of Infectious Diseases, Universitas Padjadjaran, Bandung, Indonesia; Division of Epidemiology and Biostatistics, Department of Public Health, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Rob E Aarnoutse
- Department of Pharmacy, Radboud Institute for Medical Innovation, Radboud university medical center, Nijmegen, The Netherlands
| | - Rovina Ruslami
- McGill International TB Centre, McGill University, Montreal, Quebec, Canada; Department of Biomedical Sciences, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia; TB Working Group, Research Center for Care and Control of Infectious Diseases, Universitas Padjadjaran, Bandung, Indonesia
| | - Dick Menzies
- Respiratory Epidemiology and Clinical Research Unit, Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada; McGill International TB Centre, McGill University, Montreal, Quebec, Canada; Department of Epidemiology, Biostatistics and Occupational Health, Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada; Montreal Chest Institute, McGill University Health Centre, Montreal, Quebec, Canada.
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Jin W, Qifu C, Hong Y, Hua H, Xuelin L, Xiaomin W, Shuihua L, Mutong F. Intracranial tuberculomas diagnosed with Xpert MTB/RIF Ultra assay of formalin-fixed paraffin-embedded brain tissues and treated with an optimized antituberculosis regimen: A case report. Heliyon 2024; 10:e32462. [PMID: 38961962 PMCID: PMC11219345 DOI: 10.1016/j.heliyon.2024.e32462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 05/07/2024] [Accepted: 06/04/2024] [Indexed: 07/05/2024] Open
Abstract
Diagnosis of intracranial tuberculoma remains a challenge due to its rarity, non-specific clinical presentation, and radiological findings. Herein, we describe a case of intracranial tuberculomas in a male diabetic patient who presented headache and vomiting on admission. Neuroimaging findings indicated multiple ring contrast-enhanced lesions with extensive perilesional edema. However, a cerebrospinal fluid (CSF) examination was normal. When a biopsy of brain lesions was performed, pathological characteristics of tuberculosis were absent and acid-fast staining was negative. A tuberculosis diagnosis was subsequently obtained from an Xpert MTB/RIF Ultra assay of formalin-fixed paraffin-embedded brain tissue. The patient was treated with an optimized anti-tuberculosis regimen which included high-dose intravenous administration of rifampicin and isoniazid, and oral administration of linezolid. The patient recovered well and exhibited marked clinical improvement. This case report demonstrates that when CSF analysis does not indicate the presence of intracranial tuberculomas, analysis of formalin-fixed paraffin-embedded brain tissue specimens with the Xpert MTB/RIF Ultra assay may be able to confirm a diagnosis. Furthermore, a high dose of rifampicin and isoniazid plus linezolid may improve patient outcome.
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Affiliation(s)
- Wang Jin
- Division of Pulmonary Diseases Department, The Third People's Hospital of Shenzhen, Southern University of Science and Technology, Shenzhen, Guangdong, China
- National Clinical Research Center for Infectious Disease, Southern University of Science and Technology, Shenzhen, Guangdong, China
| | - Chen Qifu
- Department of Neurosurgery, The Third People's Hospital of Shenzhen, Southern University of Science and Technology, Shenzhen, Guangdong, China
| | - Yu Hong
- Department of Pathology, The Third People's Hospital of Shenzhen, Southern University of Science and Technology, Shenzhen, Guangdong, China
| | - Huang Hua
- Department of Radiology, The Third People's Hospital of Shenzhen, Southern University of Science and Technology, Shenzhen, Guangdong, China
| | - Li Xuelin
- Department of Clinical Laboratory, The Third People's Hospital of Shenzhen, Southern University of Science and Technology, Shenzhen, Guangdong, China
| | - Wang Xiaomin
- National Clinical Research Center for Infectious Disease, Southern University of Science and Technology, Shenzhen, Guangdong, China
| | - Lu Shuihua
- Division of Pulmonary Diseases Department, The Third People's Hospital of Shenzhen, Southern University of Science and Technology, Shenzhen, Guangdong, China
- National Clinical Research Center for Infectious Disease, Southern University of Science and Technology, Shenzhen, Guangdong, China
| | - Fang Mutong
- Division of Pulmonary Diseases Department, The Third People's Hospital of Shenzhen, Southern University of Science and Technology, Shenzhen, Guangdong, China
- National Clinical Research Center for Infectious Disease, Southern University of Science and Technology, Shenzhen, Guangdong, China
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Ruslami R, Fregonese F, Apriani L, Barss L, Bedingfield N, Chiang V, Cook VJ, Fisher D, Flores E, Fox GJ, Johnston J, Lim RK, Long R, Paulsen C, Nguyen TA, Nhung NV, Gibson D, Valiquette C, Benedetti A, Menzies D. High-dose, short-duration versus standard rifampicin for tuberculosis preventive treatment: a partially blinded, three-arm, non-inferiority, randomised, controlled trial. THE LANCET. RESPIRATORY MEDICINE 2024; 12:433-443. [PMID: 38552659 DOI: 10.1016/s2213-2600(24)00076-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Revised: 02/28/2024] [Accepted: 02/29/2024] [Indexed: 06/02/2024]
Abstract
BACKGROUND Tuberculosis preventive treatment (TPT) is a key component of tuberculosis elimination. To improve completion and reduce the burden for people and health systems, short, safe, and effective TPT regimens are needed. We aimed to compare safety and treatment completion of various doses and durations of rifampicin in people who were recommended to receive TPT. METHODS This partially blinded, parallel-arm, non-inferiority, randomised, controlled, phase 2b trial was done at seven university-affiliated clinics in Canada, Indonesia, and Viet Nam. Participants aged 10 years or older were included if they had an indication for TPT according to WHO guidelines for Indonesia and Viet Nam, or Canadian guidelines for Canadian sites, and a positive tuberculin skin test or interferon-γ release assay. Participants were randomly assigned (1:1:1) to receive oral rifampicin at 10 mg/kg once daily for 4 months (standard-dose group), 20 mg/kg daily for 2 months (20 mg/kg group), or 30 mg/kg daily for 2 months (30 mg/kg group). The randomisation sequence was computer generated with blocks of variable size (three, six, and nine) and stratified by country for Indonesia and Viet Nam, and by city within Canada. Participants and investigators were masked to dose in high-dose groups, but unmasked to duration in all groups. The two co-primary outcomes were safety (in the safety population, in which participants received at least one dose of the study drug) and treatment completion (in the modified intention-to-treat [mITT] population, excluding those ineligible after randomisation). Protocol-defined adverse events were defined as grade 3 or worse, or rash or allergy of any grade, judged by an independent and masked panel as possibly or probably related to the study. A margin of 4% was used to assess non-inferiority. This study is registered with ClinicalTrials.gov, NCT03988933 (active). FINDINGS Between Sept 1, 2019, and Sept 30, 2022, 1692 people were assessed for eligibility, 1376 were randomly assigned, and eight were excluded after randomisation. 1368 participants were included in the mITT population (454 in the standard group, 461 in the 20 mg/kg group, and 453 in the 30 mg/kg group). 589 (43%) participants were male and 779 (57%) were female. 372 (82%) in the standard-dose group, 329 (71%) in the 20 mg/kg group, and 293 (65%) in the 30 mg/kg group completed treatment. No participants in the standard-dose group, one (<1%) of 441 participants in the 20 mg/kg group, and four (1%) of 423 in the 30 mg/kg group developed grade 3 hepatotoxicity. Risk of protocol-defined adverse events was higher in the 30 mg/kg group than in the standard-dose group (adjusted risk difference 4·6% [95% CI 1·8 to 7·4]) or the 20 mg/kg group (5·1% [2·3 to 7·8]). There was no difference in the risk of adverse events between the 20 mg/kg and standard-dose groups (-0·5% [95% CI -2·4 to 1·5]; non-inferiority met). Completion was lower in the 20 mg/kg group (-7·8% [95% CI -13·6 to -2·0]) and the 30 mg/kg group (-15·4% [-21·4 to -9·4]) than in the standard-dose group. INTERPRETATION In this trial, 2 months of 30 mg/kg daily rifampicin had significantly worse safety and completion than 4 months of 10 mg/kg daily and 2 months of 20 mg/kg daily (the latter, a fully blinded comparison); we do not consider 30 mg/kg to be a good option for TPT. Rifampicin at 20 mg/kg daily for 2 months was as safe as standard treatment, but with lower completion. This difference remains unexplained. FUNDING Canadian Institutes of Health Research.
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Affiliation(s)
- Rovina Ruslami
- Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia; Research Center for Care and Control of Infectious Disease, Universitas Padjadjaran, Bandung, Indonesia
| | - Federica Fregonese
- Montreal Chest Institute, Research Institute of the McGill University Health Center, Montreal, QC, Canada; McGill International TB Centre, McGill University, Montreal, QC, Canada
| | - Lika Apriani
- Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia; Research Center for Care and Control of Infectious Disease, Universitas Padjadjaran, Bandung, Indonesia
| | - Leila Barss
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Nancy Bedingfield
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Victor Chiang
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Victoria J Cook
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada; Provincial TB Services, British Columbia Centre for Disease Control, Vancouver, BC, Canada
| | - Dina Fisher
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Eri Flores
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Greg J Fox
- Faculty of Medicine and Health, The University of Sydney, NSW, Australia; Woolcock Institute of Medical Research, Glebe, NSW, Australia
| | - James Johnston
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada; Provincial TB Services, British Columbia Centre for Disease Control, Vancouver, BC, Canada
| | - Rachel K Lim
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Richard Long
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Catherine Paulsen
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Thu Anh Nguyen
- Woolcock Institute of Medical Research, Glebe, NSW, Australia
| | - Nguyen Viet Nhung
- National Lung Hospital, VNU Ha Noi, Viet Nam; University of Medicine and Pharmacy, VNU Ha Noi, Viet Nam
| | - Diana Gibson
- McGill International TB Centre, McGill University, Montreal, QC, Canada
| | - Chantal Valiquette
- Montreal Chest Institute, Research Institute of the McGill University Health Center, Montreal, QC, Canada; McGill International TB Centre, McGill University, Montreal, QC, Canada
| | - Andrea Benedetti
- Montreal Chest Institute, Research Institute of the McGill University Health Center, Montreal, QC, Canada; McGill International TB Centre, McGill University, Montreal, QC, Canada
| | - Dick Menzies
- Montreal Chest Institute, Research Institute of the McGill University Health Center, Montreal, QC, Canada; McGill International TB Centre, McGill University, Montreal, QC, Canada.
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Madadi AK, Sohn MJ. Comprehensive Therapeutic Approaches to Tuberculous Meningitis: Pharmacokinetics, Combined Dosing, and Advanced Intrathecal Therapies. Pharmaceutics 2024; 16:540. [PMID: 38675201 PMCID: PMC11054600 DOI: 10.3390/pharmaceutics16040540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Revised: 04/10/2024] [Accepted: 04/11/2024] [Indexed: 04/28/2024] Open
Abstract
Tuberculous meningitis (TBM) presents a critical neurologic emergency characterized by high mortality and morbidity rates, necessitating immediate therapeutic intervention, often ahead of definitive microbiological and molecular diagnoses. The primary hurdle in effective TBM treatment is the blood-brain barrier (BBB), which significantly restricts the delivery of anti-tuberculous medications to the central nervous system (CNS), leading to subtherapeutic drug levels and poor treatment outcomes. The standard regimen for initial TBM treatment frequently falls short, followed by adverse side effects, vasculitis, and hydrocephalus, driving the condition toward a refractory state. To overcome this obstacle, intrathecal (IT) sustained release of anti-TB medication emerges as a promising approach. This method enables a steady, uninterrupted, and prolonged release of medication directly into the cerebrospinal fluid (CSF), thus preventing systemic side effects by limiting drug exposure to the rest of the body. Our review diligently investigates the existing literature and treatment methodologies, aiming to highlight their shortcomings. As part of our enhanced strategy for sustained IT anti-TB delivery, we particularly seek to explore the utilization of nanoparticle-infused hydrogels containing isoniazid (INH) and rifampicin (RIF), alongside osmotic pump usage, as innovative treatments for TBM. This comprehensive review delineates an optimized framework for the management of TBM, including an integrated approach that combines pharmacokinetic insights, concomitant drug administration strategies, and the latest advancements in IT and intraventricular (IVT) therapy for CNS infections. By proposing a multifaceted treatment strategy, this analysis aims to enhance the clinical outcomes for TBM patients, highlighting the critical role of targeted drug delivery in overcoming the formidable challenges presented by the blood-brain barrier and the complex pathophysiology of TBM.
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Affiliation(s)
- Ahmad Khalid Madadi
- Department of Biomedical Science, Graduate School of Medicine, Inje University, 75, Bokji-ro, Busanjin-gu, Busan 47392, Republic of Korea;
| | - Moon-Jun Sohn
- Department of Biomedical Science, Graduate School of Medicine, Inje University, 75, Bokji-ro, Busanjin-gu, Busan 47392, Republic of Korea;
- Department of Neurosurgery, Neuroscience & Radiosurgery Hybrid Research Center, College of Medicine, Inje University Ilsan Paik Hospital, 170, Juhwa-ro, Ilsanseo-gu, Goyang City 10380, Republic of Korea
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8
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Guillem L, Espinosa J, Laporte-Amargos J, Sánchez A, Grijota MD, Santin M. Mortality and sequelae of tuberculous meningitis in a high-resource setting: A cohort study, 1990-2017. ENFERMEDADES INFECCIOSAS Y MICROBIOLOGIA CLINICA (ENGLISH ED.) 2024; 42:124-129. [PMID: 36737367 DOI: 10.1016/j.eimce.2023.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 10/14/2022] [Indexed: 06/18/2023]
Abstract
INTRODUCTION Tuberculous meningitis (TBM), the most serious form of tuberculosis, results in high mortality and long-term disability in low-resource countries. We investigated temporal trends in mortality and sequelae in a high-resource low-incidence country. METHODS We performed a retrospective cohort study of all adult patients with TBM at two third-level teaching hospitals in Barcelona (Spain), between January 1990 and December 2017, assessing temporal trends in mortality and sequelae after 12 months over four consecutive 7-year time windows. Rates observed across the four periods were adjusted for covariates. RESULTS Of the 135 cases included, all but one started tuberculosis (TB) treatment and 120 (89.6%) received rifampicin, isoniazid, and pyrazinamide, with or without ethambutol. The probability of being alive at month 12 was 81.8%, with no differences among the four periods: in comparison with the 1990-1996 period, the adjusted hazard ratios and 95% confidence intervals (CI) were 2.55 (0.71-9.25), 0.70 (0.13-3.85), and 1.29 (0.28-5.91) for the 1997-2003, 2004-2010, and 2011-2017 periods respectively. Sequelae were present in 28.3% at month 12, with no differences across the four periods in the adjusted analysis: in comparison with the 1990-1996 period, the odds ratios and 95% CIs were 0.80 (0.09-7.22); 1.94 (0.21-17.96), and 2.42 (0.25-23.07) for the 1997-2003, 2004-2010, and 2011-2017 periods respectively. CONCLUSION This study shows that TBM still causes high mortality and disability even in a high-resource low-incidence TB setting and without improvement over time.
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Affiliation(s)
- Lluïsa Guillem
- Department of Infectious Diseases, Bellvitge University Hospital-Bellvitge Institute for Biomedical Research (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain.
| | - Juan Espinosa
- Department of Infectious Diseases, Vall d'Hebron University Hospital, PROSICS Barcelona, Barcelona, Spain
| | - Júlia Laporte-Amargos
- Department of Infectious Diseases, Bellvitge University Hospital-Bellvitge Institute for Biomedical Research (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
| | - Adrián Sánchez
- Department of Infectious Diseases, Vall d'Hebron University Hospital, Programa de Salut Internacional de l'Institut Català de la Salut (PROSICS), Barcelona, Spain; Mycobacterial Diseases Study Group (Grupo de estudio de Infecciones por Micobacterias, Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica, GEIM-SEIMC) Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Spain
| | - María D Grijota
- Tuberculosis Unit, Department of Infectious Diseases, Bellvitge University Hospital-Bellvitge Institute for Biomedical Research (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain; Department of Fundamental and Medical-Surgical Nursing, University of Barcelona, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Miguel Santin
- Tuberculosis Unit, Department of Infectious Diseases, Bellvitge University Hospital-Bellvitge Institute for Biomedical Research (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain; Department of Clinical Sciences, University of Barcelona, L'Hospitalet de Llobregat, Barcelona, Spain.
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9
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Khadka P, Dummer J, Hill PC, Das SC. The quest to deliver high-dose rifampicin: can the inhaled approach help? Expert Opin Drug Deliv 2024; 21:31-44. [PMID: 38180078 DOI: 10.1080/17425247.2024.2301931] [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: 06/20/2023] [Accepted: 01/02/2024] [Indexed: 01/06/2024]
Abstract
INTRODUCTION Tuberculosis (TB) is a global health problem that poses a challenge to global treatment programs. Rifampicin is a potent and highly effective drug for TB treatment; however, higher oral doses than the standard dose (10 mg/kg/day) rifampicin may offer better efficacy in TB treatment. AREAS COVERED High oral dose rifampicin is not implemented in anti-TB regimens yet and requires about a 3-fold increase in dose for increased efficacy. We discuss inhaled delivery of rifampicin as an alternative or adjunct to oral high-dose rifampicin. Clinical results of safety, tolerability, and patient compliance with antibiotic dry powder inhalers are reviewed. EXPERT OPINION Clinical trials suggest that an approximately 3-fold increase in the standard oral dose of rifampicin may be required for better clinical outcomes. On the other hand, animal studies suggest that inhaled rifampicin can deliver a high concentration of the drug to the lungs and achieve approximately double the plasma concentration than that from oral rifampicin. Clinical trials on inhaled antibiotics suggest that dry powder inhalation is a patient-friendly and well-tolerated approach in treating respiratory infections compared to conventional treatments. Rifampicin, a well-known anti-TB drug given orally, is a good candidate for clinical development as a dry powder inhaler.
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Affiliation(s)
- Prakash Khadka
- School of Pharmacy, University of Otago, Dunedin, New Zealand
| | - Jack Dummer
- Department of Medicine, Otago Medical School, University of Otago, Dunedin, New Zealand
| | - Philip C Hill
- Centre for International Health, University of Otago, Dunedin, New Zealand
| | - Shyamal C Das
- School of Pharmacy, University of Otago, Dunedin, New Zealand
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10
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Lanni F, Antilus Sainte R, Hansen, M, Parigi P, Kaya F, LoMauro K, Siow B, Wilkinson RJ, Wasserman S, Podell BK, Gengenbacher M, Dartois V. A preclinical model of TB meningitis to determine drug penetration and activity at the sites of disease. Antimicrob Agents Chemother 2023; 67:e0067123. [PMID: 37966227 PMCID: PMC10720511 DOI: 10.1128/aac.00671-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 09/29/2023] [Indexed: 11/16/2023] Open
Abstract
Tuberculosis meningitis (TBM) is essentially treated with the first-line regimen used against pulmonary tuberculosis, with a prolonged continuation phase. However, clinical outcomes are poor in comparison, for reasons that are only partially understood, highlighting the need for improved preclinical tools to measure drug distribution and activity at the site of disease. A predictive animal model of TBM would also be of great value to prioritize promising drug regimens to be tested in clinical trials, given the healthy state of the development pipeline for the first time in decades. Here, we report the optimization of a rabbit model of TBM disease induced via inoculation of Mycobacterium tuberculosis into the cisterna magna, recapitulating features typical of clinical TBM: neurological deterioration within months post-infection, acid-fast bacilli in necrotic lesions in the brain and spinal cord, and elevated lactate levels in cerebrospinal fluid (CSF). None of the infected rabbits recovered or controlled the disease. We used young adult rabbits, the size of which allows for spatial drug quantitation in critical compartments of the central nervous system that cannot be collected in clinical studies. To illustrate the translational value of the model, we report the penetration of linezolid from plasma into the CSF, meninges, anatomically distinct brain areas, cervical spine, and lumbar spine. Across animals, we measured the bacterial burden concomitant with neurological deterioration, offering a useful readout for drug efficacy studies. The model thus forms the basis for building a preclinical platform to identify improved regimens and inform clinical trial design.
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Affiliation(s)
- Faye Lanni
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, New Jersey, USA
| | | | - Mark Hansen,
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, New Jersey, USA
| | - Paul Parigi
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, New Jersey, USA
| | - Firat Kaya
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, New Jersey, USA
| | - Katherine LoMauro
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, New Jersey, USA
| | - Bernard Siow
- The Francis Crick Institute, London, United Kingdom
| | - Robert J. Wilkinson
- The Francis Crick Institute, London, United Kingdom
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
- Department of Infectious Diseases, Imperial College London, London, United Kingdom
| | - Sean Wasserman
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Brendan K. Podell
- Mycobacteria Research Laboratories, Department of Microbiology, Immunology and Pathology, Colorado State University, Fort Collins, Colorado, USA
| | - Martin Gengenbacher
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, New Jersey, USA
- Department of Medical Sciences, Hackensack Meridian School of Medicine, Nutley, New Jersey, USA
| | - Véronique Dartois
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, New Jersey, USA
- Department of Medical Sciences, Hackensack Meridian School of Medicine, Nutley, New Jersey, USA
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11
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Kimuda S, Kasozi D, Namombwe S, Gakuru J, Mugabi T, Kagimu E, Rutakingirwa MK, Leon KE, Chow F, Wasserman S, Boulware DR, Cresswell FV, Bahr NC. Advancing Diagnosis and Treatment in People Living with HIV and Tuberculosis Meningitis. Curr HIV/AIDS Rep 2023; 20:379-393. [PMID: 37947980 PMCID: PMC10719136 DOI: 10.1007/s11904-023-00678-6] [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] [Accepted: 10/18/2023] [Indexed: 11/12/2023]
Abstract
PURPOSE OF REVIEW Tuberculous meningitis (TBM) is the most severe form of tuberculosis. Inadequate diagnostic testing and treatment regimens adapted from pulmonary tuberculosis without consideration of the unique nature of TBM are among the potential drivers. This review focuses on the progress being made in relation to both diagnosis and treatment of TBM, emphasizing promising future directions. RECENT FINDINGS The molecular assay GeneXpert MTB/Rif Ultra has improved sensitivity but has inadequate negative predictive value to "rule-out" TBM. Evaluations of tests focused on the host response and bacterial components are ongoing. Clinical trials are in progress to explore the roles of rifampin, fluoroquinolones, linezolid, and adjunctive aspirin. Though diagnosis has improved, novel modalities are being explored to improve the rapid diagnosis of TBM. Multiple ongoing clinical trials may change current therapies for TBM in the near future.
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Affiliation(s)
- Sarah Kimuda
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Derrick Kasozi
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Suzan Namombwe
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Jane Gakuru
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Timothy Mugabi
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Enock Kagimu
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | - Kristoffer E Leon
- Departments of Neurology and Medicine (Infectious Diseases), University of California San Francisco, San Francisco, CA, USA
| | - Felicia Chow
- Departments of Neurology and Medicine (Infectious Diseases), University of California San Francisco, San Francisco, CA, USA
| | - Sean Wasserman
- Institute for Infection and Immunity, St George's, University of London, London, United Kingdom
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - David R Boulware
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Fiona V Cresswell
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
- HIV Interventions, MRC/UVRI-LSHTM Uganda Research Unit, Entebbe, Uganda
- Global Health and Infection, Brighton and Sussex Medical School, Brighton, UK
| | - Nathan C Bahr
- Division of Infectious Diseases, Department of Medicine, University of Kansas Medical Center, Kansas City, KS, USA.
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12
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Loghin II, Vâță A, Miftode EG, Cobaschi M, Rusu ȘA, Silvaș G, Frăsinariu OE, Dorobăț CM. Characteristics of Tuberculous Meningitis in HIV-Positive Patients from Northeast Romania. Clin Pract 2023; 13:1488-1500. [PMID: 38131680 PMCID: PMC10742667 DOI: 10.3390/clinpract13060131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 11/10/2023] [Accepted: 11/14/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND AND OBJECTIVES One of the most severe forms of extrapulmonary tuberculosis (EPTB) is tuberculous meningitis (TBM), which is linked to significant morbidity and high mortality. It is well recognized that human immunodeficiency virus (HIV)-positive people are more likely to develop EPTB, including TBM, especially if they have severe immunodeficiencies. We aim to highlight the profile and the characteristics of TBM in HIV-infected patients. MATERIAL AND METHODS We conducted a retrospective clinical study based on hospital medical records of patients diagnosed with HIV/AIDS (acquired immunodeficiency syndrome) and TBM in Northeast Romania, hospitalized at "St. Parascheva" Clinical Hospital of Infectious Diseases of Iasi from 1 January 2010 to 1 December 2022. RESULTS From a total number of 1692 patients on record in our center, 195 had a HIV-tuberculosis (TB) coinfection, and 19 cases were HIV-TBM coinfected. Six cases were newly HIV-diagnosed late presenters, and thirteen patients' names were already found in the center's records with deficient immunological viral status (median CD4 lymphocyte level 47/mm3). The average age in the study group was 27 years old. The clinical manifestations and cerebrospinal fluid (CSF) variables were typical in most cases, despite the severe immunodepression of the patients. The Thwaites scoring system correctly identified 89.5% of the patients. The median admission period was 18 days; the lethality rate was 31.6%, despite access to ART and anti-TB drugs, and was associated with a more severe immunosuppression. No rifampicin resistance was detected. CONCLUSIONS TBM appeared in a minority of our HIV cohort and affected severely immunodepressed patients; the clinical and CSF variables had a typical aspect in most cases, and the Thwaites scoring system performed well for this type of patient. The lethality rate was high and was correlated with a more severe immunodepression.
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Affiliation(s)
- Isabela Ioana Loghin
- Department of Infectious Diseases, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (I.I.L.); (A.V.); (E.G.M.)
- Department of Infectious Diseases, “St. Parascheva” Clinical Hospital of Infectious Diseases, 700116 Iasi, Romania; (Ș.A.R.); (G.S.); (C.M.D.)
| | - Andrei Vâță
- Department of Infectious Diseases, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (I.I.L.); (A.V.); (E.G.M.)
- Department of Infectious Diseases, “St. Parascheva” Clinical Hospital of Infectious Diseases, 700116 Iasi, Romania; (Ș.A.R.); (G.S.); (C.M.D.)
| | - Egidia Gabriela Miftode
- Department of Infectious Diseases, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (I.I.L.); (A.V.); (E.G.M.)
- Department of Infectious Diseases, “St. Parascheva” Clinical Hospital of Infectious Diseases, 700116 Iasi, Romania; (Ș.A.R.); (G.S.); (C.M.D.)
| | - Mihaela Cobaschi
- Faculty of Medicine/Clinical II Department, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
- National Institute of Infectious Diseases “Prof. Dr. Matei Balș”, 021105 Bucharest, Romania
| | - Șerban Alin Rusu
- Department of Infectious Diseases, “St. Parascheva” Clinical Hospital of Infectious Diseases, 700116 Iasi, Romania; (Ș.A.R.); (G.S.); (C.M.D.)
| | - George Silvaș
- Department of Infectious Diseases, “St. Parascheva” Clinical Hospital of Infectious Diseases, 700116 Iasi, Romania; (Ș.A.R.); (G.S.); (C.M.D.)
| | - Otilia Elena Frăsinariu
- Department of Infectious Diseases, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (I.I.L.); (A.V.); (E.G.M.)
- Emergency Clinical Hospital for Children “St. Maria”, 700309 Iasi, Romania
| | - Carmen Mihaela Dorobăț
- Department of Infectious Diseases, “St. Parascheva” Clinical Hospital of Infectious Diseases, 700116 Iasi, Romania; (Ș.A.R.); (G.S.); (C.M.D.)
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13
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Kengo A, Nabisere R, Gausi K, Musaazi J, Buzibye A, Omali D, Aarnoutse R, Lamorde M, Dooley KE, Sloan DJ, Denti P, Sekaggya-Wiltshire C. Dolutegravir pharmacokinetics in Ugandan patients with TB and HIV receiving standard- versus high-dose rifampicin. Antimicrob Agents Chemother 2023; 67:e0043023. [PMID: 37850738 PMCID: PMC10648962 DOI: 10.1128/aac.00430-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 07/13/2023] [Indexed: 10/19/2023] Open
Abstract
Higher rifampicin doses may improve tuberculosis treatment outcomes. This could however exacerbate the existing drug interaction with dolutegravir. Moreover, the metabolism of dolutegravir may also be affected by polymorphism of UGT1A1, a gene that codes for uridine diphosphate glucuronosyltransferase. We used population pharmacokinetic modeling to compare the pharmacokinetics of dolutegravir when coadministered with standard- versus high-dose rifampicin in adults with tuberculosis and HIV, and investigated the effect of genetic polymorphisms. Data from the SAEFRIF trial, where participants were randomized to receive first-line tuberculosis treatment with either standard- 10 mg/kg or high-dose 35 mg/kg rifampicin alongside antiretroviral therapy, were used. The dolutegravir model was developed with 211 plasma concentrations from 44 participants. The median (interquartile range) rifampicin area under the curve (AUC) in the standard- and high-dose arms were 32.3 (28.7-36.7) and 153 (138-175) mg·h/L, respectively. A one-compartment model with first-order elimination and absorption through transit compartments best described dolutegravir pharmacokinetics. For a typical 56 kg participant, we estimated a clearance, absorption rate constant, and volume of distribution of 1.87 L/h, 1.42 h-1, and 12.4 L, respectively. Each 10 mg·h/L increase in the AUC of coadministered rifampicin from 32.3 mg·h/L led to a 2.3 (3.1-1.4) % decrease in dolutegravir bioavailability. Genetic polymorphism of UGT1A1 did not significantly affect dolutegravir pharmacokinetics. Simulations of trough dolutegravir concentrations show that the 50 mg twice-daily regimen attains both the primary and secondary therapeutic targets of 0.064 and 0.3 mg/L, respectively, regardless of the dose of coadministered rifampicin, unlike the once-daily regimen.
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Affiliation(s)
- Allan Kengo
- Department of Medicine, Division of Clinical Pharmacology, University of Cape Town, Cape Town, South Africa
| | - Ruth Nabisere
- Infectious Disease Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Kamunkhwala Gausi
- Department of Medicine, Division of Clinical Pharmacology, University of Cape Town, Cape Town, South Africa
| | - Joseph Musaazi
- Infectious Disease Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Allan Buzibye
- Infectious Disease Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Denis Omali
- Infectious Disease Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Rob Aarnoutse
- Department of Pharmacy, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Mohammed Lamorde
- Infectious Disease Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Kelly E. Dooley
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Centre, Nashville, Tennessee, USA
| | - Derek James Sloan
- Division of Infection and Global Health, School of Medicine, University of St. Andrews, St Andrews, United Kingdom
| | - Paolo Denti
- Department of Medicine, Division of Clinical Pharmacology, University of Cape Town, Cape Town, South Africa
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14
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Kengo A, Gausi K, Nabisere R, Musaazi J, Buzibye A, Omali D, Aarnoutse R, Lamorde M, Dooley KE, Sloan DJ, Sekaggya-Wiltshire C, Denti P. Unexpectedly low drug exposures among Ugandan patients with TB and HIV receiving high-dose rifampicin. Antimicrob Agents Chemother 2023; 67:e0043123. [PMID: 37850737 PMCID: PMC10649026 DOI: 10.1128/aac.00431-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 07/13/2023] [Indexed: 10/19/2023] Open
Abstract
We characterized the pharmacokinetics of standard- and high-dose rifampicin in Ugandan adults with tuberculosis and HIV taking dolutegravir- or efavirenz-based antiretroviral therapy. A liver model with saturable hepatic extraction adequately described the data, and the increase in exposure between high and standard doses was 4.7-fold. This was lower than what previous reports of dose-exposure nonlinearity would predict and was ascribed to 38% lower bioavailability of the rifampicin-only top-up formulation compared to the fixed-dose combination.
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Affiliation(s)
- Allan Kengo
- Department of Medicine, Division of Clinical Pharmacology, University of Cape Town, Cape Town, South Africa
| | - Kamunkhwala Gausi
- Department of Medicine, Division of Clinical Pharmacology, University of Cape Town, Cape Town, South Africa
| | - Ruth Nabisere
- Infectious Disease Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Joseph Musaazi
- Infectious Disease Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Allan Buzibye
- Infectious Disease Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Denis Omali
- Infectious Disease Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Rob Aarnoutse
- Department of Pharmacy, Radboud university medical center, Nijmegen, the Netherlands
| | - Mohammed Lamorde
- Infectious Disease Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Kelly E. Dooley
- Department of Medicine, Division of Infectious Diseases, Vanderbilt University Medical Centre, Nashville, Tennessee, USA
| | - Derek James Sloan
- Division of Infection and Global Health, School of Medicine, University of St. Andrews, Scotland, United Kingdom
| | | | - Paolo Denti
- Department of Medicine, Division of Clinical Pharmacology, University of Cape Town, Cape Town, South Africa
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15
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Stemkens R, de Jager V, Dawson R, Diacon AH, Narunsky K, Padayachee SD, Boeree MJ, van Beek SW, Colbers A, Coenen MJH, Svensson EM, Fuhr U, Phillips PPJ, te Brake LHM, Aarnoutse RE. Drug interaction potential of high-dose rifampicin in patients with pulmonary tuberculosis. Antimicrob Agents Chemother 2023; 67:e0068323. [PMID: 37768317 PMCID: PMC10583668 DOI: 10.1128/aac.00683-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 07/27/2023] [Indexed: 09/29/2023] Open
Abstract
Accumulating evidence supports the use of higher doses of rifampicin for tuberculosis (TB) treatment. Rifampicin is a potent inducer of metabolic enzymes and drug transporters, resulting in clinically relevant drug interactions. To assess the drug interaction potential of higher doses of rifampicin, we compared the effect of high-dose rifampicin (40 mg/kg daily, RIF40) and standard-dose rifampicin (10 mg/kg daily, RIF10) on the activities of major cytochrome P450 (CYP) enzymes and P-glycoprotein (P-gp). In this open-label, single-arm, two-period, fixed-order phenotyping cocktail study, adult participants with pulmonary TB received RIF10 (days 1-15), followed by RIF40 (days 16-30). A single dose of selective substrates (probe drugs) was administered orally on days 15 and 30: caffeine (CYP1A2), tolbutamide (CYP2C9), omeprazole (CYP2C19), dextromethorphan (CYP2D6), midazolam (CYP3A), and digoxin (P-gp). Intensive pharmacokinetic blood sampling was performed over 24 hours after probe drug intake. In all, 25 participants completed the study. Geometric mean ratios (90% confidence interval) of the total exposure (area under the concentration versus time curve, RIF40 versus RIF10) for each of the probe drugs were as follows: caffeine, 105% (96%-115%); tolbutamide, 80% (74%-86%); omeprazole, 55% (47%-65%); dextromethorphan, 77% (68%-86%); midazolam, 62% (49%-78%), and 117% (105%-130%) for digoxin. In summary, high-dose rifampicin resulted in no additional effect on CYP1A2, mild additional induction of CYP2C9, CYP2C19, CYP2D6, and CYP3A, and marginal inhibition of P-gp. Existing recommendations on managing drug interactions with rifampicin can remain unchanged for the majority of co-administered drugs when using high-dose rifampicin. Clinical Trials registration number NCT04525235.
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Affiliation(s)
- Ralf Stemkens
- Department of Pharmacy, Research Institute for Medical Innovation, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Rodney Dawson
- Division of Pulmonology and Department of Medicine, University of Cape Town and University of Cape Town Lung Institute, Cape Town, South Africa
| | | | - Kim Narunsky
- Division of Pulmonology and Department of Medicine, University of Cape Town and University of Cape Town Lung Institute, Cape Town, South Africa
| | - Sherman D. Padayachee
- Division of Pulmonology and Department of Medicine, University of Cape Town and University of Cape Town Lung Institute, Cape Town, South Africa
| | - Martin J. Boeree
- Department of Pulmonary Diseases, Research Institute for Medical Innovation, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Stijn W. van Beek
- Department of Pharmacy, Research Institute for Medical Innovation, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Angela Colbers
- Department of Pharmacy, Research Institute for Medical Innovation, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marieke J. H. Coenen
- Department of Clinical Chemistry, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Elin M. Svensson
- Department of Pharmacy, Research Institute for Medical Innovation, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Pharmacy, Uppsala University, Uppsala, Sweden
| | - Uwe Fuhr
- />Clinical Pharmacology, Department I of Pharmacology, Center for Pharmacology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | | | - Lindsey H. M. te Brake
- Department of Pharmacy, Research Institute for Medical Innovation, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Rob E. Aarnoutse
- Department of Pharmacy, Research Institute for Medical Innovation, Radboud University Medical Center, Nijmegen, The Netherlands
| | - on behalf of the PanACEA consortium
- Department of Pharmacy, Research Institute for Medical Innovation, Radboud University Medical Center, Nijmegen, The Netherlands
- TASK, Cape Town, South Africa
- Division of Pulmonology and Department of Medicine, University of Cape Town and University of Cape Town Lung Institute, Cape Town, South Africa
- Department of Pulmonary Diseases, Research Institute for Medical Innovation, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Clinical Chemistry, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Pharmacy, Uppsala University, Uppsala, Sweden
- />Clinical Pharmacology, Department I of Pharmacology, Center for Pharmacology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
- UCSF Center for Tuberculosis, University of California, San Francisco, California, USA
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16
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Wilkinson RJ, Donovan J, Thwaites GE, van Crevel R, Wasserman S. Treatment of tuberculous meningitis: Overdue for concerted action. Tuberculosis (Edinb) 2023; 142:102361. [PMID: 37394302 DOI: 10.1016/j.tube.2023.102361] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 05/28/2023] [Accepted: 06/01/2023] [Indexed: 07/04/2023]
Affiliation(s)
- Robert J Wilkinson
- Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, and Department of Medicine, University of Cape Town, Observatory 7925, South Africa; Francis Crick Institute, London, NW1 1AT, United Kingdom; Department of Infectious Diseases, Imperial College, London, W12 0NN, United Kingdom.
| | - Joseph Donovan
- Clinical Research Department, London School of Hygiene and Tropical Medicine, Keppel St, London, WC1E 9HT, United Kingdom
| | - Guy E Thwaites
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, UK; Oxford University Clinical Research Unit, Ho Chi Minh City, Viet Nam
| | - Reinout van Crevel
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, UK; Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Sean Wasserman
- Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, and Department of Medicine, University of Cape Town, Observatory 7925, South Africa
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17
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Cattaneo D, Torre A, Schiuma M, Civati A, Lazzarin S, Rizzardini G, Gori A, Antinori S, Gervasoni C. Management of Polypharmacy and Potential Drug-Drug Interactions in Patients with Mycobacterial Infection: A 1-Year Experience of a Multidisciplinary Outpatient Clinic. Antibiotics (Basel) 2023; 12:1171. [PMID: 37508267 PMCID: PMC10375959 DOI: 10.3390/antibiotics12071171] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 07/06/2023] [Accepted: 07/08/2023] [Indexed: 07/30/2023] Open
Abstract
In 2022, we opened an outpatient clinic for the management of polypharmacy and potential drug-drug interactions (pDDIs) in patients with mycobacterial infection (called GAP-MyTB). All patients who underwent a GAP-MyTB visit from March 2022 to March 2023 were included in this retrospective analysis. Fifty-two patients were included in the GAP-MyTB database. They were given 10.4 ± 3.7 drugs (2.8 ± 1.0 and 7.8 ± 3.9 were, respectively, antimycobacterial agents and co-medications). Overall, 262 pDDIs were identified and classified as red-flag (2%), orange-flag (72%), or yellow-flag (26%) types. The most frequent actions suggested after the GAP-MyTB assessment were to perform ECG (52%), therapeutic drug monitoring (TDM, 40%), and electrolyte monitoring (33%) among the diagnostic interventions and to reduce/stop proton pump inhibitors (37%), reduce/change statins (14%), and reduce anticholinergic burden (8%) among the pharmacologic interventions. The TDM of rifampicin revealed suboptimal exposure in 39% of patients that resulted in a TDM-guided dose increment (from 645 ± 101 to 793 ± 189 mg/day, p < 0.001). The high prevalence of polypharmacy and risk of pDDIs in patients with mycobacterial infection highlights the need for ongoing education on prescribing principles and the optimal management of individual patients. A multidisciplinary approach involving physicians and clinical pharmacologists could help achieve this goal.
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Affiliation(s)
- Dario Cattaneo
- Department of Infectious Diseases, ASST Fatebenefratelli-Sacco University Hospital, 20157 Milan, Italy
- Gestione Ambulatoriale Politerapie (GAP) Outpatient Clinic, ASST Fatebenefratelli-Sacco University Hospital, 20157 Milan, Italy
| | - Alessandro Torre
- Department of Infectious Diseases, ASST Fatebenefratelli-Sacco University Hospital, 20157 Milan, Italy
| | - Marco Schiuma
- Department of Infectious Diseases, ASST Fatebenefratelli-Sacco University Hospital, 20157 Milan, Italy
| | - Aurora Civati
- Department of Infectious Diseases, ASST Fatebenefratelli-Sacco University Hospital, 20157 Milan, Italy
| | - Samuel Lazzarin
- Department of Infectious Diseases, ASST Fatebenefratelli-Sacco University Hospital, 20157 Milan, Italy
| | - Giuliano Rizzardini
- Department of Infectious Diseases, ASST Fatebenefratelli-Sacco University Hospital, 20157 Milan, Italy
| | - Andrea Gori
- Department of Infectious Diseases, ASST Fatebenefratelli-Sacco University Hospital, 20157 Milan, Italy
| | - Spinello Antinori
- Department of Infectious Diseases, ASST Fatebenefratelli-Sacco University Hospital, 20157 Milan, Italy
| | - Cristina Gervasoni
- Department of Infectious Diseases, ASST Fatebenefratelli-Sacco University Hospital, 20157 Milan, Italy
- Gestione Ambulatoriale Politerapie (GAP) Outpatient Clinic, ASST Fatebenefratelli-Sacco University Hospital, 20157 Milan, Italy
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18
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Sekaggya-Wiltshire C, Nabisere R, Musaazi J, Otaalo B, Aber F, Alinaitwe L, Nampala J, Najjemba L, Buzibye A, Omali D, Gausi K, Kengo A, Lamorde M, Aarnoutse R, Denti P, Dooley KE, Sloan DJ. Decreased Dolutegravir and Efavirenz Concentrations With Preserved Virological Suppression in Patients With Tuberculosis and Human Immunodeficiency Virus Receiving High-Dose Rifampicin. Clin Infect Dis 2023; 76:e910-e919. [PMID: 35861296 DOI: 10.1093/cid/ciac585] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 06/27/2022] [Accepted: 07/13/2022] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Higher doses of rifampicin may improve treatment outcomes and reduce the duration of tuberculosis (TB) therapy. However, drug-drug interactions with antiretroviral therapy (ART) and safety in people with human immunodeficiency virus (HIV) have not been evaluated. METHODS This was a randomized, open-label trial where newly diagnosed TB patients were randomized to higher (35 mg/kg) or standard (10 mg/kg) daily-dose rifampicin. ART treatment-naive patients were randomized to dolutegravir- or efavirenz-based ART. At week 6, trough dolutegravir or mid-dose efavirenz plasma concentrations were assayed. HIV viral load was measured at week 24. RESULTS Among 128 patients randomized, the median CD4 count was 191 cells/mm3. The geometric mean ratio (GMR) for trough dolutegravir concentrations on higher- vs standard-dose rifampicin was 0.57 (95% confidence interval [CI], .34-.97; P = .039) and the GMR for mid-dose efavirenz was 0.63 (95% CI, .38-1.07; P = .083). There was no significant difference in attainment of targets for dolutegravir trough or efavirenz mid-dose concentrations between rifampicin doses. The incidence of HIV treatment failure at week 24 was similar between rifampicin doses (14.9% vs 14.0%, P = .901), as was the incidence of drug-related grade 3-4 adverse events (9.8% vs 6%). At week 8, fewer patients remained sputum culture positive on higher-dose rifampicin (18.6% vs 37.0%, P = .063). CONCLUSIONS Compared with standard-dose rifampicin, high-dose rifampicin reduced dolutegravir and efavirenz exposures, but HIV suppression was similar across treatment arms. Higher-dose rifampicin was well tolerated among people with HIV and associated with a trend toward faster sputum culture conversion. CLINICAL TRIALS REGISTRATION NCT03982277.
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Affiliation(s)
- Christine Sekaggya-Wiltshire
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda.,Department of Medicine, Mulago National Referral Hospital, Kampala, Uganda
| | - Ruth Nabisere
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Joseph Musaazi
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Brian Otaalo
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Florence Aber
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Lucy Alinaitwe
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Juliet Nampala
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Letisha Najjemba
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Allan Buzibye
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Denis Omali
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Kamunkhwala Gausi
- Department of Medicine, Division of Clinical Pharmacology, University of Cape Town, Cape Town, South Africa
| | - Allan Kengo
- Department of Medicine, Division of Clinical Pharmacology, University of Cape Town, Cape Town, South Africa
| | - Mohammed Lamorde
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Rob Aarnoutse
- Department of Pharmacy and Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegene, The Netherlands
| | - Paolo Denti
- Department of Medicine, Division of Clinical Pharmacology, University of Cape Town, Cape Town, South Africa
| | - Kelly E Dooley
- Department of Medicine, Division of Clinical Pharmacology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Derek J Sloan
- Division of Infection and Global Health, School of Medicine, University of St. Andrews, St. Andrews, United Kingdom
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19
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Perumal R, Naidoo K, Naidoo A, Letsoalo MP, Esmail A, Joubert I, Denti P, Wiesner L, Padayatchi N, Maartens G, Dheda K. The impact of enteral feeding and therapeutic monitoring of rifampicin with dose escalation in critically ill patients with tuberculosis. Int J Infect Dis 2023; 126:174-180. [PMID: 36462574 DOI: 10.1016/j.ijid.2022.11.033] [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: 10/11/2022] [Revised: 11/14/2022] [Accepted: 11/27/2022] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVES Critically ill patients with tuberculosis (TB) face a high mortality risk and require effective treatment. There is a paucity of data on rifampicin pharmacokinetics, the impact of continuous enteral feeding on drug absorption, and the potential of therapeutic drug monitoring (TDM) to optimize drug exposure in these patients. METHODS We performed a sequential pharmacokinetic study to determine the impact of feeding and TDM with rifampicin dose escalation in critically ill patients with TB. Noncompartmental pharmacokinetic analysis was performed. RESULTS Among 20 critically ill patients (40% were HIV-infected), median rifampicin Cmax (maximum serum concentration) in the fasted and fed states were 5.1 µg/ml versus 3.3 µg/ml, respectively (P <0.0001; geometric mean ratio 1.95; 90% confidence interval 1.46-2.60). The proportion of patients with low rifampicin concentrations in the fasted and fed states was 80% vs 100% (P-value = 0.1336). Optimized dosing led to a per-patient median rifampicin dosing of 24.6 mg/kg and a median Cmax increase from 2.4 µg/ml to 17.8 µg/ml (P-value = 0.0005; geometric mean ratio 8.29; 90% confidence interval 3.88-17.74). TDM-guided dose escalation increased the proportion of patients achieving the suggested target rifampicin concentration compared with standard dosing (83% vs 0%, P-value = 0.004). CONCLUSION We found low rifampicin concentrations in all patients receiving continuous enteral feeding. TDM-guided dose escalation provided an effective strategy to achieve target drug exposure in these critically ill patients with TB.
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Affiliation(s)
- Rubeshan Perumal
- Centre for Lung Infection and Immunity Unit, Division of Pulmonology, Department of Medicine and University of Cape Town Lung Institute, University of Cape Town, Cape Town, South Africa; Centre for the AIDS Programme of Research in South Africa, University of KwaZulu-Natal, South Africa Medical Research Council-CAPRISA HIV-TB Pathogenesis and Treatment Research Unit, University of KwaZulu-Natal, Durban, South Africa; Medical Research Council-Centre for the AIDS Programme of Research in South Africa HIV-TB Pathogenesis and Treatment Research Unit, University of KwaZulu-Natal, Durban, South Africa
| | - Kogieleum Naidoo
- Centre for the AIDS Programme of Research in South Africa, University of KwaZulu-Natal, South Africa Medical Research Council-CAPRISA HIV-TB Pathogenesis and Treatment Research Unit, University of KwaZulu-Natal, Durban, South Africa; Medical Research Council-Centre for the AIDS Programme of Research in South Africa HIV-TB Pathogenesis and Treatment Research Unit, University of KwaZulu-Natal, Durban, South Africa
| | - Anushka Naidoo
- Centre for the AIDS Programme of Research in South Africa, University of KwaZulu-Natal, South Africa Medical Research Council-CAPRISA HIV-TB Pathogenesis and Treatment Research Unit, University of KwaZulu-Natal, Durban, South Africa
| | - Marothi P Letsoalo
- Centre for the AIDS Programme of Research in South Africa, University of KwaZulu-Natal, South Africa Medical Research Council-CAPRISA HIV-TB Pathogenesis and Treatment Research Unit, University of KwaZulu-Natal, Durban, South Africa
| | - Aliasgar Esmail
- Centre for Lung Infection and Immunity Unit, Division of Pulmonology, Department of Medicine and University of Cape Town Lung Institute, University of Cape Town, Cape Town, South Africa
| | - Ivan Joubert
- Division of Critical Care Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Paolo Denti
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Nesri Padayatchi
- Centre for the AIDS Programme of Research in South Africa, University of KwaZulu-Natal, South Africa Medical Research Council-CAPRISA HIV-TB Pathogenesis and Treatment Research Unit, University of KwaZulu-Natal, Durban, South Africa; Medical Research Council-Centre for the AIDS Programme of Research in South Africa HIV-TB Pathogenesis and Treatment Research Unit, University of KwaZulu-Natal, Durban, South Africa
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Keertan Dheda
- Centre for Lung Infection and Immunity Unit, Division of Pulmonology, Department of Medicine and University of Cape Town Lung Institute, University of Cape Town, Cape Town, South Africa; South African Medical Research Council Centre for the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa; Faculty of Infectious and Tropical Diseases, Department of Infection Biology, London School of Hygiene and Tropical Medicine, London, United Kingdom.
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20
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Davis AG, Wasserman S, Stek C, Maxebengula M, Liang CJ, Stegmann S, Koekemoer S, Jackson A, Kadernani Y, Bremer M, Daroowala R, Aziz S, Goliath R, Sai LL, Sihoyiya T, Denti P, Lai RP, Crede T, Naude J, Szymanski P, Vallie Y, Banderker IA, Moosa MS, Raubenheimer P, Candy S, Offiah C, Wahl G, Vorster I, Maartens G, Black J, Meintjes G, Wilkinson RJ. A phase 2A trial of the safety and tolerability of increased dose rifampicin and adjunctive linezolid, with or without aspirin, for HIV-associated tuberculous meningitis (The LASER-TBM Trial). Clin Infect Dis 2022; 76:1412-1422. [PMID: 36482216 PMCID: PMC10110270 DOI: 10.1093/cid/ciac932] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 11/12/2022] [Accepted: 12/06/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Drug regimens which include intensified antibiotics alongside effective anti-inflammatory therapies may improve outcomes in Tuberculous Meningitis (TBM). Safety data on their use in combination and in the context of HIV is needed to inform clinical trial design. METHODS We conducted a phase 2 open-label parallel-design RCT to assess safety of high-dose rifampicin, linezolid and high-dose aspirin in HIV-associated TBM. Participants were randomised (1.4:1:1) to three treatment arms (arm 1, standard of care (SOC); arm 2 SOC + additional rifampicin (up to 35mg/kg/day)) + linezolid 1200mg/day reducing after 28/7 to 600mg/day; arm 3, as per arm 2 + aspirin 1000mg/day) for 56 days, when the primary outcome of adverse events of special interest (AESI) or death was assessed. RESULTS 52 participants with HIV-associated TBM were randomised. 59% had mild disease (MRC Grade 1) vs 39% (Grade 2) vs 2% (Grade 3). 33% had microbiologically-confirmed TBM; 41% 'possible', 25% 'probable'. AESI or death occurred in 10/16 (63%) (arm 3) vs 4/14 (29%) (arm 2) vs 6/20 (30%) (arm 1) (p = 0.083). The cumulative proportion of AESI or death (Kaplan-Meier) demonstrated worse outcomes in arm 3 vs arm 1 (p = 0.04), however only one event in arm 3 was attributable to aspirin and was mild. There was no difference in efficacy (modified Rankin scale) at day 56 between arms. CONCLUSIONS High-dose rifampicin and adjunctive linezolid can safely be added to SOC in HIV-associated TBM. Larger studies are required to evaluate whether potential toxicity associated with these interventions, particularly high-dose aspirin, is outweighed by mortality or morbidity benefit.
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Affiliation(s)
- Angharad G Davis
- The Francis Crick Institute, Midland Road, London, NW1 1AT, United Kingdom.,Faculty of Life Sciences, University College London, WC1E 6BT, United Kingdom.,Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory 7925, Republic of South Africa
| | - Sean Wasserman
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory 7925, Republic of South Africa.,Department of Medicine, University of Cape Town, Observatory 7925, Republic of South Africa
| | - Cari Stek
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory 7925, Republic of South Africa.,Department of Infectious Diseases, Imperial College London, W12 0NN, United Kingdom
| | - Mpumi Maxebengula
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory 7925, Republic of South Africa
| | - C Jason Liang
- Biostatistics Research Branch, National Institute of Allergy and Infectious Diseases, Maryland, USA
| | - Stephani Stegmann
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory 7925, Republic of South Africa
| | - Sonya Koekemoer
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory 7925, Republic of South Africa
| | - Amanda Jackson
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory 7925, Republic of South Africa
| | - Yakub Kadernani
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory 7925, Republic of South Africa
| | - Marise Bremer
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory 7925, Republic of South Africa
| | - Remy Daroowala
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory 7925, Republic of South Africa.,Department of Infectious Diseases, Imperial College London, W12 0NN, United Kingdom
| | - Saalikha Aziz
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory 7925, Republic of South Africa
| | - Rene Goliath
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory 7925, Republic of South Africa
| | - Louise Lai Sai
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory 7925, Republic of South Africa
| | - Thandi Sihoyiya
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory 7925, Republic of South Africa
| | - Paolo Denti
- The Francis Crick Institute, Midland Road, London, NW1 1AT, United Kingdom.,Department of Medicine, University of Cape Town, Observatory 7925, Republic of South Africa
| | - Rachel Pj Lai
- The Francis Crick Institute, Midland Road, London, NW1 1AT, United Kingdom.,Department of Infectious Diseases, Imperial College London, W12 0NN, United Kingdom
| | - Thomas Crede
- Mitchells Plain Hospital, 8 A Z Berman Drive, Lentegeur, Cape Town, 7785, South Africa
| | - Jonathan Naude
- Mitchells Plain Hospital, 8 A Z Berman Drive, Lentegeur, Cape Town, 7785, South Africa
| | - Patryk Szymanski
- Mitchells Plain Hospital, 8 A Z Berman Drive, Lentegeur, Cape Town, 7785, South Africa
| | - Yakoob Vallie
- New Somerset Hospital, Portswood Rd, Green Point, Cape Town, 8051, South Africa
| | | | - Muhammed S Moosa
- New Somerset Hospital, Portswood Rd, Green Point, Cape Town, 8051, South Africa
| | - Peter Raubenheimer
- Department of Medicine, University of Cape Town, Observatory 7925, Republic of South Africa
| | - Sally Candy
- Division of Diagnostic Radiology, University of Cape Town, Groote Schuur Hospital, Observatory 7925, Republic of South Africa
| | - Curtis Offiah
- Department of Neuroradiology, Imaging Department, Royal London Hospital, Barts Health NHS Trust, Whitechapel, London, E1 1BB, United Kingdom
| | - Gerda Wahl
- Department of Medicine, Walter Sisulu University, Mthatha 5117, Republic of South Africa
| | - Isak Vorster
- Division of Diagnostic Radiology, University of Cape Town, Groote Schuur Hospital, Observatory 7925, Republic of South Africa
| | - Gary Maartens
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory 7925, Republic of South Africa.,Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Observatory 7925, Republic of South Africa
| | - John Black
- Department of Medicine, Walter Sisulu University, Mthatha 5117, Republic of South Africa
| | - Graeme Meintjes
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory 7925, Republic of South Africa.,Department of Medicine, University of Cape Town, Observatory 7925, Republic of South Africa
| | - Robert J Wilkinson
- The Francis Crick Institute, Midland Road, London, NW1 1AT, United Kingdom.,Faculty of Life Sciences, University College London, WC1E 6BT, United Kingdom.,Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory 7925, Republic of South Africa.,Department of Medicine, University of Cape Town, Observatory 7925, Republic of South Africa.,Department of Infectious Diseases, Imperial College London, W12 0NN, United Kingdom
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21
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Mehta K, Narayanan N, Heysell SK, Bisson GP, Subbian S, Kurepina N, Kreiswirth BN, Vinnard C. Pharmacogenetic variability and the probability of site of action target attainment during tuberculosis meningitis treatment: A physiologically based pharmacokinetic modeling and simulations study. Tuberculosis (Edinb) 2022; 137:102271. [PMID: 36375279 DOI: 10.1016/j.tube.2022.102271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 09/01/2022] [Accepted: 10/12/2022] [Indexed: 11/22/2022]
Abstract
OBJECTIVE AND METHODS Our objective was to investigate the role of patient pharmacogenetic variability in determining site of action target attainment during tuberculous meningitis (TBM) treatment. Rifampin and isoniazid PBPK model that included SLCO1B1 and NAT2 effects on exposures respectively were obtained from literature, modified, and validated using available cerebrospinal-fluid (CSF) concentrations. Population simulations of isoniazid and rifampin concentrations in brain interstitial fluid and probability of target attainment according to genotypes and M. tuberculosis MIC levels, under standard and intensified dosing, were conducted. RESULTS The rifampin and isoniazid model predicted steady-state drug concentration within brain interstitial fluid matched with the observed CSF concentrations. At MIC level of 0.25 mg/L, 57% and 23% of the patients with wild type and heterozygous SLCO1B1 genotype respectively attained the target in CNS with rifampin standard dosing, improving to 98% and 91% respectively with 35 mg/kg dosing. At MIC level of 0.25 mg/L, 33% of fast acetylators attained the target in CNS with isoniazid standard dosing, improving to 90% with 7.5 mg/kg dosing. CONCLUSION In this study, the combined effects of pharmacogenetic and M. tuberculosis MIC variability were potent determinants of target attainment in CNS. The potential for genotype-guided dosing during TBM treatment should be further explored in prospective clinical studies.
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Affiliation(s)
| | | | - Scott K Heysell
- University of Virginia, Division of Infectious Diseases and International Health, Charlottesville, VA, USA
| | - Gregory P Bisson
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Selvakumar Subbian
- Public Health Research Institute, New Jersey Medical School, Newark, NJ, USA
| | - Natalia Kurepina
- Center for Discovery & Innovation, Hackensack Meridian Health, Nutley, NJ, USA
| | - Barry N Kreiswirth
- Center for Discovery & Innovation, Hackensack Meridian Health, Nutley, NJ, USA
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22
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Karballaei-Mirzahosseini H, Kaveh-Ahangaran R, Shahrami B, Rouini MR, Najafi A, Ahmadi A, Sadrai S, Mojtahedzadeh A, Najmeddin F, Mojtahedzadeh M. Pharmacokinetic study of high-dose oral rifampicin in critically Ill patients with multidrug-resistant Acinetobacter baumannii infection. Daru 2022; 30:311-322. [PMID: 36069988 PMCID: PMC9715901 DOI: 10.1007/s40199-022-00449-5] [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: 06/11/2022] [Accepted: 08/05/2022] [Indexed: 10/14/2022] Open
Abstract
PURPOSE Although rifampicin (RIF) is used as a synergistic agent for multidrug-resistant Acinetobacter baumannii (MDR-AB) infection, the optimal pharmacokinetic (PK) indices of this medication have not been studied in the intensive care unit (ICU) settings. This study aimed to evaluate the PK of high dose oral RIF following fasting versus fed conditions in terms of achieving the therapeutic goals in critically ill patients with MDR-AB infections. METHODS 29 critically ill patients were included in this study. Under fasting and non-fasting conditions, RIF was given at 1200 mg once daily through a nasogastric tube. Blood samples were obtained at seven time points: exactly before administration of the drug, and at 1, 2, 4, 8, 12, and 24 h after RIF ingestion. To quantify RIF in serum samples, high-performance liquid chromatography (HPLC) was used. The MONOLIX Software and the Monte Carlo simulations were employed to estimate the PK parameters and describe the population PK model. RESULTS The mean area under the curve over the last 24-h (AUC0-24) value and accuracy (mean ± standard deviation) in the fasting and fed states were 220.24 ± 119.15 and 290.55 ± 276.20 μg × h/mL, respectively. There was no significant difference among AUCs following fasting and non-fasting conditions (P > 0.05). The probability of reaching the therapeutic goals at the minimum inhibitory concentration (MIC) of 4 mg/L, was only 1.6%. CONCLUSION In critically ill patients with MDR-AB infections, neither fasting nor non-fasting administrations of high-dose oral RIF achieve the therapeutic aims. More research is needed in larger populations and with measuring the amount of protein-unbound RIF levels.
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Affiliation(s)
- Hossein Karballaei-Mirzahosseini
- Department of Clinical Pharmacy, School of Pharmacy, Tehran University of Medical Sciences, 16-Azar St., Enghelab Ave., Tehran, 14176-14418, Iran
| | - Romina Kaveh-Ahangaran
- Department of Clinical Pharmacy, School of Pharmacy, Tehran University of Medical Sciences, 16-Azar St., Enghelab Ave., Tehran, 14176-14418, Iran
| | - Bita Shahrami
- Department of Clinical Pharmacy, School of Pharmacy, Tehran University of Medical Sciences, 16-Azar St., Enghelab Ave., Tehran, 14176-14418, Iran
| | - Mohammad Reza Rouini
- Department of Pharmaceutics, School of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Atabak Najafi
- Department of Anesthesiology and Critical Care, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Arezoo Ahmadi
- Department of Anesthesiology and Critical Care, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Sima Sadrai
- Department of Pharmaceutics, School of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Farhad Najmeddin
- Department of Clinical Pharmacy, School of Pharmacy, Tehran University of Medical Sciences, 16-Azar St., Enghelab Ave., Tehran, 14176-14418, Iran.
- Research Center for Rational Use of Drugs, Tehran University of Medical Sciences, Tehran, Iran.
| | - Mojtaba Mojtahedzadeh
- Department of Clinical Pharmacy, School of Pharmacy, Tehran University of Medical Sciences, 16-Azar St., Enghelab Ave., Tehran, 14176-14418, Iran
- Research Center for Rational Use of Drugs, Tehran University of Medical Sciences, Tehran, Iran
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23
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Guillem L, Espinosa J, Laporte-Amargos J, Sánchez A, Grijota MD, Santin M. Mortality and sequelae of tuberculous meningitis in a high-resource setting: A cohort study, 1990–2017. Enferm Infecc Microbiol Clin 2022. [DOI: 10.1016/j.eimc.2022.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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24
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Campbell JI, Dubois MM, Husson RN, Lamb GS. Childhood Tuberculosis: Historical Perspectives, Recent Advances, and a Call to Action. J Pediatric Infect Dis Soc 2022; 11 Suppl 3:S63-S66. [PMID: 36314551 PMCID: PMC9620424 DOI: 10.1093/jpids/piac051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
Affiliation(s)
- Jeffrey I Campbell
- Division of Infectious Diseases, Department of Pediatrics, Boston Children’s Hospital/Harvard Medical School, Boston, MA 02115, USA
| | - Melanie M Dubois
- Division of Infectious Diseases, Department of Pediatrics, Boston Children’s Hospital/Harvard Medical School, Boston, MA 02115, USA
| | - Robert N Husson
- Division of Infectious Diseases, Department of Pediatrics, Boston Children’s Hospital/Harvard Medical School, Boston, MA 02115, USA
| | - Gabriella S Lamb
- Division of Infectious Diseases, Department of Pediatrics, Boston Children’s Hospital/Harvard Medical School, Boston, MA 02115, USA
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Pastick KA, Kagimu E, Dobbin J, Ssebambulidde K, Gakuru J, Milln J, Nakabuye B, Meya DB, Boulware DR, Cresswell FV, Bahr NC. Pregnancy-Related Tuberculous Meningitis and Immune Reconstitution Inflammatory Syndrome: A Case Series and Systematic Review. Open Forum Infect Dis 2022; 9:ofac513. [PMID: 36267255 PMCID: PMC9578166 DOI: 10.1093/ofid/ofac513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 10/03/2022] [Indexed: 11/27/2022] Open
Abstract
Background Tuberculosis is a leading cause of death among women of reproductive age. However, tuberculous meningitis, the most severe form of extrapulmonary tuberculosis, is rarely discussed in pregnancy despite this being a unique period of immune modulation that may predispose women to active disease. Methods We identified and described cases of tuberculous meningitis among pregnant or postpartum women screened during meningitis clinical trials in Uganda from 2018 to 2022. We conducted a systematic literature review via PubMed/Medline and Embase for all English-language publications from 1970 to 10 July 2022, to identify additional cases. Results We identified 8 cases of pregnancy-related tuberculous meningitis in Ugandan women living with human immunodeficiency virus (HIV) and 40 additional cases via systematic literature review (none HIV-positive). Of all combined cases, 50% (24/48) were diagnosed postpartum; 50% (24/48) had initial onset during pregnancy, of which 38% (9/24) had worsening of symptoms or disease relapse following pregnancy cessation. Diagnosis was missed or delayed in 33% (16/48) of cases. For those with known outcomes, maternal mortality was 23% (11/48) and fetal/neonatal mortality was 30% (13/44). Of maternal survivors, 30% (11/37) had residual neurologic deficits. Conclusions The true incidence of tuberculous meningitis in pregnancy or the postpartum period is unclear but likely underappreciated. To date, nearly all published cases have occurred in HIV-negative or otherwise immunocompetent women. Given the well-described physiological immunosuppression during pregnancy and subsequent reconstitution postpartum, physicians must be aware of tuberculous meningitis and pregnancy-related immune reconstitution inflammatory syndrome, especially in countries with a high burden of tuberculosis and in women living with HIV.
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Affiliation(s)
- Katelyn A Pastick
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Enock Kagimu
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Joanna Dobbin
- Primary Care and Population Health, University College London, London, United Kingdom
| | | | - Jane Gakuru
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Jack Milln
- Department of Obstetric Medicine, Queen Charlotte's and Chelsea Hospital, London, United Kingdom
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Betty Nakabuye
- Department of Obstetrics and Gynecology, Uganda Martyrs Hospital Lubaga, Kampala, Uganda
- School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - David B Meya
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - David R Boulware
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Fiona V Cresswell
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
- Global Health and Infection, Brighton and Sussex Medical School, Brighton, United Kingdom
| | - Nathan C Bahr
- Division of Infectious Diseases, Department of Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
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Skipper CP, Hullsiek KH, Cresswell FV, Tadeo KK, Okirwoth M, Blackstad M, Hernandez-Alvarado N, Fernández-Alarcón C, Walukaga S, Martyn E, Ellis J, Ssebambulidde K, Tugume L, Nuwagira E, Rhein J, Meya DB, Boulware DR, Schleiss MR. Cytomegalovirus viremia as a risk factor for mortality in HIV-associated cryptococcal and tuberculous meningitis. Int J Infect Dis 2022; 122:785-792. [PMID: 35843498 PMCID: PMC9653033 DOI: 10.1016/j.ijid.2022.07.035] [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: 03/07/2022] [Revised: 06/22/2022] [Accepted: 07/11/2022] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES CMV viremia is associated with increased mortality in persons with HIV. We previously demonstrated that CMV viremia was a risk factor for 10-week mortality in antiretroviral therapy (ART)-naïve persons with cryptococcal meningitis. We investigated whether similar observations existed over a broader cohort of patients with HIV-associated meningitis at 18 weeks. METHODS We prospectively enrolled Ugandans with cryptococcal or TB meningitis into clinical trials in 2015-2019. We quantified CMV DNA concentrations from stored baseline plasma or serum samples from 340 participants. We compared 18-week survival between those with and without CMV viremia. RESULTS We included 308 persons with cryptococcal meningitis and 32 with TB meningitis, of whom 121 (36%) had detectable CMV DNA. Baseline CD4+ T-cell counts (14 vs. 24 cells/µl; P = 0.07) and antiretroviral exposure (47% vs. 45%; P = 0.68) did not differ between persons with and without CMV viremia. The 18-week mortality was 50% (61/121) in those with CMV viremia versus 34% (74/219) in those without (P = 0.003). Detectable CMV viremia (adjusted hazard ratio [aHR] 1.60; 95% confidence interval [CI] 1.13-2.25; P = 0.008) and greater viral load (aHR 1.22 per log10 IU/ml increase; 95% CI 1.09-1.35; P <0.001) were positively associated with all-cause mortality through 18 weeks. CONCLUSION CMV viremia at baseline was associated with a higher risk of death at 18 weeks among persons with HIV-associated cryptococcal or TB meningitis, and the risk increased as the CMV viral load increased. Further investigation is warranted to determine whether CMV is a modifiable risk contributing to deaths in HIV-associated meningitis or is a biomarker of immune dysfunction.
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Affiliation(s)
- Caleb P Skipper
- University of Minnesota Medical School, Minneapolis, USA; Infectious Diseases Institute, Makerere University, Kampala, Uganda.
| | | | - Fiona V Cresswell
- Infectious Diseases Institute, Makerere University, Kampala, Uganda; Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK; Global Health and Infection, Brighton and Sussex Medical School, Brighton, UK
| | - Kiiza K Tadeo
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Michael Okirwoth
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Mark Blackstad
- University of Minnesota Medical School, Minneapolis, USA
| | | | | | | | - Emily Martyn
- Infectious Diseases Institute, Makerere University, Kampala, Uganda; Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Jayne Ellis
- Infectious Diseases Institute, Makerere University, Kampala, Uganda; Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Lillian Tugume
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Edwin Nuwagira
- Infectious Diseases Institute, Makerere University, Kampala, Uganda; Department of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Joshua Rhein
- University of Minnesota Medical School, Minneapolis, USA
| | - David B Meya
- University of Minnesota Medical School, Minneapolis, USA; Infectious Diseases Institute, Makerere University, Kampala, Uganda
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Adhikari BR, Dummer J, Gordon KC, Das SC. An expert opinion on respiratory delivery of high dose powders for lung infections. Expert Opin Drug Deliv 2022; 19:795-813. [PMID: 35695722 DOI: 10.1080/17425247.2022.2089111] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
INTRODUCTION High dose powder inhalation is evolving as an important approach to to treat lung infections. It is important to its identify applications, consider the factors affecting high dose powder delivery, and assess the effect of high dose drugs in patients. AREA COVERED Both current and pipeline high dose inhalers and their applications have been summarized. Challenges and opportunities to high dose delivery have been highlighted after reviewing formulation techniques in the context of factors affecting aerosolization, devices, and patient factors. EXPERT OPINION High dose inhaled delivery of antimicrobials is an innovative way to increase treatment efficacy of respiratory infections, tackle drug resistance, and the scarcity of new antimicrobials. The high dose inhaled technology also has potential for systemic action; however, innovations in formulation strategies and devices are required to realize its full potential. Advances in formulation strategies include the use of excipients or the engineering of particles to decrease the cohesive property of microparticles and their packing density. Similarly, selection of a synergistic drug instead of an excipient can be considered to increase aerosolization and stability. Device development focused on improving dispersion and loading capacity is also important, and modification of existing devices for high dose delivery can also be considered.
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Affiliation(s)
| | - Jack Dummer
- Department of Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Keith C Gordon
- The Dodd-Walls Centre for Photonic and Quantum Technologies, Department of Chemistry, University of Otago, Dunedin, New Zealand
| | - Shyamal C Das
- School of Pharmacy, University of Otago, Dunedin, New Zealand
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28
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Alffenaar JWC, Stocker SL, Forsman LD, Garcia-Prats A, Heysell SK, Aarnoutse RE, Akkerman OW, Aleksa A, van Altena R, de Oñata WA, Bhavani PK, Van't Boveneind-Vrubleuskaya N, Carvalho ACC, Centis R, Chakaya JM, Cirillo DM, Cho JG, D Ambrosio L, Dalcolmo MP, Denti P, Dheda K, Fox GJ, Hesseling AC, Kim HY, Köser CU, Marais BJ, Margineanu I, Märtson AG, Torrico MM, Nataprawira HM, Ong CWM, Otto-Knapp R, Peloquin CA, Silva DR, Ruslami R, Santoso P, Savic RM, Singla R, Svensson EM, Skrahina A, van Soolingen D, Srivastava S, Tadolini M, Tiberi S, Thomas TA, Udwadia ZF, Vu DH, Zhang W, Mpagama SG, Schön T, Migliori GB. Clinical standards for the dosing and management of TB drugs. Int J Tuberc Lung Dis 2022; 26:483-499. [PMID: 35650702 PMCID: PMC9165737 DOI: 10.5588/ijtld.22.0188] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 04/04/2022] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND: Optimal drug dosing is important to ensure adequate response to treatment, prevent development of drug resistance and reduce drug toxicity. The aim of these clinical standards is to provide guidance on 'best practice´ for dosing and management of TB drugs.METHODS: A panel of 57 global experts in the fields of microbiology, pharmacology and TB care were identified; 51 participated in a Delphi process. A 5-point Likert scale was used to score draft standards. The final document represents the broad consensus and was approved by all participants.RESULTS: Six clinical standards were defined: Standard 1, defining the most appropriate initial dose for TB treatment; Standard 2, identifying patients who may be at risk of sub-optimal drug exposure; Standard 3, identifying patients at risk of developing drug-related toxicity and how best to manage this risk; Standard 4, identifying patients who can benefit from therapeutic drug monitoring (TDM); Standard 5, highlighting education and counselling that should be provided to people initiating TB treatment; and Standard 6, providing essential education for healthcare professionals. In addition, consensus research priorities were identified.CONCLUSION: This is the first consensus-based Clinical Standards for the dosing and management of TB drugs to guide clinicians and programme managers in planning and implementation of locally appropriate measures for optimal person-centred treatment to improve patient care.
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Affiliation(s)
- J W C Alffenaar
- Sydney Institute for Infectious Diseases, The University of Sydney, Sydney, NSW, Australia, School of Pharmacy, The University of Sydney Faculty of Medicine and Health, Sydney, NSW, Australia, Westmead Hospital, Sydney, NSW, Australia
| | - S L Stocker
- School of Pharmacy, The University of Sydney Faculty of Medicine and Health, Sydney, NSW, Australia, Department of Clinical Pharmacology and Toxicology, St Vincent´s Hospital, Sydney, NSW, Australia, St Vincent´s Clinical Campus, University of NSW, Kensington, NSW, Australia
| | - L Davies Forsman
- Division of Infectious Diseases, Department of Medicine, Karolinska Institutet, Solna, Sweden, Department of Infectious Diseases Karolinska University Hospital, Solna, Sweden
| | - A Garcia-Prats
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg, South Africa, Department of Pediatrics, University of Wisconsin, Madison, WI
| | - S K Heysell
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, VA, USA
| | - R E Aarnoutse
- Department of Pharmacy, Radboud Institute for Health Sciences & Radboudumc Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - O W Akkerman
- University of Groningen, University Medical Center Groningen, Department of Pulmonary Diseases and Tuberculosis, Groningen, The Netherlands, University of Groningen, University Medical Center Groningen, Tuberculosis Center Beatrixoord, Haren, The Netherlands
| | - A Aleksa
- Educational Institution "Grodno State Medical University", Grodno, Belarus
| | - R van Altena
- Asian Harm Reduction Network (AHRN) and Medical Action Myanmar (MAM) in Yangon, Myanmar
| | - W Arrazola de Oñata
- Belgian Scientific Institute for Public Health (Belgian Lung and Tuberculosis Association), Brussels, Belgium
| | - P K Bhavani
- Indian Council of Medical Research-National Institute for Research in Tuberculosis-International Center for Excellence in Research, Chennai, India
| | - N Van't Boveneind-Vrubleuskaya
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands, Department of Public Health TB Control, Metropolitan Public Health Services, The Hague, The Netherlands
| | - A C C Carvalho
- Laboratório de Inovações em Terapias, Ensino e Bioprodutos (LITEB), Instituto Oswaldo Cruz, Fundação Oswaldo Cruz, Rio de Janeiro, RJ, Brazil
| | - R Centis
- Servizio di Epidemiologia Clinica delle Malattie Respiratorie, Istituti Clinici Scientifici Maugeri Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Tradate, Italy
| | - J M Chakaya
- Department of Medicine, Therapeutics and Dermatology, Kenyatta University, Nairobi, Kenya, Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - D M Cirillo
- Emerging Bacterial Pathogens Unit, Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - J G Cho
- Sydney Institute for Infectious Diseases, The University of Sydney, Sydney, NSW, Australia, Westmead Hospital, Sydney, NSW, Australia, Parramatta Chest Clinic, Parramatta, NSW, Australia
| | - L D Ambrosio
- Public Health Consulting Group, Lugano, Switzerland
| | - M P Dalcolmo
- Reference Center Hélio Fraga, Fundação Oswaldo Cruz (Fiocruz), Rio de Janeiro, RJ, Brazil
| | - P Denti
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - K Dheda
- Centre for Lung Infection and Immunity, Department of Medicine, Division of Pulmonology and UCT Lung Institute, University of Cape Town, Cape Town, South Africa, University of Cape Town Lung Institute & South African MRC Centre for the Study of Antimicrobial Resistance, Cape Town, South Africa, Faculty of Infectious and Tropical Diseases, Department of Immunology and Infection, London School of Hygiene & Tropical Medicine, London, UK
| | - G J Fox
- Faculty of Medicine and Health, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia, Woolcock Institute of Medical Research, Glebe, NSW, Australia
| | - A C Hesseling
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg, South Africa
| | - H Y Kim
- Sydney Institute for Infectious Diseases, The University of Sydney, Sydney, NSW, Australia, School of Pharmacy, The University of Sydney Faculty of Medicine and Health, Sydney, NSW, Australia, Westmead Hospital, Sydney, NSW, Australia
| | - C U Köser
- Department of Genetics, University of Cambridge, Cambridge, UK
| | - B J Marais
- Sydney Institute for Infectious Diseases, The University of Sydney, Sydney, NSW, Australia, Department of Infectious Diseases and Microbiology, The Children´s Hospital at Westmead, Westmead, NSW, Australia
| | - I Margineanu
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - A G Märtson
- Antimicrobial Pharmacodynamics and Therapeutics, Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - M Munoz Torrico
- Clínica de Tuberculosis, Instituto Nacional de Enfermedades Respiratorias, Ciudad de México, Mexico
| | - H M Nataprawira
- Division of Paediatric Respirology, Department of Child Health, Faculty of Medicine, Universitas Padjadjaran, Hasan Sadikin Hospital, Bandung, Indonesia
| | - C W M Ong
- Infectious Disease Translational Research Programme, Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Institute for Health Innovation & Technology (iHealthtech), National University of Singapore, Singapore, Division of Infectious Diseases, Department of Medicine, National University Hospital, Singapore
| | - R Otto-Knapp
- German Central Committee against Tuberculosis (DZK), Berlin, Germany
| | - C A Peloquin
- Infectious Disease Pharmacokinetics Laboratory, Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Gainesville, FL, USA
| | - D R Silva
- Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - R Ruslami
- TB/HIV Research Centre, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia, Department of Biomedical Sciences, Division of Pharmacology and Therapy, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - P Santoso
- Division of Respirology and Critical Care, Department of Internal Medicine, Faculty of Medicine, Universitas Padjadjaran/Hasan Sadikin General Hospital, Bandung, Indonesia
| | - R M Savic
- Department of Bioengineering and Therapeutic Sciences, Division of Pulmonary and Critical Care Medicine, Schools of Pharmacy and Medicine, University of California San Francisco, San Francisco, CA, USA
| | - R Singla
- Department of TB & Respiratory Diseases, National Institute of TB & Respiratory Diseases, New Delhi, India
| | - E M Svensson
- Department of Pharmacy, Radboud Institute for Health Sciences & Radboudumc Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands, Department of Pharmacy, Uppsala University, Uppsala, Sweden
| | - A Skrahina
- The Republican Research and Practical Centre for Pulmonology and TB, Minsk, Belarus
| | - D van Soolingen
- National Institute for Public Health and the Environment, TB Reference Laboratory (RIVM), Bilthoven, The Netherlands
| | - S Srivastava
- Department of Pulmonary Immunology, University of Texas Health Science Center at Tyler, Tyler, TX, USA
| | - M Tadolini
- Infectious Diseases Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy, Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - S Tiberi
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - T A Thomas
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, VA, USA
| | - Z F Udwadia
- P. D. Hinduja National Hospital and Medical Research Centre, Mumbai, India
| | - D H Vu
- National Drug Information and Adverse Drug Reaction Monitoring Centre, Hanoi University of Pharmacy, Hanoi, Vietnam
| | - W Zhang
- Department of Infectious Diseases, National Medical Center for Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, People´s Republic of China
| | - S G Mpagama
- Kilimanjaro Christian Medical University College, Moshi, United Republic of Tanzania, Kibong´oto Infectious Diseases Hospital, Sanya Juu, Siha, Kilimanjaro, United Republic of Tanzania
| | - T Schön
- Department of Infectious Diseases, Linköping University Hospital, Linköping, Sweden, Institute of Biomedical and Clinical Sciences, Division of Infection and Inflammation, Linköping University, Linköping, Sweden, Department of Infectious Diseases, Kalmar County Hospital, Kalmar, Linköping University, Linköping, Sweden
| | - G B Migliori
- Servizio di Epidemiologia Clinica delle Malattie Respiratorie, Istituti Clinici Scientifici Maugeri Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Tradate, Italy
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Ssebambulidde K, Gakuru J, Ellis J, Cresswell FV, Bahr NC. Improving Technology to Diagnose Tuberculous Meningitis: Are We There Yet? Front Neurol 2022; 13:892224. [PMID: 35711276 PMCID: PMC9195574 DOI: 10.3389/fneur.2022.892224] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 04/22/2022] [Indexed: 11/23/2022] Open
Abstract
Diagnosis of tuberculous meningitis (TBM) remains challenging due to a paucity of high-performance diagnostics. Even those that have reasonable sensitivity are not adequate to 'rule out' TBM. Therefore, a combination of clinical factors alongside microbiological, molecular, and radiological investigations are utilized, depending on availability. A low threshold for starting empiric therapy in the appropriate clinical scenario remains crucial for good outcomes in many cases. Herein, we review the current TBM diagnostics landscape with a focus on limitations frequently encountered, such as diagnostic test performance, cost, laboratory infrastructure, and clinical expertise. Though molecular technologies, particularly GeneXpert MTB/Rif Ultra, have been a step forward, diagnosis of TBM remains difficult. We also provide an overview of promising technologies, such as cerebrospinal fluid (CSF) lactate, a new lipoarabinomannan test (FujiLAM), metagenomic next-generation sequencing, and transcriptomics that may further improve our TBM diagnostic capacity and lead to better outcomes.
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Affiliation(s)
- Kenneth Ssebambulidde
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Jane Gakuru
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Jayne Ellis
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Fiona V. Cresswell
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Global Health and Infection, Brighton and Sussex Medicine School, Brighton, United Kingdom
| | - Nathan C. Bahr
- Division of Infectious Diseases, Department of Medicine, University of Kansas Medical Center, Kansas City, KS, United States
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Huynh J, Donovan J, Phu NH, Nghia HDT, Thuong NTT, Thwaites GE. Tuberculous meningitis: progress and remaining questions. Lancet Neurol 2022; 21:450-464. [PMID: 35429482 DOI: 10.1016/s1474-4422(21)00435-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 10/03/2021] [Accepted: 11/25/2021] [Indexed: 12/23/2022]
Abstract
Tuberculous meningitis is a devastating brain infection that is caused by Mycobacterium tuberculosis and is notoriously difficult to diagnose and treat. New technologies characterising the transcriptome, proteome, and metabolome have identified new molecules and pathways associated with tuberculous meningitis severity and poor outcomes that could offer novel diagnostic and therapeutic targets. The next-generation GeneXpert MTB/RIF Ultra assay, when used on CSF, offers diagnostic sensitivity for tuberculous meningitis of approximately 70%, although it is not widely available and a negative result cannot rule out tuberculous meningitis. Small trials indicate that clinical outcomes might be improved with increased doses of rifampicin, the addition of linezolid or fluoroquinolones to standard antituberculosis therapy, or treatment with adjunctive aspirin combined with corticosteroids. Large phase 3 clinical trials are underway worldwide to address these and other questions concerning the optimal management of tuberculous meningitis; these studies also form a platform for studying pathogenesis and identifying novel diagnostic and treatment strategies, by allowing the implementation of new genomic, transcriptomic, proteomic, and metabolomic technologies in nested substudies.
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Affiliation(s)
- Julie Huynh
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Oxford University, Oxford, UK; Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam
| | - Joseph Donovan
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Oxford University, Oxford, UK; Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam
| | - Nguyen Hoan Phu
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Oxford University, Oxford, UK; Vietnam National University School of Medicine, Ho Chi Minh City, Vietnam
| | - Ho Dang Trung Nghia
- Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam; Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Vietnam
| | - Nguyen Thuy Thuong Thuong
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Oxford University, Oxford, UK; Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam
| | - Guy E Thwaites
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Oxford University, Oxford, UK; Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam.
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Le Vavasseur B, Zeller V. Antibiotic Therapy for Prosthetic Joint Infections: An Overview. Antibiotics (Basel) 2022; 11:486. [PMID: 35453237 PMCID: PMC9025623 DOI: 10.3390/antibiotics11040486] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 03/29/2022] [Accepted: 04/02/2022] [Indexed: 02/04/2023] Open
Abstract
Prosthetic joint infection (PJI) is a severe complication after arthroplasty. Its management combines surgical intervention, whose type depends on the clinical situation, and prolonged high-dose antibiotics adapted to the responsible microorganism(s) and the patient. Antibiotics are only one part of the therapeutic regimen and are closely related to the surgical strategy. Their efficacy depends to a large extent on the choice and quality of the surgical procedure, and the quality of the microbiological diagnosis. Although guidelines have been published, many aspects of antibiotic therapy remain poorly established. Choosing the optimal agent(s) is one aspect, with others being optimization of drugs' pharmacokinetic/pharmacodynamic parameters, the choice of administration route, use of monotherapy or combination regimens, therapeutic drug-monitoring and patient education to improve compliance and tolerance. Herein, we address PJI management based on recent literature data, guidelines and the experience of our referral center for complex bone-and-joint infections.
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Affiliation(s)
- Benjamin Le Vavasseur
- Referral Center for Complex Bone and Joint Infections, Diaconesses Croix Saint-Simon Hospital, 75020 Paris, France;
- Department of Internal Medicine and Infectious Diseases, Diaconesses Croix Saint-Simon Hospital, 75020 Paris, France
| | - Valérie Zeller
- Referral Center for Complex Bone and Joint Infections, Diaconesses Croix Saint-Simon Hospital, 75020 Paris, France;
- Department of Internal Medicine and Infectious Diseases, Diaconesses Croix Saint-Simon Hospital, 75020 Paris, France
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Paradkar MS, Devaleenal D B, Mvalo T, Arenivas A, Thakur KT, Wolf L, Nimkar S, Inamdar S, Giridharan P, Selladurai E, Kinikar A, Valvi C, Khwaja S, Gadama D, Balaji S, Yadav Kattagoni K, Venkatesan M, Savic R, Swaminathan S, Gupta A, Gupte N, Mave V, Dooley KE. Randomized Clinical Trial of High-Dose Rifampicin With or Without Levofloxacin Versus Standard of Care for Pediatric Tuberculous Meningitis: The TBM-KIDS Trial. Clin Infect Dis 2022; 75:1594-1601. [PMID: 35291004 PMCID: PMC9617573 DOI: 10.1093/cid/ciac208] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Pediatric tuberculous meningitis (TBM) commonly causes death or disability. In adults, high-dose rifampicin may reduce mortality. The role of fluoroquinolones remains unclear. There have been no antimicrobial treatment trials for pediatric TBM. METHODS TBM-KIDS was a phase 2 open-label randomized trial among children with TBM in India and Malawi. Participants received isoniazid and pyrazinamide plus: (i) high-dose rifampicin (30 mg/kg) and ethambutol (R30HZE, arm 1); (ii) high-dose rifampicin and levofloxacin (R30HZL, arm 2); or (iii) standard-dose rifampicin and ethambutol (R15HZE, arm 3) for 8 weeks, followed by 10 months of standard treatment. Functional and neurocognitive outcomes were measured longitudinally using Modified Rankin Scale (MRS) and Mullen Scales of Early Learning (MSEL). RESULTS Of 2487 children prescreened, 79 were screened and 37 enrolled. Median age was 72 months; 49%, 43%, and 8% had stage I, II, and III disease, respectively. Grade 3 or higher adverse events occurred in 58%, 55%, and 36% of children in arms 1, 2, and 3, with 1 death (arm 1) and 6 early treatment discontinuations (4 in arm 1, 1 each in arms 2 and 3). By week 8, all children recovered to MRS score of 0 or 1. Average MSEL scores were significantly better in arm 1 than arm 3 in fine motor, receptive language, and expressive language domains (P < .01). CONCLUSIONS In a pediatric TBM trial, functional outcomes were excellent overall. The trend toward higher frequency of adverse events but better neurocognitive outcomes in children receiving high-dose rifampicin requires confirmation in a larger trial. CLINICAL TRIALS REGISTRATION NCT02958709.
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Affiliation(s)
- Mandar S Paradkar
- BJ Government Medical College–Johns Hopkins Clinical Research Site, Pune, India,Johns Hopkins India, Pune, India
| | - Bella Devaleenal D
- Department of Clinical Research, Indian Council of Medical Research–National Institute for Research in Tuberculosis, Chennai, India
| | - Tisungane Mvalo
- UNC Project Malawi, Lilongwe, Malawi,Department of Pediatrics, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Ana Arenivas
- Section of Neuropsychology, Neurological Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Kiran T Thakur
- Department of Neurology, Columbia University Irving Medical Center/New York Presbyterian Hospital, New York, New York, USA
| | - Lisa Wolf
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Smita Nimkar
- BJ Government Medical College–Johns Hopkins Clinical Research Site, Pune, India,Johns Hopkins India, Pune, India
| | - Sadaf Inamdar
- BJ Government Medical College–Johns Hopkins Clinical Research Site, Pune, India,Johns Hopkins India, Pune, India
| | - Prathiksha Giridharan
- Department of Clinical Research, Indian Council of Medical Research–National Institute for Research in Tuberculosis, Chennai, India
| | | | - Aarti Kinikar
- BJ Government Medical College–Johns Hopkins Clinical Research Site, Pune, India,Department of Pediatrics, BJ Government Medical College, Pune, India
| | - Chhaya Valvi
- BJ Government Medical College–Johns Hopkins Clinical Research Site, Pune, India,Department of Pediatrics, BJ Government Medical College, Pune, India
| | - Saltanat Khwaja
- BJ Government Medical College–Johns Hopkins Clinical Research Site, Pune, India,Johns Hopkins India, Pune, India
| | | | - Sarath Balaji
- Department of Clinical Research, Indian Council of Medical Research–National Institute for Research in Tuberculosis, Chennai, India
| | - Krishna Yadav Kattagoni
- Department of Clinical Research, Indian Council of Medical Research–National Institute for Research in Tuberculosis, Chennai, India
| | - Mythily Venkatesan
- Department of Clinical Research, Indian Council of Medical Research–National Institute for Research in Tuberculosis, Chennai, India
| | - Radojka Savic
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, San Francisco, California, USA
| | | | - Amita Gupta
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Nikhil Gupte
- BJ Government Medical College–Johns Hopkins Clinical Research Site, Pune, India,Johns Hopkins India, Pune, India,Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Vidya Mave
- BJ Government Medical College–Johns Hopkins Clinical Research Site, Pune, India,Johns Hopkins India, Pune, India,Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kelly E Dooley
- Correspondence: K. Dooley, Johns Hopkins University School of Medicine, 600 N Wolfe St, Osler 527, Baltimore, MD 21287 ()
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Quinn CM, Kasibante J, Namudde A, Bangdiwala AS, Kabahubya M, Nakasujja N, Lofgren S, Elliott A, Boulware DR, Meya DB, Cresswell FV. Neurocognitive outcomes of tuberculous meningitis in a primarily HIV-positive Ugandan cohort. Wellcome Open Res 2022; 6:208. [PMID: 35949653 PMCID: PMC9334841 DOI: 10.12688/wellcomeopenres.16967.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2022] [Indexed: 11/20/2022] Open
Abstract
Background: The toll of tuberculous meningitis (TBM) in both mortality and disability is considerable, but advancements in rehabilitation have the potential to improve the functional abilities and the quality of survivors' lives. However, the typical phenotype of neurocognitive impairment in TBM survivors remains unstudied in HIV-predominant populations in sub-Saharan Africa. Methods: We tested 36 survivors of TBM in Uganda with a comprehensive battery of neurocognitive assessments at 8 and 24 weeks after diagnosis, and compared results to a representative cohort of HIV-uninfected Ugandans. Results: While participants had a broad range of impairments at eight weeks, there was marked improvement by 24 weeks, when a phenotype of impairment including deficits in motor functioning, verbal learning and memory, processing speed, and executive function emerged. These deficits were present despite good clinician-rated functional status. The majority (23/27, 85%) had evidence of moderate to severe depression at week 8, and at week 24 (18/24, 75%). Conclusion: These findings highlight the need for more comprehensive neurocognitive assessment in the survivors of TBM, and further investment in and study of rehabilitation, including management of depression, to improve long-term outcomes in this population.
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Affiliation(s)
- Carson M Quinn
- School of Medicine, University of California San Francisco Medical Center, San Francisco, CA, USA
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - John Kasibante
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Alice Namudde
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | | | - Mable Kabahubya
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Noeline Nakasujja
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
- Department of Medicine, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
- Department of Psychiatry, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Sarah Lofgren
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, Minnesota, 55455, USA
| | - Alison Elliott
- Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK
- Medical Research Council/Uganda Virus Research-Institute Uganda Research Unit on AIDS, Entebbe, Uganda
| | - David R Boulware
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, Minnesota, 55455, USA
| | - David B Meya
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Fiona V Cresswell
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
- Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK
- Division of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, UK
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Abstract
Tuberculosis (TB) is one of the leading causes of mortality in children worldwide, but there remain significant challenges in diagnosing and treating TB infection and disease. Treatment of TB infection in children and adolescents is critical to prevent progression to TB disease and to prevent them from becoming the future reservoir for TB transmission. This article reviews the clinical approach to diagnosing and treating latent TB infection and pulmonary and extrapulmonary TB disease in children. Also discussed are emerging diagnostics and therapeutic regimens that aim to improve pediatric TB detection and outcomes.
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Affiliation(s)
- Devan Jaganath
- Division of Pediatric Infectious Diseases, University of California, San Francisco
| | - Jeanette Beaudry
- Division of Pediatric Infectious Diseases, Johns Hopkins University Baltimore, USA
| | - Nicole Salazar-Austin
- Division of Pediatric Infectious Diseases, Johns Hopkins University School of Medicine, 200 N Wolfe Street, Room 3147, Baltimore, MD 21287, USA.
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35
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Zhang M, Wang M, He JQ. Intensified Antituberculosis Therapy Regimen Containing Higher Dose Rifampin for Tuberculous Meningitis: A Systematic Review and Meta-Analysis. Front Med (Lausanne) 2022; 9:822201. [PMID: 35280900 PMCID: PMC8916538 DOI: 10.3389/fmed.2022.822201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 01/19/2022] [Indexed: 11/17/2022] Open
Abstract
Background Tuberculous meningitis is difficult to diagnose and is associated with high mortality. Recently, several studies evaluated the intensified regimen containing higher dose rifampin to treat tuberculous meningitis. However, this topic remains to be concluded. Therefore, this systematic review and meta-analysis was conducted to evaluate pharmacokinetics parameters, safety, and survival benefits of high-dose rifampin for tuberculous meningitis. Method Data were searched from PubMed, EMBASE, The Cochrane Library, and Web of Science for studies describing an antituberculosis regimen including a higher dose of rifampin for patients with tuberculous meningitis. The quality of eligible studies was evaluated via The Cochrane Risk of Bias Tool. The meta-analysis was performed by Review Manager 5.3 software, the synthesis of the data was shown in mean difference (MD) or relative risk (RR), and 95% confidence intervals (CIs). Results There were six randomized control trails included in this meta-analysis. The results showed that the concentration in plasma and cerebrospinal fluid (CSF) were significantly higher in the intervention group than the standard group [MD = 22.08, 95%CI (16.24, 27.92), p < 0.00001; MD = 0.74, 95%CI (0.42, 1.05), p < 0.00001], as well as the area under the time concentration curve between 0 and 24 h (AUC0−24) of rifampin [MD 203.56, 95%CI (153.07, 254.05), p < 0.00001] in plasma, but the overall survival did not improve [RR = 0.92, 95%CI (0.67, 1.26), p = 0.61]. For adverse events, the results showed a statistically significant lower incidence of hypersensitivity compared with the intervention group [RR = 1.72, 95%CI (1.13, 2.62), p = 0.01]. Fortunately, other common adverse drug reactions such as liver injury, neurological events, myelosuppression, and cardiotoxicity had no significant increase [RR = 0.98, 95%CI (0.77, 1.26), p = 0.90; RR = 1.10, 95%CI (0.94, 1.30), p = 0.23; RR = 0.82, 95%CI (0.59, 1.13), p = 0.22; RR = 1.11, 95%CI (0.66, 1.86), p = 0.70]. Conclusion This meta-analysis suggested that the intensified treatment regimen including a higher dose of rifampin significantly increased the rifampin concentration both in the plasma and CSF, and it was safe in patients with tuberculous meningitis, but resulted in no improvement in survival rates.
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36
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Ruiz-Bedoya CA, Mota F, Tucker EW, Mahmud FJ, Reyes-Mantilla MI, Erice C, Bahr M, Flavahan K, De Jesus P, Kim J, Foss CA, Peloquin CA, Hammoud DA, Ordonez AA, Pardo CA, Jain SK. High-dose rifampin improves bactericidal activity without increased intracerebral inflammation in animal models of tuberculous meningitis. J Clin Invest 2022; 132:155851. [PMID: 35085105 PMCID: PMC8920328 DOI: 10.1172/jci155851] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 01/26/2022] [Indexed: 11/29/2022] Open
Abstract
Tuberculous meningitis (TB meningitis) is the most severe form of tuberculosis (TB), requiring 12 months of multidrug treatment for cure, and is associated with high morbidity and mortality. High-dose rifampin (35 mg/kg/d) is safe and improves the bactericidal activity of the standard-dose (10 mg/kg/d) rifampin-containing TB regimen in pulmonary TB. However, there are conflicting clinical data regarding its benefit for TB meningitis, where outcomes may also be associated with intracerebral inflammation. We conducted cross-species studies in mice and rabbits, demonstrating that an intensified high-dose rifampin-containing regimen has significantly improved bactericidal activity for TB meningitis over the first-line, standard-dose rifampin regimen, without an increase in intracerebral inflammation. Positron emission tomography in live animals demonstrated spatially compartmentalized, lesion-specific pathology, with postmortem analyses showing discordant brain tissue and cerebrospinal fluid rifampin levels and inflammatory markers. Longitudinal multimodal imaging in the same cohort of animals during TB treatment as well as imaging studies in two cohorts of TB patients demonstrated that spatiotemporal changes in localized blood-brain barrier disruption in TB meningitis are an important driver of rifampin brain exposure. These data provide unique insights into the mechanisms underlying high-dose rifampin in TB meningitis with important implications for developing new antibiotic treatments for infections.
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Affiliation(s)
- Camilo A Ruiz-Bedoya
- Johns Hopkins University School of Medicine, Baltimore, United States of America
| | - Filipa Mota
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, United States of America
| | - Elizabeth W Tucker
- Johns Hopkins University School of Medicine, Baltimore, United States of America
| | - Farina J Mahmud
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, United States of America
| | - Maria I Reyes-Mantilla
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, United States of America
| | - Clara Erice
- Department of Anesthesiology, Johns Hopkins University School of Medicine, Baltimore, United States of America
| | - Melissa Bahr
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, United States of America
| | - Kelly Flavahan
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, United States of America
| | - Patricia De Jesus
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, United States of America
| | - John Kim
- Department of Anesthesiology, Johns Hopkins University School of Medicine, Baltimore, United States of America
| | - Catherine A Foss
- Department of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, Baltimore, United States of America
| | - Charles A Peloquin
- Infectious Disease Pharmacokinetics Laboratory, University of Florida College of Pharmacy, Gainesville, United States of America
| | - Dima A Hammoud
- Center for Infectious Disease Imaging, Radiology and Imaging Sciences, NIH, Bethesda, United States of America
| | - Alvaro A Ordonez
- Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, United States of America
| | - Carlos A Pardo
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, United States of America
| | - Sanjay K Jain
- Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, United States of America
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Tuberculous Meningitis in Children: Reducing the Burden of Death and Disability. Pathogens 2021; 11:pathogens11010038. [PMID: 35055986 PMCID: PMC8778027 DOI: 10.3390/pathogens11010038] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 12/13/2021] [Accepted: 12/21/2021] [Indexed: 11/29/2022] Open
Abstract
Tuberculous meningitis disproportionately affects young children. As the most devastating form of tuberculosis, it is associated with unacceptably high rates of mortality and morbidity even if treated. Challenging to diagnose and treat, tuberculous meningitis commonly causes long-term neurodisability in those who do survive. There remains an urgent need for strengthened surveillance, improved rapid diagnostics technology, optimised anti-tuberculosis drug therapy, investigation of new host-directed therapy, and further research on long-term functional and neurodevelopmental outcomes to allow targeted intervention. This review focuses on the neglected field of paediatric tuberculous meningitis and bridges current clinical gaps with research questions to improve outcomes from this crippling disease.
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38
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Cao Y, Wang T, He K, Xue J, Wang X, Liang J. High-dose rifampicin for the treatment of tuberculous meningitis: a meta-analysis of randomized controlled trials. J Clin Pharm Ther 2021; 47:445-454. [PMID: 34897758 DOI: 10.1111/jcpt.13555] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Revised: 10/11/2021] [Accepted: 10/17/2021] [Indexed: 11/27/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Tuberculous meningitis (TBM) is one of the most serious types of extrapulmonary tuberculosis and has caused distress to human. Effective treatment is particularly important. The aim of this meta-analysis is to compare the efficacy of high-dose and standard-dose rifampicin. METHODS Databases including PubMed, Web of Science, Embase, Scopus and the Cochrane Library databases were electronically searched to identify randomized controlled trials that reported high-dose rifampicin in treatment of patients with TBM. The retrieval time is limited from inception to June 2021. Two reviewers independently screened literature, extracted data and assessed risk bias of included studies. Meta-analysis was performed by using STATA 12.0 software. RESULTS AND DISCUSSION A total of 12 studies involving 1596 patients were included. The meta-analysis results showed no significant differences in 6-month mortality, 9-month mortality, Grade I-II AE, Grade III-V AE, hepatotoxicity, hepatotoxicity Grade I-II and cardiologic events between high-dose rifampicin (or high-dose rifampicin plus moxifloxacin or levofloxacin) and standard-dose groups. The log(Cmax ) (WMD 0.69, 95%CI 0.59-0.79, p 0.001) and log(AUC0-24h ) (WMD 0.79, 95%CI 0.71-0.88, p 0.001) were higher with high-dose rifampicin. Subgroup analysis revealed the rise of log(Cmax ) in high-dose rifampicin orally was consistent with intravenous administration compared with the control (WMD 0.69, 95%CI 0.66-0.73, p 0.001). WHAT IS NEW AND CONCLUSION High-dose rifampicin was not a protective factor for 6-month mortality, despite increased plasma Cmax and AUC0-24h . However, the above conclusions are still required to be verified through more RCTs due to the limited quantity of included studies.
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Affiliation(s)
- Yan Cao
- Tuberculosis Department, The 8th Medical Center, Chinses PLA General Hospital, Beijing, China
| | - Tao Wang
- Tuberculosis Department, The 8th Medical Center, Chinses PLA General Hospital, Beijing, China
| | - Ke He
- Tuberculosis Department, The 8th Medical Center, Chinses PLA General Hospital, Beijing, China
| | - Juanmin Xue
- Tuberculosis Department, The 8th Medical Center, Chinses PLA General Hospital, Beijing, China
| | - Xinjing Wang
- Tuberculosis Department, The 8th Medical Center, Chinses PLA General Hospital, Beijing, China
| | - Jianqin Liang
- Tuberculosis Department, The 8th Medical Center, Chinses PLA General Hospital, Beijing, China
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39
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Affiliation(s)
- H Simon Schaaf
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa, .,Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.,Department of Infectious Diseases, Imperial College London, London, UK
| | - James A Seddon
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa, .,Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.,Department of Infectious Diseases, Imperial College London, London, UK
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40
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Quinn CM, Kasibante J, Namudde A, Bangdiwala AS, Kabahubya M, Nakasujja N, Lofgren S, Elliott A, Boulware DR, Meya DB, Cresswell FV. Neurocognitive outcomes of HIV-associated tuberculous meningitis. Wellcome Open Res 2021; 6:208. [PMID: 35949653 PMCID: PMC9334841 DOI: 10.12688/wellcomeopenres.16967.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/30/2021] [Indexed: 12/15/2022] Open
Abstract
Background: The toll of tuberculous meningitis (TBM) in both mortality and disability is considerable, but advancements in rehabilitation have the potential to improve the functional abilities and the quality of survivors' lives. However, the typical phenotype of neurocognitive impairment in TBM survivors remains unstudied in HIV-predominant populations in sub-Saharan Africa. Methods: We tested 36 survivors of TBM in Uganda with a comprehensive battery of neurocognitive assessments at 8 and 24 weeks after diagnosis, and compared results to a representative cohort of HIV-uninfected Ugandans. Results: While participants had a broad range of impairments at eight weeks, there was marked improvement by 24 weeks, when a phenotype of impairment including deficits in motor functioning, verbal learning and memory, processing speed, and executive function emerged. These deficits were present despite good clinician-rated functional status. The majority (23/27, 85%) had evidence of moderate to severe depression at week 8, and at week 24 (18/24, 75%). Conclusion: These findings highlight the need for more comprehensive neurocognitive assessment in the survivors of TBM, and further investment in and study of rehabilitation, including management of depression, to improve long-term outcomes in this population.
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Affiliation(s)
- Carson M Quinn
- School of Medicine, University of California San Francisco Medical Center, San Francisco, CA, USA
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - John Kasibante
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Alice Namudde
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | | | - Mable Kabahubya
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Noeline Nakasujja
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
- Department of Medicine, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
- Department of Psychiatry, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Sarah Lofgren
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, Minnesota, 55455, USA
| | - Alison Elliott
- Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK
- Medical Research Council/Uganda Virus Research-Institute Uganda Research Unit on AIDS, Entebbe, Uganda
| | - David R Boulware
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, Minnesota, 55455, USA
| | - David B Meya
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Fiona V Cresswell
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
- Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK
- Division of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, UK
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41
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Plasma Pharmacokinetics of High-Dose Oral versus Intravenous Rifampicin in Patients with Tuberculous Meningitis: a Randomized Controlled Trial. Antimicrob Agents Chemother 2021; 65:e0014021. [PMID: 33972248 PMCID: PMC7611291 DOI: 10.1128/aac.00140-21] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Higher doses of intravenous rifampicin may improve outcomes in tuberculous meningitis but are impractical in high-burden settings. We hypothesized that plasma rifampicin exposures would be similar between oral dosing of 35 mg/kg of body weight and intravenous dosing of 20 mg/kg, which has been proposed for efficacy trials in tuberculous meningitis. We performed a randomized parallel-group pharmacokinetic study nested within a clinical trial of intensified antimicrobial therapy for tuberculous meningitis. HIV-positive participants with tuberculous meningitis were recruited from South African hospitals and randomized to one of three rifampicin dosing groups: standard (oral 10 mg/kg), high dose (oral 35 mg/kg), and intravenous (20 mg/kg). Intensive pharmacokinetic sampling was done on day 3. Data were described using noncompartmental analysis, and exposures were compared by geometric mean ratios (GMRs). Forty-six participants underwent pharmacokinetic sampling (standard dose, n = 17; high-dose oral, n = 15; intravenous, n = 14). The median CD4 count was 130 cells/mm3 (interquartile range [IQR], 66 to 253 cells/mm3). The rifampicin geometric mean area under the concentration-time curve from 0 to 24 h (AUC0-24) values were 42.9 μg · h/ml (95% confidence interval [CI], 24.5 to 75.0 μg · h/ml) for the standard dose, 295.2 μg · h/ml (95% CI, 189.9 to 458.8 μg · h/ml) for the high oral dose, and 206.5 μg · h/ml (95% CI, 154.6 to 275.8 μg · h/ml) for intravenous administration. The rifampicin AUC0-24 GMR was 1.44 (90% CI, 0.84 to 2.21) and the maximal concentration of drug in serum (Cmax) GMR was 0.89 (90% CI, 0.63 to 1.23) for high-dose oral administration with respect to intravenous dosing. The plasma rifampicin AUC0-24 was higher after an oral 35-mg/kg dose than with intravenous administration at a 20-mg/kg dose over the first few days of tuberculosis (TB) treatment. The findings support oral rifampicin dosing in future tuberculous meningitis trials.
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