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Chang CC, Harrison TS, Bicanic TA, Chayakulkeeree M, Sorrell TC, Warris A, Hagen F, Spec A, Oladele R, Govender NP, Chen SC, Mody CH, Groll AH, Chen YC, Lionakis MS, Alanio A, Castañeda E, Lizarazo J, Vidal JE, Takazono T, Hoenigl M, Alffenaar JW, Gangneux JP, Soman R, Zhu LP, Bonifaz A, Jarvis JN, Day JN, Klimko N, Salmanton-García J, Jouvion G, Meya DB, Lawrence D, Rahn S, Bongomin F, McMullan BJ, Sprute R, Nyazika TK, Beardsley J, Carlesse F, Heath CH, Ayanlowo OO, Mashedi OM, Queiroz-Telles Filho F, Hosseinipour MC, Patel AK, Temfack E, Singh N, Cornely OA, Boulware DR, Lortholary O, Pappas PG, Perfect JR. Global guideline for the diagnosis and management of cryptococcosis: an initiative of the ECMM and ISHAM in cooperation with the ASM. THE LANCET. INFECTIOUS DISEASES 2024; 24:e495-e512. [PMID: 38346436 DOI: 10.1016/s1473-3099(23)00731-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 11/02/2023] [Accepted: 11/13/2023] [Indexed: 03/21/2024]
Abstract
Cryptococcosis is a major worldwide disseminated invasive fungal infection. Cryptococcosis, particularly in its most lethal manifestation of cryptococcal meningitis, accounts for substantial mortality and morbidity. The breadth of the clinical cryptococcosis syndromes, the different patient types at-risk and affected, and the vastly disparate resource settings where clinicians practice pose a complex array of challenges. Expert contributors from diverse regions of the world have collated data, reviewed the evidence, and provided insightful guideline recommendations for health practitioners across the globe. This guideline offers updated practical guidance and implementable recommendations on the clinical approaches, screening, diagnosis, management, and follow-up care of a patient with cryptococcosis and serves as a comprehensive synthesis of current evidence on cryptococcosis. This Review seeks to facilitate optimal clinical decision making on cryptococcosis and addresses the myriad of clinical complications by incorporating data from historical and contemporary clinical trials. This guideline is grounded on a set of core management principles, while acknowledging the practical challenges of antifungal access and resource limitations faced by many clinicians and patients. More than 70 societies internationally have endorsed the content, structure, evidence, recommendation, and pragmatic wisdom of this global cryptococcosis guideline to inform clinicians about the past, present, and future of care for a patient with cryptococcosis.
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Affiliation(s)
- Christina C Chang
- Department of Infectious Diseases, Alfred Hospital, Melbourne, VIC, Australia; Department of Infectious Diseases, Central Clinical School, Monash University, Melbourne, VIC, Australia; Centre for the AIDS Programme of Research in South Africa, Durban, South Africa.
| | - Thomas S Harrison
- Institute of Infection and Immunity, St George's University London, London, UK; Clinical Academic Group in Infection and Immunity, St George's University Hospitals NHS Foundation Trust, London, UK; Medical Research Centre for Medical Mycology, University of Exeter, Exeter, UK
| | - Tihana A Bicanic
- Institute of Infection and Immunity, St George's University London, London, UK; Clinical Academic Group in Infection and Immunity, St George's University Hospitals NHS Foundation Trust, London, UK; Medical Research Centre for Medical Mycology, University of Exeter, Exeter, UK
| | - Methee Chayakulkeeree
- Division of Infectious Diseases and Tropical Medicine, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Tania C Sorrell
- Sydney Infectious Diseases Institute, University of Sydney, Sydney, NSW, Australia; Department of Infectious Diseases, Westmead Hospital, Westmead, NSW, Australia
| | - Adilia Warris
- Medical Research Centre for Medical Mycology, University of Exeter, Exeter, UK; Department of Infectious Diseases, Great Ormond Street Hospital, London, UK
| | - Ferry Hagen
- Faculty of Science, Institute for Biodiversity and Ecosystem Dynamics, University of Amsterdam, Amsterdam, Netherlands; Department of Medical Mycology, Westerdijk Fungal Biodiversity Institute, Utrecht, Netherlands; Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Andrej Spec
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St Louis, MO, USA
| | - Rita Oladele
- College of Medicine, University of Lagos, Lagos, Nigeria
| | - Nelesh P Govender
- Institute of Infection and Immunity, St George's University London, London, UK; Medical Research Centre for Medical Mycology, University of Exeter, Exeter, UK; Department of Clinical Microbiology and Infectious Diseases, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Division of Medical Microbiology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Sharon C Chen
- Sydney Infectious Diseases Institute, University of Sydney, Sydney, NSW, Australia; Department of Infectious Diseases, Westmead Hospital, Westmead, NSW, Australia; Centre for Infectious Diseases and Microbiology Laboratory Services, Institute for Clinical Pathology and Medical Research, New South Wales Health Pathology, Westmead, NSW, Australia
| | - Christopher H Mody
- Department of Microbiology, Immunology and Infectious Diseases, Department of Medicine, Snyder Institute for Chronic Diseases, University of Calgary, Calgary, AB, Canada
| | - Andreas H Groll
- Infectious Disease Research Program, and Department of Pediatric Hematology/Oncology, University Children's Hospital, Münster, Germany; Center for Bone Marrow Transplantation, and Department of Pediatric Hematology/Oncology, University Children's Hospital, Münster, Germany
| | - Yee-Chun Chen
- Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan; National Institute of Infectious Diseases and Vaccinology, National Health Research Institutes, Zhunan, Taiwan
| | - Michail S Lionakis
- Fungal Pathogenesis Section, Laboratory of Clinical Immunology & Microbiology, National Institute of Allergy & Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Alexandre Alanio
- Institut Pasteur, Centre National de Référence Mycoses Invasives et Antifongiques, Groupe de recherche Mycologie Translationnelle, Département de Mycologie, Université Paris Cité, Paris, France; Laboratoire de parasitologie-mycologie, AP-HP, Hôpital Saint-Louis, Université Paris Cité, Paris, France
| | | | - Jairo Lizarazo
- Department of Internal Medicine, Hospital Universitario Erasmo Meoz, Faculty of Health, Univesidad de Pamplona, Cúcuta, Colombia
| | - José E Vidal
- Departmento de Neurologia, Instituto de Infectologia Emílio Ribas, São Paulo, Brazil; Departamento de Moléstias Infecciosas e Parasitárias, Hospital das Clinicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil; Instituto de Medicina Tropical, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Takahiro Takazono
- Department of Infectious Diseases, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan; Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
| | - Martin Hoenigl
- Division of Infectious Diseases, Translational Medical Mycology Research Unit, European Confederation of Medical Mycology Excellence Center for Medical Mycology, Medical University of Graz, Graz, Austria; BioTechMed, Graz, Austria
| | - Jan-Willem Alffenaar
- Sydney Infectious Diseases Institute, University of Sydney, Sydney, NSW, Australia; Department of Pharmacy, Westmead Hospital, Westmead, NSW, Australia; School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Jean-Pierre Gangneux
- Institute for Health, Environment and Work Research-Irset, Inserm UMR_S 1085, University of Rennes, Rennes, France; Laboratory for Parasitology and Mycology, Centre National de Référence Mycoses Invasives et Antifongiques LA Asp-C, University Hospital of Rennes, Rennes, France
| | - Rajeev Soman
- Jupiter Hospital, Pune, India; Deenanath Mangeshkar Hospital, Pune, India; Hinduja Hospital, Mumbai, India
| | - Li-Ping Zhu
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, National Medical Center for Infectious Diseases, Huashan Hospital, Fudan University, Shanghai China
| | - Alexandro Bonifaz
- Hospital General de México, Dermatology Service, Mycology section, Universidad Nacional Autónoma de México, Mexico City, Mexico
| | - Joseph N Jarvis
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK; Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Jeremy N Day
- Department of Clinical Microbiology and Infection, Royal Devon and Exeter University Hospital NHS Trust, Exeter, UK
| | - Nikolai Klimko
- Department of Clinical Mycology, Allergy and Immunology, I Mechnikov North Western State Medical University, Staint Petersburg, Russia
| | - Jon Salmanton-García
- Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany; Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf and Excellence Center for Medical Mycology, Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany; Partner Site Bonn-Cologne, German Centre for Infection Research, Cologne, Germany
| | - Grégory Jouvion
- Histology and Pathology Unit, Ecole nationale vétérinaire d'Alfort, Maisons-Alfort, France; Dynamyc Team, Université Paris Est Créteil and Ecole nationale vétérinaire d'Alfort, Créteil, France
| | - David B Meya
- Infectious Diseases Institute, School of Medicine, College of Heath Sciences, Makerere University, Kampala, Uganda
| | - David Lawrence
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK; Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Sebastian Rahn
- Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany; Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf and Excellence Center for Medical Mycology, Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany; Partner Site Bonn-Cologne, German Centre for Infection Research, Cologne, Germany
| | - Felix Bongomin
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Gulu University, Gulu, Uganda
| | - Brendan J McMullan
- Discipline of Paediatrics, School of Clinical Medicine, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia; Department of Infectious Diseases, Sydney Children's Hospital, Randwick, Sydney, NSW, Australia
| | - Rosanne Sprute
- Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany; Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf and Excellence Center for Medical Mycology, Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany; Partner Site Bonn-Cologne, German Centre for Infection Research, Cologne, Germany
| | - Tinashe K Nyazika
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Justin Beardsley
- Sydney Infectious Diseases Institute, University of Sydney, Sydney, NSW, Australia; Department of Infectious Diseases, Westmead Hospital, Westmead, NSW, Australia
| | - Fabianne Carlesse
- Pediatric Department, Federal University of São Paulo, São Paulo, Brazil; Oncology Pediatric Institute-IOP-GRAACC, Federal Univeristy of São Paulo, São Paulo, Brazil
| | - Christopher H Heath
- Department of Microbiology, Fiona Stanley Hospital Network, PathWest Laboratory Medicine, Perth, WA, Australia; Department of Infectious Diseases, Fiona Stanley Hospital, Perth, WA, Australia; UWA Medical School, Internal Medicine, The University of Western Australia, Perth, WA, Australia
| | - Olusola O Ayanlowo
- Dermatology Unit, Department of Medicine, Lagos University Teaching Hospital, University of Lagos, Lagos, Nigeria
| | - Olga M Mashedi
- Centre for Respiratory Diseases Research, Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Mina C Hosseinipour
- Department of Medicine, Division of Infectious Diseases, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA; UNC Project Malawi, Lilongwe, Malawi
| | - Atul K Patel
- Department of Infectious Diseases, Sterling Hospitals, Ahmedabad, India
| | - Elvis Temfack
- Africa Centers for Disease Control and Prevention, Addis Ababa, Ethiopia
| | - Nina Singh
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Oliver A Cornely
- Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany; Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf and Excellence Center for Medical Mycology, Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany; Partner Site Bonn-Cologne, German Centre for Infection Research, Cologne, Germany; Clinical Trials Centre Cologne, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - David R Boulware
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Olivier Lortholary
- Université de Paris Cité, APHP, Service des Maladies Infectieuses et Tropicales, Hôpital Necker-Enfants Malades, Centre d'Infectiologie Necker-Pasteur, Institut Imagine, Paris, France; Institut Pasteur, CNRS, Unité de Mycologie Moléculaire, Centre National de Référence Mycoses Invasives et Antifongiques, UMR 2000, Paris, France
| | - Peter G Pappas
- Mycoses Study Group Central Unit, Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - John R Perfect
- Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, Durham, NC, USA; Department of Molecular Genetics and Microbiology, Duke University Medical Center, Durham, NC, USA.
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Mabovula NS, Enicker BC. A comparison of the surgical outcomes of ventriculoperitoneal versus lumbar peritoneal shunts in the management of intracranial hypertension secondary to cryptococcal meningitis in HIV infected adult patients. Clin Neurol Neurosurg 2024; 238:108184. [PMID: 38394855 DOI: 10.1016/j.clineuro.2024.108184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 02/16/2024] [Accepted: 02/17/2024] [Indexed: 02/25/2024]
Abstract
OBJECTIVE Cryptococcal meningitis (CM), an AIDS-defining illness, significantly impacts morbidity and mortality. This study aims to compare complications arising from ventriculoperitoneal shunt (VPS) and lumbar peritoneal shunt (LPS) procedures used to manage refractory intracranial hypertension (IH) secondary to CM in HIV-infected patients. METHODS Retrospective data were collected from January 2003 to January 2015 for HIV-infected adults diagnosed with refractory IH secondary to CM and subsequently shunted. Demographics, clinical characteristics, antiretroviral therapy, laboratory findings (including CD4 count and CSF results), CT brain scan results, shunt-related complications, and mortality were compared between VPS and LPS groups. RESULTS This study included 83 patients, with 60 (72%) undergoing VPS and 23 (28%) receiving LPS. Mean ages were comparable between VPS (32.5) and LPS (32.2) groups (p = 0.89). Median CD4+ counts were 76 cells/µl (IQR= 30-129) in VPS versus 54 cells/µl (IQR= 31-83) in LPS (p=0.45). VPS group showed a higher mean haemoglobin of 11.5 g/dl compared to 9.9 g/dl in the LPS group (p=0.001). CT brain scans showed hydrocephalus in 55 VPS and 13 LPS patients respectively. Shunt complications were observed in 17 (28%) VPS patients versus 10 (43.5%) LPS patients (p=0.5). Patients developing shunt sepsis in the VPS group exhibited a median CD4+ count of 117 cells/µl (IQR= 76-129) versus 48 cells/µl (IQR= 31- 66) in the LPS group (p=0.03). Early shunt malfunction occurred more frequently in the LPS group compared to VPS group (p=0.044). The mean hospital stay was 6.2 days for VPS versus 5.4 days for LPS patients (p=0.9). In-hospital mortality was 6%, occurring in three VPS and two LPS patients respectively. CONCLUSION Shunting procedures remain important surgical interventions for refractory IH secondary to HIV-related CM. However, cautious consideration is warranted for patients with CD4 counts below 200 cells/µL due to increased shunt complications. This study suggests a trend toward higher complication rates in patients undergoing LPS insertion.
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Affiliation(s)
- Ndyebo S Mabovula
- Department of Neurosurgery, Inkosi Albert Luthuli Central Hospital, 800 Vusi Mzimela Road, Cato Manor, Durban, KwaZulu Natal 4091, South Africa.
| | - Basil C Enicker
- Department of Neurosurgery, Inkosi Albert Luthuli Central Hospital, 800 Vusi Mzimela Road, Cato Manor, Durban, KwaZulu Natal 4091, South Africa.
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Tugume L, Ssebambulidde K, Kasibante J, Ellis J, Wake RM, Gakuru J, Lawrence DS, Abassi M, Rajasingham R, Meya DB, Boulware DR. Cryptococcal meningitis. Nat Rev Dis Primers 2023; 9:62. [PMID: 37945681 DOI: 10.1038/s41572-023-00472-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/09/2023] [Indexed: 11/12/2023]
Abstract
Cryptococcus neoformans and Cryptococcus gattii species complexes cause meningoencephalitis with high fatality rates and considerable morbidity, particularly in persons with deficient T cell-mediated immunity, most commonly affecting people living with HIV. Whereas the global incidence of HIV-associated cryptococcal meningitis (HIV-CM) has decreased over the past decade, cryptococcosis still accounts for one in five AIDS-related deaths globally due to the persistent burden of advanced HIV disease. Moreover, mortality remains high (~50%) in low-resource settings. The armamentarium to decrease cryptococcosis-associated mortality is expanding: cryptococcal antigen screening in the serum and pre-emptive azole therapy for cryptococcal antigenaemia are well established, whereas enhanced pre-emptive combination treatment regimens to improve survival of persons with cryptococcal antigenaemia are in clinical trials. Short courses (≤7 days) of amphotericin-based therapy combined with flucytosine are currently the preferred options for induction therapy of cryptococcal meningitis. Whether short-course induction regimens improve long-term morbidity such as depression, reduced neurocognitive performance and physical disability among survivors is the subject of further study. Here, we discuss underlying immunology, changing epidemiology, and updates on the management of cryptococcal meningitis with emphasis on HIV-associated disease.
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Affiliation(s)
- Lillian Tugume
- Infectious Diseases Institute, Makerere University, Kampala, Uganda.
| | - Kenneth Ssebambulidde
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - John Kasibante
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Jayne Ellis
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
- Clinical Research Department, Faculty of Infectious and Tropical Diseases London School of Hygiene and Tropical Medicine, London, UK
| | - Rachel M Wake
- Institute for Infection and Immunity, St George's University of London, London, UK
| | - Jane Gakuru
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - David S Lawrence
- Clinical Research Department, Faculty of Infectious and Tropical Diseases London School of Hygiene and Tropical Medicine, London, UK
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Mahsa Abassi
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Radha Rajasingham
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - David B Meya
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - David R Boulware
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
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Paccoud O, Shuping L, Mashau R, Greene G, Quan V, Meiring S, Govender NP. Impact of prior cryptococcal antigen screening on in-hospital mortality in cryptococcal meningitis or fungaemia among HIV-seropositive individuals in South Africa: a cross-sectional observational study. Clin Microbiol Infect 2023; 29:1063-1069. [PMID: 37086780 DOI: 10.1016/j.cmi.2023.04.016] [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: 02/08/2023] [Revised: 04/11/2023] [Accepted: 04/15/2023] [Indexed: 04/24/2023]
Abstract
OBJECTIVES We investigated whether patients with cryptococcal meningitis (CM) or fungaemia detected through South Africa's laboratory cryptococcal antigen (CrAg) screening programme had better outcomes than those presenting directly to the hospital. METHODS We compared 14-day in-hospital case-fatality ratios of HIV-seropositive individuals with CD4 counts below 100 cells/μL and laboratory-confirmed CM/fungaemia from 2017-2021, with or without evidence of a positive blood CrAg test within 14 days prior to diagnosis. We evaluated whether the impact of prior CrAg screening on mortality varied according to the study period (pre-COVID-19: before March 2020 vs. COVID-19: after March 2020). RESULTS Overall, 24.5% (830/3390) of patients had a prior positive CrAg test within 14 days of diagnosis. CrAg-screened patients were less likely to have an altered mental status at baseline than non-CrAg-screened patients (38.1% [296/776] vs. 42.6% [1010/2372], p = 0.03), and had a lower crude 14-day case-fatality ratio (24.7% [205/830] vs. 28.3% [724/2560]; OR, 0.83 [95% CI, 0.69-0.99]; p = 0.045). Previous CrAg screening was associated with a greater reduction in the crude 14-day mortality during the COVID-19 period (OR, 0.64 [0.47-0.87]; p = 0.005) compared with before (OR, 0.95 [0.76-1.19]; p = 0.68). After adjustment, previous CrAg screening within 14 days was associated with increased survival only during the COVID-19 period (adjusted OR, 0.70 [0.51-0.96]; p = 0.03). DISCUSSION Previous CrAg screening was associated with a survival benefit in patients hospitalized with CM/fungaemia during the COVID-19 period, with fewer patients having an altered mental status at baseline, suggesting that these patients may have been diagnosed with cryptococcosis earlier.
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Affiliation(s)
- Olivier Paccoud
- Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses, National Institute for Communicable Diseases, A Division of the National Health Laboratory Service, Johannesburg, South Africa; Université Paris Cité, Necker-Pasteur Center for Infectious Diseases and Tropical Medicine, Hospital Necker-Enfants Maladies, Assistance Publique-Hopitaux de Paris, Paris, France
| | - Liliwe Shuping
- Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses, National Institute for Communicable Diseases, A Division of the National Health Laboratory Service, Johannesburg, South Africa
| | - Rudzani Mashau
- Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses, National Institute for Communicable Diseases, A Division of the National Health Laboratory Service, Johannesburg, South Africa
| | - Greg Greene
- Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses, National Institute for Communicable Diseases, A Division of the National Health Laboratory Service, Johannesburg, South Africa
| | - Vanessa Quan
- Division of Public Health Surveillance and Response, National Institute for Communicable Diseases, A Division of the National Health Laboratory Service, Johannesburg, South Africa
| | - Susan Meiring
- Division of Public Health Surveillance and Response, National Institute for Communicable Diseases, A Division of the National Health Laboratory Service, Johannesburg, South Africa; School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Nelesh P Govender
- Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses, National Institute for Communicable Diseases, A Division of the National Health Laboratory Service, Johannesburg, South Africa; School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Institute of Infection and Immunity, St George's University of London, London, UK; Medical Research Council Centre for Medical Mycology, University of Exeter, Exeter, UK; Division of Medical Microbiology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
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Wake RM, Molloy SF, Jarvis JN, Harrison TS, Govender NP. Cryptococcal Antigenemia in Advanced Human Immunodeficiency Virus Disease: Pathophysiology, Epidemiology, and Clinical Implications. Clin Infect Dis 2023; 76:764-770. [PMID: 35986670 PMCID: PMC9938740 DOI: 10.1093/cid/ciac675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 08/11/2022] [Accepted: 08/17/2022] [Indexed: 11/14/2022] Open
Abstract
Cryptococcal antigen (CrAg) is detectable in blood prior to the onset of symptomatic cryptococcal meningitis (CM), a leading cause of death among people with advanced human immunodeficiency virus (HIV) disease globally. Highly sensitive assays can detect CrAg in blood, and screening people with HIV with low CD4 counts, followed by preemptive antifungal treatment, is recommended and widely implemented as part of a global strategy to prevent CM and end cryptococcal-related deaths. Cryptococcal antigenemia encompasses a spectrum of conditions from preclinical asymptomatic infection (cerebrospinal fluid [CSF] CrAg-negative) through subclinical (CSF CrAg-positive without overt meningism) to clinical symptomatic cryptococcal disease, usually manifesting as CM. In this review, we summarize current understanding of the pathophysiology, risk factors for, and clinical implications of cryptococcal antigenemia within this spectrum. We also provide an update on global prevalence, recommended screening and treatment strategies, and future considerations for improving outcomes among patients with cryptococcal antigenemia.
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Affiliation(s)
- Rachel M Wake
- Institute for Infection and Immunity, St George’s University of London, London, United Kingdom
- Clinical Academic Group in Infection and Immunity, St George’s University Hospitals National Health Service Foundation Trust, London, United Kingdom
| | - Síle F Molloy
- Institute for Infection and Immunity, St George’s University of London, London, United Kingdom
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Joseph N Jarvis
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Thomas S Harrison
- Institute for Infection and Immunity, St George’s University of London, London, United Kingdom
- Clinical Academic Group in Infection and Immunity, St George’s University Hospitals National Health Service Foundation Trust, London, United Kingdom
- MRC Centre for Medical Mycology, University of Exeter, Exeter, United Kingdom
| | - Nelesh P Govender
- Institute for Infection and Immunity, St George’s University of London, London, United Kingdom
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- MRC Centre for Medical Mycology, University of Exeter, Exeter, United Kingdom
- Division of the National Health Laboratory Service, Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses, National Institute for Communicable Diseases, Johannesburg, South Africa
- Division of Medical Microbiology, University of Cape Town, Cape Town, South Africa
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Levin AE, Bangdiwala AS, Nalintya E, Kagimu E, Kasibante J, Rutakingirwa MK, Mpoza E, Jjunju S, Nuwagira E, Naluyima R, Kirumira P, Hou C, Ssebambulidde K, Musubire AK, Williams DA, Abassi M, Muzoora C, Hullsiek KH, Rajasingham R, Meya DB, Boulware DR, Skipper CP. Outpatient Cryptococcal Antigen Screening Is Associated With Favorable Baseline Characteristics and Improved Survival in Persons With Cryptococcal Meningitis in Uganda. Clin Infect Dis 2023; 76:e759-e765. [PMID: 35859045 PMCID: PMC10169421 DOI: 10.1093/cid/ciac599] [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: 04/04/2022] [Revised: 07/09/2022] [Accepted: 07/15/2022] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND It is unknown whether persons with symptomatic cryptococcal meningitis detected during routine blood cryptococcal antigen (CrAg) screening have better survival than persons presenting with overt meningitis. METHODS We prospectively enrolled Ugandans with HIV and cryptocococcal meningitis from December 2018 to December 2021. Participants were treated with amphotericin-based combination therapy. We compared outcomes between persons who were CrAg screened then referred to hospital with those presenting directly to the hospital with symptomatic meningitis. RESULTS Among 489 participants with cryptococcal meningitis, 40% (194/489) received blood CrAg screening and were referred to hospital (median time to referral 2 days; interquartile range [IQR], 1-6). CrAg-screened persons referred to hospital had lower 14-day mortality than non-CrAg-screened persons who presented directly to hospital with symptomatic meningitis (12% vs 21%; hazard ratio, .51; 95% confidence interval, .32-.83; P = .006). Fewer CrAg-screened participants had altered mental status versus non-CrAg-screened participants (29% vs 41%; P = .03). CrAg-screened persons had lower quantitative cerebrospinal fluid (CSF) culture burden (median [IQR], 4570 [11-100 000] vs 26 900 [182-324 000] CFU/mL; P = .01) and lower CSF opening pressures (median [IQR], 190 [120-270] vs 225 [140-340] mmH2O; P = .004) compared with non-CrAg-screened persons. CONCLUSIONS Survival from cryptococcal meningitis was higher in persons with prior CrAg screening than those without CrAg screening. Altered mental status was the most potent predictor for mortality in a multivariate model. We suggest that CrAg screening detects cryptococcal meningitis at an earlier stage, as evidenced by a favorable baseline risk profile and notably fewer persons with altered mental status.
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Affiliation(s)
- Anna E Levin
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Ananta S Bangdiwala
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | | | - Enock Kagimu
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - John Kasibante
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | - Edward Mpoza
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Samuel Jjunju
- Department of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Edwin Nuwagira
- Department of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Rose Naluyima
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Paul Kirumira
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Cody Hou
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | | | - Abdu K Musubire
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Darlisha A Williams
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Mahsa Abassi
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Conrad Muzoora
- Department of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Katherine H Hullsiek
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Radha Rajasingham
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - David B Meya
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
- Department of Medicine, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - David R Boulware
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Caleb P Skipper
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
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7
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Chisale MRO, Jordan A, Kamudumuli PS, Mvula B, Odo M, Maida A, Kandulu J, Chilima B, Sinyiza FW, Katundu P, Lee HY, Mtegha R, Wu TSJ, Bitirinyo J, Nyirenda R, Kalua T, Greene G, Chiller T. Six months survival and risk factors for attrition for patients detected with cryptococcal antigenemia through screening in Malawi. PLoS One 2023; 18:e0284367. [PMID: 37141243 PMCID: PMC10159159 DOI: 10.1371/journal.pone.0284367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 03/29/2023] [Indexed: 05/05/2023] Open
Abstract
MAIN OBJECTIVE A cohort of adult Malawian people living with HIV (PLHIV) testing positive for cryptococcal antigenemia was observed and followed to determine the outcomes and risk factors for attrition. METHODS CONCEPT Eligible PLHIV were enrolled at 5 health facilities in Malawi, representing different levels of health care. ART naïve patients, ART defaulters returning to care, and patients with suspected or confirmed ART treatment failure with CD4 <200 cells/μL or clinical stage 3 or 4 were enrolled and received CrAg tests on whole blood specimens from August 2018 to August 2019. Hospitalized PLHIV were enrolled and tested for CrAg from January 2019 to August 2019, regardless of CD4 or clinical stage. Patients with cryptococcal antigenemia were managed per Malawian clinical guidelines and were followed up for six months. Survival and risk factors for attrition at six months were assessed. RESULTS A total of 2146 patients were screened and 112 (5.2%) had cryptococcal antigenemia. Prevalence ranged from 3.8% (Mzuzu Central Hospital) to 25.8% (Jenda Rural Hospital). Of the 112 patients with antigenemia, 33 (29.5%) were diagnosed with concurrent CM at the time of enrollment. Six-month crude survival of all patients with antigenemia (regardless of CM status) ranged from 52.3% (assuming lost-to-follow-up (LTFU) patients died) to 64.9% (if LTFU survived). Patients who were diagnosed with concurrent CM by CSF test had poor survival (27.3-39.4%). Patients with antigenemia who were not diagnosed with concurrent CM had 71.4% (if LTFU died)- 89.8% (if LTFU survived) survival at six months. In adjusted analyses, patients with cryptococcal antigenemia detected after admission to inpatient care (aHR: 2.56, 1.07-6.15) and patients with concurrent CM at the time of positive antigenemia result (aHR: 2.48, 1.04-5.92) had significantly higher hazard of attrition at six months. CONCLUSIONS Overall, our findings indicate a need for routine access to CrAg screening and pre-emptive fluconazole treatment as a way to detect cryptococcal antigenemia and prevent CM in outpatient and inpatient settings. Rapid access to diagnosis and treatment for cryptococcal meningitis (CM) with gold-standard antifungals is needed to improve survival of patients with advanced HIV in Malawi.
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Affiliation(s)
- Master R O Chisale
- Ministry of Health, Malawi, Mzuzu Central Hospital, Luwinga, Mzuzu, Malawi
- College of Medicine, University of Malawi, Zomba, Malawi
- Faculty of Science Technology and Innovations, Biological Sciences Department, Mzuzu University, Mzuzu, Malawi
| | - Alex Jordan
- Centres for Disease Control and Prevention, Mycotic Diseases Branch, Atlanta, GA, United States of America
| | - Pocha S Kamudumuli
- University of Maryland Global Initiative Corporation (UMGIC), Lilongwe, Malawi
| | - Bernard Mvula
- Ministry of Health, National HIV Unit laboratory, Lilongwe, Malawi
| | - Michael Odo
- Ministry of Health, Department of HIV and AIDS (DHA), Lilongwe, Malawi
| | - Alice Maida
- Centres for Disease Control and Prevention-Malawi, Malawi
| | - James Kandulu
- Capitol Hill (Headquarters), Ministry of Health, Ministry of Health, Lilongwe, Malawi
| | - Ben Chilima
- Public Health Institute of Malawi (PHIM), Ministry of Health, Lilongwe, Malawi
| | - Frank W Sinyiza
- Ministry of Health, Malawi, Mzuzu Central Hospital, Luwinga, Mzuzu, Malawi
| | - Pauline Katundu
- Public Health Institute of Malawi (PHIM), Ministry of Health, Lilongwe, Malawi
| | - Hsin-Yi Lee
- College of Medicine, University of Malawi, Zomba, Malawi
| | - Rebecca Mtegha
- College of Medicine, University of Malawi, Zomba, Malawi
| | - Tsung-Shu Joseph Wu
- College of Medicine, University of Malawi, Zomba, Malawi
- Luke International, Mzuzu, Malawi
| | - Joseph Bitirinyo
- Public Health Institute of Malawi (PHIM), Ministry of Health, Lilongwe, Malawi
| | - Rose Nyirenda
- Ministry of Health, Department of HIV and AIDS (DHA), Lilongwe, Malawi
| | - Thoko Kalua
- University of Maryland Global Initiative Corporation (UMGIC), Lilongwe, Malawi
| | - Greg Greene
- Centres for Disease Control and Prevention, Mycotic Diseases Branch, Atlanta, GA, United States of America
| | - Tom Chiller
- Centres for Disease Control and Prevention, Mycotic Diseases Branch, Atlanta, GA, United States of America
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Cerebrospinal Fluid Shunting in Children with Hydrocephalus and Increased Intracranial Pressure Secondary to Human Immunodeficiency Virus–Related Cryptococcal Meningitis. World Neurosurg 2022; 168:e530-e537. [DOI: 10.1016/j.wneu.2022.10.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 10/06/2022] [Accepted: 10/07/2022] [Indexed: 11/06/2022]
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9
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Naicker SD, Firacative C, van Schalkwyk E, Maphanga TG, Monroy-Nieto J, Bowers JR, Engelthaler DM, Meyer W, Govender NP. Molecular type distribution and fluconazole susceptibility of clinical Cryptococcus gattii isolates from South African laboratory-based surveillance, 2005–2013. PLoS Negl Trop Dis 2022; 16:e0010448. [PMID: 35767529 PMCID: PMC9242473 DOI: 10.1371/journal.pntd.0010448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 04/26/2022] [Indexed: 11/30/2022] Open
Abstract
As is the case globally, Cryptococcus gattii is a less frequent cause of cryptococcosis than Cryptococcus neoformans in South Africa. We performed multilocus sequence typing (MLST) and fluconazole susceptibility testing of 146 isolates randomly selected from 750 South African patients with C. gattii disease identified through enhanced laboratory surveillance, 2005 to 2013. The dominant molecular type was VGIV (101/146, 70%), followed by VGI (40/146, 27%), VGII (3/146, 2%) and VGIII (2/146, 1%). Among the 146 C. gattii isolates, 99 different sequence types (STs) were identified, with ST294 (14/146, 10%) and ST155 (10/146, 7%) being most commonly observed. The fluconazole MIC50 and MIC90 values of 105 (of 146) randomly selected C. gattii isolates were 4 μg/ml and 16 μg/ml, respectively. VGIV isolates had a lower MIC50 value compared to non-VGIV isolates, but these values were within one double-dilution of each other. HIV-seropositive patients had a ten-fold increased adjusted odds of a VGIV infection compared to HIV-seronegative patients, though with small numbers (99/136; 73% vs. 2/10; 20%), the confidence interval (CI) was wide (95% CI: 1.93–55.31, p = 0.006). Whole genome phylogeny of 98 isolates of South Africa’s most prevalent molecular type, VGIV, identified that this molecular type is highly diverse, with two interesting clusters of ten and six closely related isolates being identified, respectively. One of these clusters consisted only of patients from the Mpumalanga Province in South Africa, suggesting a similar environmental source. This study contributed new insights into the global population structure of this important human pathogen. Cryptococcus is the most common cause of meningitis among adults in South Africa. Most human disease is caused by the members of two species complexes within the genus, Cryptococcus neoformans and Cryptococcus gattii. The environmental range of these species complexes, both found in soil, overlaps in southern Africa though C. gattii is a less common human pathogen. C. gattii is divided into six molecular types: VGI, VGII, VGIII, VGIV, VGV and VGVI. In earlier molecular epidemiology studies including relatively few isolates, most southern African isolates were confirmed as molecular type VGIV. We aimed to determine the molecular diversity of C. gattii in South Africa by genotyping patient isolates obtained through laboratory surveillance, 2005–2013. We confirmed that VGIV was the dominant molecular type and that HIV-seropositive patients were more likely to be infected with VGIV compared to those HIV-seronegative. Analysis of the genomes of South African VGIV isolates revealed that they spanned the whole VGIV clade and confirmed that most isolates did not cluster specifically. However, we observed two interesting clusters of closely related isolates, consisting of patients from three neighbouring provinces in South Africa, suggesting a similar environmental source. Further studies of clinical and environmental African C. gattii isolates are needed to gain a better understanding of this pathogen.
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Affiliation(s)
- Serisha D. Naicker
- National Institute for Communicable Diseases (Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses), a Division of the National Health Laboratory Service, Johannesburg, South Africa
- School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- * E-mail:
| | - Carolina Firacative
- Studies in Translational Microbiology and Emerging Diseases (MICROS) Research Group, School of Medicine and Health Sciences, Universidad del Rosario, Bogota, Colombia
| | - Erika van Schalkwyk
- National Institute for Communicable Diseases (Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses), a Division of the National Health Laboratory Service, Johannesburg, South Africa
| | - Tsidiso G. Maphanga
- National Institute for Communicable Diseases (Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses), a Division of the National Health Laboratory Service, Johannesburg, South Africa
| | - Juan Monroy-Nieto
- Pathogen and Microbiome Division, Translational Genomics Research Institute, Flagstaff, Arizona, United States of America
| | - Jolene R. Bowers
- Pathogen and Microbiome Division, Translational Genomics Research Institute, Flagstaff, Arizona, United States of America
| | - David M. Engelthaler
- Pathogen and Microbiome Division, Translational Genomics Research Institute, Flagstaff, Arizona, United States of America
| | - Wieland Meyer
- Molecular Mycology Research Laboratory, Centre for Infectious Diseases and Microbiology, Westmead Clinical School, Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Westmead, New South Wales, Australia
- Sydney Institute for Infectious Diseases, The University of Sydney, Westmead, New South Wales, Australia
- Westmead Institute for Medical Research, Westmead, New South Wales, Australia
- Research and Educational Network, Westmead Hospital, Western Sydney Local Health District, Westmead, New South Wales, Australia
- Curtin Medical School, Curtin University, Perth, Australia
| | - Nelesh P. Govender
- National Institute for Communicable Diseases (Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses), a Division of the National Health Laboratory Service, Johannesburg, South Africa
- School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Division of Medical Microbiology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- Medical Research Council Centre for Medical Mycology, College of Medicine and Health, University of Exeter, Exeter, United Kingdom
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Larson B, Shroufi A, Muthoga C, Oladele R, Rajasingham R, Jordan A, Jarvis JN, Chiller TM, Govender NP. Induction-phase treatment costs for cryptococcal meningitis in high HIV-burden African countries: New opportunities with lower costs. Wellcome Open Res 2022; 6:140. [PMID: 35706922 PMCID: PMC9184925 DOI: 10.12688/wellcomeopenres.16776.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/16/2022] [Indexed: 11/20/2022] Open
Abstract
Introduction: Access to and the cost of induction treatment for cryptococcal meningitis (CM) is rapidly changing. The newly-announced price for flucytosine ($0.75 per 500 mg pill) and possibly lower prices for liposomal amphotericin B (AmB-L) create opportunities to reduce CM treatment costs compared to the current standard treatment in low- and middle-income countries. Methods: We developed an Excel-based cost model to estimate health system treatment costs for CM over a two-week induction phase for multiple treatment combinations, newly feasible with improved access to flucytosine and AmB-L. CM treatment costs include medications, laboratory tests and other hospital-based costs (bed-day costs and healthcare worker time). We report results from applying the model using country-specific information for South Africa, Uganda, Nigeria, and Botswana. Results: A 14-day induction-phase of seven days of inpatient AmB-D with flucytosine, followed by seven days of high-dose fluconazole as an outpatient, will cost health systems less than a 14-day hospital stay with AmB-D and fluconazole. If daily AmB-L replaces AmB-D for those with baseline renal dysfunction, with a cost of $50 or less per 50 mg vial, incremental costs would still be less than the AmB-D with fluconazole regimen. Simple oral combinations (e.g., seven days of flucytosine with fluconazole as an inpatient) are practical when AmB-D is not available, and treatment costs would remain less than the current standard treatment. Conclusions: Improved access to and lower prices for flucytosine and AmB-L create opportunities for improving CM treatment regimens. An induction regimen of flucytosine and AmB-D for seven days is less costly than standard care in the settings studied here. As this regimen has also been shown to be more effective than current standard care, countries should prioritize scaling up flucytosine access. The cost of AmB-L based regimens is highly dependent on the price of AmB-L, which currently remains unclear.
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Affiliation(s)
- Bruce Larson
- Global Health, Boston University School of Public Health, Boston, MA, 02118, USA
- Health Economics and Epidemiology Research Office, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Charles Muthoga
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Rita Oladele
- College of Medicine, Univerity of Lagos, Lagos, Nigeria
| | - Radha Rajasingham
- Division of Infectious Diseases & International Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Alexander Jordan
- Mycotic Diseases Branch, Centers for Disease Controls and Prevention, Atlanta, Georgia, USA
| | - Joseph N. Jarvis
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Tom M. Chiller
- Mycotic Diseases Branch, Centers for Disease Controls and Prevention, Atlanta, Georgia, USA
| | - Nelesh P. Govender
- National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa
- University of Witwatersrand, Johannesburg, South Africa
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11
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Xu XL, Zhao T, Huang YQ, Lu YQ, He XJ, Wu YS, Zhang W, Yu JH, Yang TT, Xu LJ, Lan K, Zhang DF, Harypursat V, Chen YK. Therapeutic lumbar puncture and lumbar drainage: which is more effective for the management of intracranial hypertension in HIV patients with cryptococcal meningitis? Results of a prospective non-randomized interventional study in China. Curr Med Res Opin 2022; 38:803-810. [PMID: 35225112 DOI: 10.1080/03007995.2022.2047539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE This study aimed to evaluate the effectiveness of therapeutic lumbar drainage (LD) compared to therapeutic lumbar puncture (LP) for the management of intracranial hypertension (ICH) among HIV-positive patients with cryptococcal meningitis (CM). METHODS The study was a multicenter prospective non-randomized interventional clinical trial. One hundred and sixteen HIV-associated CM patients were identified who presented with ICH (≥250 mmH2O). The LP group comprised 76 cases, while the LD group consisted of 40 cases. We compared mortality, intracranial pressure (ICP) normalization rate, and clinical symptom remission at 10 weeks, between the two groups. RESULTS The cumulative mortality at week 10 was 22.4% in the LP group and 20% in the LD group (p = .927), without any significant difference in mortality between the two groups. Improvement after treatment at 2-weeks, ICP normalization, and headache reversal event occurrence in the two groups showed no significant difference (p > .05). The incidence of CSF Cryptococcus clearance at two weeks in the LD group was significantly higher than in the LP group (p < .05). The frequency of invasive lumbar therapeutic procedures in the LP group during the first week was higher than that of the LD group (p < .05). Localized infection at the puncture site occurred more frequently in the LD group than in the LP group (p < .05). CONCLUSION For HIV-positive CM patients with an elevated ICP, LD and LP are comparably effective and safe options to normalize ICP. LP increases the frequency of invasive lumbar therapeutic procedures but does not incur more risk of infection events at the puncture site, while LD may accelerate CSF Cryptococcus clearance but may induce more frequent localized infection. TRIAL REGISTRATION This study was registered as one of 12 trials under a general project at the Chinese Clinical Trial Registry (ChiCTR1900021195).
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Affiliation(s)
- Xiao-Lei Xu
- Division of Infectious Diseases, Chongqing Public Health Medical Center, Chongqing, China
| | - Ting Zhao
- Division of Infectious Diseases, Chongqing Public Health Medical Center, Chongqing, China
| | - Yan-Qun Huang
- School of Biomedical Engineering, Capital Medical University, Beijing, China
| | - Yan-Qiu Lu
- Division of Infectious Diseases, Chongqing Public Health Medical Center, Chongqing, China
| | - Xue-Jiao He
- Division of Infectious Diseases, Chongqing Public Health Medical Center, Chongqing, China
| | - Yu-Shan Wu
- Division of Infectious Diseases, Chongqing Public Health Medical Center, Chongqing, China
| | - Wei Zhang
- Division of Infectious Diseases, Chongqing Public Health Medical Center, Chongqing, China
| | - Jian-Hua Yu
- Department of Infectious Diseases, Affiliated Hangzhou Xixi Hospital, Zhejiang University School of Medicine, Zhejiang, China
| | - Tong-Tong Yang
- Department of Infectious Disease, Public Health Clinical Center of Chengdu, Sichuan, China
| | - Li-Jun Xu
- National Clinical Research Center for Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Ke Lan
- Division of Infectious Disease, Longtan Hospital of Guangxi Zhuang Autonomous Region, Liuzhou, China
| | - De-Fa Zhang
- Infectious Disease Department, Tianjin Second People's Hospital, Tianjin, China
| | - Vijay Harypursat
- Division of Infectious Diseases, Chongqing Public Health Medical Center, Chongqing, China
| | - Yao-Kai Chen
- Division of Infectious Diseases, Chongqing Public Health Medical Center, Chongqing, China
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12
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Central Nervous System Cryptococcosis due to Cryptococcus gattii in the Tropics. CURRENT TROPICAL MEDICINE REPORTS 2022; 9:1-7. [PMID: 35378784 PMCID: PMC8967080 DOI: 10.1007/s40475-022-00253-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2022] [Indexed: 10/27/2022]
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13
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Larson B, Shroufi A, Muthoga C, Oladele R, Rajasingham R, Jordan A, Jarvis JN, Chiller TM, Govender NP. Induction-phase treatment costs for cryptococcal meningitis in high HIV-burden African countries: New opportunities with lower costs. Wellcome Open Res 2022; 6:140. [PMID: 35706922 PMCID: PMC9184925 DOI: 10.12688/wellcomeopenres.16776.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/24/2022] [Indexed: 11/20/2022] Open
Abstract
Introduction: Access to and the cost of induction treatment for cryptococcal meningitis (CM) is rapidly changing. The newly-announced price for flucytosine ($0.75 per 500 mg pill) and possibly lower prices for liposomal amphotericin B (AmB-L) create opportunities to reduce CM treatment costs compared to the current standard treatment in low- and middle-income countries. Methods: We developed an Excel-based cost model to estimate health system treatment costs for CM over a two-week induction phase for multiple treatment combinations, newly feasible with improved access to flucytosine and AmB-L. CM treatment costs include medications, laboratory tests and other hospital-based costs (bed-day costs and healthcare worker time). We report results from applying the model using country-specific information for South Africa, Uganda, Nigeria, and Botswana. Results: A 14-day induction-phase of seven days of inpatient AmB-D with flucytosine, followed by seven days of high-dose fluconazole as an outpatient, will cost health systems less than a 14-day hospital stay with AmB-D and fluconazole. If daily AmB-L replaces AmB-D for those with baseline renal dysfunction, with a cost of $50 or less per 50 mg vial, incremental costs would still be less than the AmB-D with fluconazole regimen. Simple oral combinations (e.g., seven days of flucytosine with fluconazole as an inpatient) are practical when AmB-D is not available, and treatment costs would remain less than the current standard treatment. Conclusions: Improved access to, and lower prices for flucytosine and AmB-L create opportunities for improving CM treatment regimens. An induction regimen of flucytosine and AmB-D for seven days is less costly than standard care in the settings studied here. As this regimen has also been shown to be more effective than current standard care, countries should prioritize scaling up flucytosine access. The cost of AmB-L based regimens is highly dependent on the price of AmB-L, which currently remains unclear.
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Affiliation(s)
- Bruce Larson
- Global Health, Boston University School of Public Health, Boston, MA, 02118, USA
- Health Economics and Epidemiology Research Office, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Charles Muthoga
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Rita Oladele
- College of Medicine, Univerity of Lagos, Lagos, Nigeria
| | - Radha Rajasingham
- Division of Infectious Diseases & International Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Alexander Jordan
- Mycotic Diseases Branch, Centers for Disease Controls and Prevention, Atlanta, Georgia, USA
| | - Joseph N. Jarvis
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Tom M. Chiller
- Mycotic Diseases Branch, Centers for Disease Controls and Prevention, Atlanta, Georgia, USA
| | - Nelesh P. Govender
- National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa
- University of Witwatersrand, Johannesburg, South Africa
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Chen YC, Kuo SF, Lin SY, Lin YS, Lee CH. Epidemiological and Clinical Characteristics, Antifungal Susceptibility, and MLST-Based Genetic Analysis of Cryptococcus Isolates in Southern Taiwan in 2013-2020. J Fungi (Basel) 2022; 8:jof8030287. [PMID: 35330289 PMCID: PMC8951076 DOI: 10.3390/jof8030287] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 03/09/2022] [Accepted: 03/10/2022] [Indexed: 02/04/2023] Open
Abstract
Cryptococcal meningoencephalitis (CM) is a treatable condition, but it leads to excessive morbidity and mortality. We collected 115 non-duplicated Cryptococcus clinical isolates during 2013−2020 in southern Taiwan to perform antifungal susceptibility testing. Multi-locus sequence typing was performed on 96 strains from patients with CM (n = 47) or cryptococcemia (n = 49). In addition, the epidemiological and clinical characteristics of patients with CM during 2013−2020 (n = 47) were compared with those during 2000−2010 (n = 46). During 2013−2020, only one C. neoformans isolate (0.9%) had a fluconazole minimum inhibitory concentration of >8 μg/mL. Amphotericin B (AMB), flucytosine (5FC), and voriconazole were highly active against all C. neoformans/C. gattii isolates. The most common sequence type was ST5. Among these 47 patients with CM, cerebrospinal fluid cryptococcal antigen (CSF CrAg) titer >1024 was a significant predictor of death (odds ratio, 48.33; 95% CI, 5.17−452.06). A standard induction therapy regimen with AMB and 5FC was used for all patients during 2013−2020, but only for 2.2% of patients in 2000−2010. The in-hospital CM mortality rate declined from 39.1% during 2000−2010 to 25.5% during 2013−2020, despite there being significantly younger patients with less CSF CrAg >1024 during 2000−2010. The study provides insight into the genetic epidemiology and antifungal susceptibility of Cryptococcus strains in southern Taiwan. The recommended antifungal drugs, AMB, 5FC, and FCZ, remained active against most of the Cryptococcus strains. Early diagnosis of patients with CM and adherence to the clinical practice guidelines cannot be overemphasized to improve the outcomes of patients with CM.
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Affiliation(s)
- Yi-Chun Chen
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 83301, Taiwan; (Y.-C.C.); (Y.-S.L.)
| | - Shu-Fang Kuo
- Department of Laboratory Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 83301, Taiwan;
- Department of Medical Biotechnology and Laboratory Sciences, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
| | - Shang-Yi Lin
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung 80756, Taiwan;
- Department of Laboratory Medicine, Kaohsiung Medical University Hospital, Kaohsiung 80756, Taiwan
- College of Medicine, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
| | - Yin-Shiou Lin
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 83301, Taiwan; (Y.-C.C.); (Y.-S.L.)
| | - Chen-Hsiang Lee
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 83301, Taiwan; (Y.-C.C.); (Y.-S.L.)
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
- Correspondence: ; Tel.: +886-7-7317123 (ext. 8304); Fax: +886-7-7-7322402
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Khaba MC, Kgole MB, Nevondo LM, Van Aswegen WJ, Mabelane T, Makhado NA. Disseminated Cryptococcal Infection in HIV-Infected Patients: A Retrospective Clinicopathological Review of 4 Autopsy Cases. CLINICAL PATHOLOGY (THOUSAND OAKS, VENTURA COUNTY, CALIF.) 2022; 15:2632010X221078234. [PMID: 35237754 PMCID: PMC8883375 DOI: 10.1177/2632010x221078234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 01/14/2022] [Indexed: 11/16/2022]
Abstract
Cryptococcosis is an opportunistic infection with high mortality if not diagnosed and treated in time. The objective of this study was to review the clinicopathological information of decendents with final autopsy diagnosis of disseminated cryptococcal infection. This study collected data from 4 decendents who presented to an academic hospital/laboratory between 1 January 2015 to 31 December 2018. Their clinical, radiological and pathological findings including treatment were reviewed. Two decendents presented with respiratory symptoms whilst the other 2 presented with meningeal symptoms. Three were confirmed HIV positive. One decendent was on ART, one had defaulted treatment and one was ART naïve. Two decendents were diagnosed with cryptococcal meningitis, one with bacterial pneumonia and one with pulmonary tuberculosis. Three decendents died in emergency unit and one in the ward whilst on antifungal therapy. The autopsy findings confirmed disseminated cryptococcal infection in all cases. A high index of suspicion should be maintained in the right clinical context. Multi-organ involvement should be suspected in all patients and be actively sought out.
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Affiliation(s)
- Moshawa Calvin Khaba
- Department of Anatomical Pathology, Dr George Mukhari Academic Laboratory, National Health Laboratory Service, Sefako Makgatho Health Sciences University, Ga-Rankuwa, South Africa
| | - Mamokoma Becky Kgole
- Department of Internal Medicine, Dr George Mukhari Academic Hospital, Sefako Makgatho Health Sciences University, Ga-Rankuwa, South Africa
| | - Lesedi Makgwethele Nevondo
- Department of Anatomical Pathology, Dr George Mukhari Academic Laboratory, National Health Laboratory Service, Sefako Makgatho Health Sciences University, Ga-Rankuwa, South Africa
| | - Willem Johannes Van Aswegen
- Department of Internal Medicine, Dr George Mukhari Academic Hospital, Sefako Makgatho Health Sciences University, Ga-Rankuwa, South Africa
| | - Tshegofatso Mabelane
- Department of Family Medicine, Job Shimankana Tabane Hospital, Sefako Makgatho Health Sciences University, Ga-Rankuwa, South Africa
| | - Ndivhuho Agnes Makhado
- Department of Medical Microbiology, Dr George Mukhari Academic Laboratory, National Health Laboratory Services, Sefako Makgatho Health Sciences University, Ga-Rankuwa, South Africa
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Case report: Disseminated cryptococcus gattii in an immunocompetent patient. IDCases 2022; 29:e01537. [PMID: 35761795 PMCID: PMC9233227 DOI: 10.1016/j.idcr.2022.e01537] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 06/08/2022] [Accepted: 06/13/2022] [Indexed: 11/23/2022] Open
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17
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Khaba MC, Ngale TC, Makhado NA. Fungal infection of the central nervous system: Autopsy analysis of six cases. SAGE Open Med Case Rep 2022; 10:2050313X221122419. [PMID: 36105784 PMCID: PMC9465580 DOI: 10.1177/2050313x221122419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 08/05/2022] [Indexed: 11/16/2022] Open
Abstract
Fungal infections of the central nervous system are fatal and rare clinical
entities observable in immunosuppressed patients from varying causes. They carry
higher risks of morbidities and mortality as compared to viral, bacterial or
parasitic central nervous system infections. This study describes
clinicopathological description of the central nervous system fungal infections
with antemortem diagnostic challenges. This is a 9-year retrospective study of
six cases composed of three females and three males with a mean age of
29.3 years. All six decedents presented with signs of meningeal irritation. They
all suffered from immunodeficiency of varying causes. The gross and microscopic
features revealed cryptococcosis, candidiasis and mucormycosis as the cause of
the central nervous system infection. Early diagnosis and appropriate medical
treatment are of paramount importance in improving the overall survival of
patients with central nervous system mycosis. A few autopsy cases with fungal
infection of the central nervous system have been described; therefore, more
autopsies studies are needed to re-enforce on the existing epidemiology of these
fatal infections. Moreover, this will assist in further elucidating the varying
gross features and tissue reaction patterns associated with them.
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18
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OUP accepted manuscript. Lab Med 2022; 53:614-618. [DOI: 10.1093/labmed/lmac037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Hurt WJ, Harrison TS, Molloy SF, Bicanic TA. Combination Therapy for HIV-Associated Cryptococcal Meningitis-A Success Story. J Fungi (Basel) 2021; 7:1098. [PMID: 34947080 PMCID: PMC8708058 DOI: 10.3390/jof7121098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 12/16/2021] [Accepted: 12/17/2021] [Indexed: 11/17/2022] Open
Abstract
Cryptococcal meningitis is the leading cause of adult meningitis in patients with HIV, and accounts for 15% of all HIV-related deaths in sub-Saharan Africa. The mainstay of management is effective antifungal therapy, despite a limited arsenal of antifungal drugs, significant progress has been made developing effective treatment strategies by using combination regimens. The introduction of fluconazole as a safe and effective step-down therapy allowed for shorter courses of more fungicidal agents to be given as induction therapy, with higher doses achieving more rapid CSF sterilisation and improved treatment outcomes. The development of early fungicidal activity (EFA), an easily measured surrogate of treatment efficacy, has enabled rapid identification of effective combinations through dose ranging phase II studies, allowing further evaluation of clinical benefit in targeted phase III studies. Recent clinical trials have shown that shorter course induction regimens using one week of amphotericin paired with flucytosine are non-inferior to traditional two-week induction regimens and that the combination of fluconazole and flucytosine offers a viable treatment alternative when amphotericin is unavailable. Access to drugs in many low and middle-income settings remains challenging but is improving, and novel strategies based on single high dose liposomal amphotericin B promise further reduction in treatment complications and toxicities. This review aims to summarise the key findings of the principal clinical trials that have led to the success story of combination therapy thus far.
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Affiliation(s)
- William J. Hurt
- Institute of Infection & Immunity, St George’s University London, London SW17 0RE, UK; (T.S.H.); (S.F.M.); (T.A.B.)
| | - Thomas S. Harrison
- Institute of Infection & Immunity, St George’s University London, London SW17 0RE, UK; (T.S.H.); (S.F.M.); (T.A.B.)
- Clinical Academic Group in Infection & Immunity, St George’s University Hospitals NHS Trust, London SW17 0QT, UK
- The MRC Centre of Medical Mycology, University of Exeter, Stocker Road, Exeter EX4 4QD, UK
| | - Síle F. Molloy
- Institute of Infection & Immunity, St George’s University London, London SW17 0RE, UK; (T.S.H.); (S.F.M.); (T.A.B.)
| | - Tihana A. Bicanic
- Institute of Infection & Immunity, St George’s University London, London SW17 0RE, UK; (T.S.H.); (S.F.M.); (T.A.B.)
- Clinical Academic Group in Infection & Immunity, St George’s University Hospitals NHS Trust, London SW17 0QT, UK
- The MRC Centre of Medical Mycology, University of Exeter, Stocker Road, Exeter EX4 4QD, UK
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20
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Makhubela VG, Khaba MC. Mycotic Pseudotumor of the Breast Secondary to Cryptococcal Infection: Report of Three Rare Cases and Literature Review. Int J Surg Pathol 2021; 30:432-436. [PMID: 34806476 DOI: 10.1177/10668969211060483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Breast masses in clinical practice are often investigated primarily for neoplastic conditions. Breast fungal infections are unusual, and few cases have been reported in the literature. The differential diagnosis for a breast mass should not be limited to neoplastic conditions as there are treatment implications. The correct diagnosis is associated with reduced and unwanted cases of surgical intervention. We describe 3 cases of cryptococcal infection of the breast that clinically masqueraded as breast malignancies.
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Larson B, Shroufi A, Muthoga C, Oladele R, Rajasingham R, Jordan A, Jarvis JN, Chiller TM, Govender NP. Induction-phase treatment costs for cryptococcal meningitis in high HIV-burden African countries: New opportunities with lower costs. Wellcome Open Res 2021; 6:140. [PMID: 35706922 PMCID: PMC9184925 DOI: 10.12688/wellcomeopenres.16776.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/25/2021] [Indexed: 11/20/2022] Open
Abstract
Introduction: Access to and the cost of induction treatment for cryptococcal meningitis (CM) is rapidly changing. The newly-announced price for flucytosine ($0.75 per 500 mg pill) and possibly lower prices for liposomal amphotericin B (AmB-L) create opportunities to reduce CM treatment costs compared to the current standard treatment in low- and middle-income countries. Methods: We developed an Excel-based cost model to estimate health system treatment costs for CM over a two-week induction phase for multiple treatment combinations, newly feasible with improved access to flucytosine and AmB-L. CM treatment costs include medications, laboratory tests and other hospital-based costs (bed-day costs and healthcare worker time). We report results from applying the model using country-specific information for South Africa, Uganda, Nigeria, and Botswana. Results: A 14-day induction-phase of seven days of inpatient AmB-D with flucytosine, followed by seven days of high-dose fluconazole as an outpatient, will cost health systems less than a 14-day hospital stay with AmB-D and fluconazole. If daily AmB-L replaces AmB-D for those with baseline renal dysfunction, with a cost of $50 or less per 50 mg vial, incremental costs would still be less than the AmB-D with fluconazole regimen. Simple oral combinations (e.g., seven days of flucytosine with fluconazole as an inpatient) are practical when AmB-D is not available, and treatment costs would remain less than the current standard treatment. Conclusions: Improved access to, and lower prices for flucytosine and AmB-L create opportunities for improving CM treatment regimens. An induction regimen of flucytosine and AmB-D for seven days is less costly than standard care in the settings studied here. As this regimen has also been shown to be more effective than current standard care, countries should prioritize scaling up flucytosine access. The cost of AmB-L based regimens is highly dependent on the price of AmB-L, which currently remains unclear.
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Affiliation(s)
- Bruce Larson
- Global Health, Boston University School of Public Health, Boston, MA, 02118, USA
- Health Economics and Epidemiology Research Office, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Charles Muthoga
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Rita Oladele
- College of Medicine, Univerity of Lagos, Lagos, Nigeria
| | - Radha Rajasingham
- Division of Infectious Diseases & International Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Alexander Jordan
- Mycotic Diseases Branch, Centers for Disease Controls and Prevention, Atlanta, Georgia, USA
| | - Joseph N. Jarvis
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Tom M. Chiller
- Mycotic Diseases Branch, Centers for Disease Controls and Prevention, Atlanta, Georgia, USA
| | - Nelesh P. Govender
- National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa
- University of Witwatersrand, Johannesburg, South Africa
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22
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Naicker SD, Magobo RE, Maphanga TG, Firacative C, van Schalkwyk E, Monroy-Nieto J, Bowers J, Engelthaler DM, Shuping L, Meyer W, Govender NP. Genotype, Antifungal Susceptibility, and Virulence of Clinical South African Cryptococcus neoformans Strains from National Surveillance, 2005-2009. J Fungi (Basel) 2021; 7:jof7050338. [PMID: 33925754 PMCID: PMC8146981 DOI: 10.3390/jof7050338] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 04/02/2021] [Accepted: 04/06/2021] [Indexed: 01/04/2023] Open
Abstract
In South Africa, Cryptococcus neoformans is the most common cause of adult meningitis. We performed multi locus sequence typing and fluconazole susceptibility testing of clinical C. neoformans isolates collected from 251 South African patients with cryptococcosis through national surveillance from 2005 to 2009. We examined the association between clinical characteristics of patients and genotype, and the effect of genotype on in-hospital mortality. We performed whole genome phylogenetic analysis of fifteen C. neoformans isolates with the molecular type VNB and tested their virulence in a Galleria mellonella model. Most isolates had the molecular type VNI (206/251, 82%), followed by VNII (25/251, 10%), VNB (15/251, 6%), and VNIV (5/251, 2%); 67 sequence types were identified. There were no differences in fluconazole minimum inhibitory concentration (MIC) values among molecular types and the majority of strains had low MIC values (MIC50 of 1 µg/mL and MIC90 of 4 µg/mL). Males were almost twice as likely of being infected with a non-VNI genotype (adjusted odds ratio [OR]: 1.65, 95% confidence interval [CI]: 0.25–10.99; p = 0.61). Compared to patients infected with a VNI genotype, those with a non-VNI genotype had a 50% reduced adjusted odds of dying in hospital (95% CI: 0.03–7.57; p = 0.62). However, for both these analyses, our estimates had wide confidence intervals spanning 1 with large p-values. Fifteen VNB strains were not as virulent in a G. mellonella larval model as the H99 reference strain. A majority of these VNB strains belonged to the VNBII clade and were very closely related by phylogenetic analysis.
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Affiliation(s)
- Serisha D. Naicker
- Center for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses, National Institute for Communicable Diseases, A Division of the National Health Laboratory Service, Johannesburg 2192, South Africa; (R.E.M.); (T.G.M.); (E.v.S.); (L.S.); (N.P.G.)
- School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 2001, South Africa
- Correspondence: ; Tel.: +27-11-555-0491
| | - Rindidzani E. Magobo
- Center for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses, National Institute for Communicable Diseases, A Division of the National Health Laboratory Service, Johannesburg 2192, South Africa; (R.E.M.); (T.G.M.); (E.v.S.); (L.S.); (N.P.G.)
| | - Tsidiso G. Maphanga
- Center for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses, National Institute for Communicable Diseases, A Division of the National Health Laboratory Service, Johannesburg 2192, South Africa; (R.E.M.); (T.G.M.); (E.v.S.); (L.S.); (N.P.G.)
| | - Carolina Firacative
- Studies in Translational Microbiology and Emerging Diseases (MICROS) Research Group, School of Medicine and Health Sciences, Universidad del Rosario, 111611 Bogota, Colombia;
| | - Erika van Schalkwyk
- Center for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses, National Institute for Communicable Diseases, A Division of the National Health Laboratory Service, Johannesburg 2192, South Africa; (R.E.M.); (T.G.M.); (E.v.S.); (L.S.); (N.P.G.)
| | - Juan Monroy-Nieto
- Pathogen and Microbiome Division, Translational Genomics Research Institute, Phoenix, AZ 85004, USA; (J.M.-N.); (J.B.); (D.M.E.)
| | - Jolene Bowers
- Pathogen and Microbiome Division, Translational Genomics Research Institute, Phoenix, AZ 85004, USA; (J.M.-N.); (J.B.); (D.M.E.)
| | - David M. Engelthaler
- Pathogen and Microbiome Division, Translational Genomics Research Institute, Phoenix, AZ 85004, USA; (J.M.-N.); (J.B.); (D.M.E.)
| | - Liliwe Shuping
- Center for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses, National Institute for Communicable Diseases, A Division of the National Health Laboratory Service, Johannesburg 2192, South Africa; (R.E.M.); (T.G.M.); (E.v.S.); (L.S.); (N.P.G.)
| | - Wieland Meyer
- Molecular Mycology Research Laboratory, Center for Infectious Diseases and Microbiology, Westmead Clinical School, Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW 2006, Australia;
- Marie Bashir Institute for Emerging Infectious Diseases and Biosecurity, University of Sydney, Sydney, NSW 2006, Australia
- Westmead Institute for Medical Research, Westmead, NSW 2145, Australia
- Research and Educational Network, Westmead Hospital, Western Sydney Local Health District, Westmead, NSW 2145, Australia
| | - Nelesh P. Govender
- Center for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses, National Institute for Communicable Diseases, A Division of the National Health Laboratory Service, Johannesburg 2192, South Africa; (R.E.M.); (T.G.M.); (E.v.S.); (L.S.); (N.P.G.)
- School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 2001, South Africa
- Division of Medical Microbiology, Faculty of Health Sciences, University of Cape Town, Cape Town 7701, South Africa
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Miot J, Leong T, Takuva S, Parrish A, Dawood H. Cost-effectiveness analysis of flucytosine as induction therapy in the treatment of cryptococcal meningitis in HIV-infected adults in South Africa. BMC Health Serv Res 2021; 21:305. [PMID: 33823842 PMCID: PMC8025344 DOI: 10.1186/s12913-021-06268-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Accepted: 03/10/2021] [Indexed: 02/05/2023] Open
Abstract
Background Cryptococcal meningitis in HIV-infected patients in sub-Saharan Africa accounts for three-quarters of the global cases and 135,000 deaths per annum. Current treatment includes the use of fluconazole and amphotericin B. Recent evidence has shown that the synergistic use of flucytosine improves efficacy and reduces toxicity, however affordability and availability has hampered access to flucytosine in many countries. This study investigated the evidence and cost implications of introducing flucytosine as induction therapy for cryptococcal meningitis in HIV-infected adults in South Africa. Methods A decision analytic cost-effectiveness and cost impact model was developed based on survival estimates from the ACTA trial and local costs for flucytosine as induction therapy in HIV-infected adults with cryptococcal meningitis in a public sector setting in South Africa. The model considered five treatment arms: (a) standard of care; 2-week course amphotericin B/fluconazole (2wk AmBd/Flu), (b) 2-week course amphotericin B/flucytosine (2wk AmBd/5FC), (c) short course; 1-week course amphotericin B/flucytosine (1wk AmBd/5FC) (d) oral course; 2-week oral fluconazole/flucytosine (oral) and e) 1-week course amphotericin B/fluconazole (1wk AmBd/Flu). A sensitivity analysis was conducted on key variables. Results The highest total treatment costs are in the 2-week AmBd/5FC arm followed by the 2-week oral regimen, the 1-week AmBd/5FC, then standard of care with the lowest cost in the 1-week AmBd/Flu arm. Compared to the lowest cost option the 1-week flucytosine course is most cost-effective at USD119/QALY. The cost impact analysis shows that the 1-week flucytosine course has an incremental cost of just over USD293 per patient per year compared to what is currently spent on standard of care. Sensitivity analyses suggest that the model is most sensitive to life expectancy and hospital costs, particularly infusion costs and length of stay. Conclusions The addition of flucytosine as induction therapy for the treatment of cryptococcal meningitis in patients infected with HIV is cost-effective when it is used as a 1-week AmBd/5FC regimen. Savings could be achieved with early discharge of patients as well as a reduction in the price of flucytosine.
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Affiliation(s)
- Jacqui Miot
- Health Economics and Epidemiology Research Office, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
| | - Trudy Leong
- National Department of Health, Affordable Medicines Directorate, Essential Drugs Programme, Pretoria, South Africa
| | - Simbarashe Takuva
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,School of Health Systems and Public Health, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | - Andrew Parrish
- Department of Internal Medicine, Cecilia Makiwane Hospital, East London, South Africa
| | - Halima Dawood
- Department of Medicine, Greys Hospital, Pietermaritzburg, KwaZulu-Natal, South Africa.,Caprisa, University of KwaZulu-Natal, Durban, South Africa
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Cryptococcal Immune Reconstitution Inflammatory Syndrome: From Blood and Cerebrospinal Fluid Biomarkers to Treatment Approaches. Life (Basel) 2021; 11:life11020095. [PMID: 33514007 PMCID: PMC7912256 DOI: 10.3390/life11020095] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 01/20/2021] [Accepted: 01/23/2021] [Indexed: 12/31/2022] Open
Abstract
Immune reconstitution inflammatory syndrome (IRIS) presents as an exaggerated immune reaction that occurs during dysregulated immune restoration in immunocompromised patients in late-stage human immunodeficiency virus (HIV) infection who have commenced antiretroviral treatments (ART). Virtually any opportunistic pathogen can provoke this type of immune restoration disorder. In this review, we focus on recent developments in the identification of risk factors for Cryptococcal IRIS and on advancements in our understanding of C-IRIS immunopathogenesis. We overview new findings in blood and cerebrospinal fluid which can potentially be useful in the prediction and diagnosis of cryptococcal meningitis IRIS (CM-IRIS). We assess current therapeutic regimens and novel treatment approaches to combat CM-IRIS. We discuss the utility of biomarkers for clinical monitoring and adjusting treatment modalities in acquired immunodeficiency syndrome (AIDS) patients co-infected with Cryptococcus who have initiated ART.
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25
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Mkoko P, Du Preez J, Naidoo S. Intracranial pressure management in patients with human immunodeficiency virus-associated cryptococcal meningitis in a resource-constrained setting. South Afr J HIV Med 2021; 21:1171. [PMID: 33391836 PMCID: PMC7756785 DOI: 10.4102/sajhivmed.v21i1.1171] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 10/20/2020] [Indexed: 11/30/2022] Open
Abstract
Background Cryptococcal meningitis (CCM) is the leading cause of meningitis in people living with HIV (PLWH) in sub-Saharan Africa (SSA). The mortality and morbidity associated with CCM remain high. Combination of antifungal therapy, diligent management of intracranial pressure (IP) and the correct timing of the introduction of antiretroviral therapy (ART) minimise the risk of mortality and morbidity. The absence of spinal manometers in many healthcare centres in SSA challenges the accurate measurement of cerebrospinal fluid (CSF) pressure and its control. Objectives We hypothesised that four lumbar punctures (LPs) in the first week of the diagnosis and treatment of CCM would reduce IP such that in-hospital mortality and morbidity of HIV-associated CCM (HIV/CCM) would be significantly reduced. Methods We conducted a retrospective study to assess whether receipt of four or more LPs in the first week of the diagnosis and treatment with combination antifungal therapy of HIV/CCM would be associated with the reduction of in-hospital mortality in adult PLWH. Results From 01 January 2016 to 31 December 2016, 116 adult patients were admitted to the Dora Nginza District Hospital in Zwide, Port Elizabeth, South Africa. After exclusion of 11 (two were younger than 18 years, two had missing hospital records and seven demised or left the hospital before 7 days of hospitalisation), 105 patients were included in the analysis. The mean age was 39.4 (standard deviation [s.d.] ± 9.7) years, 64.8% were male. All were PLWH. A total of 52.4% had defaulted ART and 25.7% were ART naïve. Forty-three patients received four or more LPs (mean = 4.58 [± 0.96]) in the first week of hospitalisation with an associated in-hospital mortality of 11.6% (n = 5/43) compared with 62 patients who received less than four LPs (mean = 2.18 [± 0.80]) with an in-hospital mortality of 29% (n = 18/62) and a relative risk of 0.80 (95% CI, 0.66–0.97), p = 0.034. Conclusion In the current study of adult PLWH presenting to hospital with HIV/CCM, four or more LPs in the first 7 days following admission and the initiation of treatment were associated with a 17.4% reduction in absolute risk of in-hospital mortality and a 20% reduction in relative risk of in-hospital mortality. This mortality difference was noted in patients who survived and were in hospital at the time of the 7-day study census and persisted until the time of hospital discharge.
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Affiliation(s)
- Philasande Mkoko
- Department of Medicine, Division of Cardiology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.,Department of Medicine, Dora Nginza Hospital, Port Elizabeth, South Africa
| | - Jessica Du Preez
- Department of Medicine, Dora Nginza Hospital, Port Elizabeth, South Africa
| | - Senlika Naidoo
- Department of Medicine, Dora Nginza Hospital, Port Elizabeth, South Africa.,Department of Medicine, Livingstone Hospital, Port Elizabeth, South Africa
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HIV-associated Cryptococcal Meningitis: a Review of Novel Short-Course and Oral Therapies. CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2020. [DOI: 10.1007/s40506-020-00239-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Abstract
Purpose of review
HIV-associated cryptococcal meningitis remains a significant public health problem in parts of Africa and Asia and a major cause of AIDS-related mortality, accounting for 15% of all AIDS-related deaths worldwide. Cryptococcal meningitis is uniformly fatal if untreated, and access to antifungal therapy in regions with the highest burden is often limited. Outcomes with fluconazole monotherapy are poor, and induction treatment with amphotericin B and high-dose fluconazole for 2 weeks is associated with significant drug-related toxicities and prolonged hospital admissions. This review focuses on the potential of novel short-course and oral combination therapies for cryptococcal meningitis.
Recent findings
Recent clinical trials have shown that shorter courses of amphotericin, if paired with oral flucytosine, rather than fluconazole, can achieve non-inferior mortality outcomes. In addition, an oral combination of fluconazole and flucytosine is a potential alternative. Liposomal amphotericin B may further simplify treatment; it is associated with fewer drug-related toxicities, and a recent phase II randomised controlled trial demonstrated that a single, high dose of liposomal amphotericin is non-inferior to 14 standard daily doses at clearing Cryptococcus from cerebrospinal fluid. This has been taken forward to an ongoing phase III, clinical endpoint study.
Summary
The incidence and mortality associated with cryptococcal meningitis is still unacceptably high. There is evidence supporting the use of short-course amphotericin B and oral combination antifungal treatment regimens for cryptococcal meningitis (CM). Ongoing research into short-course, high-dose treatment with liposomal amphotericin may also help reduce the impact of this devastating disease.
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Greene G, Lawrence DS, Jordan A, Chiller T, Jarvis JN. Cryptococcal meningitis: a review of cryptococcal antigen screening programs in Africa. Expert Rev Anti Infect Ther 2020; 19:233-244. [PMID: 32567406 DOI: 10.1080/14787210.2020.1785871] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Cryptococcal meningitis remains a significant contributor to AIDS-related mortality despite widened access to antiretroviral therapy. Cryptococcal antigen (CrAg) can be detected in the blood prior to development of meningitis. Development of highly sensitive and specific rapid diagnostic CrAg tests has helped facilitate the adoption of CrAg screening programs in 19 African countries. AREAS COVERED The biological rationale for CrAg screening and the programmatic strategies for its implementation are reviewed. We describe the approach to the investigation of patients with cryptococcal antigenemia and the importance of lumbar puncture to identify individuals who may have cryptococcal meningitis in the absence of symptoms. The limitations of current treatment recommendations and the potential role of newly defined combination antifungal therapies are discussed. A literature review was conducted using a broad database search for cryptococcal antigen screening and related terms in published journal articles dating up to December 2019. Conference abstracts, publicly available guidelines, and project descriptions were also incorporated. EXPERT OPINION As we learn more about the risks of cryptococcal antigenemia, it has become clear that the current management paradigm is inadequate. More intensive investigation and management are required to prevent the development of cryptococcal meningitis and reduce mortality associated with cryptococcal antigenemia.
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Affiliation(s)
- Greg Greene
- Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses, National Institute for Communicable Diseases, a Division of the NHLS , Johannesburg, South Africa.,Department of Clinical Research, Faculty of Infectious & Tropical Diseases, London School of Hygiene and Tropical Medicine , London, UK
| | - David S Lawrence
- Department of Clinical Research, Faculty of Infectious & Tropical Diseases, London School of Hygiene and Tropical Medicine , London, UK.,Botswana Harvard AIDS Institute Partnership , Gaborone, Botswana
| | - Alex Jordan
- Mycotic Diseases Branch, Centers for Disease Control and Prevention , Atlanta, USA
| | - Tom Chiller
- Mycotic Diseases Branch, Centers for Disease Control and Prevention , Atlanta, USA
| | - Joseph N Jarvis
- Department of Clinical Research, Faculty of Infectious & Tropical Diseases, London School of Hygiene and Tropical Medicine , London, UK.,Botswana Harvard AIDS Institute Partnership , Gaborone, Botswana
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28
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Naicker SD, Mpembe RS, Maphanga TG, Zulu TG, Desanto D, Wadula J, Mvelase N, Maluleka C, Reddy K, Dawood H, Maloba M, Govender NP. Decreasing fluconazole susceptibility of clinical South African Cryptococcus neoformans isolates over a decade. PLoS Negl Trop Dis 2020; 14:e0008137. [PMID: 32231354 PMCID: PMC7108701 DOI: 10.1371/journal.pntd.0008137] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 02/11/2020] [Indexed: 02/07/2023] Open
Abstract
Background Fluconazole is used in combination with amphotericin B for induction treatment of cryptococcal meningitis and as monotherapy for consolidation and maintenance treatment. More than 90% of isolates from first episodes of cryptococcal disease had a fluconazole minimum inhibitory concentration (MIC) ≤4 μg/ml in a Gauteng population-based surveillance study of Cryptococcus neoformans in 2007–2008. We assessed whether fluconazole resistance had emerged in clinical cryptococcal isolates over a decade. Methodology and principal findings We prospectively collected C. neoformans isolates from 1 January through 31 March 2017 from persons with a first episode of culture-confirmed cryptococcal disease at 37 South African hospitals. Isolates were phenotypically confirmed to C. neoformans species-complex level. We determined fluconazole MICs (range: 0.125 μg/ml to 64 μg/ml) of 229 C. neoformans isolates using custom-made broth microdilution panels prepared, inoculated and read according to Clinical and Laboratory Standards Institute M27-A3 and M60 recommendations. These MIC values were compared to MICs of 249 isolates from earlier surveillance (2007–2008). Clinical data were collected from patients during both surveillance periods. There were more males (61% vs 39%) and more participants on combination induction antifungal treatment (92% vs 32%) in 2017 compared to 2007–2008. The fluconazole MIC50, MIC90 and geometric mean MIC was 4 μg/ml, 8 μg/ml and 4.11 μg/ml in 2017 (n = 229) compared to 1 μg/ml, 2 μg/ml and 2.08 μg/ml in 2007–2008 (n = 249) respectively. Voriconazole, itraconazole and posaconazole Etests were performed on 16 of 229 (7%) C. neoformans isolates with a fluconazole MIC value of ≥16 μg/ml; only one had MIC values of >32 μg/ml for these three antifungal agents. Conclusions and significance Fluconazole MIC50 and MIC90 values were two-fold higher in 2017 compared to 2007–2008. Although there are no breakpoints, higher fluconazole doses may be required to maintain efficacy of standard treatment regimens for cryptococcal meningitis. Cryptococcus neoformans, a pathogenic fungal species-complex with an environmental niche, is the most common cause of meningitis among HIV-seropositive adults in sub-Saharan Africa. Fluconazole is recommended in combination with amphotericin B for induction treatment of cryptococcal meningitis and as monotherapy for consolidation and maintenance treatment. Fluconazole is also commonly prescribed to HIV-seropositive individuals for other indications; fluconazole exposure may result in secondary resistance if patients have concurrent active cryptococcal disease. Azole fungicides used in agriculture may potentially drive primary cryptococcal resistance when the fungus is exposed to these fungicides in the environment. We aimed to determine fluconazole MICs in 2017 and compare these values to those obtained in a 2007–2008 South African survey to assess whether fluconazole resistance had emerged in C. neoformans over a decade. We found that the proportion of isolates with an MIC of ≥16 μg/ml increased from 0% in 2007–2008 to 7% in 2017. MIC50 and MIC90 values were also two-fold higher in 2017 compared to 2007–2008. These study findings provided evidence for higher fluconazole dose recommendations (in combination with amphotericin B for the induction phase and as monotherapy for consolidation and maintenance phases) in the 2019 Southern African guideline for HIV-associated cryptococcosis.
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Affiliation(s)
- Serisha D. Naicker
- National Institute for Communicable Diseases (Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses), a Division of the National Health Laboratory Service, Johannesburg, South Africa
- School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- * E-mail:
| | - Ruth S. Mpembe
- National Institute for Communicable Diseases (Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses), a Division of the National Health Laboratory Service, Johannesburg, South Africa
| | - Tsidiso G. Maphanga
- National Institute for Communicable Diseases (Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses), a Division of the National Health Laboratory Service, Johannesburg, South Africa
- Department of Medical Microbiology, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa
| | - Thokozile G. Zulu
- National Institute for Communicable Diseases (Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses), a Division of the National Health Laboratory Service, Johannesburg, South Africa
| | - Daniel Desanto
- National Institute for Communicable Diseases (Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses), a Division of the National Health Laboratory Service, Johannesburg, South Africa
- School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Jeannette Wadula
- National Health Laboratory Service, Microbiology Laboratory, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa
| | - Nomonde Mvelase
- National Health Laboratory Service, Department of Medical Microbiology, RK Khan Hospital, Durban, South Africa
| | - Caroline Maluleka
- National Health Laboratory Service, Microbiology Laboratory, Dr George Mukhari Academic Hospital, Pretoria, South Africa
| | - Kessendri Reddy
- National Health Laboratory Service, Microbiology Laboratory, Tygerberg Academic Hospital, Cape Town, South Africa
| | - Halima Dawood
- National Health Laboratory Service, Microbiology Laboratory, Edendale Hospital, Pietermaritzburg, South Africa
| | - Motlatji Maloba
- National Health Laboratory Service, Department of Medical Microbiology, Universitas Academic Laboratory Complex, Bloemfontein, South Africa
| | - Nelesh P. Govender
- National Institute for Communicable Diseases (Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses), a Division of the National Health Laboratory Service, Johannesburg, South Africa
- School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Division of Medical Microbiology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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