Pharmacokinetics and safety of coformulated bictegravir, emtricitabine, and tenofovir alafenamide in children aged 2 years and older with virologically suppressed HIV: a phase 2/3, open-label, single-arm study

BACKGROUND

Coformulated bictegravir, emtricitabine, and tenofovir alafenamide is a single-tablet regimen and was efficacious and well tolerated in children and adolescents with HIV (aged 6 years to <18 years) in a 48-week phase 2/3 trial. In this study, we report data from children aged at least 2 years and weighing 14 kg to less than 25 kg.

METHODS

We conducted this open-label, multicentre, multicohort, single-arm study in South Africa, Thailand, Uganda, and the USA. Participants were virologically suppressed children with HIV, aged at least 2 years, weighing 14 kg to less than 25 kg. Participants received bictegravir (30 mg), emtricitabine (120 mg), and tenofovir alafenamide (15 mg) once daily, switching to bictegravir (50 mg), emtricitabine (200 mg), and tenofovir alafenamide (25 mg) upon attaining a bodyweight of at least 25 kg. The study included pharmacokinetic evaluation at week 2 to confirm the dose of coformulated bictegravir, emtricitabine, and tenofovir alafenamide for this weight band by comparing with previous adult data. Primary outcomes were bictegravir area under the curve over the dosing interval (AUCtau) and concentration at the end of the dosing interval (Ctau) at week 2, and incidence of treatment-emergent adverse events and laboratory abnormalities until the end of week 24 in all participants who received at least one dose of bictegravir, emtricitabine, and tenofovir alafenamide. This study is registered with ClinicalTrials.gov, NCT02881320.

FINDINGS

Overall, 22 participants were screened (from Nov 14, 2018, to Jan 11, 2020), completed treatment with bictegravir, emtricitabine, and tenofovir alafenamide (until week 48), and entered an extension phase. The geometric least squares mean (GLSM) ratio for AUCtau for bictegravir was 7·6% higher than adults (GLSM ratio 107·6%, 90% CI 96·7-119·7); Ctau was 34·6% lower than adults (65·4%, 49·1-87·2). Both parameters were within the target exposure range previously found in adults, children, or both". Grade 3-4 laboratory abnormalities occurred in four (18%) participants by the end week 24 and six (27%) by the end of week 48. Drug-related adverse events occurred in three participants (14%) by the end of week 24 and week 48; none were severe. No Grade 3-4 adverse events, serious adverse events, or adverse events leading to discontinuation occurred by the end of week 24 and week 48.

INTERPRETATION

Data support the use of single-tablet coformulated bictegravir (30 mg), emtricitabine (120 mg), and tenofovir alafenamide (15 mg) for treatment of HIV in children aged at least 2 years and weighing 14 kg to less than 25 kg.

FUNDING

Gilead Sciences.

Fixed-dose combination bictegravir, emtricitabine, and tenofovir alafenamide in adolescents and children with HIV: week 48 results of a single-arm, open-label, multicentre, phase 2/3 trial

BACKGROUND

Bictegravir is a potent integrase strand-transfer inhibitor (INSTI) with a high genetic barrier to resistance. Bictegravir, coformulated with emtricitabine and tenofovir alafenamide, is recommended by key European and US HIV treatment guidelines as the preferred single-tablet regimen for adults and adolescents. The aim of this study was to assess the pharmacokinetics, safety, and efficacy of switching to this regimen in virologically suppressed children and adolescents with HIV.

METHODS

In this single-arm, open-label trial, we enrolled virologically suppressed children and adolescents (aged 6 to <18 years) with HIV at 22 hospital clinics in South Africa, Thailand, Uganda, and the USA. Eligible participants had a bodyweight of at least 25 kg, were virologically suppressed (HIV-1 RNA <50 copies per mL) on a stable ART regimen for at least 6 months before screening, had a CD4 count of at least 200 cells per μL, and an estimated glomerular filtration rate of at least 90 mL/min per 1·73 m² by the Schwartz formula at screening. All participants received the fixed-dose regimen of coformulated bictegravir 50 mg, emtricitabine 200 mg, and tenofovir alafenamide 25 mg once daily. Pharmacokinetic analysis was used for dosing confirmation, and results compared with adult values. The primary outcomes were area under the curve at the end of the dosing interval (AUC_tau) and concentration at the end of the dosing interval (C_tau) of bictegravir, and incidence of treatment-emergent adverse events and laboratory abnormalities at week 24. Efficacy and safety analyses included all participants who received at least one dose of study drug. We report the 48-week results. This study is registered with ClinicalTrials.gov, NCT02881320.

FINDINGS

Between Sept 29, 2016 and Feb 16, 2018, we enrolled 102 participants. 100 participants received bictegravir, emtricitabine, and tenofovir alafenamide (cohort 1 [adolescents aged 12 to <18 years], n=50; cohort 2 [children aged 6 to <12 years], n=50). The mean bictegravir AUC_tau was 89 100 ng × h/mL (coefficient of variation 31·0%) in adolescents (cohort 1) and 128 000 ng × h/mL (27·8%) in children (cohort 2). Compared with adults, bictegravir C_tau was 35% lower in adolescents and 11% lower in children. The 90% CIs of both parameters were within the predefined pharmacokinetic equivalence boundary and within overall range of exposures observed in adults and deemed to be safe and efficacious (geometric least-squares mean ratio [GLSM] 86·3% [90% CI 80·0-93·0] for AUC_tau and 65·4% [58·3-73·3] for C_tau in adolescents; GLSM 125% [90% CI 117-134] for AUC_tau and 88·9% [80·6-98·0] for C_tau for children). Bictegravir, emtricitabine, and tenofovir alafenamide was well tolerated; most adverse events were grade 2 or less in severity and no study drug-related serious adverse events were reported. One participant discontinued study drug due to adverse events (grade 2 insomnia and anxiety). Virological suppression (HIV-1 RNA <50 copies per mL) was maintained by all 100 participants at week 24 and by 98 (98%) of 100 at week 48; no participants had treatment-emergent resistance.

INTERPRETATION

In adolescents and children with HIV, the bictegravir, emtricitabine, and tenofovir alafenamide single-tablet regimen was well tolerated and maintained virological suppression. Our data support the treatment of HIV in adolescents and children with this single-tablet regimen. At present, the single-tablet regimen is recommended as first-line treatment in the USA for adolescents and as an alternative regimen in children and has the potential to represent an important regimen in the paediatric population.

FUNDING

Gilead Sciences.

SARS-CoV-2-associated multisystem inflammatory syndrome in children: clinical manifestations and the role of infliximab treatment

This study was conducted to assess the clinical spectrum, management, and outcome of SARS-CoV-2-related multisystem inflammatory syndrome in children (MIS-C). We reviewed medical records of children with MIS-C diagnosis seen at the Children's Hospital of Michigan in Detroit between April and June 2020. Thirty-three children were identified including 22 who required critical care (group 1) and 11 with less intense inflammation (group 2). Children in group 1 were older (median 7.0 years) than those in group 2 (median 2.0 years). Abdominal pain was present in 68% of patients in group 1. Hypotension or shock was present in 17/22 patients in group 1. Thirteen (39.4%) had Kawasaki disease (KD)-like manifestations. Five developed coronary artery dilatation; All resolved on follow-up. Intravenous immunoglobulin (IVIG) was given to all patients in group 1 and 7/11 in group 2. Second-line therapy was needed in 13/22 (group 1) for persisting inflammation or myocardial dysfunction; 12 received infliximab. All patients recovered.Conclusion: MIS-C clinical manifestations may overlap with KD; however, MIS-C is likely a distinct inflammatory process characterized by reversible myocardial dysfunction and rarely coronary artery dilatation. Supportive care, IVIG, and second-line therapy with infliximab were associated with a favorable outcome. What is Known: • Multisystem inflammatory syndrome in children (MIS-C) manifestations include fever, gastrointestinal symptoms, shock, and occasional features of Kawasaki disease (KD). • Treatment includes immunomodulatory agents, most commonly IVIG and corticosteroids. What is New: • Spectrum of MIS-C varies from mild to severe inflammation and coronary artery dilatation occurred in 5/22 (23%) critically ill patients. • IVIG and infliximab therapy were associated with a favorable outcome including resolution of coronary dilatation; only 2/33 received corticosteroids.

Dermatological postoperative patient information leaflets: is it time for more uniformity?

INTRODUCTION

Patient information leaflets (PILs) are an important source of information for patients postoperatively. There are currently no nationally agreed standards by dermatologists for postoperative advice following skin surgery.

AIM

To assess the common themes and areas of variation in advice given in PILs after skin surgery across all National Health Service (NHS) hospitals in England and Wales.

METHODS

All acute trusts in England (n = 159) and local health boards in Wales (n = 7) were requested to provide their postoperative dermatological PILs for general sutured wound care or excision biopsy. Eight preselected parameters were assessed: minimum dressing duration, duration of pressing on a bleeding wound, postoperative analgesia, explanation of infection signs, application of petroleum jelly, scarring, whom to contact if there is a problem, and the recommended postoperative time for abstaining from active exercise.

RESULTS

PILs were received from 137 different dermatology departments belonging to 127/166 (76.5%) organisations across England and Wales. Of these, 102 PILs gave a specific duration for dressings: 45/102 (44.1%) advised a minimum of 48 h, but 28/102 (27.5%) recommended leaving dressings in place until suture removal. Regarding duration of pressing on a bleeding wound, 117 PILs gave advice, with the most common recommendation being 15 min (30/117, 25.6%), followed closely by 10 min (26/117, 22.2%). Of the 137 PILs received, 125 gave advice regarding postoperative analgesia, with paracetamol alone being the most common recommendation (24/125, 19.2%). For the remaining parameters, 111/137 (81.0%) PILs described ≥ 2 signs of infection, 42/137 (30.7%) recommended the application of petroleum jelly, 65/137 (47.4%) mentioned scarring, 137/137 (100%) highlighted whom to contact if there were postoperative problems and 87/137 (63.5%) PILs gave advice regarding postoperative abstinence from active exercise.

CONCLUSIONS

The advice given in dermatology postoperative PILs across England and Wales is highly variable. A nationally agreed template or set of postoperative advice should be considered to improve consistency.

An Outbreak of Carbapenem-Resistant Acinetobacter baumannii Infection in a Neonatal Intensive Care Unit: Investigation and Control

Objective.

To investigate the mode of transmission of and assess control measures for an outbreak of carbapenem-resistant (multidrug-resistant) Acinetobacter baumannii infection involving 6 premature infants.

Design.

An outbreak investigation based on medical record review was performed for each neonate during the outbreak (from November 2008 through January 2009) in conjunction with an infection control investigation.

Setting.

A 36-bed, level 3 neonatal intensive care unit in a university-affiliated teaching hospital in Detroit, Michigan.

Interventions.

Specimens were obtained for surveillance cultures from all infants in the unit. In addition, geographic cohorting of affected infants and their nursing staff, contact isolation, re-emphasis of adherence to infection control practices, environmental cleaning, and use of educational modules were implemented to control the outbreak.

Results.

Six infants (age, 10-197 days) with multidrug-resistant A. baumannii infection were identified. All 6 infants were premature (gestational age, 23-30 weeks) and had extremely low birth weights (birth weight, 1000 g or less). Conditions included conjunctivitis (2 infants), pneumonia (4 infants), and bacteremia (1 infant). One infant died of causes not attributed to infection with the organism; the remaining 5 infants were discharged home. All surveillance cultures of unaffected infants yielded negative results.

Conclusions.

The spread of multidrug-resistant A. baumannii infection was suspected to be due to staff members who spread the pathogen through close contact with infants. Clinical staff recognition of the importance of multidrug-resistant A. baumannii recovery from neonatal intensive care unit patients, geographic cohorting of infected patients, enhanced infection control practices, and staff education resulted in control of the spread of the organism.

The impact of ethanol lock therapy on length of stay and catheter salvage in pediatric catheter-associated bloodstream infection

BACKGROUND

Ethanol lock therapy (ELT) with systemic antimicrobial therapy (SAT) is a treatment for catheter-associated bloodstream infections (CABSI). However, its impact on hospital length of stay (LOS) is unknown.

OBJECTIVES

Assess the impact of ELT on LOS, LOS attributable to CABSI (ALOS), and catheter salvage in pediatric hematology, oncology, stem cell transplant (HOSCT) CABSI.

METHODS

Retrospective review of HOSCT CABSI from January 2009 to July 2011.

RESULTS

A total of 124 CABSI episodes were reviewed in 66 patients. Mean LOS with ELT after 1 positive blood culture (BC) was 7.1 versus 12.3 days after ≥2 positive BC (P = .014). Mean ALOS was 1.6 days with ELT versus 2.9 days without ELT (P = .018). Mean ALOS with ELT after 1 positive BC was 3.75 days versus 5.8 days after ≥2 positive BC (P = .022). Catheter salvage rate: 41 of 48 (85%) with ELT versus 49 of 68 (72%) without ELT (P = .169).

CONCLUSION

Earlier initiation of ELT may decrease ALOS.

How appropriate is the WHOQOL-BREF for assessing the quality of life of adolescents?

BACKGROUND

Using mixed-methods research, we investigated whether the adult version of the WHOQOL-BREF was acceptable and feasible to use with adolescents (13-19), and what features might need to be changed to develop it. Differences from young adults quality of life (QoL) (20-30 years) could add justification.

METHODS

Preliminary psychometric properties of the adult WHOQOL-BREF were examined in 208 adolescents and 204 young adults. Unhealthy adolescents diagnosed with acne or elevated depressive symptoms (CES-D) were compared with healthy adolescents. Cognitive interviewing used 'think aloud' techniques with six healthy adolescents during WHOQOL-BREF completion. Concepts and wording were thematically analysed for relevance, comprehension and comprehensiveness.

RESULTS

Little data were missing from the WHOQOL-BREF suggesting some feasibility and acceptability to adolescents. Compared with adults, adolescents perceived greater access to information, a better home environment, worse pain, and medication dependency. Internal consistency reliability for adolescents was good (α = .89), especially psychological and environmental QoL. Content validity especially for social and environment domains was supported. Domains validly discriminated between high- and low-depressive symptoms but not acne groups. Additional new facets on autonomy, altruism and physical fitness and changed item contents are proposed.

CONCLUSION

The evidence indicates that developing a new adolescent version is justifiable. Cross-cultural research should build on these preliminary findings.

Detection of respiratory coinfections in pediatric patients using a small volume polymerase chain reaction array respiratory panel: more evidence for combined droplet and contact isolation

BACKGROUND

In fall 2009, Children's Hospital of Michigan (CHM) instituted combined isolation precautions (contact and droplet isolation) for pediatric inpatients with upper respiratory infection (URI) symptoms to prevent health care-associated infection.

METHODS

Pediatric patients with symptoms of URI had nasopharyngeal (NP) swab samples obtained prospectively between January and April and September and December 2010 for small volume polymerase chain reaction (SVPCR) array respiratory panel (RP) multiplex nucleic acid testing. NP swabs or nasal washes were obtained for viral culture and rapid antigen testing (RAT).

RESULTS

Of 499 evaluable SVPCR array RP samples, 344 (69%) tested positive for at least 1 of the 21 tested organisms. The most commonly identified pathogen was rhinovirus/enterovirus (181/344 [53%]) for which no RAT exists at CHM. Of 344 positive specimens, 57 (17%) had at least 2 identified pathogens; 8 (2%) of these had 3. In 11% of patients, molecular testing detected pathogens or pathogen combinations requiring both contact and droplet precautions.

CONCLUSION

SVPCR array RP testing detected respiratory pathogens in pediatric patients with URI at rates higher than that of RAT and viral culture. Because of the pathogens and pathogen combinations detected, the study findings suggest that combined contact and droplet isolation precautions may be warranted to prevent health care-associated infection in pediatric inpatients with URI. Further studies will be needed to confirm these results.

Staphylococcal scalded skin syndrome in a preterm newborn presenting within first 24 h of life

A preterm neonate was noted to have diffuse blanching erythema around the mouth followed by appearance of bullous lesions on the upper back, lower neck and right scapular areas at 23 h of life. The bullae subsequently ruptured leaving an extremely tender, erythematous, denuded area of the skin, which extended over next few hours to involve most of the upper back and right shoulder regions. Nikolsky sign was positive. Clinical diagnosis of staphylococcal scalded skin syndrome was made. The throat, blood, urine and cerebrospinal fluid cultures did not yield any growth, but wound culture was positive for Staphylococcus aureus. Treatment included administration of intravenous fluids and vancomycin for 10 days. The wound area was covered with vaseline and sterile gauge dressings. On day 5 of life, epithelialisation began and was complete on the seventh day of life. She was discharged home with intact skin, without scars, on day 12 of life.

Short-dwell ethanol lock therapy in children is associated with increased clearance of central line-associated bloodstream infections

BACKGROUND

Central line-associated bloodstream infection (CLABSI) is a known complication of central line use. Salvage of infected central lines with ethanol lock therapy (ELT) with systemic antimicrobials may be an alternative treatment option in children.

METHODS

Retrospective review was performed in children with CLASBI who underwent short-dwell ELT (70% ethanol, 4- to 25-hour dwell times ≤3 days) with systemic antimicrobials from January 1, 2007 to July 15, 2009.

RESULTS

A total of 59 patients, aged 2 months to 19 years (mean ± SD = 6.3 ± 6.1 years) with 80 episodes of CLABSI were included. The CLABSI eradication rate was 86% (69/80 episodes; 95% confidence interval [CI] 78%, 94%), significantly greater than 50% (Z = 2.35, P < .05), the estimated clearance rate of CLABSI eradication using systemic antimicrobials alone. Overall central line retention was 78% (60/77 episodes, 95% CI 69%, 87%). ELT was well tolerated.

CONCLUSIONS

These findings suggest the potential benefit of short-dwell ELT combined with systemic antimicrobials in CLABSI treatment. Randomized controlled trials are needed.

A prospective trial of the effects of isotretinoin on quality of life and depressive symptoms

BACKGROUND

Isotretinoin is an efficacious treatment for acne, but has been controversially linked with depression.

OBJECTIVES

This study aimed to examine the effects of isotretinoin on quality of life(QoL) and depression using a prospective design.

METHODS

The WHOQOL-BREF QoL measure and Centre for Epidemiological Studies Depression Scale were administered to consecutive outpatients with acne who were prescribed either isotretinoin (n = 65) or antibiotic treatment (n = 31).Patients and physicians rated acne severity independently. Groups were compared at baseline with a matched community sample (n = 94) and measurements repeated at 3 months for treatment groups.

RESULTS

There were no differences between the three groups at baseline in terms of age, gender, depression or overall QoL. Acne was more severe in the treatment groups (P < 0·001). Depression was negatively correlated with QoL (P < 0·001)and hence was included as a covariate in repeated-measures analyses of QoL.Acne improved over time in both treatment groups (F = 48·2, P < 0·001). There was no detectable deterioration in depression score in either group (F = 1·1, not significant). QoL in the physical and social domains improved (P < 0·001) while psychological and environmental QoL was unchanged over time. The improvement in social QoL was greater in the isotretinoin group (P < 0·05). Those patients with higher baseline depression scores showed greater improvements in physical, psychological and social QoL (P < 0·001).

CONCLUSIONS

Treatment of acne improves QoL, particularly in those with more depressive symptoms at the outset. Mood deterioration was not detected, but the possibility of subtle or rare mood effects of isotretinoin cannot be ruled out.

Nosocomial infections and multidrug-resistant bacterial organisms in the pediatric intensive care unit

Nosocomial infections in Pediatric Intensive Care Units (PICUs) caused by multidrug-resistant bacterial organisms are increasing. This review attempts to report on significant findings in the current literature related to nosocomial infections in PICU settings with an international perspective. The types of nosocomial infections are addressed, including catheter-related bloodstream infections, ventilator-associated pneumonia, urinary tract infections, gastrointestinal infections and post-surgical wound infections. A review of emerging resistant bacterial pathogens includes methicillin-resistant Staphylococcus aureus, vancomycin-resistant Enterococcus sp., Clostridium difficile, extended-spectrum β-lactamase producing Gram-negative organisms, Klebsiella pneumoniae carbapenemase-producing strains and multi-drug resistant Acinetobacter baumannii. Basic and enhanced infection control methods for the management and control of multidrug-resistant organisms are also summarized with an emphasis on prevention.

Quantification of wound oedema after dermatological surgery

BACKGROUND

Postoperative wound oedema causing increased suture tension is thought to be a possible cause of scars known as suture marks. Quantification of such oedema has not previously been reported in the literature. Measures to accommodate wound oedema may include the adoption of alternative suture techniques and the use of more elastic suture materials.

OBJECTIVES

To quantify wound expansion after skin surgery and to identify any contributory factors, and to determine the ability of eight commonly used skin suture materials to stretch under increasing tension.

METHODS

Forty consecutive adult patients attending a dermatology department for routine skin surgery in December 2002 were recruited. Details including body site, nature of the lesion excised and dimensions of the open wound were recorded. The distance between entry and exit points of an untied suture at the time of skin surgery was measured and then repeated 24 h postoperatively. The ability of eight different suture materials to stretch when an increasing force was applied was measured by hanging standard weights from the sutures and measuring the suture length for each force applied.

RESULTS

Thirty-nine patients completed the study. All wounds expanded postoperatively, with a mean lateral expansion of 1.0 mm. There was a strong association between the width of the unsutured wound after excision and the subsequent wound expansion. Commonly used sutures in skin surgery were found to be relatively inelastic at forces under 0.2 kg. The monofilament Novofil (Davis & Geck, Danbury, CT, U.S.A.) exhibited the greatest degree of stretch of those tested.

CONCLUSIONS

There is considerable oedema in the first 24 h after skin surgery, particularly with wider excisions. This needs to be considered when choosing suturing materials and techniques to avoid excessive suture tension.

[Implantation of a "pan-cameral" intraocular lens in Africa]

In modern medicine, extraction of the cataractous lens is followed by implantation of an artificial intraocular lens. The 2 main types of intraocular lenses, the anterior and the posterior chamber types, are essentially different in design. We present here 11 cases in which, due to lack of facilities, we were compelled to implant posterior chamber intraocular lenses in the anterior chamber of the eye. Postoperatively, visual acuity improved in 82% of the operated eyes.

Recognition of pneumonia by primary health care workers in Swaziland with a simple clinical algorithm

In developing countries primary health care workers are being trained to manage and treat acute respiratory infections with a protocol developed by the WHO. We tested the ability of nurses and nursing assistants in Swaziland to recognise the signs and symptoms of pneumonia; with the results of a paediatrician's examination as "gold standard", sensitivities and specificities were calculated. Danger signs of stridor and abnormal sleepiness were poorly recognised (sensitivity 0-50%) by the health care workers, as was audible wheeze. Severe undernutrition, tachypnoea, and chest wall indrawing were well recognised. Overall, the recognition of pneumonia was good (sensitivity 71-83%, specificity 84-85%). These findings highlight topics for emphasis in training.

Standardized diagnosis of pneumonia in developing countries

The World Health Organization recommends the use of raised respiratory rate and chest wall indrawing to enable health workers in developing countries to diagnose pneumonia. We evaluated the current World Health Organization guidelines for management of the child with cough or difficult breathing in Manila, Philippines and Mbabane, Swaziland using an identical protocol in both countries. Raised respiratory rate was defined as greater than or equal to 50/minute for children ages 2 to 12 months and greater than or equal to 40/minute for children 12 months to 5 years. Chest wall indrawing was defined as inward movement of the bony structures of the lower chest wall with inspiration. In the Philippines raised respiratory rate or chest wall indrawing, when applied by a pediatrician, was found to have a sensitivity of 0.81 and specificity of 0.77 for predicting pneumonia as determined by a pediatrician with the aid of a chest roentgenogram. In Swaziland the sensitivity was 0.77 and the specificity was 0.80. When applied by health workers the sensitivity was similar but the specificity was lower. The current World Health Organization ARI case management guidelines predicted pneumonia with similar sensitivity and specificity in two very different developing countries, the Philippines and Swaziland.