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Stott KE, Mohabir JT, Bowers K, Tenor JL, Toffaletti DL, Unsworth J, Jimenez-Valverde A, Ahmadu A, Moyo M, Gondwe E, Chimang'anga W, Chasweka M, Lawrence DS, Jarvis JN, Harrison T, Hope W, Lalloo DG, Mwandumba HC, Perfect JR, Cuomo CA. Integration of genomic and pharmacokinetic data to predict clinical outcomes in HIV-associated cryptococcal meningitis. mBio 2024:e0159224. [PMID: 39189739 DOI: 10.1128/mbio.01592-24] [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: 05/30/2024] [Accepted: 07/15/2024] [Indexed: 08/28/2024] Open
Abstract
Cryptococcal meningitis causes an estimated 112,000 global deaths per annum. Genomic and phenotypic features of the infecting strain of Cryptococcus spp. have been associated with outcomes from cryptococcal meningitis. Additionally, population-level pharmacokinetic variability is well documented in these patient cohorts. The relative contribution of these factors to clinical outcomes is unknown. Based in Malawi, we conducted a sub-study of the phase 3 Ambition-CM trial (ISRCTN72509687), collecting plasma and cerebrospinal fluid at serial time points during the first 14 days of antifungal therapy. We explored the relative contribution of pathogen genotype, drug resistance phenotype, and pharmacokinetics on clinical outcomes including lumbar opening pressure, pharmacodynamic effect, and mortality. We report remarkable genomic homogeneity among infecting strains of Cryptococcus spp., within and between patients. There was no evidence of acquisition of antifungal resistance in our isolates. Genotypic features of the infecting strain were not consistently associated with adverse or favorable clinical outcomes. However, baseline fungal burden and early fungicidal activity (EFA) were associated with mortality. The strongest predictor of EFA was the level of exposure to amphotericin B. Our analysis suggests the most effective means of improving clinical outcomes from HIV-associated cryptococcal meningitis is to optimize exposure to potent antifungal therapy. IMPORTANCE HIV-associated cryptococcal meningitis is associated with a high burden of mortality. Research into the different strain types causing this disease has yielded inconsistent findings in terms of which strains are associated with worse clinical outcomes. Our study suggests that the exposure of patients to potent anti-cryptococcal drugs has a more significant impact on clinical outcomes than the strain type of the infecting organism. Future research should focus on optimizing drug exposure, particularly in the context of novel anticryptococcal drugs coming into clinical use.
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Affiliation(s)
- Katharine E Stott
- Antimicrobial Pharmacodynamics and Therapeutics Group, Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, United Kingdom
- Malawi Liverpool Wellcome Clinical Research Programme, Blantyre, Malawi
| | - Jason T Mohabir
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
| | - Katharine Bowers
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
| | - Jennifer L Tenor
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Dena L Toffaletti
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jennifer Unsworth
- Antimicrobial Pharmacodynamics and Therapeutics Group, Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, United Kingdom
| | - Ana Jimenez-Valverde
- Antimicrobial Pharmacodynamics and Therapeutics Group, Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, United Kingdom
| | - Ajisa Ahmadu
- Malawi Liverpool Wellcome Clinical Research Programme, Blantyre, Malawi
| | - Melanie Moyo
- Malawi Liverpool Wellcome Clinical Research Programme, Blantyre, Malawi
- Department of Medicine, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Ebbie Gondwe
- Malawi Liverpool Wellcome Clinical Research Programme, Blantyre, Malawi
| | - Wezi Chimang'anga
- Malawi Liverpool Wellcome Clinical Research Programme, Blantyre, Malawi
| | | | - David S Lawrence
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Tropical Medicine, London, United Kingdom
- Botswana Harvard Health Partnership, Gaborone, Botswana
- Clinical Microbiology and Infectious Diseases, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Joseph N Jarvis
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Tropical Medicine, London, United Kingdom
- Botswana Harvard Health Partnership, Gaborone, Botswana
| | - Tom Harrison
- Institute of Infection and Immunity, St George's University London, London, United Kingdom
| | - William Hope
- Antimicrobial Pharmacodynamics and Therapeutics Group, Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, United Kingdom
| | - David G Lalloo
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Henry C Mwandumba
- Malawi Liverpool Wellcome Clinical Research Programme, Blantyre, Malawi
| | - John R Perfect
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
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Liu F, Yang L, Li Y, Junier A, Ma F, Chen J, Han H, Glass Z, Zhao X, Kumamoto CA, Sang H, Xu Q. In Vitro and In Vivo Study of Amphotericin B Formulation with Quaternized Bioreducible Lipidoids. ACS Biomater Sci Eng 2020; 6:1064-1073. [DOI: 10.1021/acsbiomaterials.9b01722] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- Fang Liu
- Department of Biomedical Engineering, Tufts University, Medford, Massachusetts 02155, United States
- Southern Medical University, Jinling Hospital Department of Dermatology, Nanjing, 210002, China
| | - Liu Yang
- Department of Biomedical Engineering, Tufts University, Medford, Massachusetts 02155, United States
| | - Yamin Li
- Department of Biomedical Engineering, Tufts University, Medford, Massachusetts 02155, United States
| | - Ashlee Junier
- Department of Molecular Biology and Microbiology, Tufts University, Boston, Massachusetts 02111, United States
| | - Feihe Ma
- Department of Biomedical Engineering, Tufts University, Medford, Massachusetts 02155, United States
| | - Jinjin Chen
- Department of Biomedical Engineering, Tufts University, Medford, Massachusetts 02155, United States
| | - Haobo Han
- Department of Biomedical Engineering, Tufts University, Medford, Massachusetts 02155, United States
- Key Laboratory for Molecular Enzymology and Engineering of Ministry of Education, School of Life Sciences, Jilin University, Changchun 130012, P. R. China
| | - Zachary Glass
- Department of Biomedical Engineering, Tufts University, Medford, Massachusetts 02155, United States
| | - Xuewei Zhao
- Department of Biomedical Engineering, Tufts University, Medford, Massachusetts 02155, United States
| | - Carol A. Kumamoto
- Department of Molecular Biology and Microbiology, Tufts University, Boston, Massachusetts 02111, United States
| | - Hong Sang
- Southern Medical University, Jinling Hospital Department of Dermatology, Nanjing, 210002, China
| | - Qiaobing Xu
- Department of Biomedical Engineering, Tufts University, Medford, Massachusetts 02155, United States
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Hope W, Stone NRH, Johnson A, McEntee L, Farrington N, Santoro-Castelazo A, Liu X, Lucaci A, Hughes M, Oliver JD, Giamberardino C, Mfinanga S, Harrison TS, Perfect JR, Bicanic T. Fluconazole Monotherapy Is a Suboptimal Option for Initial Treatment of Cryptococcal Meningitis Because of Emergence of Resistance. mBio 2019; 10:e02575-19. [PMID: 31796539 PMCID: PMC6890991 DOI: 10.1128/mbio.02575-19] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Accepted: 10/23/2019] [Indexed: 12/20/2022] Open
Abstract
Cryptococcal meningitis is a lethal disease with few therapeutic options. Induction therapy with fluconazole has been consistently demonstrated to be associated with suboptimal microbiological and clinical outcomes. Exposure to fluconazole causes dynamic changes in antifungal susceptibility, which are associated with the development of aneuploidy. The implications of this phenomenon for pharmacodynamics of fluconazole for cryptococcal meningitis are poorly understood. The pharmacodynamics of fluconazole were studied using a hollow-fiber infection model (HFIM) and a well-characterized murine model of cryptococcal meningoencephalitis. The relationship between drug exposure and both antifungal killing and the emergence of resistance was quantified. The same relationships were further evaluated in a recently described group of patients with cryptococcal meningitis undergoing induction therapy with fluconazole at 800 to 1,200 mg/day. The pattern of emergence of fluconazole resistance followed an "inverted U." Resistance amplification was maximal and suppressed at ratios of the area under the concentration-time curve for the free, unbound fraction of the drug to the MIC (fAUC:MIC) of 34.5 to 138 and 305.6, respectively. Emergence of resistance was observed in vivo with an fAUC:MIC of 231.4. Aneuploidy with duplication of chromosome 1 was demonstrated to be the underlying mechanism in both experimental models. The pharmacokinetic (PK)-pharmacodynamic model accurately described the PK, antifungal killing, and emergence of resistance. Monte Carlo simulations from the clinical pharmacokinetic-pharmacodynamic model showed that only 12.8% of simulated patients receiving fluconazole at 1,200 mg/day achieved sterilization of the cerebrospinal fluid (CSF) after 2 weeks and that 83.4% had a persistent subpopulation that was resistant to fluconazole. Fluconazole is primarily ineffective due to the emergence of resistance. Treatment with 1,200 mg/day leads to the killing of a susceptible subpopulation but is compromised by the emergence of resistance.IMPORTANCE Cryptococcal meningitis is a lethal disease with few treatment options. The incidence remains high and intricately linked with the HIV/AIDS epidemic. In many parts of the world, fluconazole is the only agent that is available for the initial treatment of cryptococcal meningitis despite considerable evidence that it is associated with suboptimal microbiological and clinical outcomes. Fluconazole has a fungistatic mode of action: it predominantly inhibits growth rather than causing fungal killing. Our work shows that the pattern of fluconazole activity is caused by the emergence of resistance in Cryptococcus not detected by standard susceptibility tests, with chromosomal duplication/aneuploidy as the main mechanism. Resistance emergence is related to drug exposure and occurs with the use of clinically relevant regimens. Hence, fluconazole (and potentially other agents that target 14-alpha-demethylase) is compromised by an intrinsic property that limits its effectiveness. However, this resistance may be potentially overcome by dosage escalation or the use of combination therapy.
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Affiliation(s)
- William Hope
- Antimicrobial Pharmacodynamics and Therapeutics, University of Liverpool, Liverpool Health Partners, Liverpool, United Kingdom
- Royal Liverpool Broadgreen University Hospital Trust, Liverpool Health Partners, Liverpool, United Kingdom
| | - Neil R H Stone
- Antimicrobial Pharmacodynamics and Therapeutics, University of Liverpool, Liverpool Health Partners, Liverpool, United Kingdom
- Institute of Infection and Immunity, St. George's, University of London, London, United Kingdom
| | - Adam Johnson
- Antimicrobial Pharmacodynamics and Therapeutics, University of Liverpool, Liverpool Health Partners, Liverpool, United Kingdom
| | - Laura McEntee
- Antimicrobial Pharmacodynamics and Therapeutics, University of Liverpool, Liverpool Health Partners, Liverpool, United Kingdom
| | - Nicola Farrington
- Antimicrobial Pharmacodynamics and Therapeutics, University of Liverpool, Liverpool Health Partners, Liverpool, United Kingdom
| | - Anahi Santoro-Castelazo
- Antimicrobial Pharmacodynamics and Therapeutics, University of Liverpool, Liverpool Health Partners, Liverpool, United Kingdom
| | - Xuan Liu
- Centre for Genomics Research, University of Liverpool, Liverpool, United Kingdom
| | - Anita Lucaci
- Centre for Genomics Research, University of Liverpool, Liverpool, United Kingdom
| | - Margaret Hughes
- Centre for Genomics Research, University of Liverpool, Liverpool, United Kingdom
| | | | - Charles Giamberardino
- Division of Infectious Diseases and International Health, Duke University School of Medicine, Durham, North Carolina, USA
| | - Sayoki Mfinanga
- National Institute of Medical Research, Dar es Salaam, Tanzania
| | - Thomas S Harrison
- Institute of Infection and Immunity, St. George's, University of London, London, United Kingdom
| | - John R Perfect
- Division of Infectious Diseases and International Health, Duke University School of Medicine, Durham, North Carolina, USA
| | - Tihana Bicanic
- Institute of Infection and Immunity, St. George's, University of London, London, United Kingdom
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Le T, Ly VT, Thu NTM, Nguyen A, Thanh NT, Chau NVV, Thwaites G, Perfect J, Kolamunnage-Dona R, Hope W. Population Pharmacodynamics of Amphotericin B Deoxycholate for Disseminated Infection Caused by Talaromyces marneffei. Antimicrob Agents Chemother 2019; 63:e01739-18. [PMID: 30420478 PMCID: PMC6355582 DOI: 10.1128/aac.01739-18] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2018] [Accepted: 11/01/2018] [Indexed: 02/07/2023] Open
Abstract
Amphotericin B deoxycholate (DAmB) is a first-line agent for the initial treatment of talaromycosis. However, little is known about the population pharmacokinetics and pharmacodynamics of DAmB for talaromycosis. Pharmacokinetic data were obtained from 78 patients; among them, 55 patients had serial fungal CFU counts in blood also available for analysis. A population pharmacokinetic-pharmacodynamic model was fitted to the data. The relationships between the area under the concentration-time curve (AUC)/MIC and the time to blood culture sterilization and the time to death were investigated. There was only modest pharmacokinetic variability in the average AUC, with a mean ± standard deviation of 11.51 ± 3.39 mg·h/liter. The maximal rate of drug-induced kill was 0.133 log10 CFU/ml/h, and the plasma concentration of the DAmB that induced the half-maximal rate of kill was 0.02 mg/liter. Fifty percent of patients sterilized their bloodstreams by 83.16 h (range, 13 to 264 h). A higher initial fungal burden was associated with a longer time to sterilization (hazard ratio [HR], 0.51; 95% confidence interval [CI], 0.36 to 0.70; P < 0.001). There was a weak relationship between AUC/MIC and the time to sterilization, although this did not reach statistical significance (HR, 1.03; 95% CI, 1.00 to 1.06, P = 0.091). Furthermore, there was no relationship between the AUC/MIC and time to death (HR, 0.97; 95% CI, 0.88 to 1.08; P = 0.607) or early fungicidal activity {slope = log[(0.500 - 0.003·(AUC/MIC)]; P = 0.319} adjusted for the initial fungal burden. The population pharmacokinetics of DAmB are surprisingly consistent. The time to sterilization of the bloodstream may be a useful pharmacodynamic endpoint for future studies. (This study has been registered at the ISRCTN registry under no. ISRCTN59144167.).
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Affiliation(s)
- Thuy Le
- Division of Infectious Diseases and International Health, Duke University School of Medicine, Durham, North Carolina, USA
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Vo Trieu Ly
- Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
- University of Medicine and Pharmacy, Ho Chi Minh City, Vietnam
| | - Nguyen Thi Mai Thu
- Division of Infectious Diseases and International Health, Duke University School of Medicine, Durham, North Carolina, USA
| | - Ashley Nguyen
- University of Houston College of Pharmacy, Houston, Texas, USA
| | - Nguyen Tat Thanh
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | | | - Guy Thwaites
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - John Perfect
- Division of Infectious Diseases and International Health, Duke University School of Medicine, Durham, North Carolina, USA
| | - Ruwanthi Kolamunnage-Dona
- Department of Biostatistics, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - William Hope
- Antimicrobial Pharmacodynamics and Therapeutics, Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
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Le T, Ly VT, Thu NTM, Nguyen A, Thanh NT, Chau NVV, Thwaites G, Perfect J, Kolamunnage-Dona R, Hope W. Population Pharmacodynamics of Amphotericin B Deoxycholate for Disseminated Infection Caused by
Talaromyces marneffei. Antimicrob Agents Chemother 2019; 63. [DOI: https:/doi.org/10.1128/aac.01739-18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2018] [Accepted: 11/01/2018] [Indexed: 05/14/2024] Open
Abstract
Amphotericin B deoxycholate (DAmB) is a first-line agent for the initial treatment of talaromycosis. However, little is known about the population pharmacokinetics and pharmacodynamics of DAmB for talaromycosis.
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Affiliation(s)
- Thuy Le
- Division of Infectious Diseases and International Health, Duke University School of Medicine, Durham, North Carolina, USA
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Vo Trieu Ly
- Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
- University of Medicine and Pharmacy, Ho Chi Minh City, Vietnam
| | - Nguyen Thi Mai Thu
- Division of Infectious Diseases and International Health, Duke University School of Medicine, Durham, North Carolina, USA
| | - Ashley Nguyen
- University of Houston College of Pharmacy, Houston, Texas, USA
| | - Nguyen Tat Thanh
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | | | - Guy Thwaites
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - John Perfect
- Division of Infectious Diseases and International Health, Duke University School of Medicine, Durham, North Carolina, USA
| | - Ruwanthi Kolamunnage-Dona
- Department of Biostatistics, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - William Hope
- Antimicrobial Pharmacodynamics and Therapeutics, Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
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Concentration-dependent plasma protein binding: Expect the unexpected. Eur J Pharm Sci 2018; 122:341-346. [DOI: 10.1016/j.ejps.2018.07.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 06/30/2018] [Accepted: 07/02/2018] [Indexed: 11/20/2022]
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