1
|
Dionne JA, Anchang-Kimbi J, Hao J, Long D, Apinjoh T, Tih P, Mbah R, Ngah EN, Juliano JJ, Kahn M, Bruxvoort K, Van Der Pol B, Tita ATN, Marrazzo J, Achidi E. Trimethoprim-Sulfamethoxazole Plus Azithromycin to Prevent Malaria and Sexually Transmitted Infections in Pregnant Women With HIV (PREMISE): A Randomized, Double-Masked, Placebo-Controlled, Phase IIB Clinical Trial. Open Forum Infect Dis 2024; 11:ofae274. [PMID: 38807754 PMCID: PMC11130525 DOI: 10.1093/ofid/ofae274] [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: 03/15/2024] [Accepted: 05/06/2024] [Indexed: 05/30/2024] Open
Abstract
Background This trial tested the effectiveness of a novel regimen to prevent malaria and sexually transmitted infections (STIs) among pregnant women with HIV in Cameroon. Our hypothesis was that the addition of azithromycin (AZ) to standard daily trimethoprim-sulfamethoxazole (TMP-SMX) prophylaxis would reduce malaria and STI infection rates at delivery. Methods Pregnant women with HIV at gestational age <28 weeks were randomized to adjunctive monthly oral AZ 1 g daily or placebo for 3 days and both groups received daily standard oral TMP-SMX through delivery. Primary outcomes were (1) positive peripheral malaria infection by microscopy or polymerase chain reaction and (2) composite bacterial genital STI (Chlamydia trachomatis, Neisseria gonorrhoeae, or syphilis) at delivery. Relative risk and 95% confidence intervals were estimated using 2 × 2 tables with significance as P < .05. Results Pregnant women with HIV (n = 308) were enrolled between March 2018 and August 2020: 155 women were randomized to TMP-SMX-AZ and 153 women to TMP-SMX-placebo. Groups were similar at baseline and loss to follow up was 3.2%. There was no difference in the proportion with malaria (16.3% in TMP-SMX-AZ vs 13.2% in TMP-SMX; relative risk, 1.24 [95% confidence interval, .71-2.16]) or STI at delivery (4.2% in TMP-SMX-AZ vs 5.8% in TMP-SMX; relative risk, 0.72 [95% confidence interval, .26-2.03]). Adverse birth outcomes were not significantly different, albeit lower in the TMP-SMX-AZ arm (preterm delivery 6.7% vs 10.7% [P = .3]; low birthweight 3.4% vs 5.4% [P = .6]). Conclusions The addition of monthly azithromycin to daily TMP-SMX prophylaxis in pregnant women living with HIV in Cameroon did not reduce the risk of malaria or bacterial STI at delivery.
Collapse
Affiliation(s)
- Jodie A Dionne
- Department of Medicine, Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Center for Women's Reproductive Health, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | | | - Jiaying Hao
- Departments of Biostatistics and Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Dustin Long
- Departments of Biostatistics and Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Tobias Apinjoh
- Department of Parasitology and Immunology, University of Buea, Buea, Cameroon
| | - Pius Tih
- Cameroon Baptist Convention Health Services, Cameroon Health Initiative at UAB, Bamenda, Cameroon
| | - Rahel Mbah
- Cameroon Baptist Convention Health Services, Cameroon Health Initiative at UAB, Bamenda, Cameroon
| | - Edward Ndze Ngah
- Cameroon Baptist Convention Health Services, Cameroon Health Initiative at UAB, Bamenda, Cameroon
| | - Jonathan J Juliano
- Department of Medicine, Division of Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Mauricio Kahn
- Department of Medicine, Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Katia Bruxvoort
- Department of Medicine, Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Departments of Biostatistics and Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Barbara Van Der Pol
- Department of Medicine, Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Alan T N Tita
- Center for Women's Reproductive Health, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jeanne Marrazzo
- Department of Medicine, Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Eric Achidi
- Department of Parasitology and Immunology, University of Buea, Buea, Cameroon
| |
Collapse
|
2
|
Lee JJ, Kakuru A, Jacobson KB, Kamya MR, Kajubi R, Ranjit A, Gaw SL, Parsonnet J, Benjamin-Chung J, Dorsey G, Jagannathan P, Roh ME. Monthly Sulfadoxine-Pyrimethamine During Pregnancy Prevents Febrile Respiratory Illnesses: A Secondary Analysis of a Malaria Chemoprevention Trial in Uganda. Open Forum Infect Dis 2024; 11:ofae143. [PMID: 38585183 PMCID: PMC10995957 DOI: 10.1093/ofid/ofae143] [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: 01/08/2024] [Accepted: 03/18/2024] [Indexed: 04/09/2024] Open
Abstract
Background Trials evaluating antimalarials for intermittent preventive treatment in pregnancy (IPTp) have shown that dihydroartemisinin-piperaquine (DP) is a more efficacious antimalarial than sulfadoxine-pyrimethamine (SP); however, SP is associated with higher birthweight, suggesting that SP demonstrates "nonmalarial" effects. Chemoprevention of nonmalarial febrile illnesses (NMFIs) was explored as a possible mechanism. Methods In this secondary analysis, we leveraged data from 654 pregnant Ugandan women without HIV infection who participated in a randomized controlled trial comparing monthly IPTp-SP with IPTp-DP. Women were enrolled between 12 and 20 gestational weeks and followed through delivery. NMFIs were measured by active and passive surveillance and defined by the absence of malaria parasitemia. We quantified associations among IPTp regimens, incident NMFIs, antibiotic prescriptions, and birthweight. Results Mean "birthweight for gestational age" Z scores were 0.189 points (95% CI, .045-.333) higher in women randomized to IPTp-SP vs IPTp-DP. Women randomized to IPTp-SP had fewer incident NMFIs (incidence rate ratio, 0.74; 95% CI, .58-.95), mainly respiratory NMFIs (incidence rate ratio, 0.69; 95% CI, .48-1.00), vs IPTp-DP. Counterintuitively, respiratory NMFI incidence was positively correlated with birthweight in multigravidae. In total 75% of respiratory NMFIs were treated with antibiotics. Although overall antibiotic prescriptions were similar between arms, for each antibiotic prescribed, "birthweight for gestational age" Z scores increased by 0.038 points (95% CI, .001-.074). Conclusions Monthly IPTp-SP was associated with reduced respiratory NMFI incidence, revealing a potential nonmalarial mechanism of SP and supporting current World Health Organization recommendations for IPTp-SP, even in areas with high-grade SP resistance. While maternal respiratory NMFIs are known risk factors of lower birthweight, most women in our study were presumptively treated with antibiotics, masking the potential benefit of SP on birthweight mediated through preventing respiratory NMFIs.
Collapse
Affiliation(s)
- Jordan John Lee
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University, Stanford, California, USA
- Department of Epidemiology and Population Health, Stanford University, Stanford, California, USA
| | - Abel Kakuru
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Karen B Jacobson
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University, Stanford, California, USA
- Kaiser Permanente Northern California Division of Research, Vaccine Study Center, Oakland, California, USA
| | - Moses R Kamya
- Infectious Diseases Research Collaboration, Kampala, Uganda
- Department of Medicine, Makerere University, Kampala, Uganda
| | - Richard Kajubi
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Anju Ranjit
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco, San Francisco, California, USA
| | - Stephanie L Gaw
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco, San Francisco, California, USA
| | - Julie Parsonnet
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University, Stanford, California, USA
- Department of Epidemiology and Population Health, Stanford University, Stanford, California, USA
| | - Jade Benjamin-Chung
- Department of Epidemiology and Population Health, Stanford University, Stanford, California, USA
- Chan Zuckerberg Biohub, San Francisco, California, USA
| | - Grant Dorsey
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Prasanna Jagannathan
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University, Stanford, California, USA
- Department of Microbiology and Immunology, Stanford University, Stanford, California, USA
| | - Michelle E Roh
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
- Malaria Elimination Initiative, Institute for Global Health Sciences, University of California San Francisco, San Francisco, California, USA
| |
Collapse
|
3
|
Madanitsa M, Barsosio HC, Minja DTR, Mtove G, Kavishe RA, Dodd J, Saidi Q, Onyango ED, Otieno K, Wang D, Ashorn U, Hill J, Mukerebe C, Gesase S, Msemo OA, Mwapasa V, Phiri KS, Maleta K, Klein N, Magnussen P, Lusingu JPA, Kariuki S, Mosha JF, Alifrangis M, Hansson H, Schmiegelow C, Gutman JR, Chico RM, Ter Kuile FO. Effect of monthly intermittent preventive treatment with dihydroartemisinin-piperaquine with and without azithromycin versus monthly sulfadoxine-pyrimethamine on adverse pregnancy outcomes in Africa: a double-blind randomised, partly placebo-controlled trial. Lancet 2023; 401:1020-1036. [PMID: 36913959 PMCID: PMC10063957 DOI: 10.1016/s0140-6736(22)02535-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Revised: 09/28/2022] [Accepted: 12/06/2022] [Indexed: 03/12/2023]
Abstract
BACKGROUND Intermittent preventive treatment in pregnancy (IPTp) with dihydroartemisinin-piperaquine is more effective than IPTp with sulfadoxine-pyrimethamine at reducing malaria infection during pregnancy in areas with high-grade resistance to sulfadoxine-pyrimethamine by Plasmodium falciparum in east Africa. We aimed to assess whether IPTp with dihydroartemisinin-piperaquine, alone or combined with azithromycin, can reduce adverse pregnancy outcomes compared with IPTp with sulfadoxine-pyrimethamine. METHODS We did an individually randomised, double-blind, three-arm, partly placebo-controlled trial in areas of high sulfadoxine-pyrimethamine resistance in Kenya, Malawi, and Tanzania. HIV-negative women with a viable singleton pregnancy were randomly assigned (1:1:1) by computer-generated block randomisation, stratified by site and gravidity, to receive monthly IPTp with sulfadoxine-pyrimethamine (500 mg of sulfadoxine and 25 mg of pyrimethamine for 1 day), monthly IPTp with dihydroartemisinin-piperaquine (dosed by weight; three to five tablets containing 40 mg of dihydroartemisinin and 320 mg of piperaquine once daily for 3 consecutive days) plus a single treatment course of placebo, or monthly IPTp with dihydroartemisinin-piperaquine plus a single treatment course of azithromycin (two tablets containing 500 mg once daily for 2 consecutive days). Outcome assessors in the delivery units were masked to treatment group. The composite primary endpoint was adverse pregnancy outcome, defined as fetal loss, adverse newborn baby outcomes (small for gestational age, low birthweight, or preterm), or neonatal death. The primary analysis was by modified intention to treat, consisting of all randomised participants with primary endpoint data. Women who received at least one dose of study drug were included in the safety analyses. This trial is registered with ClinicalTrials.gov, NCT03208179. FINDINGS From March-29, 2018, to July 5, 2019, 4680 women (mean age 25·0 years [SD 6·0]) were enrolled and randomly assigned: 1561 (33%; mean age 24·9 years [SD 6·1]) to the sulfadoxine-pyrimethamine group, 1561 (33%; mean age 25·1 years [6·1]) to the dihydroartemisinin-piperaquine group, and 1558 (33%; mean age 24·9 years [6.0]) to the dihydroartemisinin-piperaquine plus azithromycin group. Compared with 335 (23·3%) of 1435 women in the sulfadoxine-pyrimethamine group, the primary composite endpoint of adverse pregnancy outcomes was reported more frequently in the dihydroartemisinin-piperaquine group (403 [27·9%] of 1442; risk ratio 1·20, 95% CI 1·06-1·36; p=0·0040) and in the dihydroartemisinin-piperaquine plus azithromycin group (396 [27·6%] of 1433; 1·16, 1·03-1·32; p=0·017). The incidence of serious adverse events was similar in mothers (sulfadoxine-pyrimethamine group 17·7 per 100 person-years, dihydroartemisinin-piperaquine group 14·8 per 100 person-years, and dihydroartemisinin-piperaquine plus azithromycin group 16·9 per 100 person-years) and infants (sulfadoxine-pyrimethamine group 49·2 per 100 person-years, dihydroartemisinin-piperaquine group 42·4 per 100 person-years, and dihydroartemisinin-piperaquine plus azithromycin group 47·8 per 100 person-years) across treatment groups. 12 (0·2%) of 6685 sulfadoxine-pyrimethamine, 19 (0·3%) of 7014 dihydroartemisinin-piperaquine, and 23 (0·3%) of 6849 dihydroartemisinin-piperaquine plus azithromycin treatment courses were vomited within 30 min. INTERPRETATION Monthly IPTp with dihydroartemisinin-piperaquine did not improve pregnancy outcomes, and the addition of a single course of azithromycin did not enhance the effect of monthly IPTp with dihydroartemisinin-piperaquine. Trials that combine sulfadoxine-pyrimethamine and dihydroartemisinin-piperaquine for IPTp should be considered. FUNDING European & Developing Countries Clinical Trials Partnership 2, supported by the EU, and the UK Joint-Global-Health-Trials-Scheme of the Foreign, Commonwealth and Development Office, Medical Research Council, Department of Health and Social Care, Wellcome, and the Bill-&-Melinda-Gates-Foundation.
Collapse
Affiliation(s)
- Mwayiwawo Madanitsa
- School of Global and Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi; Department of Clinical Sciences, Academy of Medical Sciences, Malawi University of Science and Technology, Thyolo, Malawi
| | - Hellen C Barsosio
- Kenya Medical Research Institute, Centre for Global Health Research, Kisumu, Kenya
| | - Daniel T R Minja
- National Institute for Medical Research, Tanga Centre, Tanga, Tanzania
| | - George Mtove
- National Institute for Medical Research, Tanga Centre, Tanga, Tanzania
| | - Reginald A Kavishe
- Kilimanjaro Clinical Research Institute and Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - James Dodd
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Queen Saidi
- Kilimanjaro Clinical Research Institute and Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Eric D Onyango
- Kenya Medical Research Institute, Centre for Global Health Research, Kisumu, Kenya
| | - Kephas Otieno
- Kenya Medical Research Institute, Centre for Global Health Research, Kisumu, Kenya
| | - Duolao Wang
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Ulla Ashorn
- Centre for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Jenny Hill
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Samwel Gesase
- National Institute for Medical Research, Tanga Centre, Tanga, Tanzania
| | - Omari A Msemo
- National Institute for Medical Research, Tanga Centre, Tanga, Tanzania
| | - Victor Mwapasa
- School of Global and Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Kamija S Phiri
- School of Global and Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Kenneth Maleta
- School of Global and Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Nigel Klein
- Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Pascal Magnussen
- Centre for Medical Parasitology, Department of Immunology and Microbiology, University of Copenhagen and Department of Infectious Diseases, Copenhagen University Hospital, Copenhagen, Denmark
| | - John P A Lusingu
- National Institute for Medical Research, Tanga Centre, Tanga, Tanzania
| | - Simon Kariuki
- School of Global and Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Jacklin F Mosha
- Kilimanjaro Clinical Research Institute and Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Michael Alifrangis
- Centre for Medical Parasitology, Department of Immunology and Microbiology, University of Copenhagen and Department of Infectious Diseases, Copenhagen University Hospital, Copenhagen, Denmark
| | - Helle Hansson
- Centre for Medical Parasitology, Department of Immunology and Microbiology, University of Copenhagen and Department of Infectious Diseases, Copenhagen University Hospital, Copenhagen, Denmark
| | - Christentze Schmiegelow
- Centre for Medical Parasitology, Department of Immunology and Microbiology, University of Copenhagen and Department of Infectious Diseases, Copenhagen University Hospital, Copenhagen, Denmark
| | - Julie R Gutman
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - R Matthew Chico
- Department of Disease Control, London School of Hygiene & Tropical Medicine, London, UK
| | - Feiko O Ter Kuile
- Kenya Medical Research Institute, Centre for Global Health Research, Kisumu, Kenya; Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK.
| |
Collapse
|
4
|
Chaponda EB, Bruce J, Michelo C, Chandramohan D, Chico RM. Assessment of syndromic management of curable sexually transmitted and reproductive tract infections among pregnant women: an observational cross-sectional study. BMC Pregnancy Childbirth 2021; 21:98. [PMID: 33516183 PMCID: PMC7847014 DOI: 10.1186/s12884-021-03573-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 01/19/2021] [Indexed: 01/22/2023] Open
Abstract
Background This study estimated the prevalence of curable sexually transmitted and reproductive tract infections (STIs/RTIs) among pregnant women attending antenatal care (ANC) in rural Zambia, evaluated the effectiveness of syndromic management of STIs/RTIs versus reference-standard laboratory diagnoses, and identified determinants of curable STIs/RTIs during pregnancy. Methods A total of 1086 pregnant women were enrolled at ANC booking, socio-demographic information and biological samples were collected, and the provision of syndromic management based care was documented. The Piot-Fransen model was used to evaluate the effectiveness of syndromic management versus etiological testing, and univariate and multivariate logistic regression analyses were used to identify determinants of STIs/RTIs. Results Participants had a mean age of 25.6 years and a mean gestational age of 22.0 weeks. Of 1084 women, 700 had at least one STI/RTI (64.6%; 95% confidence interval [CI], 61.7, 67.4). Only 10.2% of infected women received any treatment for a curable STI/RTI (excluding syphilis). Treatment was given to 0 of 56 women with chlamydia (prevalence 5.2%; 95% CI, 4.0, 6.6), 14.7% of participants with gonorrhoea (prevalence 3.1%; 95% CI, 2.2, 4.4), 7.8% of trichomoniasis positives (prevalence 24.8%; 95% CI, 22.3, 27.5) and 7.5% of women with bacterial vaginosis (prevalence 48.7%; 95% CI, 45.2, 51.2). An estimated 7.1% (95% CI, 5.6, 8.7) of participants had syphilis and received treatment. Women < 20 years old were more likely (adjusted odds ratio [aOR] = 5.01; 95% CI: 1.23, 19.44) to have gonorrhoea compared to women ≥30. The odds of trichomoniasis infection were highest among primigravidae (aOR = 2.40; 95% CI: 1.69, 3.40), decreasing with each subsequent pregnancy. Women 20 to 29 years old were more likely to be diagnosed with bacterial vaginosis compared to women ≥30 (aOR = 1.58; 95% CI: 1.19, 2.10). Women aged 20 to 29 and ≥ 30 years had higher odds of infection with syphilis, aOR = 3.96; 95% CI: 1.40, 11.20 and aOR = 3.29; 95% CI: 1.11, 9.74 respectively, compared to women under 20. Conclusions Curable STIs/RTIs were common and the majority of cases were undetected and untreated. Alternative approaches are urgently needed in the ANC setting in rural Zambia. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-021-03573-3.
Collapse
Affiliation(s)
| | - Jane Bruce
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Charles Michelo
- Department of Epidemiology, School of Public Health, University of Zambia, Lusaka, Zambia.,Strategic Centre for Health Systems Metrics and Evaluations, School of Public Health, University of Zambia, Lusaka, Zambia
| | - Daniel Chandramohan
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - R Matthew Chico
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| |
Collapse
|
5
|
Akinyotu O, Bello F, Abdus-Salam R, Arowojolu A. A randomized controlled trial of azithromycin and sulphadoxine-pyrimethamine as prophylaxis against malaria in pregnancy among human immunodeficiency virus-positive women. Trans R Soc Trop Med Hyg 2020; 113:463-470. [PMID: 31140565 DOI: 10.1093/trstmh/trz028] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 02/14/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Malaria and human immunodeficiency virus (HIV) infections in pregnancy are important and major contributing factors to maternal morbidity and mortality in sub-Saharan Africa. Prevention of malaria in HIV-positive pregnant woman will reduce the burden of malaria-HIV comorbidity. The objective of this study was to compare effects and safety of azithromycin (AZ) with sulphadoxine-pyrimethamine (SP) for intermittent preventive therapy for malaria in HIV-positive pregnant women. METHODS We performed a randomized, controlled, open-label pregnancy trial of 140 HIV-positive pregnant patients attending antenatal clinics at the University College Hospital and Adeoyo Maternity Teaching Hospital, Ibadan, Nigeria. Participants were enrolled from a gestational age of 16 weeks and randomized to receive AZ or SP. The primary outcome was peripheral parasitaemia at delivery. Secondary outcomes were drug tolerability, foetal outcome and birthweight. The χ2 test (or Fisher's exact test, as appropriate) and Student's t test were used in the per-protocol analysis. The level of statistical significance was p<0.05. RESULTS A total of 123 participants (87.9%) completed the study: 60 participants received AZ and 63 received SP. The incidence of malaria parasitaemia at delivery in the AZ group was 6 (10.0%), compared with 7 (11.1%) in the SP group (relative risk 0.89 [95% confidence interval 0.28 to 2.82], p=0.84). Placental parasitization was demonstrated in 1 (1.6%) participant in the SP group compared with 3 (5.0%) in the AZ group (p=0.36). CONCLUSIONS The findings suggest that AZ is comparable to SP in malaria prevention and safety in HIV-positive pregnant women.
Collapse
Affiliation(s)
- Oriyomi Akinyotu
- Department of Obstetrics and Gynaecology, University College Hospital, Ibadan, Oyo State, Nigeria
| | - Folasade Bello
- Department of Obstetrics and Gynaecology, College of Medicine, University of Ibadan, Ibadan, Oyo State, Nigeria
| | - Rukiyat Abdus-Salam
- Department of Obstetrics and Gynaecology, College of Medicine, University of Ibadan, Ibadan, Oyo State, Nigeria.,Adeoyo Maternity Teaching Hospital, Yemetu, Ibadan, Oyo State, Nigeria
| | - Ayodele Arowojolu
- Department of Obstetrics and Gynaecology, College of Medicine, University of Ibadan, Ibadan, Oyo State, Nigeria
| |
Collapse
|
6
|
Gadoth A, Shannon CL, Hoff NA, Mvumbi G, Musene K, Okitolonda-Wemakoy E, Hoffman RM, Rimoin AW, Klausner JD. Prenatal chlamydial, gonococcal, and trichomonal screening in the Democratic Republic of Congo for case detection and management. Int J STD AIDS 2020; 31:221-229. [PMID: 31996095 DOI: 10.1177/0956462419888315] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Prenatal Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG), and Trichomonas vaginalis (TV) infections are associated with adverse birth outcomes. As rapid diagnostic tests become available, it is important to evaluate prenatal sexually transmitted infection (STI) prevalence, as well as the acceptability and feasibility of prenatal screening programs. We recruited 371 pregnant women from four clinics in Kisantu Health Zone, Democratic Republic of Congo (DRC) from October 2016 to March 2017. Trained clinicians collected cervical swabs, and samples were tested by nucleic acid amplification for CT, NG, and TV using a GeneXpert® system. Those testing positive for an STI were treated and asked to return after 4–8 weeks for tests-of-cure. Screening for STIs was widely accepted (99%). STI prevalence at baseline was CT, 3.2%; NG, 1.5%; and TV, 14%; treatment completion was 97%. Symptoms were reported among 34% of STI-positive women at baseline, compared with 37% of STI-negative women. Upon first test-of-cure, 100% of returning women were cured of CT ( n = 10) and NG ( n = 5), but only 47% were cured of TV. This study demonstrates the feasibility of implementing diagnostic STI testing for case detection and treatment among expectant mothers in DRC, with implications for maternal and birth outcomes.
Collapse
Affiliation(s)
- Adva Gadoth
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, CA, USA
| | - Chelsea L Shannon
- Division of Infectious Diseases, Department of Medicine, University of California, Los Angeles, CA, USA
| | - Nicole A Hoff
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, CA, USA
| | - Gisèle Mvumbi
- Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo
| | - Kamy Musene
- Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo
| | | | - Risa M Hoffman
- Division of Infectious Diseases, Department of Medicine, University of California, Los Angeles, CA, USA
| | - Anne W Rimoin
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, CA, USA
| | - Jeffrey D Klausner
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, CA, USA.,Division of Infectious Diseases, Department of Medicine, University of California, Los Angeles, CA, USA
| |
Collapse
|
7
|
Unger HW, Hansa AP, Buffet C, Hasang W, Teo A, Randall L, Ome-Kaius M, Karl S, Anuan AA, Beeson JG, Mueller I, Stock SJ, Rogerson SJ. Sulphadoxine-pyrimethamine plus azithromycin may improve birth outcomes through impacts on inflammation and placental angiogenesis independent of malarial infection. Sci Rep 2019; 9:2260. [PMID: 30783215 PMCID: PMC6381158 DOI: 10.1038/s41598-019-38821-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 01/10/2019] [Indexed: 12/23/2022] Open
Abstract
Intermittent preventive treatment with sulphadoxine-pyrimethamine (SP) and SP plus azithromycin (SPAZ) reduces low birthweight (<2,500 g) in women without malarial and reproductive tract infections. This study investigates the impact of SPAZ on associations between plasma biomarkers of inflammation and angiogenesis and adverse pregnancy outcomes in 2,012 Papua New Guinean women. Concentrations of C-reactive protein (CRP), α-1-acid glycoprotein (AGP), soluble endoglin (sEng), soluble fms-like tyrosine kinase-1 (sFlt-1) and placental growth factor (PlGF) were measured at enrolment and delivery in a trial comparing SPAZ to SP plus chloroquine (SPCQ). At antenatal enrolment higher CRP (adjusted odds ratio 1.52; 95% confidence interval [CI] 1.03–2.25), sEng (4.35; 1.77, 10.7) and sFlt1 (2.21; 1.09, 4.48) were associated with preterm birth, and higher sEng with low birthweight (1.39; 1.11,3.37), in SPCQ recipients only. Increased enrolment sFlt1:PlGF ratios associated with LBW in all women (1.46; 1.11, 1.90). At delivery, higher AGP levels were strongly associated with low birthweight, preterm birth and small-for-gestational age babies in the SPCQ arm only. Restricting analyses to women without malaria infection did not materially alter these relationships. Women receiving SPAZ had lower delivery AGP and CRP levels (p < 0.001). SPAZ may protect against adverse pregnancy outcomes by reducing inflammation and preventing its deleterious consequences, including dysregulation of placental angiogenesis, in women with and without malarial infection.
Collapse
Affiliation(s)
- Holger W Unger
- Department of Medicine at the Doherty Institute, University of Melbourne, Parkville, Victoria, Australia.
| | - Annjaleen P Hansa
- Department of Medicine at the Doherty Institute, University of Melbourne, Parkville, Victoria, Australia.,Central Clinical School and Department of Microbiology, Monash University, Victoria, Australia
| | - Christelle Buffet
- Department of Medicine at the Doherty Institute, University of Melbourne, Parkville, Victoria, Australia
| | - Wina Hasang
- Department of Medicine at the Doherty Institute, University of Melbourne, Parkville, Victoria, Australia
| | - Andrew Teo
- Department of Medicine at the Doherty Institute, University of Melbourne, Parkville, Victoria, Australia
| | - Louise Randall
- Department of Medicine at the Doherty Institute, University of Melbourne, Parkville, Victoria, Australia
| | - Maria Ome-Kaius
- Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea.,Walter and Eliza Hall Institute, Parkville, Victoria, Australia.,Department of Medical Biology, University of Melbourne, Parkville, Victoria, Australia
| | - Stephan Karl
- Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea.,Walter and Eliza Hall Institute, Parkville, Victoria, Australia.,Department of Medical Biology, University of Melbourne, Parkville, Victoria, Australia.,Australian Institute of Tropical Health and Medicine, James Cook University, Cairns, Australia
| | - Ayen A Anuan
- Department of Medicine at the Doherty Institute, University of Melbourne, Parkville, Victoria, Australia
| | - James G Beeson
- Department of Medicine at the Doherty Institute, University of Melbourne, Parkville, Victoria, Australia.,Central Clinical School and Department of Microbiology, Monash University, Victoria, Australia.,Burnet Institute, Melbourne, Victoria, Australia
| | - Ivo Mueller
- Walter and Eliza Hall Institute, Parkville, Victoria, Australia.,Department of Medical Biology, University of Melbourne, Parkville, Victoria, Australia.,Institut Pasteur, Paris, France
| | - Sarah J Stock
- Tommy's Centre for Maternal and Fetal Health, MRC Centre for Reproductive Health, Queen's Medical Research Institute, Edinburgh, UK
| | - Stephen J Rogerson
- Department of Medicine at the Doherty Institute, University of Melbourne, Parkville, Victoria, Australia
| |
Collapse
|
8
|
Chico RM, Chaponda EB, Ariti C, Chandramohan D. Sulfadoxine-Pyrimethamine Exhibits Dose-Response Protection Against Adverse Birth Outcomes Related to Malaria and Sexually Transmitted and Reproductive Tract Infections. Clin Infect Dis 2017; 64:1043-1051. [PMID: 28329383 PMCID: PMC5399940 DOI: 10.1093/cid/cix026] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2016] [Accepted: 01/11/2017] [Indexed: 11/29/2022] Open
Abstract
Background. We conducted a prospective cohort study in Zambia among pregnant women who received intermittent preventive treatment using sulfadoxine-pyrimethamine (IPTp-SP). Methods. We calculated the odds ratios (ORs) of adverse birth outcomes by IPTp-SP exposure, 0–1 dose (n = 126) vs ≥2 doses (n = 590) and ≥2 doses (n = 310) vs ≥3 doses (n = 280) in 7 categories of malaria infection and sexually transmitted and reproductive tract infections (STIs/RTIs). Results. We found no significant differences in baseline prevalence of infection across IPTp-SP exposure groups. However, among women given 2 doses compared to 0–1 dose, the odds of any adverse birth outcome were reduced 45% (OR, 0.55; 95% confidence interval [CI], 0.36, 0.86) and 13% further with ≥3 doses (OR, 0.43; 95% CI, 0.27, 0.68). Two or more doses compared to 0–1 dose reduced preterm delivery by 58% (OR, 0.42; 95% CI, 0.27, 0.67) and 21% further with ≥3 doses (OR, 0.21; 95% CI, 0.13, 0.35). Women with malaria at enrollment who received ≥2 doses vs 0-1 had 76% lower odds of any adverse birth outcome (OR, 0.24; 95% 0.09, 0.66), and Neisseria gonorrhoeae and/or Chlamydia trachomatis had 92% lower odds of any adverse birth outcome (OR, 0.08; 95% CI, 0.01, 0.64). Women with neither a malaria infection nor STIs/RTIs who received ≥2 doses had 73% fewer adverse birth outcomes (OR, 0.27; 95% CI, 0.11, 0.68). Conclusions. IPTp-SP appears to protect against malaria, STIs/RTIs, and other unspecified causes of adverse birth outcome.
Collapse
Affiliation(s)
- R Matthew Chico
- Department of Disease Control, London School of Hygiene & Tropical Medicine, United Kingdom
| | - Enesia Banda Chaponda
- Department of Disease Control, London School of Hygiene & Tropical Medicine, United Kingdom.,Department of Biological Sciences, University of Zambia, Lusaka, Zambia
| | - Cono Ariti
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, United Kingdom
| | - Daniel Chandramohan
- Department of Disease Control, London School of Hygiene & Tropical Medicine, United Kingdom
| |
Collapse
|
9
|
Rogerson SJ, Unger HW. Prevention and control of malaria in pregnancy - new threats, new opportunities? Expert Rev Anti Infect Ther 2016; 15:361-375. [PMID: 27973923 DOI: 10.1080/14787210.2017.1272411] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Over 100 million women and their babies are at risk of malaria in pregnancy each year. Malaria prevention in pregnancy relies on long-lasting insecticidal nets (LLINs), and, in Africa, intermittent preventive treatment in pregnancy (IPTp). Increasing resistance of malaria parasites to sulfadoxine-pyrimethamine, the only drug endorsed for IPTp, and increasing mosquito resistance to pyrethroids used in LLINs, threaten the efficacy of these proven strategies, while operational challenges restrict their implementation in areas of great need. Areas Covered: This review summarizes strategies for malaria prevention in pregnancy (both currently used and those undergoing preclinical and clinical evaluation), primarily drawing on publications and study protocols from the last decade. Challenges associated with each strategy are discussed, including the particular problem of HIV and malaria in pregnancy, and areas of further research are highlighted. Expert Commentary: Alternative drugs for IPTp are needed. Dihydroartemisinin-piperaquine is particularly promising, but requires further evaluation, and might contribute to artemisinin resistance. Intermittent screening and treatment in pregnancy (ISTp) is an alternative to IPTp that could reduce unnecessary antenatal drug exposure and resistance risk, but it is not recommended with current, insensitive screening tests. Optimal strategies for areas of low or declining malaria transmission remain to be determined.
Collapse
Affiliation(s)
- Stephen J Rogerson
- a Department of Medicine at the Doherty Institute , University of Melbourne , Melbourne , Australia
| | - Holger W Unger
- a Department of Medicine at the Doherty Institute , University of Melbourne , Melbourne , Australia.,b Department of Obstetrics and Gynaecology , Royal Infirmary of Edinburgh , Edinburgh , UK
| |
Collapse
|
10
|
Chaponda EB, Chico RM, Bruce J, Michelo C, Vwalika B, Mharakurwa S, Chaponda M, Chipeta J, Chandramohan D. Malarial Infection and Curable Sexually Transmitted and Reproductive Tract Infections Among Pregnant Women in a Rural District of Zambia. Am J Trop Med Hyg 2016; 95:1069-1076. [PMID: 27672205 DOI: 10.4269/ajtmh.16-0370] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Accepted: 08/09/2016] [Indexed: 11/07/2022] Open
Abstract
Malarial infection and curable sexually transmitted and reproductive tract infections (STIs/RTIs) are important causes of adverse birth outcomes. Reducing the burden of these infections in pregnancy requires interventions that can be easily integrated into the antenatal care (ANC) package. However, efforts to integrate the control of malarial infection and curable STIs/RTIs in pregnancy have been hampered by a lack of evidence related to their coinfection. Thus, we investigated the prevalence of coinfection among pregnant women of rural Zambia. A prospective cohort study was conducted in Nchelenge District, Zambia, involving 1,086 first ANC attendees. We screened participants for peripheral malarial infection and curable STIs/RTIs (syphilis, Chlamydia, gonorrhea, trichomoniasis, and bacterial vaginosis), and collected relevant sociodemographic data at booking. Factors associated with malarial and STI/RTI coinfection were explored using univariate and multivariate regression models. Among participants with complete results (N = 1,071), 38.7% (95% confidence interval [CI] = 35.7-41.6) were coinfected with malaria parasites and at least one STI/RTI; 18.9% (95% CI = 16.5-21.2) were infected with malaria parasites only; 26.0% (95% CI = 23.5-28.8) were infected with at least one STI/RTI but no malaria parasites, and 16.4% (95% CI = 14.1-18.6) had no infection. Human immunodeficiency virus (HIV)-infected women had a higher risk of being coinfected than HIV-uninfected women (odds ratio [OR] = 3.59 [95% CI = 1.73-7.48], P < 0.001). The prevalence of malarial and STI/RTI coinfection was high in this population. An integrated approach to control malarial infection and STIs/RTIs is needed to reduce this dual burden in pregnancy.
Collapse
Affiliation(s)
- Enesia Banda Chaponda
- Department of Biological Sciences, University of Zambia, Lusaka, Zambia. .,Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - R Matthew Chico
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Jane Bruce
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Charles Michelo
- Department of Public Health, University of Zambia School of Medicine, Lusaka, Zambia
| | - Bellington Vwalika
- Department of Obstetrics and Gynaecology, University of Zambia School of Medicine, Lusaka, Zambia
| | - Sungano Mharakurwa
- Faculty of Health Sciences, Africa University, Mutare, Zimbabwe.,Department of Medical Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Mike Chaponda
- Department of Clinical Sciences, Tropical Diseases Research Centre, Ndola, Zambia
| | - James Chipeta
- Department of Paediatrics and Child Health, University of Zambia School of Medicine, Lusaka, Zambia
| | - Daniel Chandramohan
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| |
Collapse
|
11
|
High Resistance to Azithromycin in Clinical Samples from Patients with Sexually Transmitted Diseases in Guangxi Zhuang Autonomous Region, China. PLoS One 2016; 11:e0159787. [PMID: 27467164 PMCID: PMC4965067 DOI: 10.1371/journal.pone.0159787] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Accepted: 07/08/2016] [Indexed: 11/30/2022] Open
Abstract
Azithromycin is used as an alternative medicine in patients with syphilis who are intolerant to penicillin. Nevertheless, the report of treatment failure of azithromycin for patients with syphilis has raised concerns in China in the past years. In this study, 178 patients with early syphilis, who were treated in sexually transmitted infections clinics in four cities in Guangxi Zhuang Autonomous Region were enrolled to investigate the regional prevalence of Treponema pallidum strain resistant to azithromycin. Nested PCR was performed to amplify the 23S ribosomal RNA (23SrRNA) gene. The point mutation of A2058G in 23SrRNA, which confers Treponema pallidum resistance to azithromycin, was measured by endonuclease digestion of PCR amplification products using MboII. A2058G point mutation was detected in 91.0% (162/178; 95% CI, 86.8%, 95.2%) of the specimens, but no difference in prevalence of azithromycin resistance was found between the patients who had taken antibiotics before enrollment and the patients who had not (91.8% vs. 89.4%), nor between the patients with and without past sexually transmitted infections (87.1% vs. 93.1%). We concluded that azithromycin may not be suitable for syphilis as a treatment option in Guangxi Zhuang Autonomous Region because of the extremely high prevalence of resistance in the general syphilis population.
Collapse
|
12
|
van der Eem L, Dubbink JH, Struthers HE, McIntyre JA, Ouburg S, Morré SA, Kock MM, Peters RPH. Evaluation of syndromic management guidelines for treatment of sexually transmitted infections in South African women. Trop Med Int Health 2016; 21:1138-46. [PMID: 27350659 DOI: 10.1111/tmi.12742] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To evaluate the performance of three different guidelines for the management of vaginal discharge syndrome (VDS) for women living in a rural setting in South Africa. METHODS We conducted a secondary analysis of data from a cross-sectional study in Mopani District, South Africa. The 2015 and 2008 guidelines of the South African Department of Health (DoH) and the most recent WHO guidelines were evaluated for adequate treatment of Chlamydia trachomatis, Neisseria gonorrhoeae, Mycoplasma genitalium and Trichomonas vaginalis infection. RESULTS Of the 489 women included in this analysis, 35% presented with VDS according to the DoH and 30% per WHO definition of VDS. Fifty-six per cent of the women with VDS would be treated adequately for these STI when using the 2015 DoH guideline, whereas 76% (P = 0.01) and 64% (P = 0.35) would receive adequate treatment with the 2008 DoH and WHO guidelines, respectively. Of the symptomatic women who tested negative for all four STI, STI treatment would have been indicated for 36% as per 2015 DoH guideline vs. 69% (P < 0.001) per 2008 DoH and 67% (P < 0.001) per WHO guidelines. CONCLUSION A considerable proportion of symptomatic women infected with these common curable STI would receive adequate treatment when using a syndromic management approach, and significant differences exist between the three guidelines. Many symptomatic women without these STI receive broad-spectrum antibiotics, so new approaches are needed to improve syndromic STI control.
Collapse
Affiliation(s)
- Lisette van der Eem
- Anova Health Institute, Johannesburg and Tzaneen, South Africa.,African Woman Foundation, Amsterdam, The Netherlands
| | - Jan Henk Dubbink
- Anova Health Institute, Johannesburg and Tzaneen, South Africa.,Institute for Public Health Genomics, University of Maastricht, Maastricht, The Netherlands.,Department of Medical Microbiology & Infection Control, VU University Medical Centre, Amsterdam, The Netherlands
| | - Helen E Struthers
- Anova Health Institute, Johannesburg and Tzaneen, South Africa.,Department of Internal Medicine, University of Cape Town, Cape Town, South Africa
| | - James A McIntyre
- Anova Health Institute, Johannesburg and Tzaneen, South Africa.,School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Sander Ouburg
- Department of Medical Microbiology & Infection Control, VU University Medical Centre, Amsterdam, The Netherlands
| | - Servaas A Morré
- Institute for Public Health Genomics, University of Maastricht, Maastricht, The Netherlands.,Department of Medical Microbiology & Infection Control, VU University Medical Centre, Amsterdam, The Netherlands
| | - Marleen M Kock
- Department of Medical Microbiology, University of Pretoria, Pretoria, South Africa.,Tshwane Academic Division, National Health Laboratory Service, Pretoria, South Africa
| | - Remco P H Peters
- Anova Health Institute, Johannesburg and Tzaneen, South Africa.,Department of Medical Microbiology, University of Pretoria, Pretoria, South Africa
| |
Collapse
|
13
|
Dey SK, Das AK, Sen S, Hazra A. Comparative evaluation of 2 g single dose versus conventional dose azithromycin in uncomplicated skin and skin structure infections. Indian J Pharmacol 2016; 47:365-9. [PMID: 26288467 PMCID: PMC4527055 DOI: 10.4103/0253-7613.161254] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2015] [Revised: 06/02/2015] [Accepted: 06/25/2015] [Indexed: 11/23/2022] Open
Abstract
Objectives: Uncomplicated skin and skin structure infections (uSSSIs) are a common clinical problem. Majority are caused by staphylococci and streptococci. Different oral antibiotics are used for uSSSI, with comparable efficacy but varying treatment duration, cost, and adverse event profile. Azithromycin is used in uSSSI in adults conventionally in a dose of 500 mg once for 5 days. The extensive tissue distribution of the drug and its long elimination half-life prompted us to explore whether a single 2 g dose of the drug would produce a response in uSSSI comparable to conventional dosing. Materials and Methods: We conducted a parallel group, open-label, randomized, controlled trial (CTRI/2015/07/005969) with subjects of either sex, ≥12 years of age, presenting with uSSSI to the dermatology outpatient department. One group (n = 146) received 2 g single supervised dose while the other (n = 146) received conventional dose of 500 mg once daily for 5 days. Subjects were followed up on day 4 and day 8. Complete clinical cure implied complete healing of lesions, without residual signs or symptoms, within 7 days. Results: High cure rate was observed in both arms (97.97% and 98.63%, respectively) along with noticeable improvement in symptom profile from baseline but without statistically significant difference between groups. However, excellent adherence (defined as no tablets missed) was better in single dosing arm (98.65% vs. 86.30%). Tolerability was also comparable between groups with the majority of adverse events encountered being gastrointestinal in nature and mild. Conclusions: Single 2 g azithromycin dose achieved the same result as conventional azithromycin dosing in uSSSI with comparable tolerability but with the advantage of assured adherence. This dose can, therefore, be recommended as an alternative and administration supervised if feasible.
Collapse
Affiliation(s)
- Sudipta Kumar Dey
- Department of Pharmacology, Institute of Postgraduate Medical Education and Research, Kolkata, West Bengal, India
| | - Amal Kanti Das
- Department of Pharmacology, Institute of Postgraduate Medical Education and Research, Kolkata, West Bengal, India
| | - Sumit Sen
- Department of Dermatology, Institute of Postgraduate Medical Education and Research, Kolkata, West Bengal, India
| | - Avijit Hazra
- Department of Pharmacology, Institute of Postgraduate Medical Education and Research, Kolkata, West Bengal, India
| |
Collapse
|
14
|
Pharmacokinetics of Transfer of Azithromycin into the Breast Milk of African Mothers. Antimicrob Agents Chemother 2015; 60:1592-9. [PMID: 26711756 DOI: 10.1128/aac.02668-15] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Accepted: 12/13/2015] [Indexed: 01/26/2023] Open
Abstract
Azithromycin (AZI) is used for its antibiotic and antimalarial properties in pregnancy. Reported estimates of AZI breast milk transfer, based on concentrations in mostly single samples from small numbers of women, have suggested that infant intake is safe. To better characterize infant intake and the associated potential benefits and risks, AZI was measured by liquid chromatography-mass spectrometry in four breast milk samples taken over 28 days postpartum from each of 20 Gambian women given 2 g AZI during labor. A population pharmacokinetic model utilizing published parameters for AZI disposition in pregnancy, the present breast milk concentrations, and increasing/decreasing sigmoid maximum-effect (Emax) functions adequately described temporal changes in the milk/plasma ratio. The median estimated absolute and relative cumulative infant doses were 4.5 mg/kg of body weight (95% prediction interval, 0.6 to 7.0 mg/kg) and 15.7% (95% prediction interval, 2.0 to 27.8%) of the maternal dose, respectively; the latter exceeded the recommended 10% safety limit. Although some infants with bacterial infections may benefit from AZI in breast milk, there is a risk of hypertrophic pyloric stenosis with a worst-case number needed to harm of 60 based on the present and available epidemiologic data. (This study has been registered at ClinicalTrials.gov under registration no. NCT01800942.).
Collapse
|
15
|
Desai M, Gutman J, L'lanziva A, Otieno K, Juma E, Kariuki S, Ouma P, Were V, Laserson K, Katana A, Williamson J, ter Kuile FO. Intermittent screening and treatment or intermittent preventive treatment with dihydroartemisinin-piperaquine versus intermittent preventive treatment with sulfadoxine-pyrimethamine for the control of malaria during pregnancy in western Kenya: an open-label, three-group, randomised controlled superiority trial. Lancet 2015; 386:2507-19. [PMID: 26429700 PMCID: PMC4718402 DOI: 10.1016/s0140-6736(15)00310-4] [Citation(s) in RCA: 147] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Every year, more than 32 million pregnancies in sub-Saharan Africa are at risk of malaria infection and its adverse consequences. The effectiveness of the intermittent preventive treatment with sulfadoxine-pyrimethamine strategy recommended by WHO is threatened by high levels of parasite resistance. We aimed to assess the efficacy and safety of two alternative strategies: intermittent screening with malaria rapid diagnostic tests and treatment of women who test positive with dihydroartemisinin-piperaquine, and intermittent preventive treatment with dihydroartemisinin-piperaquine. METHODS We did this open-label, three-group, randomised controlled superiority trial at four sites in western Kenya with high malaria transmission and sulfadoxine-pyrimethamine resistance. HIV-negative pregnant women between 16 and 32 weeks' gestation were randomly assigned (1:1:1), via computer-generated permuted-block randomisation (block sizes of three, six, and nine), to receive intermittent screening and treatment with dihydroartemisinin-piperaquine, intermittent preventive treatment with dihydroartemisinin-piperaquine, or intermittent preventive treatment with sulfadoxine-pyrimethamine. Study participants, study clinic nurses, and the study coordinator were aware of treatment allocation, but allocation was concealed from study investigators, delivery unit nurses, and laboratory staff. The primary outcome was malaria infection at delivery, defined as a composite of peripheral or placental parasitaemia detected by placental histology, microscopy, or rapid diagnostic test. The primary analysis was by modified intention to treat. This study is registered with ClinicalTrials.gov, number NCT01669941. FINDINGS Between Aug 21, 2012, and June 19, 2014, we randomly assigned 1546 women to receive intermittent screening and treatment with dihydroartemisinin-piperaquine (n=515), intermittent preventive treatment with dihydroartemisinin-piperaquine (n=516), or intermittent preventive treatment with sulfadoxine-pyrimethamine (n=515); 1368 (88%) women comprised the intention-to-treat population for the primary endpoint. Prevalence of malaria infection at delivery was lower in the intermittent preventive treatment with dihydroartemisinin-piperaquine group than in the intermittent preventive treatment with sulfadoxine-pyrimethamine group (15 [3%] of 457 women vs 47 [10%] of 459 women; relative risk 0·32, 95% CI 0·18-0·56; p<0·0001), but not in the intermittent screening and treatment with dihydroartemisinin-piperaquine group (57 [13%] of 452 women; 1·23, 0·86-1·77; p=0·26). Compared with intermittent preventive treatment with sulfadoxine-pyrimethamine, intermittent preventive treatment with dihydroartemisinin-piperaquine was associated with a lower incidence of malaria infection during pregnancy (192·0 vs 54·4 events per 100 person-years; incidence rate ratio [IRR] 0·28, 95% CI 0·22-0·36; p<0·0001) and clinical malaria during pregnancy (37·9 vs 6·1 events; 0·16, 0·08-0·33; p<0·0001), whereas intermittent screening and treatment with dihydroartemisinin-piperaquine was associated with a higher incidence of malaria infection (232·0 events; 1·21, 1·03-1·41; p=0·0177) and clinical malaria (53·4 events; 1·41, 1·00-1·98; p=0·0475). We recorded 303 maternal and infant serious adverse events, which were least frequent in the intermittent preventive treatment with dihydroartemisinin-piperaquine group. INTERPRETATION At current levels of rapid diagnostic test sensitivity, intermittent screening and treatment is not a suitable alternative to intermittent preventive treatment with sulfadoxine-pyrimethamine in the context of high sulfadoxine-pyrimethamine resistance and malaria transmission. However, dihydroartemisinin-piperaquine is a promising alternative drug to replace sulfadoxine-pyrimethamine for intermittent preventive treatment. Future studies should investigate the efficacy, safety, operational feasibility, and cost-effectiveness of intermittent preventive treatment with dihydroartemisinin-piperaquine. FUNDING The Malaria in Pregnancy Consortium, which is funded through a grant from the Bill & Melinda Gates Foundation to the Liverpool School of Tropical Medicine.
Collapse
Affiliation(s)
- Meghna Desai
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA; Centers for Disease Control and Prevention (CDC), Kisumu, Kenya.
| | - Julie Gutman
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Anne L'lanziva
- Centers for Disease Control and Prevention (CDC), Kisumu, Kenya
| | - Kephas Otieno
- Kenya Medical Research Institute, Centre for Global Health Research, Kisumu, Kenya
| | - Elizabeth Juma
- Kenya Medical Research Institute, Centre for Global Health Research, Kisumu, Kenya
| | - Simon Kariuki
- Kenya Medical Research Institute, Centre for Global Health Research, Kisumu, Kenya
| | - Peter Ouma
- Kenya Medical Research Institute, Centre for Global Health Research, Kisumu, Kenya
| | - Vincent Were
- Kenya Medical Research Institute, Centre for Global Health Research, Kisumu, Kenya
| | - Kayla Laserson
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - John Williamson
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | |
Collapse
|
16
|
Affiliation(s)
- R Matthew Chico
- London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK.
| | - William J Moss
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| |
Collapse
|
17
|
Lanjouw E, Ouburg S, de Vries HJ, Stary A, Radcliffe K, Unemo M. Background review for the '2015 European guideline on the management of Chlamydia trachomatis infections'. Int J STD AIDS 2015:0956462415618838. [PMID: 26608578 DOI: 10.1177/0956462415618838] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
SummaryChlamydia trachomatis infections are major public health concerns globally. Of particular grave concern is that the majority of persons with anogenital Chlamydia trachomatis infections are asymptomatic and accordingly not aware of their infection, and this silent infection can subsequently result in severe reproductive tract complications and sequelae. The current review paper provides all background, evidence base and discussions for the 2015 European guideline on the management of Chlamydia trachomatis infections (Lanjouw E, et al. Int J STD AIDS 2015). Comprehensive information and recommendations are included regarding the diagnosis, treatment and prevention of anogenital, pharyngeal and conjunctival Chlamydia trachomatis infections in European countries. However, Chlamydia trachomatis also causes the eye infection trachoma, which is not a sexually transmitted infection. The 2015 European Chlamydia trachomatis guideline provides up-to-date guidance regarding broader indications for testing and treatment of Chlamydia trachomatis infections; clearer recommendation of using validated nucleic acid amplification tests only for diagnosis; advice on (repeated) Chlamydia trachomatis testing; recommendation of increased testing to reduce the incidence of pelvic inflammatory disease and prevent exposure to infection and recommendations to identify, verify and report Chlamydia trachomatis variants. Improvement of access to testing, test performance, diagnostics, antimicrobial treatment and follow-up of Chlamydia trachomatis patients are crucial to control its spread.
Collapse
Affiliation(s)
- E Lanjouw
- Department of Dermatology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - S Ouburg
- Laboratory of Immunogenetics, Department of Medical Microbiology and Infection Control, VU University Medical Center, Amsterdam, The Netherlands
| | - H J de Vries
- Department of Dermatology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands STI Outpatient Clinic, Infectious Disease Cluster, Health Service Amsterdam, Amsterdam, The Netherlands Center for Infection and Immunology Amsterdam (CINIMA), Academic Medical Center (AMC), University of Amsterdam, Amsterdam, The Netherlands
| | - A Stary
- Outpatients' Centre for Infectious Venereodermatological Diseases, Vienna, Austria
| | - K Radcliffe
- University Hospital Birmingham Foundation NHS Trust, Birmingham, UK
| | - M Unemo
- WHO Collaborating Center for Gonorrhoea and other Sexually Transmitted Infections, National Reference Laboratory for Pathogenic Neisseria, Department of Laboratory Medicine, Microbiology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| |
Collapse
|
18
|
Roca A, Oluwalana C, Camara B, Bojang A, Burr S, Davis TME, Bailey R, Kampmann B, Mueller J, Bottomley C, D'Alessandro U. Prevention of bacterial infections in the newborn by pre-delivery administration of azithromycin: Study protocol of a randomized efficacy trial. BMC Pregnancy Childbirth 2015; 15:302. [PMID: 26585192 PMCID: PMC4653934 DOI: 10.1186/s12884-015-0737-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Accepted: 11/10/2015] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Neonatal deaths, estimated at approximately 4 million annually, now account for almost 40% of global mortality in children aged under-five. Bacterial sepsis is a leading cause of neonatal mortality. Assuming the mother is the main source for bacterial transmission to newborns, the primary objective of the trial is to determine the impact of one oral dose of azithromycin, given to women in labour, on the newborn's bacterial carriage in the nasopharynx. Secondary objectives include the impact of the intervention on bacterial colonization in the baby and the mother during the first month of life. METHODS/DESIGN This is a Phase III, double -blind, placebo controlled randomized clinical trial in which 830 women in labour were randomized to either a single dose of 2 g oral azithromycin or placebo (ratio 1:1). The trial included pregnant women in labour aged 18 to 45 years attending study health centres in the Western Gambia. A post-natal check of the mother and baby was conducted at the health centre by study clinicians before discharge and 8-10 days after delivery. Home follow up visits were conducted daily during the first week and then weekly until week 8 after delivery. Vaginal swabs and breast milk samples were collected from the mothers, and the pathogens Streptococcus pneumoniae, Group B Streptococcus (GBS) and Staphylococcus aureus were isolated from the study samples. For bacterial isolates, susceptibility pattern to azithromycin was determined using disk diffusion and E-test. Eye swabs were collected from newborns with eye discharge during the follow up period, and Chlamydial infection was assessed using molecular methods. DISCUSSION This is a proof-of-concept study to assess the impact of antibiotic preventive treatment of women during labour on bacterial infections in the newborn. If the trial confirms this hypothesis, the next step will be to assess the impact of this intervention on neonatal sepsis. The proposed intervention should be easily implementable in developing countries. TRIAL REGISTRATION ClinicalTrials.gov Identifier--NCT01800942--First received: February 26, 2013.
Collapse
Affiliation(s)
- Anna Roca
- Medical Research Council Unit, Fajara, The Gambia.
- London School of Hygiene and Tropical Medicine, London, United Kingdom.
| | | | - Bully Camara
- Medical Research Council Unit, Fajara, The Gambia.
| | | | - Sarah Burr
- London School of Hygiene and Tropical Medicine, London, United Kingdom.
| | - Timothy M E Davis
- School of Medicine and Pharmacology, University of Western Australia, Fremantle Hospital, Fremantle, Western Australia, Australia.
| | - Robin Bailey
- London School of Hygiene and Tropical Medicine, London, United Kingdom.
| | | | | | | | - Umberto D'Alessandro
- Medical Research Council Unit, Fajara, The Gambia.
- London School of Hygiene and Tropical Medicine, London, United Kingdom.
| |
Collapse
|
19
|
Chico RM, Cano J, Ariti C, Collier TJ, Chandramohan D, Roper C, Greenwood B. Influence of malaria transmission intensity and the 581G mutation on the efficacy of intermittent preventive treatment in pregnancy: systematic review and meta-analysis. Trop Med Int Health 2015; 20:1621-33. [PMID: 26325263 DOI: 10.1111/tmi.12595] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To estimate where intermittent preventive treatment (IPTp) using sulphadoxine-pyrimethamine (SP) could be withdrawn as an intervention due to declining malaria transmission intensity, or due to increasing prevalence of the Plasmodium falciparum dihydropteroate synthetase resistance mutation at codon 581G. METHODS We conducted a systematic review and meta-analysis of protection against the incidence of low birth weight (LBW) conferred by ≥2 doses of IPTp-SP. We matched these outcomes to a proxy measure of malaria incidence in women of the same studies, applied meta-regression models to these data and conducted sensitivity analysis of the 581G mutation. RESULTS Variation in the protective effect of IPTp-SP against LBW could not be explained by malaria transmission intensity. Among primi- and secundigravidae, IPTp-SP protected against LBW where 581G was ≤10.1% [odds ratio (OR): 0.49; 95% confidence intervals (CI): 0.29, 0.81; P = <0.01] and 581G was >10.1% (OR = 0.73; 95% CI: 0.29, 1.81; P = 0.03). Random-effects models among multigravidae showed that IPTp-SP protects against LBW where 581G was ≤10.1% (OR = 0.56; 95% CI: 0.37, 0.86; P = 0.07), a finding of borderline statistical significance. No evidence of protection against LBW was observed where 581G was >10.1% (OR = 0.96; 95% CI: 0.70, 1.34; P = 0.47). CONCLUSION There appears to be a prevalence of 581G above which IPTp-SP no longer protects against LBW. Pregnancy studies are urgently needed where 581G is >10.1% to define the specific prevalence threshold where new strategies should be deployed.
Collapse
Affiliation(s)
| | - Jorge Cano
- London School of Hygiene & Tropical Medicine, London, UK
| | - Cono Ariti
- London School of Hygiene & Tropical Medicine, London, UK.,Nuffield Trust, London, UK
| | | | | | - Cally Roper
- London School of Hygiene & Tropical Medicine, London, UK
| | | |
Collapse
|
20
|
Unger HW, Wangnapi RA, Ome-Kaius M, Boeuf P, Karl S, Mueller I, Rogerson SJ. Azithromycin-containing intermittent preventive treatment in pregnancy affects gestational weight gain, an important predictor of birthweight in Papua New Guinea - an exploratory analysis. MATERNAL AND CHILD NUTRITION 2015; 12:699-712. [PMID: 26373537 DOI: 10.1111/mcn.12215] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
In Papua New Guinea, intermittent preventive treatment with sulphadoxine-pyrimethamine and azithromycin (SPAZ-IPTp) increased birthweight despite limited impact on malaria and sexually transmitted infections. To explore possible nutrition-related mechanisms, we evaluated associations between gestational weight gain (GWG), enrolment body mass index (BMI) and mid-upper arm circumference (MUAC), and birthweight. We investigated whether the increase in birthweight associated with SPAZ-IPTp may partly be driven by a treatment effect on GWG. The mean GWG rate was 393 g/week (SD 250; n = 948). A 100 g/week increase in GWG was associated with a 14 g (95% CI 2.6, 25.4) increase in birthweight (P = 0.016). Enrolment BMI and MUAC also positively correlated with birthweight. SPAZ-IPTp was associated with increased GWG [58 g/week (26, 900), P < 0.001, n = 948] and with increased birthweight [48 g, 95% CI (8, 880), P = 0.019] when all eligible women were considered (n = 1947). Inclusion of GWG reduced the birthweight coefficient associated with SPAZ-IPTp by 18% from 44 to 36 g (n = 948), although SPAZ-IPTp was not significantly associated with birthweight among women for whom GWG data were available (P = 0.13, n = 948). One month post-partum, fewer women who had received SPAZ-IPTp had a low post-partum BMI (<18.5 kg m(-2) ) [adjusted risk ratio: 0.55 (95% CI 0.36, 0.82), P = 0.004] and their babies had a reduced risk of wasting [risk ratio 0.39 (95% CI 0.21, 0.72), P = 0.003]. SPAZ-IPTp increased GWG, which could explain its impact on birthweight and maternal post-partum BMI. Future trials of SPAZ-IPTp must incorporate detailed anthropometric evaluations to investigate mechanisms of effects on maternal and child health.
Collapse
Affiliation(s)
- Holger W Unger
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia.,Vector Borne Diseases Unit, Papua New Guinea Institute of Medical Research (PNG IMR), Goroka, Papua New Guinea
| | - Regina A Wangnapi
- Vector Borne Diseases Unit, Papua New Guinea Institute of Medical Research (PNG IMR), Goroka, Papua New Guinea
| | - Maria Ome-Kaius
- Vector Borne Diseases Unit, Papua New Guinea Institute of Medical Research (PNG IMR), Goroka, Papua New Guinea
| | - Philippe Boeuf
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia.,Victorian Infectious Diseases Service, Melbourne Health, Melbourne, Victoria, Australia
| | - Stephan Karl
- Infection and Immunity Division, Walter and Eliza Hall Institute of Medical Research (WEHI), Melbourne, Victoria, Australia.,Department of Medical Biology, University of Melbourne, Melbourne, Victoria, Australia
| | - Ivo Mueller
- Infection and Immunity Division, Walter and Eliza Hall Institute of Medical Research (WEHI), Melbourne, Victoria, Australia.,Department of Medical Biology, University of Melbourne, Melbourne, Victoria, Australia.,Barcelona Centre for International Health Research (CRESIB), Barcelona, Spain
| | - Stephen J Rogerson
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia. .,Victorian Infectious Diseases Service, Melbourne Health, Melbourne, Victoria, Australia.
| |
Collapse
|
21
|
Unger HW, Ome-Kaius M, Wangnapi RA, Umbers AJ, Hanieh S, Suen CSNLW, Robinson LJ, Rosanas-Urgell A, Wapling J, Lufele E, Kongs C, Samol P, Sui D, Singirok D, Bardaji A, Schofield L, Menendez C, Betuela I, Siba P, Mueller I, Rogerson SJ. Sulphadoxine-pyrimethamine plus azithromycin for the prevention of low birthweight in Papua New Guinea: a randomised controlled trial. BMC Med 2015; 13:9. [PMID: 25591391 PMCID: PMC4305224 DOI: 10.1186/s12916-014-0258-3] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Accepted: 12/16/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Intermittent preventive treatment in pregnancy has not been evaluated outside of Africa. Low birthweight (LBW, <2,500 g) is common in Papua New Guinea (PNG) and contributing factors include malaria and reproductive tract infections. METHODS From November 2009 to February 2013, we conducted a parallel group, randomised controlled trial in pregnant women (≤ 26 gestational weeks) in PNG. Sulphadoxine-pyrimethamine (1,500/75 mg) plus azithromycin (1 g twice daily for 2 days) (SPAZ) monthly from second trimester (intervention) was compared against sulphadoxine-pyrimethamine and chloroquine (450 to 600 mg, daily for three days) (SPCQ) given once, followed by SPCQ placebo (control). Women were assigned to treatment (1:1) using a randomisation sequence with block sizes of 32. Participants were blinded to assignments. The primary outcome was LBW. Analysis was by intention-to-treat. RESULTS Of 2,793 women randomised, 2,021 (72.4%) were included in the primary outcome analysis (SPCQ: 1,008; SPAZ: 1,013). The prevalence of LBW was 15.1% (305/2,021). SPAZ reduced LBW (risk ratio [RR]: 0.74, 95% CI: 0.60-0.91, P = 0.005; absolute risk reduction (ARR): 4.5%, 95% CI: 1.4-7.6; number needed to treat: 22), and preterm delivery (0.62, 95% CI: 0.43-0.89, P = 0.010), and increased mean birthweight (41.9 g, 95% CI: 0.2-83.6, P = 0.049). SPAZ reduced maternal parasitaemia (RR: 0.57, 95% CI: 0.35-0.95, P = 0.029) and active placental malaria (0.68, 95% CI: 0.47-0.98, P = 0.037), and reduced carriage of gonorrhoea (0.66, 95% CI: 0.44-0.99, P = 0.041) at second visit. There were no treatment-related serious adverse events (SAEs), and the number of SAEs (intervention 13.1% [181/1,378], control 12.7% [174/1,374], P = 0.712) and AEs (intervention 10.5% [144/1,378], control 10.8% [149/1,374], P = 0.737) was similar. A major limitation of the study was the high loss to follow-up for birthweight. CONCLUSIONS SPAZ was efficacious and safe in reducing LBW, possibly acting through multiple mechanisms including the effect on malaria and on sexually transmitted infections. The efficacy of SPAZ in the presence of resistant parasites and the contribution of AZ to bacterial antibiotic resistance require further study. The ability of SPAZ to improve pregnancy outcomes warrants further evaluation. TRIAL REGISTRATION ClinicalTrials.gov NCT01136850 (06 April 2010).
Collapse
Affiliation(s)
- Holger W Unger
- Department of Medicine (Royal Melbourne Hospital), The University of Melbourne, Post Office Royal Melbourne Hospital, Parkville, Victoria, 3050, Australia. .,Papua New Guinea Institute of Medical Research, PO Box 60, Goroka, Eastern Highlands Province, 441, Papua New Guinea.
| | - Maria Ome-Kaius
- Papua New Guinea Institute of Medical Research, PO Box 60, Goroka, Eastern Highlands Province, 441, Papua New Guinea.
| | - Regina A Wangnapi
- Papua New Guinea Institute of Medical Research, PO Box 60, Goroka, Eastern Highlands Province, 441, Papua New Guinea.
| | - Alexandra J Umbers
- Department of Medicine (Royal Melbourne Hospital), The University of Melbourne, Post Office Royal Melbourne Hospital, Parkville, Victoria, 3050, Australia. .,Papua New Guinea Institute of Medical Research, PO Box 60, Goroka, Eastern Highlands Province, 441, Papua New Guinea.
| | - Sarah Hanieh
- Department of Medicine (Royal Melbourne Hospital), The University of Melbourne, Post Office Royal Melbourne Hospital, Parkville, Victoria, 3050, Australia.
| | | | - Leanne J Robinson
- Papua New Guinea Institute of Medical Research, PO Box 60, Goroka, Eastern Highlands Province, 441, Papua New Guinea. .,Walter and Eliza Hall Institute (WEHI), Parkville, Victoria, 3052, Australia.
| | - Anna Rosanas-Urgell
- Papua New Guinea Institute of Medical Research, PO Box 60, Goroka, Eastern Highlands Province, 441, Papua New Guinea. .,Institute of Tropical Medicine, Nationalestraat 155, 2000, Antwerpen, Belgium.
| | - Johanna Wapling
- Papua New Guinea Institute of Medical Research, PO Box 60, Goroka, Eastern Highlands Province, 441, Papua New Guinea.
| | - Elvin Lufele
- Papua New Guinea Institute of Medical Research, PO Box 60, Goroka, Eastern Highlands Province, 441, Papua New Guinea.
| | - Charles Kongs
- Papua New Guinea Institute of Medical Research, PO Box 60, Goroka, Eastern Highlands Province, 441, Papua New Guinea.
| | - Paula Samol
- Papua New Guinea Institute of Medical Research, PO Box 60, Goroka, Eastern Highlands Province, 441, Papua New Guinea.
| | - Desmond Sui
- Papua New Guinea Institute of Medical Research, PO Box 60, Goroka, Eastern Highlands Province, 441, Papua New Guinea.
| | - Dupain Singirok
- Papua New Guinea Institute of Medical Research, PO Box 60, Goroka, Eastern Highlands Province, 441, Papua New Guinea.
| | - Azucena Bardaji
- Barcelona Centre for International Health Research (CRESIB), Hospital Clínic-Universitat de Barcelona, Rossello, 132, 7th floor, 08036, Barcelona, Spain.
| | - Louis Schofield
- Walter and Eliza Hall Institute (WEHI), Parkville, Victoria, 3052, Australia. .,Australian Institute of Tropical Health and Medicine, Faculty of Medicine, Health, and Molecular Sciences, James Cook University, Townsville, Queensland, 4811, Australia.
| | - Clara Menendez
- Barcelona Centre for International Health Research (CRESIB), Hospital Clínic-Universitat de Barcelona, Rossello, 132, 7th floor, 08036, Barcelona, Spain.
| | - Inoni Betuela
- Papua New Guinea Institute of Medical Research, PO Box 60, Goroka, Eastern Highlands Province, 441, Papua New Guinea.
| | - Peter Siba
- Papua New Guinea Institute of Medical Research, PO Box 60, Goroka, Eastern Highlands Province, 441, Papua New Guinea.
| | - Ivo Mueller
- Walter and Eliza Hall Institute (WEHI), Parkville, Victoria, 3052, Australia. .,Barcelona Centre for International Health Research (CRESIB), Hospital Clínic-Universitat de Barcelona, Rossello, 132, 7th floor, 08036, Barcelona, Spain. .,Department of Medical Biology, The University of Melbourne, Parkville, Victoria, 3010, Australia.
| | - Stephen J Rogerson
- Department of Medicine (Royal Melbourne Hospital), The University of Melbourne, Post Office Royal Melbourne Hospital, Parkville, Victoria, 3050, Australia.
| |
Collapse
|
22
|
McGready R, Kang J, Watts I, Tyrosvoutis MEG, Torchinsky MB, Htut AM, Tun NW, Keereecharoen L, Wangsing C, Hanboonkunupakarn B, Nosten FH. Audit of antenatal screening for syphilis and HIV in migrant and refugee women on the Thai-Myanmar border: a descriptive study. F1000Res 2014; 3:123. [PMID: 26664698 PMCID: PMC4654433 DOI: 10.12688/f1000research.4190.2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/11/2015] [Indexed: 11/25/2022] Open
Abstract
Objective: The antenatal prevalence of syphilis and HIV/AIDS in migrants and refugees is poorly documented. The aim of this study was to audit the first year of routine syphilis screening in the same population and reassess the trends in HIV rates. Methods: From August 2012 to July 2013, 3600 pregnant women were screened for HIV (ELISA) and syphilis (VDRL with TPHA confirmation) at clinics along the Thai-Myanmar border. Results: Seroprevalence for HIV 0.47% (95% CI 0.30-0.76) (17/3,599), and syphilis 0.39% (95% CI 0.23-0.65) (14/3,592), were low. Syphilis was significantly lower in refugees (0.07% 95% CI 0.01-0.38) (1/1,469), than in migrants (0.61% 95% CI 0.36-1.04) (13/2,123). The three active (VDRL≥1:8 and TPHA reactive) syphilis cases with VDRL titres of 1:32 were easy to counsel and treat. Women with low VDRL titres (>75% were < 1:8) and TPHA reactive results, in the absence of symptoms and both the woman and her husband having only one sexual partner in their lifetime, and the inability to determine the true cause of the positive results presented ethical difficulties for counsellors. Conclusion: As HIV and syphilis testing becomes available in more and more settings, the potential impact of false positive results should be considered, especially in populations with low prevalence for these diseases. This uncertainty must be considered in order to counsel patients and partners accurately and safely about the results of these tests, without exposing women to increased risk for abuse or abandonment. Our findings highlight the complexities of counselling patients about these tests and the global need for more conclusive syphilis testing strategies.
Collapse
Affiliation(s)
- Rose McGready
- Shoklo Malaria Research Unit, 63110, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, 63110, Thailand ; Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, 10400, Thailand ; Centre for Tropical Medicine, Nuffield Department of Medicine, University of Oxford, Oxford, OX3 7BN, UK
| | - Joy Kang
- Shoklo Malaria Research Unit, 63110, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, 63110, Thailand
| | - Isabella Watts
- Shoklo Malaria Research Unit, 63110, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, 63110, Thailand
| | - Mary Ellen G Tyrosvoutis
- Shoklo Malaria Research Unit, 63110, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, 63110, Thailand
| | - Miriam B Torchinsky
- Shoklo Malaria Research Unit, 63110, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, 63110, Thailand
| | - Aung Myo Htut
- Shoklo Malaria Research Unit, 63110, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, 63110, Thailand
| | - Nay Win Tun
- Shoklo Malaria Research Unit, 63110, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, 63110, Thailand
| | - Lily Keereecharoen
- Shoklo Malaria Research Unit, 63110, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, 63110, Thailand
| | - Chirapat Wangsing
- Shoklo Malaria Research Unit, 63110, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, 63110, Thailand
| | - Borimas Hanboonkunupakarn
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, 10400, Thailand
| | - François H Nosten
- Shoklo Malaria Research Unit, 63110, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, 63110, Thailand ; Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, 10400, Thailand ; Centre for Tropical Medicine, Nuffield Department of Medicine, University of Oxford, Oxford, OX3 7BN, UK
| |
Collapse
|