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Dangarembizi R, Wasserman S, Hoving JC. Emerging and re-emerging fungal threats in Africa. Parasite Immunol 2023; 45:e12953. [PMID: 36175380 PMCID: PMC9892204 DOI: 10.1111/pim.12953] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 09/22/2022] [Accepted: 09/26/2022] [Indexed: 02/04/2023]
Abstract
The emergence of deadly fungal infections in Africa is primarily driven by a disproportionately high burden of human immunodeficiency virus (HIV) infections, lack of access to quality health care, and the unavailability of effective antifungal drugs. Immunocompromised people in Africa are therefore at high risk of infection from opportunistic fungal pathogens such as Cryptococcus neoformans and Pneumocystis jirovecii, which are associated with high morbidity, mortality, and related socioeconomic impacts. Other emerging fungal threats include Emergomyces spp., Histoplasma spp., Blastomyces spp., and healthcare-associated multi-drug resistant Candida auris. Socioeconomic development and the Covid-19 pandemic may influence shifts in epidemiology of invasive fungal diseases on the continent. This review discusses the epidemiology, clinical manifestations, and current management strategies available for these emerging fungal diseases in Africa. We also discuss gaps in knowledge, policy, and research to inform future efforts at managing these fungal threats.
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Affiliation(s)
- Rachael Dangarembizi
- Division of Physiological Sciences, Department of Human Biology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa,Neuroscience Institute, Faculty of Health Sciences, University of Cape Town, Groote Schuur Hospital, Cape Town, South Africa,CMM AFRICA Medical Mycology Research Unit, Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa,Contact information of corresponding author Dr Rachael Dangarembizi, Division of Physiological Sciences, Department of Human Biology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa, Neuroscience Institute, Faculty of Health Sciences, University of Cape Town, Groote Schuur Hospital, Cape Town, South Africa, CMM AFRICA Medical Mycology Research Unit, Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa,
| | - Sean Wasserman
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa,Division of Infectious Diseases and HIV Medicine, Department of Medicine, University of Cape Town, Groote Schuur Hospital, Cape Town, South Africa
| | - Jennifer Claire Hoving
- Division of Immunology, Department of Pathology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa,Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa,CMM AFRICA Medical Mycology Research Unit, Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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Giamberardino CD, Schell WA, Tenor JL, Toffaletti DL, Palmucci JR, Marius C, Boua JVK, Soltow Q, Mansbach R, Moseley MA, Thompson JW, Dubois LG, Hope W, Perfect JR, Shaw KJ. Efficacy of APX2039 in a Rabbit Model of Cryptococcal Meningitis. mBio 2022; 13:e0234722. [PMID: 36222509 PMCID: PMC9765414 DOI: 10.1128/mbio.02347-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 09/14/2022] [Indexed: 11/20/2022] Open
Abstract
Cryptococcal Meningitis (CM) is uniformly fatal if not treated, and treatment options are limited. We previously reported on the activity of APX2096, the prodrug of the novel Gwt1 inhibitor APX2039, in a mouse model of CM. Here, we investigated the efficacy of APX2039 in mouse and rabbit models of CM. In the mouse model, the controls had a mean lung fungal burden of 5.95 log10 CFU/g, whereas those in the fluconazole-, amphotericin B-, and APX2039-treated mice were 3.56, 4.59, and 1.50 log10 CFU/g, respectively. In the brain, the control mean fungal burden was 7.97 log10 CFU/g, while the burdens were 4.64, 7.16, and 1.44 log10 CFU/g for treatment with fluconazole, amphotericin B, and APX2039, respectively. In the rabbit model of CM, the oral administration of APX2039 at 50 mg/kg of body weight twice a day (BID) resulted in a rapid decrease in the cerebrospinal fluid (CSF) fungal burden, and the burden was below the limit of detection by day 10 postinfection. The effective fungicidal activity (EFA) was -0.66 log10 CFU/mL/day, decreasing from an average of 4.75 log10 CFU/mL to 0 CFU/mL, over 8 days of therapy, comparing favorably with good clinical outcomes in humans associated with reductions of the CSF fungal burden of -0.4 log10 CFU/mL/day, and, remarkably, 2-fold the EFA of amphotericin B deoxycholate in this model (-0.33 log10 CFU/mL/day). A total drug exposure of the area under the concentration-time curve from 0 to 24 h (AUC0-24) of 25 to 50 mg · h/L of APX2039 resulted in near-maximal antifungal activity. These data support the further preclinical and clinical evaluation of APX2039 as a new oral fungicidal monotherapy for the treatment of CM. IMPORTANCE Cryptococcal meningitis (CM) is a fungal disease with significant global morbidity and mortality. The gepix Gwt1 inhibitors are a new class of antifungal drugs. Here, we demonstrated the efficacy of APX2039, the second member of the gepix class, in rabbit and mouse models of cryptococcal meningitis. We also analyzed the drug levels in the blood and cerebrospinal fluid in the highly predictive rabbit model and built a mathematical model to describe the behavior of the drug with respect to the elimination of the fungal pathogen. We demonstrated that the oral administration of APX2039 resulted in a rapid decrease in the CSF fungal burden, with an effective fungicidal activity of -0.66 log10 CFU/mL/day, comparing favorably with good clinical outcomes in humans associated with reductions of -0.4 log10 CFU/mL/day. The drug APX2039 had good penetration of the central nervous system and is an excellent candidate for future clinical testing in humans for the treatment of CM.
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Affiliation(s)
- Charles D. Giamberardino
- Duke University School of Medicine, Department of Medicine, Division of Infectious Diseases, Durham, North Carolina, USA
| | - Wiley A. Schell
- Duke University School of Medicine, Department of Medicine, Division of Infectious Diseases, Durham, North Carolina, USA
| | - Jennifer L. Tenor
- Duke University School of Medicine, Department of Medicine, Division of Infectious Diseases, Durham, North Carolina, USA
| | - Dena L. Toffaletti
- Duke University School of Medicine, Department of Medicine, Division of Infectious Diseases, Durham, North Carolina, USA
| | - Julia R. Palmucci
- Duke University School of Medicine, Department of Medicine, Division of Infectious Diseases, Durham, North Carolina, USA
| | - Choiselle Marius
- Duke University School of Medicine, Department of Surgery, Durham, North Carolina, USA
| | - Jane-Valeriane K. Boua
- Duke University School of Medicine, Department of Neurosurgery, Durham, North Carolina, USA
| | | | | | - M. Arthur Moseley
- Duke University School of Medicine, Duke Proteomics and Metabolomics Core Facility, Center for Genomic and Computational Biology, Durham, North Carolina, USA
| | - J. Will Thompson
- Duke University School of Medicine, Duke Proteomics and Metabolomics Core Facility, Center for Genomic and Computational Biology, Durham, North Carolina, USA
| | - Laura G. Dubois
- Duke University School of Medicine, Duke Proteomics and Metabolomics Core Facility, Center for Genomic and Computational Biology, Durham, North Carolina, USA
| | - William Hope
- Antimicrobial Pharmacodynamics and Therapeutics, University of Liverpool, Liverpool Health Partners, Liverpool, United Kingdom
| | - John R. Perfect
- Duke University School of Medicine, Department of Medicine, Division of Infectious Diseases, Durham, North Carolina, USA
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Lawrence DS, Muthoga C, Meya DB, Tugume L, Williams D, Rajasingham R, Boulware DR, Mwandumba HC, Moyo M, Dziwani EN, Maheswaran H, Kanyama C, Hosseinipour MC, Chawinga C, Meintjes G, Schutz C, Comins K, Bango F, Muzoora C, Jjunju S, Nuwagira E, Mosepele M, Leeme T, Ndhlovu CE, Hlupeni A, Shamu S, Boyer-Chammard T, Molloy SF, Youssouf N, Chen T, Shiri T, Jaffar S, Harrison TS, Jarvis JN, Niessen LW. Cost-effectiveness of single, high-dose, liposomal amphotericin regimen for HIV-associated cryptococcal meningitis in five countries in sub-Saharan Africa: an economic analysis of the AMBITION-cm trial. Lancet Glob Health 2022; 10:e1845-e1854. [PMID: 36400090 PMCID: PMC10009915 DOI: 10.1016/s2214-109x(22)00450-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 09/25/2022] [Accepted: 09/30/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND HIV-associated cryptococcal meningitis is a leading cause of AIDS-related mortality. The AMBITION-cm trial showed that a regimen based on a single high dose of liposomal amphotericin B deoxycholate (AmBisome group) was non-inferior to the WHO-recommended treatment of seven daily doses of amphotericin B deoxycholate (control group) and was associated with fewer adverse events. We present a five-country cost-effectiveness analysis. METHODS The AMBITION-cm trial enrolled patients with HIV-associated cryptococcal meningitis from eight hospitals in Botswana, Malawi, South Africa, Uganda, and Zimbabwe. Taking a health service perspective, we collected country-specific unit costs and individual resource-use data per participant over the 10-week trial period, calculating mean cost per participant by group, mean cost-difference between groups, and incremental cost-effectiveness ratio per life-year saved. Non-parametric bootstrapping and scenarios analyses were performed including hypothetical real-world resource use. The trial registration number is ISRCTN72509687, and the trial has been completed. FINDINGS The AMBITION-cm trial enrolled 844 participants, and 814 were included in the intention-to-treat analysis (327 from Uganda, 225 from Malawi, 107 from South Africa, 84 from Botswana, and 71 from Zimbabwe) with 407 in each group, between Jan 31, 2018, and Feb 17, 2021. Using Malawi as a representative example, mean total costs per participant were US$1369 (95% CI 1314-1424) in the AmBisome group and $1237 (1181-1293) in the control group. The incremental cost-effectiveness ratio was $128 (59-257) per life-year saved. Excluding study protocol-driven cost, using a real-world toxicity monitoring schedule, the cost per life-year saved reduced to $80 (15-275). Changes in the duration of the hospital stay and antifungal medication cost showed the greatest effect in sensitivity analyses. Results were similar across countries, with the cost per life-year saved in the real-world scenario ranging from $71 in Botswana to $121 in Uganda. INTERPRETATION The AmBisome regimen was cost-effective at a low incremental cost-effectiveness ratio. The regimen might be even less costly and potentially cost-saving in real-world implementation given the lower drug-related toxicity and the potential for shorter hospital stays. FUNDING European Developing Countries Clinical Trials Partnership, Swedish International Development Cooperation Agency, Wellcome Trust and Medical Research Council, UKAID Joint Global Health Trials, and the National Institute for Health Research. TRANSLATIONS For the Chichewa, Isixhosa, Luganda, Setswana and Shona translations of the abstract see Supplementary Materials section.
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Affiliation(s)
- David S Lawrence
- Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK; Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana.
| | - Charles Muthoga
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - David B Meya
- Infectious Diseases Institute, College of Health Sciences, School of Medicine, Makerere University, Kampala, Uganda; Department of Medicine, School of Medicine, Makerere University, Kampala, Uganda; University of Minnesota, Minneapolis, MN, USA
| | - Lillian Tugume
- Infectious Diseases Institute, College of Health Sciences, School of Medicine, Makerere University, Kampala, Uganda
| | - Darlisha Williams
- Infectious Diseases Institute, College of Health Sciences, School of Medicine, Makerere University, Kampala, Uganda; University of Minnesota, Minneapolis, MN, USA
| | - Radha Rajasingham
- Infectious Diseases Institute, College of Health Sciences, School of Medicine, Makerere University, Kampala, Uganda; University of Minnesota, Minneapolis, MN, USA
| | - David R Boulware
- Infectious Diseases Institute, College of Health Sciences, School of Medicine, Makerere University, Kampala, Uganda; University of Minnesota, Minneapolis, MN, USA
| | - Henry C Mwandumba
- Department of Clinical Science, Liverpool School of Tropical Medicine, Liverpool, UK; Malawi-Liverpool-Wellcome Clinical Research Programme, Blantyre, Malawi; Department of Medicine, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Melanie Moyo
- Malawi-Liverpool-Wellcome Clinical Research Programme, Blantyre, Malawi; Department of Medicine, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Eltas N Dziwani
- Malawi-Liverpool-Wellcome Clinical Research Programme, Blantyre, Malawi
| | | | - Cecilia Kanyama
- Lilongwe Medical Relief Trust (University of North Carolina Project), Lilongwe, Malawi; Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Mina C Hosseinipour
- Lilongwe Medical Relief Trust (University of North Carolina Project), Lilongwe, Malawi; Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Chimwemwe Chawinga
- Lilongwe Medical Relief Trust (University of North Carolina Project), Lilongwe, Malawi
| | - Graeme Meintjes
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-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
| | - Charlotte Schutz
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-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
| | - Kyla Comins
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-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
| | - Funeka Bango
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Conrad Muzoora
- Infectious Diseases Institute, College of Health Sciences, School of Medicine, Makerere University, Kampala, Uganda; Mbarara University of Science and Technology, Mbarara, Uganda
| | - Samuel Jjunju
- Infectious Diseases Institute, College of Health Sciences, School of Medicine, Makerere University, Kampala, Uganda
| | - Edwin Nuwagira
- Infectious Diseases Institute, College of Health Sciences, School of Medicine, Makerere University, Kampala, Uganda; Mbarara University of Science and Technology, Mbarara, Uganda
| | - Mosepele Mosepele
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana; Department of Internal Medicine, University of Botswana, Gaborone, Botswana
| | - Tshepo Leeme
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Chiratidzo E Ndhlovu
- Internal Medicine Unit, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Admire Hlupeni
- Internal Medicine Unit, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Shepherd Shamu
- Internal Medicine Unit, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Timothée Boyer-Chammard
- Institut Pasteur, National Reference Centres, Molecular Mycology Unit and National Reference Centre for Invasive Mycoses and Antifungals, Joint Research Unit 2000, Paris, France; Université de Paris, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, Hôpital Necker Enfants Malades, AssistancePublique-Hôpitaux de Paris, University Hospital Institute Imagine, Paris, France
| | - Síle F Molloy
- Institute of Infection and Immunity, St George's University London, London, UK
| | - Nabila Youssouf
- Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK; Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana; Department of Internal Medicine, University of Botswana, Gaborone, Botswana
| | - Tao Chen
- Department of Public Health and Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK; Institute of Population Health, University of Liverpool, Liverpool, UK
| | | | - Shabbar Jaffar
- Department of Public Health and Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Thomas S Harrison
- Institute of Infection and Immunity, St George's University London, London, UK; Clinical Academic Group in Infection and Immunity, St George's University Hospitals NHS Foundation Trust, London, UK; Medical Research Council Centre for Medical Mycology, University of Exeter, Exeter, UK
| | - Joseph N Jarvis
- Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK; Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Louis W Niessen
- Department of Public Health and Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK; Department of International Health, Johns Hopkins School of Public Health, Baltimore, MD, USA
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Shiri T, Birungi J, Garrib AV, Kivuyo SL, Namakoola I, Mghamba J, Musinguzi J, Kimaro G, Mutungi G, Nyirenda MJ, Okebe J, Ramaiya K, Bachmann M, Sewankambo NK, Mfinanga S, Jaffar S, Niessen LW. Patient and health provider costs of integrated HIV, diabetes and hypertension ambulatory health services in low-income settings - an empirical socio-economic cohort study in Tanzania and Uganda. BMC Med 2021; 19:230. [PMID: 34503496 PMCID: PMC8431904 DOI: 10.1186/s12916-021-02094-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 08/11/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Integration of health services might be an efficient strategy for managing multiple chronic conditions in sub-Saharan Africa, considering the scope of treatments and synergies in service delivery. Proven to promote compliance, integration may lead to increased economies-of-scale. However, evidence on the socio-economic consequences of integration for providers and patients is lacking. We assessed the clinical resource use, staff time, relative service efficiency and overall societal costs associated with integrating HIV, diabetes and hypertension services in single one-stop clinics where persons with one or more of these conditions were managed. METHODS 2273 participants living with HIV infection, diabetes, or hypertension or combinations of these conditions were enrolled in 10 primary health facilities in Tanzania and Uganda and followed-up for up to 12 months. We collected data on resources used from all participants and on out-of-pocket costs in a sub-sample of 1531 participants, while a facility-level costing study was conducted at each facility. Health worker time per participant was assessed in a time-motion morbidity-stratified study among 228 participants. The mean health service cost per month and out-of-pocket costs per participant visit were calculated in 2020 US$ prices. Nested bootstrapping from these samples accounted for uncertainties. A data envelopment approach was used to benchmark the efficiency of the integrated services. Last, we estimated the budgetary consequences of integration, based on prevalence-based projections until 2025, for both country populations. RESULTS Their average retention after 1 year service follow-up was 1911/2273 (84.1%). Five hundred and eighty-two of 2273 (25.6%) participants had two or all three chronic conditions and 1691/2273 (74.4%) had a single condition. During the study, 84/2239 (3.8%) participants acquired a second or third condition. The mean service costs per month of managing two conditions in a single participant were $39.11 (95% CI 33.99, 44.33), $32.18 (95% CI 30.35, 34.07) and $22.65 (95% CI 21.86, 23.43) for the combinations of HIV and diabetes and of HIV and hypertension, diabetes and hypertension, respectively. These costs were 34.4% (95% CI 17.9%, 41.9%) lower as compared to managing any two conditions separately in two different participants. The cost of managing an individual with all three conditions was 48.8% (95% CI 42.1%, 55.3%) lower as compared to managing these conditions separately. Out-of-pocket healthcare expenditure per participant per visit was $7.33 (95% CI 3.70, 15.86). This constituted 23.4% (95% CI 9.9, 54.3) of the total monthly service expenditure per patient and 11.7% (95% CI 7.3, 22.1) of their individual total household income. The integrated clinics' mean efficiency benchmark score was 0.86 (range 0.30-1.00) suggesting undercapacity that could serve more participants without compromising quality of care. The estimated budgetary consequences of managing multi-morbidity in these types of integrated clinics is likely to increase by 21.5% (range 19.2-23.4%) in the next 5 years, including substantial savings of 21.6% on the provision of integrated care for vulnerable patients with multi-morbidities. CONCLUSION Integration of HIV services with diabetes and hypertension control reduces both health service and household costs, substantially. It is likely an efficient and equitable way to address the increasing burden of financially vulnerable households among Africa's ageing populations. Additional economic evidence is needed from longer-term larger-scale implementation studies to compare extended integrated care packages directly simultaneously with evidence on sustained clinical outcomes.
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Affiliation(s)
- Tinevimbo Shiri
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK
| | - Josephine Birungi
- The AIDS Support Organisation, Mulago Hospital Complex, Kampala, Uganda
- Medical Research Council/Uganda Virus Research Institute & London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Anupam V Garrib
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK
| | - Sokoine L Kivuyo
- National Institutes for Medical Research, Dar es Salaam, Tanzania
| | - Ivan Namakoola
- Medical Research Council/Uganda Virus Research Institute & London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Janneth Mghamba
- Directors Office, Ministry of Health, Community Development, Gender, Elderly and Children, Kampala, Uganda
| | - Joshua Musinguzi
- Directors Office, Ministry of Health, Community Development, Gender, Elderly and Children, Kampala, Uganda
| | - Godfather Kimaro
- School of Public Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Gerald Mutungi
- Non-Communicable Diseases Control Programme, Ministry of Health, Kampala, Uganda
| | - Moffat J Nyirenda
- The AIDS Support Organisation, Mulago Hospital Complex, Kampala, Uganda
- London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Joseph Okebe
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK
| | - Kaushik Ramaiya
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK
- Hindu Mandal Hospital, Dar es Salaam, Tanzania
| | - M Bachmann
- Norwich Medical School, University of East Anglia, Norwich, UK
| | | | - Sayoki Mfinanga
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK
- National Institutes for Medical Research, Dar es Salaam, Tanzania
- School of Public Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Shabbar Jaffar
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK
| | - Louis W Niessen
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK.
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
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HIV-associated Cryptococcal Meningitis: a Review of Novel Short-Course and Oral Therapies. CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2020. [DOI: 10.1007/s40506-020-00239-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Abstract
Purpose of review
HIV-associated cryptococcal meningitis remains a significant public health problem in parts of Africa and Asia and a major cause of AIDS-related mortality, accounting for 15% of all AIDS-related deaths worldwide. Cryptococcal meningitis is uniformly fatal if untreated, and access to antifungal therapy in regions with the highest burden is often limited. Outcomes with fluconazole monotherapy are poor, and induction treatment with amphotericin B and high-dose fluconazole for 2 weeks is associated with significant drug-related toxicities and prolonged hospital admissions. This review focuses on the potential of novel short-course and oral combination therapies for cryptococcal meningitis.
Recent findings
Recent clinical trials have shown that shorter courses of amphotericin, if paired with oral flucytosine, rather than fluconazole, can achieve non-inferior mortality outcomes. In addition, an oral combination of fluconazole and flucytosine is a potential alternative. Liposomal amphotericin B may further simplify treatment; it is associated with fewer drug-related toxicities, and a recent phase II randomised controlled trial demonstrated that a single, high dose of liposomal amphotericin is non-inferior to 14 standard daily doses at clearing Cryptococcus from cerebrospinal fluid. This has been taken forward to an ongoing phase III, clinical endpoint study.
Summary
The incidence and mortality associated with cryptococcal meningitis is still unacceptably high. There is evidence supporting the use of short-course amphotericin B and oral combination antifungal treatment regimens for cryptococcal meningitis (CM). Ongoing research into short-course, high-dose treatment with liposomal amphotericin may also help reduce the impact of this devastating disease.
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Wirth F, Ishida K. Antifungal drugs: An updated review of central nervous system pharmacokinetics. Mycoses 2020; 63:1047-1059. [PMID: 32772402 DOI: 10.1111/myc.13157] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 07/23/2020] [Accepted: 08/02/2020] [Indexed: 01/06/2023]
Abstract
Invasive fungal infections (IFIs) in the central nervous system (CNS) are particularly hard to treat and are associated with high morbidity and mortality rates. Four chemical classes of systemic antifungal agents are used for the treatment of IFIs (eg meningitis), including polyenes, triazoles, pyrimidine analogues and echinocandins. This review will address all of these classes and discuss their penetration and accumulation in the CNS. Treatment of fungal meningitis is based on the antifungal that shows good penetration and accumulation in the CNS. Pharmacokinetic data concerning the entry of antifungal agents into the intracranial compartments are faulty. This review will provide an overview of the ability of systemic antifungals to penetrate the CNS, based on previously published drug physicochemical properties and pharmacokinetic data, for evaluation of the most promising antifungal drugs for the treatment of fungal CNS infections. The studies selected and discussed in this review are from 1990 to 2019.
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Affiliation(s)
- Fernanda Wirth
- Laboratory of Antifungal Chemotherapy, Department of Microbiology, Institute of Biomedical Sciences, University of São Paulo, São Paulo, Brazil
| | - Kelly Ishida
- Laboratory of Antifungal Chemotherapy, Department of Microbiology, Institute of Biomedical Sciences, University of São Paulo, São Paulo, Brazil
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