1
|
Jones NT, Abadie R, Keller CL, Jones K, Ledet Iii LF, Fox JE, Klapper VG, Potharaju P, Siddaiah H, Kaye AM, Shekoohi S, Kaye AD, Varrassi G. Treatment and Toxicity Considerations in Tuberculosis: A Narrative Review. Cureus 2024; 16:e62698. [PMID: 39036175 PMCID: PMC11259524 DOI: 10.7759/cureus.62698] [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: 03/26/2024] [Accepted: 06/19/2024] [Indexed: 07/23/2024] Open
Abstract
Tuberculosis remains one of the most significant bacterial infections plaguing the medical community worldwide. The bacteria Mycobacterium tuberculosis retains the ability to manifest as an active infection, latent infection, miliary infection, or reactivation of latent infections in times of immunosuppression. Therefore, the medication regimen to treat the condition revolves around four medications, each with a mechanism that targets a different part of the bacteria. Isoniazid weakens the cell wall but produces neuropathy and hepatotoxicity as side effects. Rifampin interrupts protein synthesis but creates the opportunity for many drug-to-drug interactions and red-orange discolorations as side effects. Pyrazinamide is poorly understood, but it is believed to acidify the internal environment of the bacteria, with gout exacerbations and arthralgias as major side effects. Ethambutol also works as a bacteriostatic medication to interrupt the cell membrane; however, its mechanism is poorly understood. The most concerning side effect is optic neuropathy. The unfavorable side effect profile for tuberculosis treatment may contribute to the higher rates of medication noncompliance with therapy and needs to be addressed in the future.
Collapse
Affiliation(s)
- Nicholas T Jones
- School of Medicine, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Raegan Abadie
- School of Medicine, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Camryn L Keller
- School of Medicine, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Kamryn Jones
- School of Medicine, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Lloyd F Ledet Iii
- School of Medicine, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Julia E Fox
- School of Medicine, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Vincent G Klapper
- Department of Internal Medicine, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Pooja Potharaju
- Department of Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Harish Siddaiah
- Department of Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Adam M Kaye
- Department of Pharmacy Practice, Thomas J. Long School of Pharmacy and Health Sciences, University of the Pacific, Stockton, USA
| | - Sahar Shekoohi
- Department of Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Alan D Kaye
- Department of Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
| | | |
Collapse
|
2
|
Abdelgawad N, Wasserman S, Abdelwahab MT, Davis A, Stek C, Wiesner L, Black J, Meintjes G, Wilkinson RJ, Denti P. Linezolid Population Pharmacokinetic Model in Plasma and Cerebrospinal Fluid Among Patients With Tuberculosis Meningitis. J Infect Dis 2024; 229:1200-1208. [PMID: 37740554 PMCID: PMC11011161 DOI: 10.1093/infdis/jiad413] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 09/09/2023] [Accepted: 09/20/2023] [Indexed: 09/24/2023] Open
Abstract
BACKGROUND Linezolid is evaluated in novel treatment regimens for tuberculous meningitis (TBM). Linezolid pharmacokinetics have not been characterized in this population, particularly in cerebrospinal fluid (CSF), as well as, following its co-administration with high-dose rifampicin. We aimed to characterize linezolid plasma and CSF pharmacokinetics in adults with TBM. METHODS In the LASER-TBM pharmacokinetic substudy, the intervention groups received high-dose rifampicin (35 mg/kg) plus 1200 mg/day of linezolid for 28 days, which was then reduced to 600 mg/day. Plasma sampling was done on day 3 (intensive) and day 28 (sparse). A lumbar CSF sample was obtained on both visits. RESULTS Thirty participants contributed 247 plasma and 28 CSF observations. Their median age and weight were 40 years (range, 27-56) and 58 kg (range, 30-96). Plasma pharmacokinetics was described by a 1-compartment model with first-order absorption and saturable elimination. Maximal clearance was 7.25 L/h, and the Michaelis-Menten constant was 27.2 mg/L. Rifampicin cotreatment duration did not affect linezolid pharmacokinetics. CSF-plasma partitioning correlated with CSF total protein up to 1.2 g/L, where the partition coefficient reached a maximal value of 37%. The plasma-CSF equilibration half-life was ∼3.5 hours. CONCLUSIONS Linezolid was readily detected in CSF despite high-dose rifampicin coadministration. These findings support continued clinical evaluation of linezolid plus high-dose rifampicin for the treatment of TBM in adults. Clinical Trials Registration. ClinicalTrials.gov (NCT03927313).
Collapse
Affiliation(s)
- Noha Abdelgawad
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, South Africa
| | - Sean Wasserman
- Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, South Africa
- Institute for Infection and Immunity, St George's University of London, United Kingdom
| | - Mahmoud Tareq Abdelwahab
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, South Africa
| | - Angharad Davis
- Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, South Africa
- The Francis Crick Institute, London, United Kingdom
- Faculty of Life Sciences, University College London, United Kingdom
| | - Cari Stek
- Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, South Africa
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, South Africa
| | - John Black
- Department of Medicine, Walter Sisulu University, Mthatha, South Africa
| | - Graeme Meintjes
- Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, South Africa
- Department of Medicine, University of Cape Town, South Africa
| | - Robert J Wilkinson
- Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, South Africa
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, University of Cape Town, South Africa
- The Francis Crick Institute, London, United Kingdom
- Department of Infectious Diseases, Imperial College London, United Kingdom
| | - Paolo Denti
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, South Africa
| |
Collapse
|
3
|
Jain S, Chen X, Arun B, Meza ON, Sarhan M, Singh M, Jeon B, Mane K, Shah M, Tucker E, Carroll L, Freundlich J, Peloquin C, Ivaturi V. Dynamic PET Reveals Compartmentalized Brain and Lung Tissue Antibiotic Exposures. RESEARCH SQUARE 2024:rs.3.rs-4096014. [PMID: 38562706 PMCID: PMC10984015 DOI: 10.21203/rs.3.rs-4096014/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
Tuberculosis (TB) remains a leading cause of death, but antibiotic treatments for tuberculous meningitis, the deadliest form of TB, are based on those developed for pulmonary TB and not optimized for brain penetration. Here, we performed first-in-human dynamic 18F-pretomanid positron emission tomography (PET) studies in eight human subjects for three-dimensional, multi-compartmental in situ visualization of antibiotic concentration-time exposures (area under the curve - AUC), demonstrating preferential brain (AUCtissue/plasma 2.25) versus lung (AUCtissue/plasma 0.97) tissue partitioning. Preferential, antibiotic-specific partitioning into brain or lung tissues of antibiotics active against MDR strains were confirmed in experimentally-infected mice and rabbits, using dynamic PET with chemically identical antibiotic radioanalogs, and postmortem mass spectrometry measurements. PET-facilitated pharmacokinetic modeling predicted human dosing necessary to attain therapeutic brain exposures in human subjects. These data were used to design optimized, pretomanid-based regimens which were evaluated at human equipotent dosing in a mouse model of TB meningitis, demonstrating excellent bactericidal activity without an increase in intracerebral inflammation or brain injury. Importantly, several antibiotic regimens demonstrated discordant activities in brain and lung tissues in the same animal, correlating with the compartmentalized tissue exposures of the component antibiotics. These data provide a mechanistic basis for the compartmentalized activities of antibiotic regimens, with important implications for the development of antimicrobial regimens for meningitis and other infections in compartments with unique antibiotic penetration.
Collapse
Affiliation(s)
| | - Xueyi Chen
- Johns Hopkins University School of Medicine
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
4
|
Tucker EW, Ruiz-Bedoya CA, Mota F, Erice C, Kim J, de Jesus P, Jahdav R, Bahr M, Flavahan K, Chen X, Peloquin CA, Freundlich JS, Jain SK. Linezolid does not improve bactericidal activity of rifampin-containing first-line regimens in animal models of TB meningitis. Int J Antimicrob Agents 2024; 63:107048. [PMID: 38061419 PMCID: PMC10841818 DOI: 10.1016/j.ijantimicag.2023.107048] [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: 08/24/2023] [Revised: 11/15/2023] [Accepted: 11/28/2023] [Indexed: 01/02/2024]
Abstract
Tuberculous meningitis (TB meningitis) is the most devastating form of tuberculosis (TB) and there is a critical need to optimize treatment. Linezolid is approved for multidrug resistant TB and has shown encouraging results in retrospective TB meningitis studies, with several clinical trials underway assessing its additive effects on high-dose (35 mg/kg/day) or standard-dose (10 mg/kg/day) rifampin-containing regimens. However, the efficacy of adjunctive linezolid to rifampin-containing first-line TB meningitis regimens and the tissue pharmacokinetics (PK) in the central nervous system (CNS) are not known. We therefore conducted cross-species studies in two mammalian (rabbits and mice) models of TB meningitis to test the efficacy of linezolid when added to the first-line TB regimen and measure detailed tissue PK (multicompartmental positron emission tomography [PET] imaging and mass spectrometry). Addition of linezolid did not improve the bactericidal activity of the high-dose rifampin-containing regimen in either animal model. Moreover, the addition of linezolid to standard-dose rifampin in mice also did not improve its efficacy. Linezolid penetration (tissue/plasma) into the CNS was compartmentalized with lower than previously reported brain and cerebrospinal fluid (CSF) penetration, which decreased further two weeks after initiation of treatment. These results provide important data regarding the addition of linezolid for the treatment of TB meningitis.
Collapse
Affiliation(s)
- Elizabeth W Tucker
- Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Camilo A Ruiz-Bedoya
- Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Filipa Mota
- Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Clara Erice
- Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - John Kim
- Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Patricia de Jesus
- Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ravindra Jahdav
- Department of Pharmacology, Physiology and Neuroscience, Rutgers University-New Jersey Medical School, Newark, NJ, USA
| | - Melissa Bahr
- Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kelly Flavahan
- Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Xueyi Chen
- Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Charles A Peloquin
- Infectious Disease Pharmacokinetics Laboratory, Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Gainesville, FL, USA
| | - Joel S Freundlich
- Department of Pharmacology, Physiology and Neuroscience, Rutgers University-New Jersey Medical School, Newark, NJ, USA
| | - Sanjay K Jain
- Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| |
Collapse
|
5
|
Mazanhanga M, Joubert A, Castel S, Van de Merwe M, Maartens G, Wasserman S, Wiesner L. Validation of a quantitative liquid chromatography tandem mass spectrometry assay for linezolid in cerebrospinal fluid and its application to patients with HIV-associated TB-meningitis. Heliyon 2023; 9:e21962. [PMID: 38034739 PMCID: PMC10685187 DOI: 10.1016/j.heliyon.2023.e21962] [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: 09/26/2023] [Revised: 10/25/2023] [Accepted: 11/01/2023] [Indexed: 12/02/2023] Open
Abstract
Tuberculous meningitis treatment outcomes are poor and alternative regimens are under investigation. Reliable methods to measure drug concentrations in cerebrospinal fluid are required to evaluate distribution into the cerebrospinal fluid. A simple and quick method was developed and validated to analyse linezolid in human cerebrospinal fluid. Samples were prepared by protein precipitation followed by isocratic liquid chromatography and tandem mass spectrometry. The run time was 3.5 min. Accuracy and precision were assessed in three independent validation batches with a calibration range of 0.100-20.0 μg/mL. The method was used to analyse cerebrospinal fluid samples from patients with tuberculous meningitis enrolled in a clinical trial. Potentially infective patient samples could be decontaminated using Nanosep® nylon and Costar® nylon filter tubes under biosafety level 3 conditions before analysis. The filtration process did not significantly affect the quantification of linezolid. Linezolid concentration in cerebrospinal fluid obtained from tuberculous meningitis patients ranged from 0.197 μg/mL to 15.0 μg/mL. The ratio between average CSF and plasma linezolid concentrations varied with time, reaching a maximum of 0.9 at 6 h after dosing.
Collapse
Affiliation(s)
- Marian Mazanhanga
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Anton Joubert
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Sandra Castel
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Marthinus Van de Merwe
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Sean Wasserman
- Division of Infectious Diseases and HIV Medicine, 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
| |
Collapse
|
6
|
Abdelgawad N, Wasserman S, Abdelwahab MT, Davis A, Stek C, Wiesner L, Black J, Meintjes G, Wilkinson RJ, Denti P. Linezolid population pharmacokinetic model in plasma and cerebrospinal fluid among patients with tuberculosis meningitis. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.04.06.23288230. [PMID: 37066148 PMCID: PMC10104225 DOI: 10.1101/2023.04.06.23288230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/18/2023]
Abstract
Background Linezolid is being evaluated in novel treatment regimens for tuberculous meningitis (TBM). The pharmacokinetics of linezolid have not been characterized in this population, particularly in cerebrospinal fluid (CSF) where exposures may be affected by changes in protein concentration and rifampicin co-administration. Methods This was a sub-study of a phase 2 clinical trial of intensified antibiotic therapy for adults with HIV-associated TBM. Participants in the intervention groups received high-dose rifampicin (35 mg/kg) plus linezolid 1200 mg daily for 28 days followed by 600 mg daily until day 56. Plasma was intensively sampled, and lumbar CSF was collected at a single timepoint in a randomly allocated sampling window, within 3 days after enrolment. Sparse plasma and CSF samples were also obtained on day 28. Linezolid concentrations were analyzed using non-linear mixed effects modelling. Results 30 participants contributed 247 plasma and 28 CSF linezolid observations. Plasma PK was best described by a one-compartment model with first-order absorption and saturable elimination. The typical value of maximal clearance was 7.25 L/h. Duration of rifampicin co-treatment (compared on day 3 versus day 28) did not affect linezolid pharmacokinetics. Partitioning between plasma and CSF correlated with CSF total protein concentration up to 1.2 g/L where the partition coefficient reached a maximal value of 37%. The equilibration half-life between plasma and CSF was estimated at ∼3.5 hours. Conclusion Linezolid was readily detected in CSF despite co-administration of the potent inducer rifampicin at high doses. These findings support continued clinical evaluation of linezolid plus high-dose rifampicin for the treatment of TBM in adults.
Collapse
|
7
|
Davis AG, Dreyer AJ, Albertyn C, Maxebengula M, Stek C, Wasserman S, Marais S, Bateman K, Solms M, Joska J, Wilkinson RJ, Nightingale S. Cognitive Impairment in Tuberculous Meningitis. Clin Infect Dis 2023; 76:842-849. [PMID: 36262054 PMCID: PMC9989126 DOI: 10.1093/cid/ciac831] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 10/03/2022] [Accepted: 10/17/2022] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Cognitive impairment is reported as a common complication in adult tuberculous meningitis (TBM), yet few studies have systematically assessed the frequency and nature of impairment. Moreover, the impact of impairment on functioning and medication adherence has not been described. METHODS A cognitive test battery (10 measures assessing 7 cognitive domains) was administered to 34 participants with human immunodeficiency virus (HIV)-associated TBM 6 months after diagnosis. Cognitive performance was compared with that a comparator group of 66 people with HIV without a history of tuberculosis. A secondary comparison was made between participants with TBM and 26 participants with HIV 6 months after diagnosis of tuberculosis outside the central nervous system (CNS). Impact on functioning was evaluated, including through assessment of medication adherence. RESULTS Of 34 participants with TBM, 16 (47%) had low performance on cognitive testing. Cognition was impaired across all domains. Global cognitive performance was significantly lower in participants with TBM than in people with HIV (mean T score, 41 vs 48, respectively; P < .001). These participants also had lower global cognition scores than those with non-CNS tuberculosis (mean global T score, 41 vs 46; P = .02). Functional outcomes were not significantly correlated with cognitive performance in the subgroup of participants in whom this was assessed (n = 19). CONCLUSIONS Low cognitive performance following HIV-associated TBM is common. This effect is independent of, and additional to, effects of HIV and non-CNS tuberculosis disease. Further studies are needed to understand longer-term outcomes, clarify the association with treatment adherence, a key predictor of outcome in TBM, and develop context-specific tools to identify individuals with cognitive difficulties in order to improve outcomes in TBM.
Collapse
Affiliation(s)
- Angharad G Davis
- The Francis Crick Institute, London, United Kingdom.,Faculty of Life Sciences, University College London, London, United Kingdom.,Wellcome Centre for Infectious Diseases Research in Africa and Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, Republic of South Africa
| | - Anna J Dreyer
- Division of Neuropsychiatry, Department of Psychiatry and Mental Health, HIV Mental Health Research Unit, Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Christine Albertyn
- Division of Neurology, Department of Medicine, Stellenbosch University, Cape Town, South Africa.,Division of Neurology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Mpumi Maxebengula
- Wellcome Centre for Infectious Diseases Research in Africa and Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, Republic of South Africa
| | - Cari Stek
- Wellcome Centre for Infectious Diseases Research in Africa and Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, Republic of South Africa.,Department of Infectious Diseases, Imperial College London, London, United Kingdom
| | - Sean Wasserman
- Wellcome Centre for Infectious Diseases Research in Africa and Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, Republic of South Africa.,Division of Infectious Diseases and HIV Medicine, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Suzaan Marais
- Division of Neurology, Department of Medicine, University of Cape Town, Cape Town, South Africa.,Neurology Research Group, Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Kathleen Bateman
- Division of Neurology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Mark Solms
- Division of Psychology, University of Cape Town, Cape Town, South Africa
| | - John Joska
- Division of Neuropsychiatry, Department of Psychiatry and Mental Health, HIV Mental Health Research Unit, Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Robert J Wilkinson
- The Francis Crick Institute, London, United Kingdom.,Faculty of Life Sciences, University College London, London, United Kingdom.,Wellcome Centre for Infectious Diseases Research in Africa and Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, Republic of South Africa.,Department of Infectious Diseases, Imperial College London, London, United Kingdom
| | - Sam Nightingale
- Division of Neuropsychiatry, Department of Psychiatry and Mental Health, HIV Mental Health Research Unit, Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| |
Collapse
|
8
|
Barichello T, Rocha Catalão CH, Rohlwink UK, van der Kuip M, Zaharie D, Solomons RS, van Toorn R, Tutu van Furth M, Hasbun R, Iovino F, Namale VS. Bacterial meningitis in Africa. Front Neurol 2023; 14:822575. [PMID: 36864913 PMCID: PMC9972001 DOI: 10.3389/fneur.2023.822575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 01/18/2023] [Indexed: 02/16/2023] Open
Abstract
Bacterial meningitis differs globally, and the incidence and case fatality rates vary by region, country, pathogen, and age group; being a life-threatening disease with a high case fatality rate and long-term complications in low-income countries. Africa has the most significant prevalence of bacterial meningitis illness, and the outbreaks typically vary with the season and the geographic location, with a high incidence in the meningitis belt of the sub-Saharan area from Senegal to Ethiopia. Streptococcus pneumoniae (pneumococcus) and Neisseria meningitidis (meningococcus) are the main etiological agents of bacterial meningitis in adults and children above the age of one. Streptococcus agalactiae (group B Streptococcus), Escherichia coli, and Staphylococcus aureus are neonatal meningitis's most common causal agents. Despite efforts to vaccinate against the most common causes of bacterial neuro-infections, bacterial meningitis remains a significant cause of mortality and morbidity in Africa, with children below 5 years bearing the heaviest disease burden. The factors attributed to this continued high disease burden include poor infrastructure, continued war, instability, and difficulty in diagnosis of bacterial neuro-infections leading to delay in treatment and hence high morbidity. Despite having the highest disease burden, there is a paucity of African data on bacterial meningitis. In this article, we discuss the common etiologies of bacterial neuroinfectious diseases, diagnosis and the interplay between microorganisms and the immune system, and the value of neuroimmune changes in diagnostics and therapeutics.
Collapse
Affiliation(s)
- Tatiana Barichello
- Graduate Program in Health Sciences, University of Southern Santa Catarina (UNESC), Criciúma, SC, Brazil
- Faillace Department of Psychiatry and Behavioral Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Carlos Henrique Rocha Catalão
- Faillace Department of Psychiatry and Behavioral Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, United States
- Department of Neuroscience and Behavioral Science, Ribeirao Preto Medical School, University of São Paulo (USP), Ribeirao Preto, SP, Brazil
| | - Ursula K. Rohlwink
- Pediatric Neurosurgery Unit, Red Cross War Memorial Children's Hospital, Cape Town, South Africa
- Division of Neurosurgery, University of Cape Town, Cape Town, South Africa
- Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Martijn van der Kuip
- Department of Pediatric Infectious Diseases and Immunology, Amsterdam Infection and Immunity Institute, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, Netherlands
| | - Dan Zaharie
- Department of Anatomical Pathology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- National Health Laboratory Services, Tygerberg Hospital, Cape Town, South Africa
| | - Regan S. Solomons
- Department of Pediatric and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Ronald van Toorn
- Department of Pediatric and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Marceline Tutu van Furth
- Department of Pediatric Infectious Diseases and Immunology, Amsterdam Infection and Immunity Institute, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, Netherlands
| | - Rodrigo Hasbun
- Division of Infectious Diseases, Department of Internal Medicine, UT Health, McGovern Medical School, Houston, TX, United States
| | - Federico Iovino
- Department of Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Vivian Ssonko Namale
- Columbia University Irving Medical Center and New York Presbyterian Hospital, New York, NY, United States
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
| |
Collapse
|
9
|
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.
Collapse
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
| |
Collapse
|