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Jensen TO, Grandits GA, Jain MK, Murray TA, Grund B, Shaw-Saliba K, Matthay MA, Abassi M, Ardelt M, Baker JV, Chen P, Dewar RL, Goodman AL, Hatlen TJ, Highbarger HC, Holodniy M, Lallemand P, Laverdure S, Leshnower BG, Looney D, Moschopoulos CD, Mugerwa H, Murray DD, Mylonakis E, Nagy-Agren S, Rehman MT, Rupert A, Stevens RA, Turville S, Weintrob A, Wick K, Lundgren J, Ko ER. Effect of Neutralizing Monoclonal Antibody Treatment on Early Trajectories of Virologic and Immunologic Biomarkers in Patients Hospitalized With COVID-19. J Infect Dis 2024; 229:671-679. [PMID: 37948759 PMCID: PMC10938202 DOI: 10.1093/infdis/jiad446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 10/06/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND Neutralizing monoclonal antibodies (nmAbs) failed to show clear benefit for hospitalized patients with coronavirus disease 2019 (COVID-19). Dynamics of virologic and immunologic biomarkers remain poorly understood. METHODS Participants enrolled in the Therapeutics for Inpatients with COVID-19 trials were randomized to nmAb versus placebo. Longitudinal differences between treatment and placebo groups in levels of plasma nucleocapsid antigen (N-Ag), anti-nucleocapsid antibody, C-reactive protein, interleukin-6, and D-dimer at enrollment, day 1, 3, and 5 were estimated using linear mixed models. A 7-point pulmonary ordinal scale assessed at day 5 was compared using proportional odds models. RESULTS Analysis included 2149 participants enrolled between August 2020 and September 2021. Treatment resulted in 20% lower levels of plasma N-Ag compared with placebo (95% confidence interval, 12%-27%; P < .001), and a steeper rate of decline through the first 5 days (P < .001). The treatment difference did not vary between subgroups, and no difference was observed in trajectories of other biomarkers or the day 5 pulmonary ordinal scale. CONCLUSIONS Our study suggests that nmAb has an antiviral effect assessed by plasma N-Ag among hospitalized patients with COVID-19, with no blunting of the endogenous anti-nucleocapsid antibody response. No effect on systemic inflammation or day 5 clinical status was observed. CLINICAL TRIALS REGISTRATION NCT04501978.
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Affiliation(s)
- Tomas O Jensen
- Centre of Excellence for Health, Immunity, and Infections, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Greg A Grandits
- Division of Biostatistics, University of Minnesota, Minneapolis, Minnesota, USA
| | - Mamta K Jain
- Southwestern Medical Center, University of Texas, Dallas, Texas USA
| | - Thomas A Murray
- Division of Biostatistics, University of Minnesota, Minneapolis, Minnesota, USA
| | - Birgit Grund
- School of Statistics, University of Minnesota, Minneapolis, Minnesota, USA
| | - Kathryn Shaw-Saliba
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Michael A Matthay
- Division of Pulmonary and Critical Care Medicine, University of California SanFrancisco, San Francisco, California, USA
| | - Mahsa Abassi
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Magdalena Ardelt
- Division of Pulmonary and Critical Care Medicine, University of California SanFrancisco, San Francisco, California, USA
| | - Jason V Baker
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, Minnesota, USA
- Division of Infectious Diseases, Hennepin Healthcare, Minneapolis, Minnesota, USA
| | - Peter Chen
- Women's Guild Lung Institute, Department of medicine and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Robin L Dewar
- Frederick National Laboratory for Cancer Research, Frederick, Maryland, USA
| | - Anna L Goodman
- Medical Research Council Clinical Trials Unit, University College London, London, United Kingdom
- Department of Infectious Diseases, Guy's and St Thomas’ National Health Service Foundation Trust, London, United Kingdom
| | - Timothy J Hatlen
- Lundquist Institute, Harbor-University of California Los Angeles Medical Center, Torrance, California, USA
| | | | - Mark Holodniy
- Department of Medicine, Infectious Diseases, Stanford University, Stanford, California, USA
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
| | - Perrine Lallemand
- Frederick National Laboratory for Cancer Research, Frederick, Maryland, USA
| | - Sylvain Laverdure
- Laboratory of Human Retrovirology and Immunoinformatics, Frederick National Laboratory for Cancer Research, Frederick, Maryland, USA
| | - Bradley G Leshnower
- Division of Cardiothoracic Surgery, Emory School of Medicine, Atlanta, Georgia, USA
| | - David Looney
- Division of Infectious Diseases and Global Public Health, University of California San Diego, San Diego, California, USA
| | | | | | - Daniel D Murray
- Centre of Excellence for Health, Immunity, and Infections, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | | | - Stephanie Nagy-Agren
- Salem Veterans Affairs Medical Center, Virginia, USA
- Virginia Tech Carilion School of Medicine, Virginia, USA
| | - M Tauseef Rehman
- Frederick National Laboratory for Cancer Research, Frederick, Maryland, USA
| | - Adam Rupert
- Frederick National Laboratory for Cancer Research, Frederick, Maryland, USA
| | - Randy A Stevens
- Frederick National Laboratory for Cancer Research, Frederick, Maryland, USA
| | - Stuart Turville
- The Kirby Institute, University of New South Wales, Sydney, Australia
| | - Amy Weintrob
- Infectious Diseases Section, Washington DC Veterans Affairs Medical Center, Washington, District of Columbia, USA
| | - Katherine Wick
- Department of Internal Medicine, University of California Davis, Davis, California, USA
| | - Jens Lundgren
- Centre of Excellence for Health, Immunity, and Infections, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Emily R Ko
- Division of General Internal Medicine, Department of Medicine, Duke University Health System, Durham, North Carolina, USA
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McHale TC, Boulware DR, Kasibante J, Ssebambulidde K, Skipper CP, Abassi M. Diagnosis and management of cryptococcal meningitis in HIV-infected adults. Clin Microbiol Rev 2023; 36:e0015622. [PMID: 38014977 PMCID: PMC10870732 DOI: 10.1128/cmr.00156-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2023] Open
Abstract
Cryptococcal meningitis is a leading cause of morbidity and mortality globally, especially in people with advanced HIV disease. Cryptococcal meningitis is responsible for nearly 20% of all deaths related to advanced HIV disease, with the burden of disease predominantly experienced by people in resource-limited countries. Major advancements in diagnostics have introduced low-cost, easy-to-use antigen tests with remarkably high sensitivity and specificity. These tests have led to improved diagnostic accuracy and are essential for screening campaigns to reduce the burden of cryptococcosis. In the last 5 years, several high-quality, multisite clinical trials have led to innovations in therapeutics that have allowed for simplified regimens, which are better tolerated and result in less intensive monitoring and management of medication adverse effects. One trial found that a shorter, 7-day course of deoxycholate amphotericin B is as effective as the longer 14-day course and that flucytosine is an essential partner drug for reducing mortality in the acute phase of disease. Single-dose liposomal amphotericin B has also been found to be as effective as a 7-day course of deoxycholate amphotericin B. These findings have allowed for simpler and safer treatment regimens that also reduce the burden on the healthcare system. This review provides a detailed discussion of the latest evidence guiding the clinical management and special circumstances that make cryptococcal meningitis uniquely difficult to treat.
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Affiliation(s)
- Thomas C. McHale
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - David R. Boulware
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - John Kasibante
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | - Caleb P. Skipper
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Mahsa Abassi
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
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Boulware DR, Atukunda M, Kagimu E, Musubire AK, Akampurira A, Tugume L, Ssebambulidde K, Kasibante J, Nsangi L, Mugabi T, Gakuru J, Kimuda S, Kasozi D, Namombwe S, Turyasingura I, Rutakingirwa MK, Mpoza E, Kigozi E, Muzoora C, Ellis J, Skipper CP, Matkovits T, Williamson PR, Williams DA, Fieberg A, Hullsiek KH, Abassi M, Dai B, Meya DB. Oral Lipid Nanocrystal Amphotericin B for Cryptococcal Meningitis: A Randomized Clinical Trial. Clin Infect Dis 2023; 77:1659-1667. [PMID: 37606364 PMCID: PMC10724459 DOI: 10.1093/cid/ciad440] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Indexed: 08/23/2023] Open
Abstract
BACKGROUND Amphotericin B is the gold standard treatment for severe mycoses. A new orally delivered, less-toxic formulation of amphotericin has been developed. METHODS In our randomized clinical trial, we tested oral lipid nanocrystal (LNC) amphotericin B (MAT2203, Matinas Biopharma) vs intravenous (IV) amphotericin for human immunodeficiency virus-associated cryptococcal meningitis in 4 sequential cohorts. Two pilot cohorts assessed safety and tolerability (n = 10 each), and 2 cohorts assessed efficacy with/without 2 IV loading doses (n = 40 each). The experimental arm received 1.8 g/d oral LNC amphotericin through 2 weeks with 100 mg/kg/d flucytosine, then 1.2 g/d LNC amphotericin through 6 weeks. The randomized control arm (n = 41) received 7 days of IV amphotericin with flucytosine, then 7 days of fluconazole 1200 mg/d. The primary end point was cerebrospinal fluid (CSF) early fungicidal activity (EFA). RESULTS We randomized 80 participants to oral LNC amphotericin + flucytosine with (n = 40) and without (n = 40) 2 IV loading doses and 41 control participants to IV amphotericin + flucytosine. Mean EFA was 0.40 log10 colony-forming units (CFU)/mL/d for all-oral LNC amphotericin, 0.42 log10 Cryptococcus CFU/mL/d for oral LNC amphotericin with IV loading doses, and 0.46 log10 CFU/mL/d for IV amphotericin controls. LNC amphotericin groups achieved 2-week CSF sterility in 63% (44 of 70) vs 68% (23 of 34) of controls. The 18-week survival was 85% (34 of 40) with all-oral LNC amphotericin, 90% (36 of 40) with oral LNC amphotericin given IV loading doses, and 85% (35 of 41) with IV amphotericin.Grade 3-4 laboratory adverse events occurred less frequently in LNC amphotericin groups (41%) than the IV amphotericin group (61%, P = .05), particularly for anemia (21% vs 44%; P = .01) and potassium (5% vs 17%; P = .04). CONCLUSIONS This new oral amphotericin B LNC formulation appears promising for cryptococcal meningitis with antifungal activity, similar survival, and less toxicity than IV amphotericin. CLINICAL TRIALS REGISTRATION NCT04031833.
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Affiliation(s)
- David R Boulware
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | | | - Enock Kagimu
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Abdu K Musubire
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | - 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, Maryland, USA
| | - John Kasibante
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Laura Nsangi
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Timothy Mugabi
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Jane Gakuru
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Sarah Kimuda
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Derrick Kasozi
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Suzan Namombwe
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | | | - Edward Mpoza
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Enos Kigozi
- Department of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Conrad Muzoora
- Department of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Jayne Ellis
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Caleb P Skipper
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | | | - Peter R Williamson
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Darlisha A Williams
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Ann Fieberg
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Kathy H Hullsiek
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Mahsa Abassi
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Biyue Dai
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - David B Meya
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
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Kasibante J, Irfanullah E, Wele A, Okafor E, Ssebambulidde K, Okurut S, Kagimu E, Gakuru J, Rutakingirwa MK, Mugabi T, Nuwagira E, Jjunju S, Mpoza E, Tugume L, Nsangi L, Musibire AK, Muzoora C, Rhein J, Meya DB, Boulware DR, Abassi M. Utility of Cerebrospinal Fluid Protein Levels as a Potential Predictive Biomarker of Disease Severity in HIV-Associated Cryptococcal Meningitis. medRxiv 2023:2023.12.10.23299793. [PMID: 38168371 PMCID: PMC10760268 DOI: 10.1101/2023.12.10.23299793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
Background Cerebrospinal fluid (CSF) protein levels exhibit high variability in HIV-associated cryptococcal meningitis from being normal to markedly elevated. However, the clinical implications of CSF protein levels in cryptococcal meningitis remain unclear. Methods We analysed data from 890 adults with HIV-associated cryptococcal meningitis randomized into two clinical trials in Uganda between 2015 and 2021. CSF protein was grouped into ≥100 mg/dL (n=249) and <100 mg/dL (n=641). We described baseline clinical variables and mortality by CSF protein levels. Results Approximately one-third of individuals had a baseline CSF protein ≥100 mg/dL. Those with CSF protein ≥100 mg/dL were more likely to present with Glasgow coma scale scores <15 (P<0.01), self-reported seizures at baseline (P=0.02), higher CD4 T-cells (p<0.001), and higher CSF white cells (p<0.001). Moreover, those with a baseline CSF protein ≥100 mg/dL also had a lower baseline CSF fungal burden (p<0.001) and a higher percentage of sterile CSF cultures at day 14 (p=0.02). Individuals with CSF protein ≥100 mg/dL demonstrated a more pronounced immune response consisting of upregulation of immune effector molecules pro-inflammatory cytokines, type-1 T-helper cell cytokines, type-3 chemokines, and immune-exhaustion marker (p<0.05). 18-week mortality risk in individuals with a CSF protein <100 mg/dL was 34% higher, (unadjusted Hazard Ratio 1.34; 95% CI, 1.05 to 1.70; p=0.02) than those with ≥100 mg/dL. Conclusion In cryptococcal meningitis, individuals with CSF protein ≥100 mg/dL more frequently presented with seizures, altered mental status, immune activation, and favourable fungal outcomes. Baseline CSF protein levels may serve as a surrogate marker of immune activation and prognosis.
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Affiliation(s)
- John Kasibante
- Infectious Diseases Institute, College of health sciences, Makerere University. P.O. Box 22418, Kampala, Uganda
| | - Eesha Irfanullah
- Division of Infectious Diseases & International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA
| | - Abduljewad Wele
- Division of Infectious Diseases & International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA
| | - Elizabeth Okafor
- Division of Infectious Diseases & International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA
| | - Kenneth Ssebambulidde
- Infectious Diseases Institute, College of health sciences, Makerere University. P.O. Box 22418, Kampala, Uganda
| | - Samuel Okurut
- Infectious Diseases Institute, College of health sciences, Makerere University. P.O. Box 22418, Kampala, Uganda
| | - Enock Kagimu
- Infectious Diseases Institute, College of health sciences, Makerere University. P.O. Box 22418, Kampala, Uganda
| | - Jane Gakuru
- Infectious Diseases Institute, College of health sciences, Makerere University. P.O. Box 22418, Kampala, Uganda
| | - Morris K. Rutakingirwa
- Infectious Diseases Institute, College of health sciences, Makerere University. P.O. Box 22418, Kampala, Uganda
| | - Timothy Mugabi
- Infectious Diseases Institute, College of health sciences, Makerere University. P.O. Box 22418, Kampala, Uganda
| | - Edwin Nuwagira
- Department of Medicine, Mbarara University of Science and Technology, P.O Box 1410, Mbarara, Uganda
| | - Samuel Jjunju
- Infectious Diseases Institute, College of health sciences, Makerere University. P.O. Box 22418, Kampala, Uganda
| | - Edward Mpoza
- Infectious Diseases Institute, College of health sciences, Makerere University. P.O. Box 22418, Kampala, Uganda
| | - Lillian Tugume
- Infectious Diseases Institute, College of health sciences, Makerere University. P.O. Box 22418, Kampala, Uganda
| | - Laura Nsangi
- Infectious Diseases Institute, College of health sciences, Makerere University. P.O. Box 22418, Kampala, Uganda
| | - Abdu K Musibire
- Infectious Diseases Institute, College of health sciences, Makerere University. P.O. Box 22418, Kampala, Uganda
| | - Conrad Muzoora
- Department of Medicine, Mbarara University of Science and Technology, P.O Box 1410, Mbarara, Uganda
| | - Joshua Rhein
- Division of Infectious Diseases & International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA
| | - David B. Meya
- Infectious Diseases Institute, College of health sciences, Makerere University. P.O. Box 22418, Kampala, Uganda
- Division of Infectious Diseases & International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA
| | - David R. Boulware
- Division of Infectious Diseases & International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA
| | - Mahsa Abassi
- Division of Infectious Diseases & International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA
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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: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [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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6
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Bahr NC, Skipper CP, Huppler-Hullsiek K, Ssebambulidde K, Morawski BM, Engen NW, Nuwagira E, Quinn CM, Ramachandran PS, Evans EE, Lofgren SM, Abassi M, Muzoora C, Wilson MR, Meya DB, Rhein J, Boulware DR. Recurrence of Symptoms Following Cryptococcal Meningitis: Characterizing a Diagnostic Conundrum With Multiple Etiologies. Clin Infect Dis 2023; 76:1080-1087. [PMID: 36303432 PMCID: PMC10226736 DOI: 10.1093/cid/ciac853] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 10/12/2022] [Accepted: 10/26/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Cryptococcal meningitis is a common cause of AIDS-related mortality. Although symptom recurrence after initial treatment is common, the etiology is often difficult to decipher. We sought to summarize characteristics, etiologies, and outcomes among persons with second-episode symptomatic recurrence. METHODS We prospectively enrolled Ugandans with cryptococcal meningitis and obtained patient characteristics, antiretroviral therapy (ART) and cryptococcosis histories, clinical outcomes, and cerebrospinal fluid (CSF) analysis results. We independently adjudicated cases of second-episode meningitis to categorize patients as (1) microbiological relapse, (2) paradoxical immune reconstitution inflammatory syndrome (IRIS), (3) persistent elevated intracranial pressure (ICP) only, or (4) persistent symptoms only, along with controls of primary cryptococcal meningitis. We compared groups with chi-square or Kruskal-Wallis tests as appropriate. RESULTS 724 participants were included (n = 607 primary episode, 81 relapse, 28 paradoxical IRIS, 2 persistently elevated ICP, 6 persistent symptoms). Participants with culture-positive relapse had lower CD4 (25 cells/μL; IQR: 9-76) and lower CSF white blood cell (WBC; 4 cells/μL; IQR: 4-85) counts than paradoxical IRIS (CD4: 78 cells/μL; IQR: 47-142; WBC: 45 cells/μL; IQR: 8-128). Among those with CSF WBC <5 cells/μL, 86% (43/50) had relapse. Among those with CD4 counts <50 cells/μL, 91% (39/43) had relapse. Eighteen-week mortality (from current symptom onset) was 47% among first episodes of cryptococcal meningitis, 31% in culture-positive relapses, and 14% in paradoxical IRIS. CONCLUSIONS Poor immune reconstitution was noted more often in relapse than IRIS as evidenced by lower CSF WBC and blood CD4 counts. These easily obtained laboratory values should prompt initiation of antifungal treatment while awaiting culture results. CLINICAL TRIALS REGISTRATION NCT01802385.
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Affiliation(s)
- Nathan C Bahr
- Division of Infectious Diseases, Department of Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Caleb P Skipper
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Kathy Huppler-Hullsiek
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | | | - Bozena M Morawski
- Cancer Data Registry of Idaho, Idaho Hospital Association, Boise, Idaho, USA
| | - Nicole W Engen
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Edwin Nuwagira
- Department of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Carson M Quinn
- Department of Neurology, Harvard Medical School, Boston, Massachusetts, USA
- Weill Institute of Neurosciences, Department of Neurology, University of California, San Francisco, San Francisco, California, USA
| | - Prashanth S Ramachandran
- Weill Institute of Neurosciences, Department of Neurology, University of California, San Francisco, San Francisco, California, USA
| | - Emily E Evans
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Sarah M Lofgren
- 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
| | - Michael R Wilson
- Weill Institute of Neurosciences, Department of Neurology, University of California, San Francisco, San Francisco, California, USA
| | - David B Meya
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Joshua Rhein
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - David R Boulware
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
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7
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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8
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Skipper CP, Hullsiek KH, Stadelman A, Williams DA, Ssebambulidde K, Okafor E, Tugume L, Nuwagira E, Akampurira A, Musubire AK, Abassi M, Muzoora C, Rhein J, Boulware DR, Meya DB. Sterile Cerebrospinal Fluid Culture at Cryptococcal Meningitis Diagnosis Is Associated with High Mortality. J Fungi (Basel) 2022; 9:46. [PMID: 36675867 PMCID: PMC9866844 DOI: 10.3390/jof9010046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 12/21/2022] [Accepted: 12/22/2022] [Indexed: 12/29/2022] Open
Abstract
Cryptococcus is the leading cause of AIDS-related meningitis in sub-Saharan Africa. The clinical implications of a sterile cerebrospinal fluid (CSF) culture among individuals diagnosed with cryptococcal meningitis using CSF cryptococcal antigen (CrAg) are unclear. We prospectively enrolled 765 HIV-positive Ugandans with first-episode cryptococcal meningitis from November 2010 to May 2017. All persons were treated with amphotericin-based induction therapy. We grouped participants by tertile of baseline CSF quantitative Cryptococcus culture burden and compared clinical characteristics, CSF immune profiles, and 18-week mortality. We found 55 (7%) CSF CrAg-positive participants with sterile CSF cultures. Compared to the non-sterile groups, participants with sterile CSF cultures had higher CD4 counts, lower CSF opening pressures, and were more frequently receiving ART. By 18 weeks, 47% [26/55] died in the sterile culture group versus 35% [83/235] in the low culture tertile, 46% [107/234] in the middle tertile, and 56% [135/241] in the high tertile (p < 0.001). The sterile group had higher levels of CSF interferon-gamma (IFN-γ), IFN-α, interleukin (IL)-6, IL-17, G-CSF, GM-CSF, and chemokine CXCL2 compared with non-sterile groups. Despite persons with sterile CSF cultures having higher CD4 counts, lower CSF opening pressures, and CSF cytokine profiles associated with better Cryptococcus control (e.g., IFN-γ predominant), mortality was similar to those with higher fungal burdens. This unexpected finding challenges the traditional paradigm that increasing CSF fungal burdens are associated with increased mortality but is consistent with a damage-response framework model.
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Affiliation(s)
- Caleb P Skipper
- Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA
- Infectious Diseases Institute, Makerere University, Kampala 7062, Uganda
| | | | - Anna Stadelman
- School of Public Health, University of Minnesota, Minneapolis, MN 55455, USA
| | - Darlisha A Williams
- Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA
- Infectious Diseases Institute, Makerere University, Kampala 7062, Uganda
| | | | - Elizabeth Okafor
- Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA
| | - Lillian Tugume
- Infectious Diseases Institute, Makerere University, Kampala 7062, Uganda
| | - Edwin Nuwagira
- Department of Medicine, Mbarara University of Science and Technology, Mbarara 1410, Uganda
| | - Andrew Akampurira
- Infectious Diseases Institute, Makerere University, Kampala 7062, Uganda
| | - Abdu K Musubire
- Infectious Diseases Institute, Makerere University, Kampala 7062, Uganda
| | - Mahsa Abassi
- Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA
- Infectious Diseases Institute, Makerere University, Kampala 7062, Uganda
| | - Conrad Muzoora
- Department of Medicine, Mbarara University of Science and Technology, Mbarara 1410, Uganda
| | - Joshua Rhein
- Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA
- Infectious Diseases Institute, Makerere University, Kampala 7062, Uganda
| | - David R Boulware
- Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA
| | - David B Meya
- Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA
- Infectious Diseases Institute, Makerere University, Kampala 7062, Uganda
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9
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Atukunda M, Kagimu E, Rutakingirwa MK, Tugume L, Nsangi L, Musubire A, Gakuru J, Mugabi T, Akampurira A, Ssebambulidde K, Kasibante J, Ellis J, Mpoza E, Williams DA, Fieberg AM, Skipper C, Abassi M, Hullsiek KH, Meya D, Boulware DR. 869. Oral Encochleated Amphotericin B for Cryptococcal Meningitis: a Phase II Randomized Trial. Open Forum Infect Dis 2022. [PMCID: PMC9752325 DOI: 10.1093/ofid/ofac492.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Background Intravenous (IV) amphotericin B is the gold standard treatment of severe mycoses. A new orally absorbed, less-toxic formulation of amphotericin has been developed (Matinas Biopharma). We evaluated the efficacy of this novel anti-fungal agent amongst adults with cryptococcal meningitis. Methods We conducted a phase II randomized clinical trial testing oral encochleated amphotericin B (cAMB) versus IV amphotericin B for first episode cryptococcal meningitis in Kampala, Uganda from December 2020 to August 2021. Participants were HIV-positive, CSF cryptococcal antigen (CrAg) positive, and had the capacity to consent and take oral medications (GCS=15). Participants in the experimental arm received two loading doses of either IV deoxycholate amphotericin B 1.0 mg/kg/day or liposomal amphotericin 3 mg/kg/day, followed by 1.8g oral cAMB daily in 6 divided doses through 2 weeks with flucytosine (5FC) at 100mg/kg/day, and thereafter cAMB at 1.2g daily in 4 divided doses through 6 weeks. Participants in the control arm received 7 days of IV amphotericin B (deoxycholate or liposomal) with 5FC, then 7 days of fluconazole 1200mg/day. After 14 days, all participants received fluconazole 800mg/day through 10 weeks and thereafter a maintenance dose of 200mg/day. Results We randomized 40 participants to oral cAMB + 5FC and 30 control participants to IV amphotericin + 5FC. With cAMB the 30-day survival was 97.5% (39/40) and 18-week survival was 90% (36/40) compared with 87% (26/30) 18-week survival in IV amphotericin controls. The CSF Early Fungicidal Activity (EFA) was lower with oral cAMB (mean EFA = 0.42 log10Cryptococcus CFU/mL/day; 95%CI, 0.29 to 0.54) versus IV amphotericin (mean EFA = 0.52 log10 CFU/mL/day; 95%CI, 0.39 to 0.66). Among those CSF culture positive at baseline, CSF sterility was achieved by 2 weeks in 65% (24/37) of cAMB participants and 68% (17/25) of controls. Grade >=3 laboratory adverse events were more common with IV amphotericin. Grade 3–4 anaemia occurred in 10% (n=4) with cAMB versus 37% (n=11) with IV amphotericin. Grade 3 hypokalaemia (< 3mEq/L) occurred in 5% (n=2) with cAMB versus 27% (n=8) with IV amphotericin. Conclusion Novel oral cAMB appears to be a safe agent with promising efficacy for HIV-related cryptococcal meningitis. Disclosures All Authors: No reported disclosures.
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Affiliation(s)
- Mucunguzi Atukunda
- Infectious Diseases Institute, Makerere University, Kampala, Kampala, Uganda
| | - Enock Kagimu
- Infectious Diseases Institute, Makerere University, Kampala, Kampala, Uganda
| | - Morris K Rutakingirwa
- Infectious diseases institute, College of health sciences, Makerere University, Kampala Uganda, Kampala, Kampala, Uganda
| | - Lillian Tugume
- Infectious Diseases Institute, Makerere University, Kampala, Kampala, Uganda
| | - Laura Nsangi
- Infectious Diseases Institute, Makerere University, Kampala, Kampala, Uganda
| | - Abdu Musubire
- Infectious Diseases Institute, Makerere University, Kampala, Kampala, Uganda
| | - Jane Gakuru
- Infectious Diseases Institute, Makerere University, Kampala, Kampala, Uganda
| | - Timothy Mugabi
- Infectious Diseases Institute, Makerere University, Kampala, Kampala, Uganda
| | - Andrew Akampurira
- Infectious Diseases Institute, Makerere University, Kampala, Kampala, Uganda
| | | | - John Kasibante
- Infectious Diseases Institute, Makerere University, Kampala, Kampala, Uganda
| | - Jayne Ellis
- Infectious Diseases Institute, Makerere University, Kampala, Kampala, Uganda
| | - Edward Mpoza
- Infectious Diseases Institute, Makerere University, Kampala, Kampala, Uganda
| | | | | | | | | | | | - David Meya
- Infectious Diseases Institute, Makerere University, Kampala, Kampala, Uganda
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10
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Lofgren SM, Velamakanni SS, Huppler Hullsiek K, Bangdiwala AS, Namudde A, Musubire AK, Mpoza E, Abassi M, Pastick KA, Nuwagira E, Evans EE, Rajsasingham R, Williams DA, Muzoora C, Creswell FV, Rhein J, Bond DJ, Nakasujja N, Meya DB, Boulware DR. A secondary analysis of depression outcomes from a randomized controlled trial of adjunctive sertraline for HIV-associated cryptococcal meningitis. Wellcome Open Res 2022. [DOI: 10.12688/wellcomeopenres.16363.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background: Depression is a risk factor for worse HIV outcomes in persons living with HIV/AIDS, including engagement-in-care, HIV medication adherence, and retention-in-care. Depression has a prevalence of more than three times as high as in the general population. Despite this, there are few randomized studies of antidepressants in HIV-infected Africans, including those with opportunistic infections. Methods: We enrolled 460 HIV-infected Ugandans with cryptococcal meningitis into a randomized clinical trial of adjunctive sertraline vs placebo (2015-2017). We defined depression using the Center for Epidemiologic Studies Depression Scale (CES-D) score of >15, and severe depression as >26 at one and three months after meningitis diagnosis and initiation of treatment. We evaluated the relationship between sertraline and depression, as well as associations with persistent depression, at three months. Results: At one- and three-months post meningitis diagnosis, 62% (108/174) and 44% (74/169) of all subjects had depression (CES>15), respectively. At three months, sertraline-treated subjects had consistent risk for depression as placebo-treated subjects but were significantly less likely to have severe depression (CES>26) (OR 0.335; 95%CI, 0.130-0.865). Of those with depression at one month, sertraline-treated subjects were less likely than placebo-treated subjects to be depressed at three months (p=0.05). Sertraline was the only factor we found significant in predicting persistent depression at three months among those with depression at one month. Conclusions: Depression is highly prevalent in HIV-infected persons who have survived cryptococcal meningitis. We found that sertraline is associated with a modest reduction in depression in those with depression at baseline and a significant decrease in severe depression.
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11
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Bourguiba F, Kacem H, Nasr S, Abassi M, Hlil E, Dhahri J, Taibi K, Belmabrouk H. Electrical and magnetic properties of 6H-BaTiO3−δ B site doped: The case of double cation couple (Fe3+Mo6+) and (Fe3+W6+). INORG CHEM COMMUN 2022. [DOI: 10.1016/j.inoche.2022.109882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Barkauskas C, Mylonakis E, Poulakou G, Young BE, Vock DM, Siegel L, Engen N, Grandits G, Mosaly NR, Vekstein AM, Rogers R, Shehadeh F, Kaczynski M, Mylona EK, Syrigos KN, Rapti V, Lye DC, Hui DS, Leither L, Knowlton KU, Jain MK, Marines-Price R, Osuji A, Overcash JS, Kalomenidis I, Barmparessou Z, Waters M, Zepeda K, Chen P, Torbati S, Kiweewa F, Sebudde N, Almasri E, Hughes A, Bhagani SR, Rodger A, Sandkovsky U, Gottlieb RL, Nnakelu E, Trautner B, Menon V, Lutaakome J, Matthay M, Robinson P, Protopapas K, Koulouris N, Kimuli I, Baduashvili A, Braun DL, Günthard HF, Ramachandruni S, Kidega R, Kim K, Hatlen TJ, Phillips AN, Murray DD, Jensen TO, Padilla ML, Accardi EX, Shaw-Saliba K, Dewar RL, Teitelbaum M, Natarajan V, Laverdure S, Highbarger HC, Rehman MT, Vogel S, Vallée D, Crew P, Atri N, Schechner AJ, Pett S, Hudson F, Badrock J, Touloumi G, Brown SM, Self WH, North CM, Ginde AA, Chang CC, Kelleher A, Nagy-Agren S, Vasudeva S, Looney D, Nguyen HH, Sánchez A, Weintrob AC, Grund B, Sharma S, Reilly CS, Paredes R, Bednarska A, Gerry NP, Babiker AG, Davey VJ, Gelijns AC, Higgs ES, Kan V, Matthews G, Argyraki K, Lourida P, Bakakos P, Vlachakos V, Balis E, Zakynthinos S, Sigala I, Gianniou N, Dima E, Magkouta S, Thompson BT, Synolaki E, Konstanta S, Vlachou M, Stathopoulou P, Panagopoulos P, Petrakis V, Papazoglou D, Tompaidou E, Isaakidou E, Leontis K, Legenne P, Nitsotolis T, Athanasiou K, Myrodia M, Kyriakoulis K, Trontzas I, Arfara-Melanini M, Kolonia V, Kityo C, Mugerwa H, Lukaakome J, Chandra R, Nsereko C, Lubega G, Kibirige M, Nakahima W, Wangi D, Aguti E, Generous L, Massa R, Nalaki M, Magala F, Lane HC, Nabaggala PK, Kityo C, Mugerwa H, Faith OD, Florence A, Emmanuel O, Beacham MP, Geoffrey A, Nakiboneka D, Apiyo P, Neaton JD, Kiweewa F, Kirenga B, Kimuli I, Atukunda A, Muttamba W, Remmy K, Segawa I, Pheona N, Kigere D, Mbabazi QL, Lundgren JD, Boersalino L, Nyakoolo G, Kiweewa F, Fred A, Alupo A, Ebong D, Monday E, Nalubwama RN, Kainja M, Ambrose M, Barkauskas C, Kwehayo V, Nalubega MG, Ongoli A, Obbo S, Alaba J, Magombe G, Tino H, Obonya E, Lutaakome J, Kitonsa J, Mylonakis E, Onyango M, Naboth T, Naluyinda H, Nanyunja R, Irene M, Jane B, Wimfred K, Leonar S, Deus T, Babra N, Poulakou G, Taire P, Lutaakone J, Nabankema E, Ogavu J, Mugerwa O, Okoth I, Mwebaze R, Mugabi T, Makhoba A, Arikiriza P, Young BE, Theresa N, Nakayima H, Frank K, Ramgi P, Pereira K, Osinusi A, Cao H, Stumpp M, Goncalves S, Ramanathan K, Vock DM, Baseler B, Holley HP, Jankelevich S, Adams A, Becker N, Dolney S, Hissey D, Simpson S, Kim MH, Beeler J, Siegel L, Harmon L, Asomah M, Jato Y, Stottlemyer A, Tang O, Vanderpuye S, Yeon L, Buehn M, Eccard-Koons V, Frary S, Engen N, MacDonald L, Cash J, Hoopengardner L, Linton J, Schaffhauser M, Nelson M, Spinelli-Nadzam M, Proffitt C, Lee C, Engel T, Grandits G, Fontaine L, Osborne C, Hohn M, Galcik M, Thompson D, Chang W, Sherman BT, Rupert AW, Baseler M, Lallemand P, Mosaly NR, Imamichi T, Paudel S, Cook K, Haupt K, Highbarger J, Hazen A, Badralmaa Y, Smith K, Patel B, Kubernac R, Vekstein AM, Hoover ML, Brown C, DuChateau N, Ellis S, Flosi A, Fox L, Johnson L, Nelson R, Stojanovic J, Treagus A, Rogers R, Wenner C, Williams R, Shehadeh F, Kaczynski M, Mylona EK, Syrigos KN, Rapti V, Lye DC, Hui DS, Leither L, Knowlton KU, Jain MK, Marines-Price R, Osuji A, Overcash JS, Kalomenidis I, Barmparessou Z, Waters M, Zepeda K, Chen P, Torbati S, Kiweewa F, Sebudde N, Almasri E, Hughes A, Bhagani SR, Rodger A, Sandkovsky U, Gottlieb RL, Nnakelu E, Trautner B, Menon V, Lutaakome J, Matthay M, Robinson P, Protopapas K, Koulouris N, Kimuli I, Baduashvili A, Braun DL, Günthard HF, Ramachandruni S, Kidega R, Kim K, Hatlen TJ, Phillips AN, Murray DD, Jensen TO, Padilla ML, Accardi EX, Shaw-Saliba K, Dewar RL, Teitelbaum M, Natarajan V, Laverdure S, Highbarger HC, Rehman MT, Vogel S, Vallée D, Crew P, Atri N, Schechner AJ, Pett S, Hudson F, Badrock J, Touloumi G, Brown SM, Self WH, North CM, Ginde AA, Chang CC, Kelleher A, Nagy-Agren S, Vasudeva S, Looney D, Nguyen HH, Sánchez A, Weintrob AC, Grund B, Sharma S, Reilly CS, Paredes R, Bednarska A, Gerry NP, Babiker AG, Davey VJ, Gelijns AC, Higgs ES, Kan V, Matthews G, Thompson BT, Legenne P, Chandra R, Lane HC, Neaton JD, Lundgren JD, Sahner D, Tierney J, Herpin BR, Smolskis MC, McKay LA, Cahill K, Sardana R, Raim SS, Hensely L, Lorenzo J, Mock R, Zuckerman J, Miller M, Chung L, Kang N, Adam SJ, Read S, Draghia-Akli R, Carlsen A, Carter A, Denning E, DuChene A, Eckroth K, Frase A, Gandits G, Harrison M, Kaiser P, Koopmeiners J, Meger S, Murray T, Quan K, Quan SF, Thompson G, Walski J, Wentworth D, Moskowitz AJ, Bagiella E, Moquete E, O’Sullivan K, Marks ME, Kinzel E, Burris S, Bedoya G, Gupta L, Overbey JR, Padillia ML, Santos M, Gillinov MA, Miller MA, Taddei-Peters WC, Fenton K, Mack M, Berhe M, Haley C, Dishner E, Bettacchi C, Golden K, Duhaime E, Ryan M, Burris S, Tallmadge C, Estrada L, Jones F, Villa S, Wang S, Robert R, Coleman T, Clariday L, Baker R, Hurutado-Rodriguez M, Iram N, Fresnedo M, Davis A, Leonard K, Ramierez N, Thammavong J, Duque K, Turner E, Fisher T, Robinson D, Ransom D, Maldonado N, Lusk E, Killian A, Palacious A, Solis E, Jerrow J, Watts M, Whitacre H, Cothran E, Smith PK, Ko ER, Dreyer GR, Stafford N, Brooks M, Der T, Witte M, Gamarallage R, Franzone J, Ivey N, Lumsden RH, Mourad A, Holland TL, Motta M, Lane K, McGowan LM, Stout J, Aloor H, Bragg KM, Toledo B, McLendon-Arvik B, Bussadori B, Hollister BA, Griffin M, Giangiacomo DM, Rodriguez V, Parrino PE, Spindel S, Bansal A, Baumgarten K, Hand J, Vonderhaar D, Nossaman B, Laudun S, Ames D, Broussard S, Hernandez N, Isaac G, Dinh H, Zheng Y, Tran S, McDaniel H, Crovetto N, Perin E, Costello B, Manian P, Sohail MR, Postalian A, Hinsu P, Watson C, Chen J, Fink M, Sturgis L, Kim W, Mahon K, Parenti J, Kappenman C, Knight A, Sturek JM, Barros A, Enfield KB, Kadl A, Green CJ, Simon RM, Fox A, Thornton K, Adams A, Traverse JH, Rhame F, Huelster J, Kethireddy R, Salamanca J, Majeski C, Skelton P, Zarambo M, Sarafolean A, Oldmixon C, Ringwood N, Muzikansky A, Morse R, Brower RG, Reineck LA, Aggarwal NR, Bienstock K, Steingrub JH, Hou PK, Steingrub JS, Tidswell MA, Kozikowski LA, Kardos C, DeSouza L, Romain S, Talmor D, Shapiro N, Andromidas K, Banner-Goodspeed V, Bolstad M, Boyle KL, Cabrera P, deVilla A, Ellis JC, Grafals A, Hayes S, Higgins C, Kurt L, Kurtzman N, Redman K, Rosseto E, Scaffidi D, Shapiro N, Talmor D, Filbin MR, Hibbert KA, Parry B, Margolin J, Hillis B, Hamer R, Jones AE, Galbraith J, Nandi U, Hendey G, Matthay MA, Kangelaris K, Ashktorab K, Gropper R, Agrawal A, Almasri E, Fayed M, Hubel KA, Garcia RL, Lim GW, Chang SY, Hendey G, Lin MY, Vargas J, Sihota H, Beutler R, Rogers AJ, Wilson JG, Vojnik R, Perez C, McDowell JH, Albertson T, Hardy E, Harper R, Moss MA, Ginde AA, Chauhan L, Douin DJ, Martinez F, Finck LL, Bastman J, Hyzy RC, Park PK, Hyzy RC, Park PK, Nelson K, McSparron JI, Co IN, Wang BR, Jimenez J, Sullins B, Olbrich N, Gong MN, Richardson LD, Gong MN, Nair R, Lopez B, Amosu O, Tzehaie H, Nkemdirim W, Boujid S, Mosier JM, Hypes C, Campbell ES, Bixby B, Gilson B, Lopez A, Hite RD, Terndrup TE, Wiedemann HP, Hudock K, Tanzeem H, More H, Martinkovic J, Sellers S, Houston J, Burns M, Hough CL, Robinson BH, Hough CL, Khan A, Krol OF, Mills E, Kinjal M, Briceno G, Reddy R, Hubel K, Parimon T, Caudill A, Mattison B, Jackman SE, Chen PE, Bayoumi E, Ojukwu C, Fine D, Weissberg G, Isip K, Choi-Kuaea Y, Mehdikhani S, Dar TB, Augustin NBF, Tran D, Dukov JE, O’Mahony DS, Wilson DM, Wallick JA, Duven AM, Fletcher DD, Files DC, Miller C, Gibbs KW, Flores LS, LaRose ME, Landreth LD, Palacios DR, Parks L, Hicks M, Goodwin AJ, Kilb EF, Lematty CT, Patti K, Bledsoe J, Brown S, Lanspa M, Pelton I, Armbruster BP, Montgomery Q, Kumar N, Fergus M, Imel K, Palmer G, Webb B, Klippel C, Jensen H, Duckworth S, Gray A, Burke T, Knox D, Lumpkin J, Aston VT, Rice TW, Self WH, Rice TW, Casey JD, Johnson J, 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Davidson S, Bice DJ, Ognenovska K, Cabrera G, Flynn R, Chia PY, Lee TH, Lin RJ, Ong SW, Puah SH, Yeo TW, Ongko J, Yeo HP, Kwaghe V, Zaiyad H, Idoko G, Uche B, Selvamuthu P, Kumarasamy N, Beulah FE, Govindarajan N, Mariyappan K, Losso MH, Abela C, Moretto R, Belloc CG, Ludueña J, Amar J, Losso MH, Toibaro J, Macias LM, Fernandez L, Frare PS, Chaio SR, Pachioli V, Timpano SM, Sanchez MDL, Sierra MDP, Stanek V, Belloso W, Cilenti FL, Valentini RN, Stryjewski ME, Locatelli N, Riera MCS, Salgado C, Baeck IM, Di Castelnuovo V, Zarza SM, Parmar MK, Goodman AL, Gregory A, Goodall K, Harris N, Wyncoll J, Luntiel A, Patterson C, Morales J, Witele E, Preston A, Nandani A, Price D, Nell J, Patel B, Hays C, Jones G, Davidson J, Pantazis N, Gioukari V, Souliou T, Antoniadou A, Kavatha D, Grigoropoulou S, Tziolos R, Oikonomopoulo C, Moschopoulos C, Tzimopoulos K, Koromilias A. Efficacy and Safety of Ensovibep for Adults Hospitalized With COVID-19 : A Randomized Controlled Trial. Ann Intern Med 2022; 175:1266-1274. [PMID: 35939810 PMCID: PMC9384272 DOI: 10.7326/m22-1503] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Ensovibep (MP0420) is a designed ankyrin repeat protein, a novel class of engineered proteins, under investigation as a treatment of SARS-CoV-2 infection. OBJECTIVE To investigate if ensovibep, in addition to remdesivir and other standard care, improves clinical outcomes among patients hospitalized with COVID-19 compared with standard care alone. DESIGN Double-blind, randomized, placebo-controlled, clinical trial. (ClinicalTrials.gov: NCT04501978). SETTING Multinational, multicenter trial. PARTICIPANTS Adults hospitalized with COVID-19. INTERVENTION Intravenous ensovibep, 600 mg, or placebo. MEASUREMENTS Ensovibep was assessed for early futility on the basis of pulmonary ordinal scores at day 5. The primary outcome was time to sustained recovery through day 90, defined as 14 consecutive days at home or place of usual residence after hospital discharge. A composite safety outcome that included death, serious adverse events, end-organ disease, and serious infections was assessed through day 90. RESULTS An independent data and safety monitoring board recommended that enrollment be halted for early futility after 485 patients were randomly assigned and received an infusion of ensovibep (n = 247) or placebo (n = 238). The odds ratio (OR) for a more favorable pulmonary outcome in the ensovibep (vs. placebo) group at day 5 was 0.93 (95% CI, 0.67 to 1.30; P = 0.68; OR > 1 would favor ensovibep). The 90-day cumulative incidence of sustained recovery was 82% for ensovibep and 80% for placebo (subhazard ratio [sHR], 1.06 [CI, 0.88 to 1.28]; sHR > 1 would favor ensovibep). The primary composite safety outcome at day 90 occurred in 78 ensovibep participants (32%) and 70 placebo participants (29%) (HR, 1.07 [CI, 0.77 to 1.47]; HR < 1 would favor ensovibep). LIMITATION The trial was prematurely stopped because of futility, limiting power for the primary outcome. CONCLUSION Compared with placebo, ensovibep did not improve clinical outcomes for hospitalized participants with COVID-19 receiving standard care, including remdesivir; no safety concerns were identified. PRIMARY FUNDING SOURCE National Institutes of Health.
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Affiliation(s)
| | - Christina Barkauskas
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Duke Health, Durham, North Carolina
| | - Eleftherios Mylonakis
- Division of Infectious Diseases, Rhode Island Hospital and The Miriam Hospital, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Garyfallia Poulakou
- 3rd Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, Sotiria General Hospital, Athens, Greece
| | | | - David M Vock
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota
| | - Lianne Siegel
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota
| | - Nicole Engen
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota
| | - Greg Grandits
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota
| | | | | | - Ralph Rogers
- Division of Infectious Diseases, Rhode Island Hospital and The Miriam Hospital, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Fadi Shehadeh
- Division of Infectious Diseases, Rhode Island Hospital and The Miriam Hospital, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Matthew Kaczynski
- Division of Infectious Diseases, Rhode Island Hospital and The Miriam Hospital, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Evangelia K Mylona
- Division of Infectious Diseases, Rhode Island Hospital and The Miriam Hospital, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Konstantinos N Syrigos
- 3rd Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, Sotiria General Hospital, Athens, Greece
| | - Vasiliki Rapti
- 3rd Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, Sotiria General Hospital, Athens, Greece
| | - David C Lye
- National Centre for Infectious Diseases, Tan Tock Seng Hospital, Lee Kong Chian School of Medicine, Singapore
| | - Diong Shiau Hui
- National Centre for Infectious Diseases, Tan Tock Seng Hospital, Singapore
| | - Lindsay Leither
- Division of Pulmonary and Critical Care, Department of Medicine, Intermountain Medical Center, Salt Lake City, Utah
| | - Kirk U Knowlton
- Cardiovascular Department, Intermountain Medical Center, Salt Lake City, Utah
| | - Mamta K Jain
- UT Southwestern Medical Center and Parkland Health and Hospital Systems, Dallas, Texas
| | - Rubria Marines-Price
- UT Southwestern Medical Center and Parkland Health and Hospital Systems, Dallas, Texas
| | - Alice Osuji
- UT Southwestern Medical Center and Parkland Health and Hospital Systems, Dallas, Texas
| | | | - Ioannis Kalomenidis
- 1st Department of Critical Care and Pulmonary Medicine, Medical School, National and Kapodistrian University of Athens, Evaggelismos General Hospital, Athens, Greece
| | - Zafeiria Barmparessou
- 1st Department of Critical Care and Pulmonary Medicine, Medical School, National and Kapodistrian University of Athens, Evaggelismos General Hospital, Athens, Greece
| | | | | | - Peter Chen
- Cedars-Sinai Medical Center, Los Angeles, California
| | - Sam Torbati
- Cedars-Sinai Medical Center, Los Angeles, California
| | | | | | - Eyad Almasri
- University of California, San Francisco-Fresno, Fresno, California
| | - Alyssa Hughes
- University of California, San Francisco-Fresno, Fresno, California
| | | | | | | | | | | | - Barbara Trautner
- Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas
| | - Vidya Menon
- NYC Health + Hospitals/Lincoln, Bronx, New York
| | - Joseph Lutaakome
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene & Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Michael Matthay
- University of California, San Francisco, Medical Center, Fresno, California
| | - Philip Robinson
- Hoag Memorial Hospital Presbyterian, Newport Beach, California
| | - Konstantinos Protopapas
- 4th Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, Attikon University General Hospital, Athens, Greece
| | - Nikolaos Koulouris
- 1st Respiratory Medicine Department, Medical School, National and Kapodistrian University of Athens, Sotiria General Hospital, Athens, Greece
| | - Ivan Kimuli
- Makerere University Lung Institute, Kampala, Uganda
| | - Amiran Baduashvili
- Division of Hospital Medicine, University of Colorado Hospital - Anschutz Medical Campus, Aurora, Colorado
| | - Dominique L Braun
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich and Institute of Medical Virology, University of Zurich, Zurich, Switzerland
| | - Huldrych F Günthard
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich and Institute of Medical Virology, University of Zurich, Zurich, Switzerland
| | | | | | - Kami Kim
- Division of Infectious Diseases, University of South Florida and Global Emerging Diseases Institute, Tampa General Hospital, Tampa, Florida
| | - Timothy J Hatlen
- Lundquist Institute for Biomedical Innovation, Torrance, California
| | | | - Daniel D Murray
- CHIP Center of Excellence for Health, Immunity, and Infections and Department of Infectious Diseases, Rigshospitalet, Copenhagen, Denmark
| | - Tomas O Jensen
- CHIP Center of Excellence for Health, Immunity, and Infections and Department of Infectious Diseases, Rigshospitalet, Copenhagen, and Department of Pulmonary and Infectious Diseases, North Zealand University Hospital, Hillerod, Denmark
| | | | - Evan X Accardi
- Icahn School of Medicine at Mount Sinai, New York, New York
| | - Katy Shaw-Saliba
- National Institute of Allergy and Infectious Diseases, Bethesda, Maryland
| | - Robin L Dewar
- Frederick National Laboratory for Cancer Research, Frederick, Maryland
| | | | - Ven Natarajan
- Frederick National Laboratory for Cancer Research, Frederick, Maryland
| | - Sylvain Laverdure
- Laboratory of Human Retrovirology and Immunoinformatics, National Institutes of Health, Frederick, Maryland
| | | | - M Tauseef Rehman
- Frederick National Laboratory for Cancer Research, Frederick, Maryland
| | - Susan Vogel
- Office of Clinical Research Policy and Regulatory Operations, National Institutes of Health, Bethesda, Maryland
| | - David Vallée
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | - Page Crew
- Collaborative Clinical Research Branch, National Institutes of Health, Bethesda, Maryland
| | - Negin Atri
- Office of Clinical Research Policy and Regulatory Operations, National Institutes of Health, Bethesda, Maryland
| | | | - Sarah Pett
- The Medical Research Council Clinical Trials Unit at University College London, London, England
| | - Fleur Hudson
- The Medical Research Council Clinical Trials Unit at University College London, London, England
| | - Jonathan Badrock
- The Medical Research Council Clinical Trials Unit at University College London, London, England
| | - Giota Touloumi
- Department of Hygiene, Epidemiology and Medical Statistics, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Samuel M Brown
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, and Department of Internal Medicine, University of Utah, Murray, Utah
| | - Wesley H Self
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Crystal M North
- Division of Pulmonary and Critical Care, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Adit A Ginde
- University of Colorado School of Medicine, Aurora, Colorado
| | - Christina C Chang
- The Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
| | - Anthony Kelleher
- The Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
| | | | | | - David Looney
- The Veterans Medical Research Foundation, San Diego, California
| | - Hien H Nguyen
- Veterans Affairs Northern California Health Care System, Sacramento, California
| | | | - Amy C Weintrob
- Infectious Diseases Section, Washington Veterans Affairs Medical Center, Washington, DC
| | - Birgit Grund
- School of Statistics, University of Minnesota, Minneapolis, Minnesota
| | - Shweta Sharma
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota
| | - Cavan S Reilly
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota
| | - Roger Paredes
- Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Agnieszka Bednarska
- Wojewódzki Szpital Zakaźny w Warszawie, Medical University of Warsaw, Warsaw, Poland
| | - Norman P Gerry
- Advanced Biomedical Laboratories, Cinnaminson, New Jersey
| | - Abdel G Babiker
- The Medical Research Council Clinical Trials Unit at University College London, London, England
| | | | - Annetine C Gelijns
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Elizabeth S Higgs
- National Institute of Allergy and Infectious Diseases, Bethesda, Maryland
| | - Virginia Kan
- Infectious Diseases Section, Veterans Affairs Medical Center, Washington, DC
| | - Gail Matthews
- The Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
| | - K. Argyraki
- Sotiria General, Medical School, National & Kapodistrian University of Athens
| | - P. Lourida
- Sotiria General Hospital, Medical School, National & Kapodistrian University of Athens
| | - P. Bakakos
- Sotiria General Hospital, Medical School, National & Kapodistrian University of Athens
| | - V. Vlachakos
- Evangelismos General Hospital, Medical School, National & Kapodistrian University of Athens
| | - E. Balis
- Evangelismos General Hospital, Medical School, National & Kapodistrian University of Athens
| | - S. Zakynthinos
- Evangelismos General Hospital, Medical School, National & Kapodistrian University of Athens
| | - I. Sigala
- Evangelismos General Hospital, Medical School, National & Kapodistrian University of Athens
| | - N. Gianniou
- Evangelismos General Hospital, Medical School, National & Kapodistrian University of Athens
| | - E. Dima
- Evangelismos General Hospital, Medical School, National & Kapodistrian University of Athens
| | - S. Magkouta
- Evangelismos General Hospital, Medical School, National & Kapodistrian University of Athens
| | - B Taylor Thompson
- Division of Pulmonary and Critical Care, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - E. Synolaki
- Evangelismos General Hospital, Medical School, National & Kapodistrian University of Athens
| | - S. Konstanta
- Evangelismos General Hospital, Medical School, National & Kapodistrian University of Athens
| | - M. Vlachou
- Evangelismos General Hospital, Medical School, National & Kapodistrian University of Athens
| | - P. Stathopoulou
- Evangelismos General Hospital, Medical School, National & Kapodistrian University of Athens
| | - P. Panagopoulos
- Alexandroupolis General Hospital, Medical School, Democritus University of Thrace
| | - V. Petrakis
- Alexandroupolis General Hospital, Medical School, Democritus University of Thrace
| | - D. Papazoglou
- Alexandroupolis General Hospital, Medical School, Democritus University of Thrace
| | - E. Tompaidou
- Alexandroupolis General Hospital, Medical School, Democritus University of Thrace
| | - E. Isaakidou
- Alexandroupolis General Hospital, Medical School, Democritus University of Thrace
| | - K. Leontis
- 3rd Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, Sotiria General Hospital, Athens, Greece
| | | | - T. Nitsotolis
- 3rd Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, Sotiria General Hospital, Athens, Greece
| | - K. Athanasiou
- 3rd Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, Sotiria General Hospital, Athens, Greece
| | - M.D. Myrodia
- 3rd Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, Sotiria General Hospital, Athens, Greece
| | - K. Kyriakoulis
- 3rd Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, Sotiria General Hospital, Athens, Greece
| | - I. Trontzas
- 3rd Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, Sotiria General Hospital, Athens, Greece
| | - M. Arfara-Melanini
- 3rd Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, Sotiria General Hospital, Athens, Greece
| | - V. Kolonia
- 3rd Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, Sotiria General Hospital, Athens, Greece
| | - Cissy Kityo
- Uganda SCC, JCRC/MRC/UVRI Uganda Research Unit
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - H Clifford Lane
- National Institute of Allergy and Infectious Diseases, Bethesda, Maryland
| | | | | | | | | | | | | | | | | | | | | | - James D Neaton
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota
| | | | | | | | | | | | | | | | | | | | | | - Jens D Lundgren
- CHIP Center of Excellence for Health, Immunity, and Infections and Department of Infectious Diseases, Rigshospitalet, Copenhagen, Denmark
| | | | | | | | | | | | | | | | | | | | | | - Christina Barkauskas
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Duke Health, Durham, North Carolina
| | | | | | | | | | | | | | | | | | | | | | - Eleftherios Mylonakis
- Division of Infectious Diseases, Rhode Island Hospital and The Miriam Hospital, Alpert Medical School of Brown University, Providence, Rhode Island
| | | | | | | | | | | | | | | | | | | | | | - Garyfallia Poulakou
- 3rd Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, Sotiria General Hospital, Athens, Greece
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Patrícia Ramgi
- CISPOC: Centro de Investigaçäo e Treino em Saúde da Polana Caniço, Maputo, Mozambique
| | - Kássia Pereira
- CISPOC: Centro de Investigaçäo e Treino em Saúde da Polana Caniço, Maputo, Mozambique
| | | | - Huyen Cao
- Gilead Sciences, Foster City, California
| | | | | | | | - David M. Vock
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota
| | | | | | | | - Amy Adams
- Leidos Biomedical Research, Frederick, Maryland
| | | | | | | | | | - Mi Ha Kim
- Leidos Biomedical Research, Frederick, Maryland
| | - Joy Beeler
- Leidos Biomedical Research, Frederick, Maryland
| | - Lianne Siegel
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota
| | - Liam Harmon
- Leidos Biomedical Research, Frederick, Maryland
| | | | - Yvonne Jato
- Leidos Biomedical Research, Frederick, Maryland
| | | | - Olivia Tang
- Leidos Biomedical Research, Frederick, Maryland
| | | | | | - Molly Buehn
- Leidos Biomedical Research, Frederick, Maryland
| | | | - Sadie Frary
- Leidos Biomedical Research, Frederick, Maryland
| | - Nicole Engen
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota
| | | | | | | | | | | | | | | | | | | | | | - Greg Grandits
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota
| | | | | | - Matt Hohn
- Leidos Biomedical Research, Frederick, Maryland
| | | | | | - Weizhong Chang
- Frederick National Laboratory for Cancer Research/Leidos Biomedical Research, Frederick, Maryland
| | - Brad T. Sherman
- Frederick National Laboratory for Cancer Research/Leidos Biomedical Research, Frederick, Maryland
| | - Adam W. Rupert
- Frederick National Laboratory for Cancer Research/Leidos Biomedical Research, Frederick, Maryland
| | - Michael Baseler
- Frederick National Laboratory for Cancer Research/Leidos Biomedical Research, Frederick, Maryland
| | - Perrine Lallemand
- Frederick National Laboratory for Cancer Research/Leidos Biomedical Research, Frederick, Maryland
| | | | - Tom Imamichi
- Frederick National Laboratory for Cancer Research/Leidos Biomedical Research, Frederick, Maryland
| | - Sharada Paudel
- Frederick National Laboratory for Cancer Research/Leidos Biomedical Research, Frederick, Maryland
| | - Kyndal Cook
- Frederick National Laboratory for Cancer Research/Leidos Biomedical Research, Frederick, Maryland
| | - Kendra Haupt
- Frederick National Laboratory for Cancer Research/Leidos Biomedical Research, Frederick, Maryland
| | - Jeroen Highbarger
- Frederick National Laboratory for Cancer Research/Leidos Biomedical Research, Frederick, Maryland
| | - Allison Hazen
- Frederick National Laboratory for Cancer Research/Leidos Biomedical Research, Frederick, Maryland
| | - Yunden Badralmaa
- Frederick National Laboratory for Cancer Research/Leidos Biomedical Research, Frederick, Maryland
| | - Kenneth Smith
- Advanced Biomedical Laboratories, Cinnaminson, New Jersey
| | - Bhakti Patel
- Advanced Biomedical Laboratories, Cinnaminson, New Jersey
| | | | | | | | | | | | | | | | | | | | | | | | | | - Ralph Rogers
- Division of Infectious Diseases, Rhode Island Hospital and The Miriam Hospital, Alpert Medical School of Brown University, Providence, Rhode Island
| | | | | | - Fadi Shehadeh
- Division of Infectious Diseases, Rhode Island Hospital and The Miriam Hospital, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Matthew Kaczynski
- Division of Infectious Diseases, Rhode Island Hospital and The Miriam Hospital, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Evangelia K. Mylona
- Division of Infectious Diseases, Rhode Island Hospital and The Miriam Hospital, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Konstantinos N. Syrigos
- 3rd Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, Sotiria General Hospital, Athens, Greece
| | - Vasiliki Rapti
- 3rd Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, Sotiria General Hospital, Athens, Greece
| | - David C. Lye
- National Centre for Infectious Diseases, Tan Tock Seng Hospital, Lee Kong Chian School of Medicine, Singapore
| | - Diong Shiau Hui
- National Centre for Infectious Diseases, Tan Tock Seng Hospital, Singapore
| | - Lindsay Leither
- Division of Pulmonary and Critical Care, Department of Medicine, Intermountain Medical Center, Salt Lake City, Utah
| | - Kirk U. Knowlton
- Cardiovascular Department, Intermountain Medical Center, Salt Lake City, Utah
| | - Mamta K. Jain
- UT Southwestern Medical Center and Parkland Health and Hospital Systems, Dallas, Texas
| | - Rubria Marines-Price
- UT Southwestern Medical Center and Parkland Health and Hospital Systems, Dallas, Texas
| | - Alice Osuji
- UT Southwestern Medical Center and Parkland Health and Hospital Systems, Dallas, Texas
| | | | - Ioannis Kalomenidis
- 1st Department of Critical Care and Pulmonary Medicine, Medical School, National and Kapodistrian University of Athens, Evaggelismos General Hospital, Athens, Greece
| | - Zafeiria Barmparessou
- 1st Department of Critical Care and Pulmonary Medicine, Medical School, National and Kapodistrian University of Athens, Evaggelismos General Hospital, Athens, Greece
| | | | | | - Peter Chen
- Cedars-Sinai Medical Center, Los Angeles, California
| | - Sam Torbati
- Cedars-Sinai Medical Center, Los Angeles, California
| | | | | | - Eyad Almasri
- University of California, San Francisco–Fresno, Fresno, California
| | - Alyssa Hughes
- University of California, San Francisco–Fresno, Fresno, California
| | | | | | | | | | | | - Barbara Trautner
- Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas
| | - Vidya Menon
- NYC Health + Hospitals/Lincoln, Bronx, New York
| | - Joseph Lutaakome
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene & Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Michael Matthay
- University of California, San Francisco, Medical Center, Fresno, California
| | - Philip Robinson
- Hoag Memorial Hospital Presbyterian, Newport Beach, California
| | - Konstantinos Protopapas
- 4th Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, Attikon University General Hospital, Athens, Greece
| | - Nikolaos Koulouris
- 1st Respiratory Medicine Department, Medical School, National and Kapodistrian University of Athens, Sotiria General Hospital, Athens, Greece
| | - Ivan Kimuli
- Makerere University Lung Institute, Kampala, Uganda
| | - Amiran Baduashvili
- Division of Hospital Medicine, University of Colorado Hospital - Anschutz Medical Campus, Aurora, Colorado
| | - Dominique L. Braun
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich and Institute of Medical Virology, University of Zurich, Zurich, Switzerland
| | - Huldrych F. Günthard
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich and Institute of Medical Virology, University of Zurich, Zurich, Switzerland
| | | | | | - Kami Kim
- Division of Infectious Diseases, University of South Florida and Global Emerging Diseases Institute, Tampa General Hospital, Tampa, Florida
| | | | | | - Daniel D. Murray
- CHIP Center of Excellence for Health, Immunity, and Infections and Department of Infectious Diseases, Rigshospitalet, Copenhagen, Denmark
| | - Tomas O. Jensen
- CHIP Center of Excellence for Health, Immunity, and Infections and Department of Infectious Diseases, Rigshospitalet, Copenhagen, and Department of Pulmonary and Infectious Diseases, North Zealand University Hospital, Hillerod, Denmark
| | | | | | - Katy Shaw-Saliba
- National Institute of Allergy and Infectious Diseases, Bethesda, Maryland
| | - Robin L. Dewar
- Frederick National Laboratory for Cancer Research, Frederick, Maryland
| | | | - Ven Natarajan
- Frederick National Laboratory for Cancer Research, Frederick, Maryland
| | - Sylvain Laverdure
- Laboratory of Human Retrovirology and Immunoinformatics, National Institutes of Health, Frederick, Maryland
| | | | - M. Tauseef Rehman
- Frederick National Laboratory for Cancer Research, Frederick, Maryland
| | - Susan Vogel
- Office of Clinical Research Policy and Regulatory Operations, National Institutes of Health, Bethesda, Maryland
| | - David Vallée
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | - Page Crew
- Collaborative Clinical Research Branch, National Institutes of Health, Bethesda, Maryland
| | - Negin Atri
- Office of Clinical Research Policy and Regulatory Operations, National Institutes of Health, Bethesda, Maryland
| | | | - Sarah Pett
- The Medical Research Council Clinical Trials Unit at University College London, London, England
| | - Fleur Hudson
- The Medical Research Council Clinical Trials Unit at University College London, London, England
| | - Jonathan Badrock
- The Medical Research Council Clinical Trials Unit at University College London, London, England
| | - Giota Touloumi
- Department of Hygiene, Epidemiology and Medical Statistics, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Samuel M. Brown
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, and Department of Internal Medicine, University of Utah, Murray, Utah
| | - Wesley H. Self
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Crystal M. North
- Division of Pulmonary and Critical Care, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Adit A. Ginde
- University of Colorado School of Medicine, Aurora, Colorado
| | - Christina C. Chang
- The Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
| | - Anthony Kelleher
- The Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
| | | | | | - David Looney
- The Veterans Medical Research Foundation, San Diego, California
| | - Hien H. Nguyen
- Veterans Affairs Northern California Health Care System, Sacramento, California
| | | | - Amy C. Weintrob
- Infectious Diseases Section, Washington Veterans Affairs Medical Center, Washington, DC
| | - Birgit Grund
- School of Statistics, University of Minnesota, Minneapolis, Minnesota
| | - Shweta Sharma
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota
| | - Cavan S. Reilly
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota
| | - Roger Paredes
- Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Agnieszka Bednarska
- Wojewódzki Szpital Zakaźny w Warszawie, Medical University of Warsaw, Warsaw, Poland
| | | | - Abdel G. Babiker
- The Medical Research Council Clinical Trials Unit at University College London, London, England
| | | | - Annetine C. Gelijns
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Elizabeth S. Higgs
- National Institute of Allergy and Infectious Diseases, Bethesda, Maryland
| | - Virginia Kan
- Infectious Diseases Section, Veterans Affairs Medical Center, Washington, DC
| | - Gail Matthews
- The Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
| | - B. Taylor Thompson
- Division of Pulmonary and Critical Care, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | | | | | - H. Clifford Lane
- National Institute of Allergy and Infectious Diseases, Bethesda, Maryland
| | - James D. Neaton
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota
| | - Jens D. Lundgren
- CHIP Center of Excellence for Health, Immunity, and Infections and Department of Infectious Diseases, Rigshospitalet, Copenhagen, Denmark
| | - David Sahner
- Department of Clinical Research, National Institute of Allergy and Infectious Diseases
| | - John Tierney
- Department of Clinical Research, National Institute of Allergy and Infectious Diseases
| | - Betsey R. Herpin
- Department of Clinical Research, National Institute of Allergy and Infectious Diseases
| | - Mary C. Smolskis
- Department of Clinical Research, National Institute of Allergy and Infectious Diseases
| | - Laura A. McKay
- Department of Clinical Research, National Institute of Allergy and Infectious Diseases
| | - Kelly Cahill
- Department of Clinical Research, National Institute of Allergy and Infectious Diseases
| | - Ratna Sardana
- Department of Clinical Research, National Institute of Allergy and Infectious Diseases
| | - Sharon Segal Raim
- Department of Clinical Research, National Institute of Allergy and Infectious Diseases
| | - Lisa Hensely
- Department of Clinical Research, National Institute of Allergy and Infectious Diseases
| | - Joshua Lorenzo
- Department of Clinical Research, National Institute of Allergy and Infectious Diseases
| | - Rebecca Mock
- Department of Clinical Research, National Institute of Allergy and Infectious Diseases
| | - Judith Zuckerman
- Department of Clinical Research, National Institute of Allergy and Infectious Diseases
| | - Mark Miller
- Department of Clinical Research, National Institute of Allergy and Infectious Diseases
| | - Lucy Chung
- Department of Clinical Research, National Institute of Allergy and Infectious Diseases
| | - Nayon Kang
- Department of Clinical Research, National Institute of Allergy and Infectious Diseases
| | - Stacey J. Adam
- Foundation for the National Institutes of Health, The Accelerating COVID-19 Therapeutic Interventions and Vaccines (ACTIV) and Operation Warp Speed
| | - Sarah Read
- Foundation for the National Institutes of Health, The Accelerating COVID-19 Therapeutic Interventions and Vaccines (ACTIV) and Operation Warp Speed
| | - Ruxandra Draghia-Akli
- Foundation for the National Institutes of Health, The Accelerating COVID-19 Therapeutic Interventions and Vaccines (ACTIV) and Operation Warp Speed
| | - Amy Carlsen
- INSIGHT SDMC, Division of Biostatistics, School of Public Health and School of Statistics, University of Minnesota, Minneapolis, Minnesota
| | - Anita Carter
- INSIGHT SDMC, Division of Biostatistics, School of Public Health and School of Statistics, University of Minnesota, Minneapolis, Minnesota
| | - Eileen Denning
- INSIGHT SDMC, Division of Biostatistics, School of Public Health and School of Statistics, University of Minnesota, Minneapolis, Minnesota
| | - Alain DuChene
- INSIGHT SDMC, Division of Biostatistics, School of Public Health and School of Statistics, University of Minnesota, Minneapolis, Minnesota
| | - Kate Eckroth
- INSIGHT SDMC, Division of Biostatistics, School of Public Health and School of Statistics, University of Minnesota, Minneapolis, Minnesota
| | - Alex Frase
- INSIGHT SDMC, Division of Biostatistics, School of Public Health and School of Statistics, University of Minnesota, Minneapolis, Minnesota
| | - Greg Gandits
- INSIGHT SDMC, Division of Biostatistics, School of Public Health and School of Statistics, University of Minnesota, Minneapolis, Minnesota
| | - Merrie Harrison
- INSIGHT SDMC, Division of Biostatistics, School of Public Health and School of Statistics, University of Minnesota, Minneapolis, Minnesota
| | - Payton Kaiser
- INSIGHT SDMC, Division of Biostatistics, School of Public Health and School of Statistics, University of Minnesota, Minneapolis, Minnesota
| | - Joseph Koopmeiners
- INSIGHT SDMC, Division of Biostatistics, School of Public Health and School of Statistics, University of Minnesota, Minneapolis, Minnesota
| | - Sue Meger
- INSIGHT SDMC, Division of Biostatistics, School of Public Health and School of Statistics, University of Minnesota, Minneapolis, Minnesota
| | - Thomas Murray
- INSIGHT SDMC, Division of Biostatistics, School of Public Health and School of Statistics, University of Minnesota, Minneapolis, Minnesota
| | - Kien Quan
- INSIGHT SDMC, Division of Biostatistics, School of Public Health and School of Statistics, University of Minnesota, Minneapolis, Minnesota
| | - Siu Fun Quan
- INSIGHT SDMC, Division of Biostatistics, School of Public Health and School of Statistics, University of Minnesota, Minneapolis, Minnesota
| | - Greg Thompson
- INSIGHT SDMC, Division of Biostatistics, School of Public Health and School of Statistics, University of Minnesota, Minneapolis, Minnesota
| | - Jamie Walski
- INSIGHT SDMC, Division of Biostatistics, School of Public Health and School of Statistics, University of Minnesota, Minneapolis, Minnesota
| | - Deborah Wentworth
- INSIGHT SDMC, Division of Biostatistics, School of Public Health and School of Statistics, University of Minnesota, Minneapolis, Minnesota
| | - Alan J. Moskowitz
- Cardiothoracic Surgical Trials Network (CTSN) International Coordinating Center (ICC), Icahn School of Medicine at Mount Sinai, New York
| | - Emilia Bagiella
- Cardiothoracic Surgical Trials Network (CTSN) International Coordinating Center (ICC), Icahn School of Medicine at Mount Sinai, New York
| | - Ellen Moquete
- Cardiothoracic Surgical Trials Network (CTSN) International Coordinating Center (ICC), Icahn School of Medicine at Mount Sinai, New York
| | - Karen O’Sullivan
- Cardiothoracic Surgical Trials Network (CTSN) International Coordinating Center (ICC), Icahn School of Medicine at Mount Sinai, New York
| | - Mary E. Marks
- Cardiothoracic Surgical Trials Network (CTSN) International Coordinating Center (ICC), Icahn School of Medicine at Mount Sinai, New York
| | - Emily Kinzel
- Cardiothoracic Surgical Trials Network (CTSN) International Coordinating Center (ICC), Icahn School of Medicine at Mount Sinai, New York
| | - Sarah Burris
- Cardiothoracic Surgical Trials Network (CTSN) International Coordinating Center (ICC), Icahn School of Medicine at Mount Sinai, New York
| | - Gabriela Bedoya
- Cardiothoracic Surgical Trials Network (CTSN) International Coordinating Center (ICC), Icahn School of Medicine at Mount Sinai, New York
| | - Lola Gupta
- Cardiothoracic Surgical Trials Network (CTSN) International Coordinating Center (ICC), Icahn School of Medicine at Mount Sinai, New York
| | - Jessica R. Overbey
- Cardiothoracic Surgical Trials Network (CTSN) International Coordinating Center (ICC), Icahn School of Medicine at Mount Sinai, New York
| | - Maria L. Padillia
- Cardiothoracic Surgical Trials Network (CTSN) International Coordinating Center (ICC), Icahn School of Medicine at Mount Sinai, New York
| | - Milerva Santos
- Cardiothoracic Surgical Trials Network (CTSN) International Coordinating Center (ICC), Icahn School of Medicine at Mount Sinai, New York
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Amy Adams
- University of Virginia Health Systems
| | | | | | | | | | | | | | | | | | | | - Cathryn Oldmixon
- Prevention and Early Treatment of Acute Lung Injury (PETAL) ICC, Massachusetts General Hospital, Boston, Massachusetts
| | - Nancy Ringwood
- Prevention and Early Treatment of Acute Lung Injury (PETAL) ICC, Massachusetts General Hospital, Boston, Massachusetts
| | - Ariela Muzikansky
- Prevention and Early Treatment of Acute Lung Injury (PETAL) ICC, Massachusetts General Hospital, Boston, Massachusetts
| | - Richard Morse
- Prevention and Early Treatment of Acute Lung Injury (PETAL) ICC, Massachusetts General Hospital, Boston, Massachusetts
| | - Roy G. Brower
- PETAL Steering Committee Chair, Johns Hopkins University
| | | | | | | | - Jay H. Steingrub
- ALIGNE Site Coordinating Center (SCC) Lead Investigators, Baystate Medical Center
| | - Peter K. Hou
- ALIGNE Site Coordinating Center (SCC) Lead Investigators, Brigham and Women's Hospital
| | | | | | | | | | | | | | - Daniel Talmor
- Boston SCC Lead Investigators, Beth Israel Deaconess Medical Center
| | - Nathan Shapiro
- Boston SCC Lead Investigators, Beth Israel Deaconess Medical Center
| | | | | | | | | | | | | | | | | | | | | | - Lisa Kurt
- Beth Israel Deaconess Medical Center
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Gregory Hendey
- California SCC Lead Investigators, David Geffen School of Medicine at UCLA
| | - Michael A. Matthay
- University of California San Francisco, University of San Francisco Mount Zion
| | - Kirsten Kangelaris
- University of California San Francisco, University of San Francisco Mount Zion
| | - Kimia Ashktorab
- University of California San Francisco, University of San Francisco Mount Zion
| | - Rachel Gropper
- University of California San Francisco, University of San Francisco Mount Zion
| | - Anika Agrawal
- University of California San Francisco, University of San Francisco Mount Zion
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Marc A. Moss
- Colorado SCC Lead Investigators, University of Colorado Hospital
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Michelle N. Gong
- Montefiore-Sinai SCC Lead Investigators: Montefiore Medical Center
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Catherine L. Hough
- Pacific Northwest SCC Lead Investigators, Oregon Health & Science University
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Todd W. Rice
- Vanderbilt SCC Lead Investigators, Vanderbilt University Medical Center
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Jim Wong
- Carilion Roanoke Memorial Hospital
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Laura Popielski
- INSIGHT Washington ICC, Veterans Affairs (VA) Medical Center, Washington, DC
| | - Amy Kambo
- INSIGHT Washington ICC, Veterans Affairs (VA) Medical Center, Washington, DC
| | - Kimberley Viens
- INSIGHT Washington ICC, Veterans Affairs (VA) Medical Center, Washington, DC
| | - Melissa Turner
- INSIGHT Washington ICC, Veterans Affairs (VA) Medical Center, Washington, DC
| | - Michael J. Vjecha
- INSIGHT Washington ICC, Veterans Affairs (VA) Medical Center, Washington, DC
| | | | | | | | | | | | | | | | | | | | - Mamta K. Jain
- University of Texas Southwestern Medical Center, Dallas, Texas
| | | | - Tianna Petersen
- University of Texas Southwestern Medical Center, Dallas, Texas
| | - Dena Kamel
- University of Texas Southwestern Medical Center, Dallas, Texas
| | - Laura Hansen
- University of Texas Southwestern Medical Center, Dallas, Texas
| | - Angie Garcia
- University of Texas Southwestern Medical Center, Dallas, Texas
| | - Mina Kim
- University of Texas Southwestern Medical Center, Dallas, Texas
| | | | - Sonia Gonzales
- University of Texas Southwestern Medical Center, Dallas, Texas
| | | | - Asa Oxner
- University of South Florida, Tampa General Hospital
| | - Lucy Guerra
- University of South Florida, Tampa General Hospital
| | - Thanh Tran
- University of South Florida, Tampa General Hospital
| | | | | | | | | | | | - Avon Cuenca
- Lundquist Institute for Biomedical Innovation
| | | | - Eric Daar
- Lundquist Institute for Biomedical Innovation
| | | | | | | | | | | | | | | | - Jason V. Baker
- Hennepin Healthcare Research Institute, Minneapolis, Minnesota
| | - Anne Frosch
- Hennepin Healthcare Research Institute, Minneapolis, Minnesota
| | | | - Hodan Jibrell
- Hennepin Healthcare Research Institute, Minneapolis, Minnesota
| | - Melanie Lo
- Hennepin Healthcare Research Institute, Minneapolis, Minnesota
| | | | - Shari Mackedanz
- Hennepin Healthcare Research Institute, Minneapolis, Minnesota
| | - Linh Ngo
- Hennepin Healthcare Research Institute, Minneapolis, Minnesota
| | | | | | | | | | | | | | | | | | | | | | | | | | - Tammy Bremer
- INSIGHT US Department of Veterans Affairs (VA) ICC
| | - Tara Burke
- INSIGHT US Department of Veterans Affairs (VA) ICC
| | | | | | | | | | | | | | - John Van
- Michael E. DeBakey VA Medical Center, Houston, Texas
| | - Laura Dillon
- Michael E. DeBakey VA Medical Center, Houston, Texas
| | - Yiqun Wang
- Michael E. DeBakey VA Medical Center, Houston, Texas
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Kan Lu
- Veterans Affairs Palo Alto Health Care System
| | | | | | | | | | | | | | | | | | | | - Dorthe Raben
- INSIGHT Copenhagen ICC, CHIP (Centre of Excellence for Health, Immunity and Infections), Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Bitten Aagaard
- INSIGHT Copenhagen ICC, CHIP (Centre of Excellence for Health, Immunity and Infections), Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Charlotte B. Nielsen
- INSIGHT Copenhagen ICC, CHIP (Centre of Excellence for Health, Immunity and Infections), Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Katharina Krapp
- INSIGHT Copenhagen ICC, CHIP (Centre of Excellence for Health, Immunity and Infections), Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Bente Rosdahl Nykjær
- INSIGHT Copenhagen ICC, CHIP (Centre of Excellence for Health, Immunity and Infections), Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Christina Olsson
- INSIGHT Copenhagen ICC, CHIP (Centre of Excellence for Health, Immunity and Infections), Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Katja Lisa Kanne
- INSIGHT Copenhagen ICC, CHIP (Centre of Excellence for Health, Immunity and Infections), Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Anne Louise Grevsen
- INSIGHT Copenhagen ICC, CHIP (Centre of Excellence for Health, Immunity and Infections), Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Zillah Maria Joensen
- INSIGHT Copenhagen ICC, CHIP (Centre of Excellence for Health, Immunity and Infections), Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Tina Bruun
- INSIGHT Copenhagen ICC, CHIP (Centre of Excellence for Health, Immunity and Infections), Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Ane Bojesen
- INSIGHT Copenhagen ICC, CHIP (Centre of Excellence for Health, Immunity and Infections), Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Frederik Woldbye
- INSIGHT Copenhagen ICC, CHIP (Centre of Excellence for Health, Immunity and Infections), Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Nick E. Normand
- INSIGHT Copenhagen ICC, CHIP (Centre of Excellence for Health, Immunity and Infections), Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Thomas Benfield
- Denmark Copenhagen University Hospital - Amager and Hvidovre, Center of Research & Disruption of Infectious Diseases, Department of Infectious Diseases
| | - Clara Lundetoft Clausen
- Denmark Copenhagen University Hospital - Amager and Hvidovre, Center of Research & Disruption of Infectious Diseases, Department of Infectious Diseases
| | - Nichlas Hovmand
- Denmark Copenhagen University Hospital - Amager and Hvidovre, Center of Research & Disruption of Infectious Diseases, Department of Infectious Diseases
| | - Simone Bastrup Israelsen
- Denmark Copenhagen University Hospital - Amager and Hvidovre, Center of Research & Disruption of Infectious Diseases, Department of Infectious Diseases
| | - Katrine Iversen
- Denmark Copenhagen University Hospital - Amager and Hvidovre, Center of Research & Disruption of Infectious Diseases, Department of Infectious Diseases
| | - Caecilie Leding
- Denmark Copenhagen University Hospital - Amager and Hvidovre, Center of Research & Disruption of Infectious Diseases, Department of Infectious Diseases
| | - Karen Brorup Pedersen
- Denmark Copenhagen University Hospital - Amager and Hvidovre, Center of Research & Disruption of Infectious Diseases, Department of Infectious Diseases
| | - Louise Thorlacius-Ussing
- Denmark Copenhagen University Hospital - Amager and Hvidovre, Center of Research & Disruption of Infectious Diseases, Department of Infectious Diseases
| | - Michaela Tinggaard
- Denmark Copenhagen University Hospital - Amager and Hvidovre, Center of Research & Disruption of Infectious Diseases, Department of Infectious Diseases
| | - Sandra Tingsgard
- Denmark Copenhagen University Hospital - Amager and Hvidovre, Center of Research & Disruption of Infectious Diseases, Department of Infectious Diseases
| | | | - Rikke Overgaard
- Herlev-Gentofte Hospital, Respiratory Medicine Section, Department of Internal Medicine
| | - Ema Rastoder
- Herlev-Gentofte Hospital, Respiratory Medicine Section, Department of Internal Medicine
| | - Christian Heerfordt
- Herlev-Gentofte Hospital, Respiratory Medicine Section, Department of Internal Medicine
| | - Caroline Hedsund
- Herlev-Gentofte Hospital, Respiratory Medicine Section, Department of Internal Medicine
| | | | | | | | - Christina Bergsoe
- Herlev-Gentofte Hospital, Respiratory Medicine Section, Department of Internal Medicine
| | | | | | | | | | | | - Inge K. Holden
- Odense University Hospital, Department of Infectious Diseases
| | | | - Marie Helleberg
- Dept. of Infectious Diseases, Rigshospitalet, Copenhagen University Hospital
| | - Jan Gerstoft
- Dept. of Infectious Diseases, Rigshospitalet, Copenhagen University Hospital
| | - Ole Kirk
- Dept. of Infectious Diseases, Rigshospitalet, Copenhagen University Hospital
| | - Tina Bruun
- Dept. of Infectious Diseases, Rigshospitalet, Copenhagen University Hospital
| | | | | | | | | | | | | | | | | | | | - Henrik Nielsen
- Aalborg University Hospital, Department of Infectious Diseases
| | | | | | | | - Daria Podlekareva
- Department of Respiratory Medicine, Bispebjerg Hospital, Copenhagen, Denmark
| | - Stine Johnsen
- Department of Respiratory Medicine, Bispebjerg Hospital, Copenhagen, Denmark
| | - Lothar Wiese
- Department of Infectious Diseases, Zealand University Hospital Roskilde and Department of Internal Medicine, Zealand University Hospital Koge
| | - Lene Surland Knudsen
- Department of Infectious Diseases, Zealand University Hospital Roskilde and Department of Internal Medicine, Zealand University Hospital Koge
| | - Maria Expósito
- Spain INSIGHT SCC Spain, Hospital Universitari Germans Trias i Pujol, Badalona
| | - José Badillo
- Spain INSIGHT SCC Spain, Hospital Universitari Germans Trias i Pujol, Badalona
| | - Ana Martínez
- Spain INSIGHT SCC Spain, Hospital Universitari Germans Trias i Pujol, Badalona
| | - Elena Abad
- Spain INSIGHT SCC Spain, Hospital Universitari Germans Trias i Pujol, Badalona
| | - Ana Chamorro
- Spain INSIGHT SCC Spain, Hospital Universitari Germans Trias i Pujol, Badalona
| | - Lourdes Mateu
- Hospital Universitari Germans Trias i Pujol, Badalona
| | - Sergio España
- Hospital Universitari Germans Trias i Pujol, Badalona
| | | | | | - Gemma Lladós
- Hospital Universitari Germans Trias i Pujol, Badalona
| | | | | | | | | | - Sergiu Padure
- Hospital General Universitario Gregorio Marañón, Madrid
| | - Jimena Gomez
- Hospital General Universitario Gregorio Marañón, Madrid
| | | | - Eva Cervilla
- Hospital General Universitario Gregorio Marañón, Madrid
| | | | | | - Paco Lopez
- Hospital General Universitario Gregorio Marañón, Madrid
| | | | - Leire Balerdi
- Barcelona Institute for Global Health (ISGlobal), Hospital Clínic - Universitat de Barcelona, Barcelona
| | - Almudena Legarda
- Barcelona Institute for Global Health (ISGlobal), Hospital Clínic - Universitat de Barcelona, Barcelona
| | - Montserrat Roldan
- Barcelona Institute for Global Health (ISGlobal), Hospital Clínic - Universitat de Barcelona, Barcelona
| | - Laura Letona
- Barcelona Institute for Global Health (ISGlobal), Hospital Clínic - Universitat de Barcelona, Barcelona
| | - José Muñoz
- Barcelona Institute for Global Health (ISGlobal), Hospital Clínic - Universitat de Barcelona, Barcelona
| | | | | | | | | | | | | | | | | | | | | | | | - E. Orviz
- Hospital Clínico San Carlos, Madrid
| | | | | | | | | | | | | | - Cristina Acosta
- Internal Medicine Department, University Hospital Arnau de Vilanova, Lleida
| | | | - Emily West
- Switzerland Department of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich and Institute of Medical Virology, University of Zurich, Zurich, Switzerland
| | - Khadija M’Rabeth-Bensalah
- Switzerland Department of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich and Institute of Medical Virology, University of Zurich, Zurich, Switzerland
| | - Mareile L. Eichinger
- Switzerland Department of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich and Institute of Medical Virology, University of Zurich, Zurich, Switzerland
| | - Manuela Grüttner-Durmaz
- Switzerland Department of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich and Institute of Medical Virology, University of Zurich, Zurich, Switzerland
| | - Christina Grube
- Switzerland Department of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich and Institute of Medical Virology, University of Zurich, Zurich, Switzerland
| | - Veronika Zink
- Switzerland Department of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich and Institute of Medical Virology, University of Zurich, Zurich, Switzerland
| | - Josefine Goes
- Switzerland Department of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich and Institute of Medical Virology, University of Zurich, Zurich, Switzerland
| | - Tengiz Tsertsvadze
- Georgia SCC, Infectious Diseases, AIDS and Clinical Immunology Research Center, Tbilisi, Georgia
| | - Akaki Abutidze
- Georgia SCC, Infectious Diseases, AIDS and Clinical Immunology Research Center, Tbilisi, Georgia
| | - Nikoloz Chkhartishvili
- Georgia SCC, Infectious Diseases, AIDS and Clinical Immunology Research Center, Tbilisi, Georgia
| | - Revaz Metchurtchlishvili
- Georgia SCC, Infectious Diseases, AIDS and Clinical Immunology Research Center, Tbilisi, Georgia
| | - Marina Endeladze
- Georgia SCC, Infectious Diseases, AIDS and Clinical Immunology Research Center, Tbilisi, Georgia
| | | | | | | | - Piotr Pulik
- Poland SCC, Wojewodzki Szpital Zakazny Warsaw
| | | | - Roman Fishchuk
- Ukraine Central City Clinical Hospital of Ivano-Frankivsk City, Ukraine
| | - Olena Kobrynska
- Ukraine Central City Clinical Hospital of Ivano-Frankivsk City, Ukraine
| | | | - Ivanna Kirieieva
- Ukraine Central City Clinical Hospital of Ivano-Frankivsk City, Ukraine
| | - Mykhailo Kuziuk
- Ukraine Central City Clinical Hospital of Ivano-Frankivsk City, Ukraine
| | - Mark Polizzotto
- INSIGHT Sydney ICC, The Kirby Institute, University of New South Wales, Sydney, Australia
| | - Catherine Carey
- INSIGHT Sydney ICC, The Kirby Institute, University of New South Wales, Sydney, Australia
| | - Nila J. Dharan
- INSIGHT Sydney ICC, The Kirby Institute, University of New South Wales, Sydney, Australia
| | - Sally Hough
- INSIGHT Sydney ICC, The Kirby Institute, University of New South Wales, Sydney, Australia
| | - Sophie Virachit
- INSIGHT Sydney ICC, The Kirby Institute, University of New South Wales, Sydney, Australia
| | - Sarah Davidson
- INSIGHT Sydney ICC, The Kirby Institute, University of New South Wales, Sydney, Australia
| | - Daniel J. Bice
- INSIGHT Sydney ICC, The Kirby Institute, University of New South Wales, Sydney, Australia
| | - Katherine Ognenovska
- INSIGHT Sydney ICC, The Kirby Institute, University of New South Wales, Sydney, Australia
| | - Gesalit Cabrera
- INSIGHT Sydney ICC, The Kirby Institute, University of New South Wales, Sydney, Australia
| | - Ruth Flynn
- INSIGHT Sydney ICC, The Kirby Institute, University of New South Wales, Sydney, Australia
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- INSIGHT SCC Argentina, Coordinación en Investigación Clínica Académica en Latinoamérica
| | - Cecilia Abela
- INSIGHT SCC Argentina, Coordinación en Investigación Clínica Académica en Latinoamérica
| | - Renzo Moretto
- INSIGHT SCC Argentina, Coordinación en Investigación Clínica Académica en Latinoamérica
| | - Carlos G. Belloc
- INSIGHT SCC Argentina, Coordinación en Investigación Clínica Académica en Latinoamérica
| | - Jael Ludueña
- INSIGHT SCC Argentina, Coordinación en Investigación Clínica Académica en Latinoamérica
| | - Josefina Amar
- INSIGHT SCC Argentina, Coordinación en Investigación Clínica Académica en Latinoamérica
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Clara Salgado
- Centro de Educacion Medica e Investigaciones Clinicas, Buenos Aires
| | - Ines M. Baeck
- Centro de Educacion Medica e Investigaciones Clinicas, Buenos Aires
| | | | - Stella M. Zarza
- Centro de Educacion Medica e Investigaciones Clinicas, Buenos Aires
| | - Mahesh K.B. Parmar
- INSIGHT London ICC, MRC Clinical Trials Unit at UC, London, United Kingdom
| | - Anna L. Goodman
- INSIGHT London ICC, MRC Clinical Trials Unit at UC, London, United Kingdom
| | - Adam Gregory
- INSIGHT London ICC, MRC Clinical Trials Unit at UC, London, United Kingdom
| | - Katharine Goodall
- INSIGHT London ICC, MRC Clinical Trials Unit at UC, London, United Kingdom
| | - Nicola Harris
- INSIGHT London ICC, MRC Clinical Trials Unit at UC, London, United Kingdom
| | - James Wyncoll
- INSIGHT London ICC, MRC Clinical Trials Unit at UC, London, United Kingdom
| | | | | | | | - E. Witele
- United Kingdom SCC: Royal Free Hospital
| | | | | | | | | | | | | | | | | | - Nikos Pantazis
- Greece SCC, Medical School, National & Kapodistrian University of Athens
| | - Vicky Gioukari
- Greece SCC, Medical School, National & Kapodistrian University of Athens
| | - Tania Souliou
- Greece SCC, Medical School, National & Kapodistrian University of Athens
| | - A. Antoniadou
- Attikon University General Hospital, Medical School, National & Kapodistrian University of Athens
| | - D. Kavatha
- Attikon University General Hospital, Medical School, National & Kapodistrian University of Athens
| | - S. Grigoropoulou
- Attikon University General Hospital, Medical School, National & Kapodistrian University of Athens
| | - R.N. Tziolos
- Attikon University General Hospital, Medical School, National & Kapodistrian University of Athens
| | - C. Oikonomopoulo
- Attikon University General Hospital, Medical School, National & Kapodistrian University of Athens
| | - C. Moschopoulos
- Attikon University General Hospital, Medical School, National & Kapodistrian University of Athens
| | - K. Tzimopoulos
- Sotiria General Hospital, Medical School, National & Kapodistrian University of Athens
| | - A. Koromilias
- Sotiria General Hospital, Medical School, National & Kapodistrian University of Athens
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13
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Kagimu E, Engen N, Ssebambulidde K, Kasibante J, Kiiza TK, Mpoza E, Tugume L, Nuwagira E, Nsangi L, Williams DA, Hullsiek KH, Boulware DR, Meya DB, Rhein J, Abassi M, Musubire AK. Therapeutic Lumbar Punctures in Human Immunodeficiency Virus-Associated Cryptococcal Meningitis: Should Opening Pressure Direct Management? Open Forum Infect Dis 2022; 9:ofac416. [PMID: 36092828 PMCID: PMC9454029 DOI: 10.1093/ofid/ofac416] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 08/12/2022] [Indexed: 11/13/2022] Open
Abstract
Background Increased intracranial pressure (ICP) frequently complicates cryptococcal meningitis. Therapeutic lumbar punctures (LPs) have acute survival benefits in the first week, and we sought to understand the longer-term survival impact of therapeutic LPs. Methods We prospectively enrolled human immunodeficiency virus (HIV)-seropositive adults with cryptococcal meningitis from 2013 to 2017 in Uganda. We assessed the association between clinical characteristics, CSF parameters, and 14- and 30-day mortality by baseline ICP. We also assessed 30-day mortality by number of follow-up therapeutic LPs performed within 7 days. Results Our analysis included 533 participants. Participants with baseline ICP >350 mm H2O were more likely to have Glasgow Coma Scale (GCS) score <15 (P < .001), seizures (P < .01), and higher quantitative cryptococcal cultures (P < .001), whereas participants with ICP <200 mm H2O were more likely to have baseline sterile CSF cultures (P < .001) and CSF white blood cell count ≥5 cells/µL (P = .02). Thirty-day mortality was higher in participants with baseline ICP >350 mm H2O and ICP <200 mm H2O as compared with baseline ICP 200-350 mm H2O (hazard ratio, 1.55 [95% confidence interval, 1.10-2.19]; P = .02). Among survivors at least 7 days, the 30-day relative mortality was 50% higher among participants who did not receive any additional therapeutic LPs compared to those with ≥1 additional follow-up LP (33% vs 22%; P = .04), irrespective of baseline ICP. Conclusions Management of increased ICP remains crucial in improving clinical outcomes in cryptococcal meningitis. Guidelines should consider an approach to therapeutic LPs that is not dictated by baseline ICP.
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Affiliation(s)
- Enock Kagimu
- Correspondence: Enock Kagimu, MD, Infectious Diseases Institute, Makerere University, PO Box 22418, Kampala, Uganda ()
| | - Nicole Engen
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Kenneth Ssebambulidde
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - John Kasibante
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Tadeo K Kiiza
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Edward Mpoza
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Lillian Tugume
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Edwin Nuwagira
- Department of Internal Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Laura Nsangi
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Darlisha A Williams
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda,Division of Infectious Diseases, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Kathy Huppler Hullsiek
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - David R Boulware
- Division of Infectious Diseases, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - David B Meya
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda,Division of Infectious Diseases, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA,School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Joshua Rhein
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda,Division of Infectious Diseases, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA
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14
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Tugume L, Fieberg A, Ssebambulidde K, Nuwagira E, Williams DA, Mpoza E, Rutakingirwa MK, Kagimu E, Kasibante J, Nsangi L, Jjunju S, Musubire AK, Muzoora C, Lawrence DS, Rhein J, Meya DB, Hullsiek KH, Boulware DR, Abassi M. Association of Hyponatremia on Mortality in Cryptococcal Meningitis: A Prospective Cohort. Open Forum Infect Dis 2022; 9:ofac301. [PMID: 35891691 PMCID: PMC9307099 DOI: 10.1093/ofid/ofac301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 06/15/2022] [Indexed: 11/15/2022] Open
Abstract
Background Sodium abnormalities are frequent in central nervous system infections and may be caused by cerebral salt wasting, syndrome of inappropriate antidiuretic hormone secretion, or medication adverse events. In cryptococcal meningitis (CM), the prevalence of baseline hyponatremia and whether hyponatremia adversely impacts survival is unknown. Methods We conducted a secondary analysis of data from 2 randomized trials of human immunodeficiency virus-infected adult Ugandans with CM. We grouped serum sodium into 3 categories: <125, 125-129, and 130-145 mmol/L. We assessed whether baseline sodium abnormalities were associated with clinical characteristics and survival. Results Of 816 participants with CM, 741 (91%) had a baseline sodium measurement available: 121 (16%) had grade 3-4 hyponatremia (<125 mmol/L), 194 (26%) had grade 2 hyponatremia (125-129 mmol/L), and 426 (57%) had a baseline sodium of 130-145 mmol/L. Hyponatremia (<125 mmol/L) was associated with higher initial cerebrospinal fluid (CSF) quantitative culture burden (P < .001), higher initial CSF opening pressure (P < .01), lower baseline Glasgow Coma Scale score (P < .01), and a higher percentage of baseline seizures (P = .03). Serum sodium <125 mmol/L was associated with increased 2-week mortality in unadjusted and adjusted survival analyses (adjusted hazard ratio, 1.87 [95% confidence interval, 1.26-2.79]; P < .01) compared to those with sodium 130-145 mmol/L. Conclusions Hyponatremia is common in CM and is associated with excess mortality. A standardized management approach to correctly diagnose and correct hyponatremia in CM needs to be developed and tested.
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Affiliation(s)
- Lillian Tugume
- Correspondence: Lillian Tugume, MBChB, MPH, Infectious Diseases Institute, Makerere University, PO Box 22418, Kampala, Uganda ()
| | - Ann Fieberg
- Department of Biostatistics, University of Minnesota, Minneapolis, Minnesota, USA
| | - Kenneth Ssebambulidde
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Edwin Nuwagira
- Department of Internal Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Darlisha A Williams
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
- Department of Biostatistics, University of Minnesota, Minneapolis, Minnesota, USA
| | - Edward Mpoza
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Morris K Rutakingirwa
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Enoch Kagimu
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - John Kasibante
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Laura Nsangi
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Samuel Jjunju
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Abdu K Musubire
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
- Department of Biostatistics, University of Minnesota, Minneapolis, Minnesota, USA
| | - Conrad Muzoora
- Department of Internal Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - David S Lawrence
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Joshua Rhein
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
- Department of Biostatistics, University of Minnesota, Minneapolis, Minnesota, USA
| | - David B Meya
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
- Department of Biostatistics, University of Minnesota, Minneapolis, Minnesota, USA
- School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | | | - David R Boulware
- Division of Infectious Diseases, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Mahsa Abassi
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
- Division of Infectious Diseases, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
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15
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Abassi M, Bangdiwala AS, Nuwagira E, Kandole Tadeo K, Okirwoth M, Williams DA, Mpoza E, Tugume L, Ssebambulidde K, Huppler Hullsiek K, Musubire AK, Muzoora C, Rhein J, Meya DB, Boulware DR. Cerebrospinal Fluid Lactate as a Prognostic Marker of Disease Severity and Mortality in Cryptococcal Meningitis. Clin Infect Dis 2021; 73:e3077-e3082. [PMID: 33249459 PMCID: PMC8563209 DOI: 10.1093/cid/ciaa1749] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Cerebrospinal fluid (CSF) lactate levels can be used to differentiate between bacterial and viral meningitis. We measured CSF lactate in individuals with cryptococcal meningitis to determine its clinical significance. METHODS We measured point-of-care CSF lactate at the bedside of 319 Ugandan adults living with human immunodeficiency virus at diagnosis of cryptococcal meningitis. We summarized demographic variables and clinical characteristics by CSF lactate tertiles. We evaluated the association of CSF lactate with clinical characteristics and survival. RESULTS Individuals with high CSF lactate >5 mmol/L at cryptococcal diagnosis more likely presented with altered mental status (P < .0001), seizures (P = .0005), elevated intracranial opening pressure (P = .03), higher CSF white cells (P = .007), and lower CSF glucose (P = .0003) compared with those with mid-range (3.1 to 5 mmol/L) or low (≤3 mmol/L) CSF lactate levels. Two-week mortality was higher among individuals with high baseline CSF lactate >5 mmol/L (35%; 38 of 109) compared with individuals with mid-range (22%; 25 of 112) or low CSF lactate (9%; 9 of 97; P =<.0001). After multivariate adjustment, CSF lactate >5 mmol/L remained independently associated with excess mortality (adjusted hazard ratio = 3.41; 95% confidence interval, 1.55-7.51; P = .002). We found no correlation between baseline CSF lactate levels and blood capillary lactate levels. CONCLUSIONS Baseline point-of-care CSF lactate levels are a prognostic marker of disease severity and mortality in cryptococcal meningitis. Individuals with an elevated baseline CSF lactate level are more likely to present with altered mental status, seizures, and elevated CSF opening pressure and are at a greater risk of death. Future studies are needed to determine targeted therapeutic management strategies in persons with high CSF lactate.
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Affiliation(s)
- Mahsa Abassi
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
- University of Minnesota, Minneapolis, Minnesota, USA
| | | | - Edwin Nuwagira
- Mbarara University of Science and Technology Mbarara, Uganda
| | | | - Michael Okirwoth
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Darlisha A Williams
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
- University of Minnesota, Minneapolis, Minnesota, USA
| | - Edward Mpoza
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Lillian Tugume
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | | | - Abdu K Musubire
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
- School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Conrad Muzoora
- Mbarara University of Science and Technology Mbarara, Uganda
| | - Joshua Rhein
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
- University of Minnesota, Minneapolis, Minnesota, USA
| | - David B Meya
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
- University of Minnesota, Minneapolis, Minnesota, USA
- School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
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16
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Pullen MF, Hullsiek KH, Rhein J, Musubire AK, Tugume L, Nuwagira E, Abassi M, Ssebambulidde K, Mpoza E, Kiggundu R, Akampurira A, Nabeta HW, Schutz C, Evans EE, Rajasingham R, Skipper CP, Pastick KA, Williams DA, Morawski BM, Bangdiwala AS, Meintjes G, Muzoora C, Meya DB, Boulware DR. Cerebrospinal Fluid Early Fungicidal Activity as a Surrogate Endpoint for Cryptococcal Meningitis Survival in Clinical Trials. Clin Infect Dis 2021; 71:e45-e49. [PMID: 31912875 DOI: 10.1093/cid/ciaa016] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 01/06/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND In cryptococcal meningitis phase 2 clinical trials, early fungicidal activity (EFA) of Cryptococcus clearance from cerebrospinal fluid (CSF) is used as a surrogate endpoint for all-cause mortality. The Food and Drug Administration allows for using surrogate endpoints for accelerated regulatory approval, but EFA as a surrogate endpoint requires further validation. We examined the relationship between rate of CSF Cryptococcus clearance (EFA) and mortality through 18 weeks. METHODS We pooled individual-level CSF data from 3 sequential cryptococcal meningitis clinical trials conducted during 2010-2017. All 738 subjects received amphotericin + fluconazole induction therapy and had serial quantitative CSF cultures. The log10-transformed colony-forming units (CFUs) per mL CSF were analyzed by general linear regression versus day of culture over the first 10 days. RESULTS Mortality through 18 weeks was 37% for EFA > = 0.60 (n = 170), 36% for 0.40-0.59 (n = 182), 39% for 0.30-0.39 (n = 112), 35% for 0.20-0.29 (n = 87), and 50% for those with EFA < 0.20 CFU/mL/day (n = 187). The hazard ratio for 18-week mortality, comparing those with EFA < 0.20 to those with EFA > = 0.20, was 1.60 (95% confidence interval, 1.25, 2.04; P = .002). The lowest EFA group had lower median CD4 T-cell counts (P < .01) and lower proportion of patients with CSF pleocytosis (P < .001). CONCLUSIONS EFA is associated with all-cause mortality in cryptococcal meningitis. An EFA threshold of > = 0.20 log10 CFU/mL/day was associated with similar 18-week mortality (37%) compared to 50% mortality with EFA < 0.20. This EFA threshold may be considered a target for a surrogate endpoint. This builds upon existing studies to validate EFA as a surrogate endpoint.
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Affiliation(s)
- Matthew F Pullen
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Katherine Huppler Hullsiek
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Joshua Rhein
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, MN, USA.,Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Abdu K Musubire
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Lillian Tugume
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Edwin Nuwagira
- Department of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Mahsa Abassi
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, MN, USA
| | | | - Edward Mpoza
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Ruben Kiggundu
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | - Henry W Nabeta
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Charlotte Schutz
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, and Department of Medicine, University of Cape Town, South Africa
| | - Emily E Evans
- Department of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Radha Rajasingham
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Caleb P Skipper
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Katelyn A Pastick
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Darlisha A Williams
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, MN, USA.,Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Bozena M Morawski
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Ananta S Bangdiwala
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Graeme Meintjes
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, and Department of Medicine, University of Cape Town, South Africa
| | - Conrad Muzoora
- Department of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - David B Meya
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, MN, USA.,Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - David R Boulware
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, MN, USA
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17
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Lofgren SM, Velamakanni SS, Huppler Hullsiek K, Bangdiwala AS, Namudde A, Musubire AK, Mpoza E, Abassi M, Pastick KA, Nuwagira E, Evans EE, Rajsasingham R, Williams DA, Muzoora C, Creswell FV, Rhein J, Bond DJ, Nakasujja N, Meya DB, Boulware DR. The effect of sertraline on depression and associations with persistent depression in survivors of HIV-related cryptococcal meningitis. Wellcome Open Res 2021. [DOI: 10.12688/wellcomeopenres.16363.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Depression is a risk factor for worse outcomes in persons living with HIV/AIDS and has a prevalence more than three times as high as in the general population. Despite this, there are few randomized studies of antidepressants in HIV-infected Africans. Methods: We enrolled 460 HIV-infected Africans with cryptococcal meningitis into a randomized clinical trial of adjunctive sertraline vs placebo (2015-2017). We defined depression using depression using a Center for Epidemiologic Studies Depression Scale (CES-D) score of >15, and severe depression as >26 at one and three months after meningitis diagnosis and initiation of treatment.We evaluated the relationship between sertraline and depression, as well as associations with persistent depression, at three months. Results: At one- and three-months post meningitis diagnosis, 62% (108/174) and 44% (74/169) of all subjects had depression (CES>15), respectively. At three months, sertraline-treated subjects had consistent risk for depression as placebo-treated subjects but were significantly less likely to have severe depression (CES>26) (OR 0.335; 95%CI, 0.130-0.865). Of those with depression at one month, sertraline-treated subjects were less likely than placebo-treated subjects to be depressed at three months (p=0.05). Sertraline was the only factor we found significant in predicting persistent depression at three months among those who had depression at one month. Conclusions: Depression is highly prevalent in HIV-infected persons who have survived cryptococcal meningitis. We found that sertraline is associated with a modest reduction in depression in those with depression at baseline and a significant decrease in severe depression.
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18
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Pullen MF, Pastick KA, Williams DA, Nascene AA, Bangdiwala AS, Okafor EC, Hullsiek KH, Skipper CP, Lofgren SM, Engen N, Abassi M, McDonald EG, Lee TC, Rajasingham R, Boulware DR. Lessons Learned From Conducting Internet-Based Randomized Clinical Trials During a Global Pandemic. Open Forum Infect Dis 2020; 8:ofaa602. [PMID: 33553471 PMCID: PMC7798626 DOI: 10.1093/ofid/ofaa602] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 12/05/2020] [Indexed: 11/14/2022] Open
Abstract
As the severe acute respiratory syndrome coronavirus 2 pandemic evolved, it was apparent that well designed and rapidly conducted randomized clinical trials were urgently needed. However, traditional clinical trial design presented several challenges. Notably, disease prevalence initially varied by time and region, and the pockets of outbreaks evolved geographically over time. Coupled with an occupational hazard from in-person study visits, timely recruitment would prove difficult in a traditional in-person clinical trial. Thus, our team opted to launch nationwide internet-based clinical trials using patient-reported outcome measures. In total, 2795 participants were recruited using traditional and social media, with screening and enrollment performed via an online data capture system. Follow-up surveys and survey reminders were similarly managed through this online system with manual participant outreach in the event of missing data. In this report, we present a narrative of our experience running internet-based clinical trials and provide recommendations for the design of future clinical trials during a world pandemic.
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Affiliation(s)
- Matthew F Pullen
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Katelyn A Pastick
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Darlisha A Williams
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Alanna A Nascene
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Ananta S Bangdiwala
- School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Elizabeth C Okafor
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | | | - Caleb P Skipper
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Sarah M Lofgren
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Nicole Engen
- School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Mahsa Abassi
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Emily G McDonald
- Department of Medicine, McGill University, Montreal, Québec, Canada
| | - Todd C Lee
- Department of Medicine, McGill University, Montreal, Québec, Canada
| | - Radha Rajasingham
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - David R Boulware
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA.,School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
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19
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Chesdachai S, Engen NW, Rhein J, Tugume L, Kiiza Kandole T, Abassi M, Ssebambulidde K, Kasibante J, Williams DA, Skipper CP, Hullsiek KH, Musubire AK, Rajasingham R, Meya DB, Boulware DR. Baseline Serum C-Reactive Protein Level Predicts Mortality in Cryptococcal Meningitis. Open Forum Infect Dis 2020; 7:ofaa530. [PMID: 33335936 PMCID: PMC7727340 DOI: 10.1093/ofid/ofaa530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 10/23/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND C-reactive protein (CRP) is an acute phase protein produced by the liver in response to systemic inflammation. CRP is a helpful surrogate biomarker used for following the progression and resolution of infection. We aimed to determine the association of baseline CRP level and the temporal change in CRP over time with cryptococcal meningitis outcome. METHODS We reviewed 168 prospectively enrolled HIV-infected Ugandans with confirmed first-episode cryptococcal meningitis. Baseline plasma CRP collected within 5 days of meningitis diagnosis was categorized into quartiles. We compared baseline CRP with 18-week survival using time-to-event analysis. RESULTS Of 168 participants, the baseline first quartile of serum CRP was <29.0 mg/L, second quartile 29.0-49.5 mg/L, third quartile 49.6-83.6 mg/L, and fourth quartile >83.6 mg/L. Baseline CD4 count, HIV viral load, and cerebrospinal fluid results did not differ by CRP quartile. Participants with CRP >49.5 mg/L more likely presented with Glasgow Coma Scale (GCS) <15 (P = .03). The 18-week mortality rate was 55% (46/84) in the highest 2 quartile CRP groups (>49.5 mg/L), 41% (17/42) in the mid-range CRP group (29.0-49.5 mg/L), and 14% (6/42) in the low-CRP group (<29.0 mg/L; P < .001). After adjustment for possible confounding factors including GCS <15, CRP remained significantly associated with mortality (adjusted hazard ratio, 1.084 per 10 mg/L; 95% CI, 1.031-1.139; P = .0016). CONCLUSIONS Higher baseline CRP is associated with increased mortality in HIV-infected individuals with first-episode cryptococcal meningitis. CRP could be a surrogate marker for undiagnosed coinfections or may reflect immune dysregulation, leading to worse outcomes in persons with advanced AIDS and concomitant cryptococcal meningitis.
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Affiliation(s)
- Supavit Chesdachai
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA,Correspondence: Supavit Chesdachai, MD, 420 Delaware Street SE, MMC 284, Minneapolis, MN 55455 ()
| | - Nicole W Engen
- Division of Biostatistics, University of Minnesota, Minneapolis, Minnesota, USA
| | - Joshua Rhein
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Lillian Tugume
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Tadeo Kiiza Kandole
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Mahsa Abassi
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Kenneth Ssebambulidde
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - John Kasibante
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Darlisha A Williams
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Caleb P Skipper
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Kathy H Hullsiek
- Division of Biostatistics, University of Minnesota, Minneapolis, Minnesota, USA
| | - Abdu K Musubire
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Radha Rajasingham
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - David B Meya
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - David R Boulware
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
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20
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Skipper CP, Pastick KA, Engen NW, Bangdiwala AS, Abassi M, Lofgren SM, Williams DA, Okafor EC, Pullen MF, Nicol MR, Nascene AA, Hullsiek KH, Cheng MP, Luke D, Lother SA, MacKenzie LJ, Drobot G, Kelly LE, Schwartz IS, Zarychanski R, McDonald EG, Lee TC, Rajasingham R, Boulware DR. Hydroxychloroquine in Nonhospitalized Adults With Early COVID-19 : A Randomized Trial. Ann Intern Med 2020; 173:623-631. [PMID: 32673060 PMCID: PMC7384270 DOI: 10.7326/m20-4207] [Citation(s) in RCA: 354] [Impact Index Per Article: 88.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND No effective oral therapy exists for early coronavirus disease 2019 (COVID-19). OBJECTIVE To investigate whether hydroxychloroquine could reduce COVID-19 severity in adult outpatients. DESIGN Randomized, double-blind, placebo-controlled trial conducted from 22 March through 20 May 2020. (ClinicalTrials.gov: NCT04308668). SETTING Internet-based trial across the United States and Canada (40 states and 3 provinces). PARTICIPANTS Symptomatic, nonhospitalized adults with laboratory-confirmed COVID-19 or probable COVID-19 and high-risk exposure within 4 days of symptom onset. INTERVENTION Oral hydroxychloroquine (800 mg once, followed by 600 mg in 6 to 8 hours, then 600 mg daily for 4 more days) or masked placebo. MEASUREMENTS Symptoms and severity at baseline and then at days 3, 5, 10, and 14 using a 10-point visual analogue scale. The primary end point was change in overall symptom severity over 14 days. RESULTS Of 491 patients randomly assigned to a group, 423 contributed primary end point data. Of these, 341 (81%) had laboratory-confirmed infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) or epidemiologically linked exposure to a person with laboratory-confirmed infection; 56% (236 of 423) were enrolled within 1 day of symptoms starting. Change in symptom severity over 14 days did not differ between the hydroxychloroquine and placebo groups (difference in symptom severity: relative, 12%; absolute, -0.27 point [95% CI, -0.61 to 0.07 point]; P = 0.117). At 14 days, 24% (49 of 201) of participants receiving hydroxychloroquine had ongoing symptoms compared with 30% (59 of 194) receiving placebo (P = 0.21). Medication adverse effects occurred in 43% (92 of 212) of participants receiving hydroxychloroquine versus 22% (46 of 211) receiving placebo (P < 0.001). With placebo, 10 hospitalizations occurred (2 non-COVID-19-related), including 1 hospitalized death. With hydroxychloroquine, 4 hospitalizations occurred plus 1 nonhospitalized death (P = 0.29). LIMITATION Only 58% of participants received SARS-CoV-2 testing because of severe U.S. testing shortages. CONCLUSION Hydroxychloroquine did not substantially reduce symptom severity in outpatients with early, mild COVID-19. PRIMARY FUNDING SOURCE Private donors.
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Affiliation(s)
- Caleb P Skipper
- University of Minnesota, Minneapolis, Minnesota (C.P.S., K.A.P., N.W.E., A.S.B., M.A., S.M.L., D.A.W., E.C.O., M.F.P., M.R.N., A.A.N., K.H.H., R.R., D.R.B.)
| | - Katelyn A Pastick
- University of Minnesota, Minneapolis, Minnesota (C.P.S., K.A.P., N.W.E., A.S.B., M.A., S.M.L., D.A.W., E.C.O., M.F.P., M.R.N., A.A.N., K.H.H., R.R., D.R.B.)
| | - Nicole W Engen
- University of Minnesota, Minneapolis, Minnesota (C.P.S., K.A.P., N.W.E., A.S.B., M.A., S.M.L., D.A.W., E.C.O., M.F.P., M.R.N., A.A.N., K.H.H., R.R., D.R.B.)
| | - Ananta S Bangdiwala
- University of Minnesota, Minneapolis, Minnesota (C.P.S., K.A.P., N.W.E., A.S.B., M.A., S.M.L., D.A.W., E.C.O., M.F.P., M.R.N., A.A.N., K.H.H., R.R., D.R.B.)
| | - Mahsa Abassi
- University of Minnesota, Minneapolis, Minnesota (C.P.S., K.A.P., N.W.E., A.S.B., M.A., S.M.L., D.A.W., E.C.O., M.F.P., M.R.N., A.A.N., K.H.H., R.R., D.R.B.)
| | - Sarah M Lofgren
- University of Minnesota, Minneapolis, Minnesota (C.P.S., K.A.P., N.W.E., A.S.B., M.A., S.M.L., D.A.W., E.C.O., M.F.P., M.R.N., A.A.N., K.H.H., R.R., D.R.B.)
| | - Darlisha A Williams
- University of Minnesota, Minneapolis, Minnesota (C.P.S., K.A.P., N.W.E., A.S.B., M.A., S.M.L., D.A.W., E.C.O., M.F.P., M.R.N., A.A.N., K.H.H., R.R., D.R.B.)
| | - Elizabeth C Okafor
- University of Minnesota, Minneapolis, Minnesota (C.P.S., K.A.P., N.W.E., A.S.B., M.A., S.M.L., D.A.W., E.C.O., M.F.P., M.R.N., A.A.N., K.H.H., R.R., D.R.B.)
| | - Matthew F Pullen
- University of Minnesota, Minneapolis, Minnesota (C.P.S., K.A.P., N.W.E., A.S.B., M.A., S.M.L., D.A.W., E.C.O., M.F.P., M.R.N., A.A.N., K.H.H., R.R., D.R.B.)
| | - Melanie R Nicol
- University of Minnesota, Minneapolis, Minnesota (C.P.S., K.A.P., N.W.E., A.S.B., M.A., S.M.L., D.A.W., E.C.O., M.F.P., M.R.N., A.A.N., K.H.H., R.R., D.R.B.)
| | - Alanna A Nascene
- University of Minnesota, Minneapolis, Minnesota (C.P.S., K.A.P., N.W.E., A.S.B., M.A., S.M.L., D.A.W., E.C.O., M.F.P., M.R.N., A.A.N., K.H.H., R.R., D.R.B.)
| | - Kathy H Hullsiek
- University of Minnesota, Minneapolis, Minnesota (C.P.S., K.A.P., N.W.E., A.S.B., M.A., S.M.L., D.A.W., E.C.O., M.F.P., M.R.N., A.A.N., K.H.H., R.R., D.R.B.)
| | - Matthew P Cheng
- Research Institute of the McGill University Health Centre and McGill University, Montréal, Quebec, Canada (M.P.C., E.G.M., T.C.L.)
| | - Darlette Luke
- M Health Fairview Investigational Drug Service Pharmacy, Minneapolis, Minnesota (D.L.)
| | - Sylvain A Lother
- University of Manitoba, Winnipeg, Manitoba, Canada (S.A.L., L.J.M., G.D., R.Z.)
| | - Lauren J MacKenzie
- University of Manitoba, Winnipeg, Manitoba, Canada (S.A.L., L.J.M., G.D., R.Z.)
| | - Glen Drobot
- University of Manitoba, Winnipeg, Manitoba, Canada (S.A.L., L.J.M., G.D., R.Z.)
| | - Lauren E Kelly
- George & Fay Yee Centre for Healthcare Innovation, Winnipeg, Manitoba, Canada (L.E.K.)
| | | | - Ryan Zarychanski
- University of Manitoba, Winnipeg, Manitoba, Canada (S.A.L., L.J.M., G.D., R.Z.)
| | - Emily G McDonald
- Research Institute of the McGill University Health Centre and McGill University, Montréal, Quebec, Canada (M.P.C., E.G.M., T.C.L.)
| | - Todd C Lee
- Research Institute of the McGill University Health Centre and McGill University, Montréal, Quebec, Canada (M.P.C., E.G.M., T.C.L.)
| | - Radha Rajasingham
- University of Minnesota, Minneapolis, Minnesota (C.P.S., K.A.P., N.W.E., A.S.B., M.A., S.M.L., D.A.W., E.C.O., M.F.P., M.R.N., A.A.N., K.H.H., R.R., D.R.B.)
| | - David R Boulware
- University of Minnesota, Minneapolis, Minnesota (C.P.S., K.A.P., N.W.E., A.S.B., M.A., S.M.L., D.A.W., E.C.O., M.F.P., M.R.N., A.A.N., K.H.H., R.R., D.R.B.)
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21
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Lofgren SM, Nicol MR, Bangdiwala AS, Pastick KA, Okafor EC, Skipper CP, Pullen MF, Engen NW, Abassi M, Williams DA, Nascene AA, Axelrod ML, Lother SA, MacKenzie LJ, Drobot G, Marten N, Cheng MP, Zarychanski R, Schwartz IS, Silverman M, Chagla Z, Kelly LE, McDonald EG, Lee TC, Hullsiek KH, Boulware DR, Rajasingham R. Safety of Hydroxychloroquine Among Outpatient Clinical Trial Participants for COVID-19. Open Forum Infect Dis 2020; 7:ofaa500. [PMID: 33204764 PMCID: PMC7654376 DOI: 10.1093/ofid/ofaa500] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 10/15/2020] [Indexed: 12/24/2022] Open
Abstract
Background Use of hydroxychloroquine in hospitalized patients with coronavirus disease 2019 (COVID-19), especially in combination with azithromycin, has raised safety concerns. Here, we report safety data from 3 outpatient randomized clinical trials. Methods We conducted 3 randomized, double-blind, placebo-controlled trials investigating hydroxychloroquine as pre-exposure prophylaxis, postexposure prophylaxis, and early treatment for COVID-19 using an internet-based design. We excluded individuals with contraindications to hydroxychloroquine. We collected side effects and serious adverse events. We report descriptive analyses of our findings. Results We enrolled 2795 participants. The median age of research participants (interquartile range) was 40 (34–49) years, and 59% (1633/2767) reported no chronic medical conditions. Overall 2544 (91%) participants reported side effect data, and 748 (29%) reported at least 1 medication side effect. Side effects were reported in 40% with once-daily, 36% with twice-weekly, 31% with once-weekly hydroxychloroquine, compared with 19% with placebo. The most common side effects were upset stomach or nausea (25% with once-daily, 19% with twice-weekly, and 18% with once-weekly hydroxychloroquine, vs 11% for placebo), followed by diarrhea, vomiting, or abdominal pain (23% for once-daily, 17% twice-weekly, and 13% once-weekly hydroxychloroquine, vs 7% for placebo). Two individuals were hospitalized for atrial arrhythmias, 1 on placebo and 1 on twice-weekly hydroxychloroquine. No sudden deaths occurred. Conclusions Data from 3 outpatient COVID-19 trials demonstrated that gastrointestinal side effects were common but mild with the use of hydroxychloroquine, while serious side effects were rare. No deaths occurred related to hydroxychloroquine. Randomized clinical trials, in cohorts of healthy outpatients, can safely investigate whether hydroxychloroquine is efficacious for COVID-19. ClinicalTrials.gov Identifier NCT04308668 for postexposure prophylaxis and early treatment trials; NCT04328467 for pre-exposure prophylaxis trial.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Mahsa Abassi
- University of Minnesota, Minneapolis, Minnesota, USA
| | | | | | | | - Sylvain A Lother
- Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Lauren J MacKenzie
- Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Glen Drobot
- Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Nicole Marten
- George & Fay Yee Centre for Healthcare Innovation, Winnipeg, Manitoba, Canada
| | - Matthew P Cheng
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada.,Clinical Practice Assessment Unit, Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Ryan Zarychanski
- Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.,George & Fay Yee Centre for Healthcare Innovation, Winnipeg, Manitoba, Canada
| | - Ilan S Schwartz
- Division of Infectious Diseases, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Michael Silverman
- Lawson Research Institute, St. Joseph's Healthcare Center, London, Ontario
| | - Zain Chagla
- McMaster University, Hamilton, Ontario, Canada
| | - Lauren E Kelly
- George & Fay Yee Centre for Healthcare Innovation, Winnipeg, Manitoba, Canada
| | - Emily G McDonald
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada.,Clinical Practice Assessment Unit, Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Todd C Lee
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada.,Clinical Practice Assessment Unit, Department of Medicine, McGill University, Montreal, Quebec, Canada
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22
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Lofgren SM, Nicol MR, Bangdiwala AS, Pastick KA, Okafor EC, Skipper CP, Pullen MF, Engen NW, Abassi M, Williams DA, Nascene AA, Axelrod ML, Lother SA, MacKenzie LJ, Drobot G, Marten N, Cheng MP, Zarychanshi R, Schwartz IS, Silverman M, Chagla Z, Kelly LE, McDonald EG, Lee TC, Hullsiek KH, Boulware DR, Rajasingham R. Safety of Hydroxychloroquine among Outpatient Clinical Trial Participants for COVID-19. medRxiv 2020. [PMID: 32743591 DOI: 10.1101/2020.07.16.20155531] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Use of hydroxychloroquine in hospitalized patients with COVID-19, especially in combination with azithromycin, has raised safety concerns. Here, we report safety data from three outpatient randomized clinical trials. METHODS We conducted three randomized, double-blind, placebo-controlled trials investigating hydroxychloroquine as pre-exposure prophylaxis, post-exposure prophylaxis and early treatment for COVID-19. We excluded individuals with contraindications to hydroxychloroquine. We collected side effects and serious adverse events. We report descriptive analyses of our findings. RESULTS We enrolled 2,795 participants. The median age of research participants was 40 (IQR 34-49) years, and 59% (1633/2767) reported no chronic medical conditions. Overall 2,324 (84%) participants reported side effect data, and 638 (27%) reported at least one medication side effect. Side effects were reported in 29% with daily, 36% with twice weekly, 31% with once weekly hydroxychloroquine compared to 19% with placebo. The most common side effects were upset stomach or nausea (25% with daily, 18% with twice weekly, 16% with weekly, vs. 10% for placebo), followed by diarrhea, vomiting, or abdominal pain (23% for daily, 16% twice weekly, 12% weekly, vs. 6% for placebo). Two individuals were hospitalized for atrial arrhythmias, one on placebo and one on twice weekly hydroxychloroquine. No sudden deaths occurred. CONCLUSION Data from three outpatient COVID-19 trials demonstrated that gastrointestinal side effects were common but mild with the use of hydroxychloroquine, while serious side effects were rare. No deaths occurred related to hydroxychloroquine. Randomized clinical trials can safely investigate whether hydroxychloroquine is efficacious for COVID-19.
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23
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Lother SA, Abassi M, Agostinis A, Bangdiwala AS, Cheng MP, Drobot G, Engen N, Hullsiek KH, Kelly LE, Lee TC, Lofgren SM, MacKenzie LJ, Marten N, McDonald EG, Okafor EC, Pastick KA, Pullen MF, Rajasingham R, Schwartz I, Skipper CP, Turgeon AF, Zarychanski R, Boulware DR. Post-exposure prophylaxis or pre-emptive therapy for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2): study protocol for a pragmatic randomized-controlled trial. Can J Anaesth 2020; 67:1201-1211. [PMID: 32383125 PMCID: PMC7205369 DOI: 10.1007/s12630-020-01684-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 04/21/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) emerged in December 2019 causing the coronavirus disease (COVID-19) pandemic. Currently, there is a lack of evidence-based therapies to prevent COVID-19 following exposure to the virus, or to prevent worsening of symptoms following confirmed infection. We describe the design of a clinical trial of hydroxychloroquine for post-exposure prophylaxis (PEP) and pre-emptive therapy (PET) for COVID-19. METHODS We will conduct two nested multicentre international double-blind randomized placebo-controlled clinical trials of hydroxychloroquine for: 1) PEP of asymptomatic household contacts or healthcare workers exposed to COVID-19 within the past four days, and 2) PET for symptomatic outpatients with COVID-19 showing symptoms for less than four days. We will recruit 1,500 patients each for the PEP and PET trials. Participants will be randomized 1:1 to receive five days of hydroxychloroquine or placebo. The primary PEP trial outcome will be the incidence of symptomatic COVID-19. The primary PET trial outcome will be an ordinal scale of disease severity (not hospitalized, hospitalized without intensive care, hospitalization with intensive care, or death). Participant screening, informed consent, and follow-up will be exclusively internet-based with appropriate regulatory and research ethics board approvals in Canada and the United States. DISCUSSION These complementary randomized-controlled trials are innovatively designed and adequately powered to rapidly answer urgent questions regarding the effectiveness of hydroxychloroquine to reduce virus transmission and disease severity of COVID-19 during a pandemic. In-person participant follow-up will not be conducted to facilitate social distancing strategies and reduce risks of exposure to study personnel. Innovative trial approaches are needed to urgently assess therapeutic options to mitigate the global impact of this pandemic. TRIALS REGISTRATION clinicaltrials.gov (NCT04308668); registered 16 March, 2020.
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Affiliation(s)
- Sylvain A Lother
- Department of Internal Medicine, Section of Critical Care, University of Manitoba, Winnipeg, MB, Canada.
- Section of Infectious Diseases, Department of Internal Medicine, University of Manitoba, Winnipeg, MB, Canada.
| | - Mahsa Abassi
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Alyssa Agostinis
- Division of Infectious Diseases, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
- School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Ananta S Bangdiwala
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Matthew P Cheng
- Divisions of Infectious Diseases & Medical Microbiology, McGill University Health Centre, Montreal, QC, Canada
- McGill Interdisciplinary Initiative in Infection and Immunity, Montreal, QC, Canada
| | - Glen Drobot
- Department of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Nicole Engen
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Kathy H Hullsiek
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Lauren E Kelly
- Department of Pediatrics and Child Health, Department of Pharmacology, University of Manitoba, Winnipeg, MB, Canada
| | - Todd C Lee
- Clinical Practice Assessment Unit, Department of Medicine, McGill University, Montreal, QC, Canada
| | - Sarah M Lofgren
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Lauren J MacKenzie
- Section of Infectious Diseases, Department of Internal Medicine, University of Manitoba, Winnipeg, MB, Canada
- Department of Community Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Nicole Marten
- Critical Care Research, St-Boniface Hospital, Winnipeg, MB, Canada
| | - Emily G McDonald
- Clinical Practice Assessment Unit, Department of Medicine, McGill University, Montreal, QC, Canada
| | | | - Katelyn A Pastick
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Matthew F Pullen
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Radha Rajasingham
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Ilan Schwartz
- Division of Infectious Diseases, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Caleb P Skipper
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Alexis F Turgeon
- CHU de Québec - Université Laval Research Centre, Population Health and Optimal Health Practices Research Unit Trauma - Emergency - Critical Care Medicine, Université Laval, Quebec, QC, Canada
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Faculty of Medicine, Université Laval, Quebec, QC, Canada
| | - Ryan Zarychanski
- Department of Internal Medicine, Section of Critical Care, University of Manitoba, Winnipeg, MB, Canada
- Department of Internal Medicine, Section of Hematology and Oncology, University of Manitoba, Winnipeg, MB, Canada
- Department of Medical Oncology and Hematology, CancerCare Manitoba, Winnipeg, MB, Canada
| | - David R Boulware
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
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Boulware DR, Pullen MF, Bangdiwala AS, Pastick KA, Lofgren SM, Okafor EC, Skipper CP, Nascene AA, Nicol MR, Abassi M, Engen NW, Cheng MP, LaBar D, Lother SA, MacKenzie LJ, Drobot G, Marten N, Zarychanski R, Kelly LE, Schwartz IS, McDonald EG, Rajasingham R, Lee TC, Hullsiek KH. A Randomized Trial of Hydroxychloroquine as Postexposure Prophylaxis for Covid-19. N Engl J Med 2020; 383:517-525. [PMID: 32492293 PMCID: PMC7289276 DOI: 10.1056/nejmoa2016638] [Citation(s) in RCA: 890] [Impact Index Per Article: 222.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Coronavirus disease 2019 (Covid-19) occurs after exposure to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). For persons who are exposed, the standard of care is observation and quarantine. Whether hydroxychloroquine can prevent symptomatic infection after SARS-CoV-2 exposure is unknown. METHODS We conducted a randomized, double-blind, placebo-controlled trial across the United States and parts of Canada testing hydroxychloroquine as postexposure prophylaxis. We enrolled adults who had household or occupational exposure to someone with confirmed Covid-19 at a distance of less than 6 ft for more than 10 minutes while wearing neither a face mask nor an eye shield (high-risk exposure) or while wearing a face mask but no eye shield (moderate-risk exposure). Within 4 days after exposure, we randomly assigned participants to receive either placebo or hydroxychloroquine (800 mg once, followed by 600 mg in 6 to 8 hours, then 600 mg daily for 4 additional days). The primary outcome was the incidence of either laboratory-confirmed Covid-19 or illness compatible with Covid-19 within 14 days. RESULTS We enrolled 821 asymptomatic participants. Overall, 87.6% of the participants (719 of 821) reported a high-risk exposure to a confirmed Covid-19 contact. The incidence of new illness compatible with Covid-19 did not differ significantly between participants receiving hydroxychloroquine (49 of 414 [11.8%]) and those receiving placebo (58 of 407 [14.3%]); the absolute difference was -2.4 percentage points (95% confidence interval, -7.0 to 2.2; P = 0.35). Side effects were more common with hydroxychloroquine than with placebo (40.1% vs. 16.8%), but no serious adverse reactions were reported. CONCLUSIONS After high-risk or moderate-risk exposure to Covid-19, hydroxychloroquine did not prevent illness compatible with Covid-19 or confirmed infection when used as postexposure prophylaxis within 4 days after exposure. (Funded by David Baszucki and Jan Ellison Baszucki and others; ClinicalTrials.gov number, NCT04308668.).
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Affiliation(s)
- David R Boulware
- From the University of Minnesota (D.R.B., M.F.P., A.S.B., K.A.P., S.M.L., E.C.O., C.P.S., A.A.N., M.R.N., M.A., N.W.E., R.R., K.H.H.) and M Health Fairview Investigational Drug Service Pharmacy (D.L.), Minneapolis; and the Research Institute of the McGill University Health Centre and the Clinical Practice Assessment Unit, Department of Medicine, McGill University, Montreal (M.P.C., E.G.M., T.C.L.), the Department of Internal Medicine, University of Manitoba (S.A.L., L.J.M., G.D., N.M., R.Z.), the Research Institute in Oncology and Hematology, CancerCare Manitoba, University of Manitoba (R.Z.), and the George and Fay Yee Centre for Healthcare Innovation (L.E.K.), Winnipeg, and the University of Alberta, Edmonton (I.S.S.) - all in Canada
| | - Matthew F Pullen
- From the University of Minnesota (D.R.B., M.F.P., A.S.B., K.A.P., S.M.L., E.C.O., C.P.S., A.A.N., M.R.N., M.A., N.W.E., R.R., K.H.H.) and M Health Fairview Investigational Drug Service Pharmacy (D.L.), Minneapolis; and the Research Institute of the McGill University Health Centre and the Clinical Practice Assessment Unit, Department of Medicine, McGill University, Montreal (M.P.C., E.G.M., T.C.L.), the Department of Internal Medicine, University of Manitoba (S.A.L., L.J.M., G.D., N.M., R.Z.), the Research Institute in Oncology and Hematology, CancerCare Manitoba, University of Manitoba (R.Z.), and the George and Fay Yee Centre for Healthcare Innovation (L.E.K.), Winnipeg, and the University of Alberta, Edmonton (I.S.S.) - all in Canada
| | - Ananta S Bangdiwala
- From the University of Minnesota (D.R.B., M.F.P., A.S.B., K.A.P., S.M.L., E.C.O., C.P.S., A.A.N., M.R.N., M.A., N.W.E., R.R., K.H.H.) and M Health Fairview Investigational Drug Service Pharmacy (D.L.), Minneapolis; and the Research Institute of the McGill University Health Centre and the Clinical Practice Assessment Unit, Department of Medicine, McGill University, Montreal (M.P.C., E.G.M., T.C.L.), the Department of Internal Medicine, University of Manitoba (S.A.L., L.J.M., G.D., N.M., R.Z.), the Research Institute in Oncology and Hematology, CancerCare Manitoba, University of Manitoba (R.Z.), and the George and Fay Yee Centre for Healthcare Innovation (L.E.K.), Winnipeg, and the University of Alberta, Edmonton (I.S.S.) - all in Canada
| | - Katelyn A Pastick
- From the University of Minnesota (D.R.B., M.F.P., A.S.B., K.A.P., S.M.L., E.C.O., C.P.S., A.A.N., M.R.N., M.A., N.W.E., R.R., K.H.H.) and M Health Fairview Investigational Drug Service Pharmacy (D.L.), Minneapolis; and the Research Institute of the McGill University Health Centre and the Clinical Practice Assessment Unit, Department of Medicine, McGill University, Montreal (M.P.C., E.G.M., T.C.L.), the Department of Internal Medicine, University of Manitoba (S.A.L., L.J.M., G.D., N.M., R.Z.), the Research Institute in Oncology and Hematology, CancerCare Manitoba, University of Manitoba (R.Z.), and the George and Fay Yee Centre for Healthcare Innovation (L.E.K.), Winnipeg, and the University of Alberta, Edmonton (I.S.S.) - all in Canada
| | - Sarah M Lofgren
- From the University of Minnesota (D.R.B., M.F.P., A.S.B., K.A.P., S.M.L., E.C.O., C.P.S., A.A.N., M.R.N., M.A., N.W.E., R.R., K.H.H.) and M Health Fairview Investigational Drug Service Pharmacy (D.L.), Minneapolis; and the Research Institute of the McGill University Health Centre and the Clinical Practice Assessment Unit, Department of Medicine, McGill University, Montreal (M.P.C., E.G.M., T.C.L.), the Department of Internal Medicine, University of Manitoba (S.A.L., L.J.M., G.D., N.M., R.Z.), the Research Institute in Oncology and Hematology, CancerCare Manitoba, University of Manitoba (R.Z.), and the George and Fay Yee Centre for Healthcare Innovation (L.E.K.), Winnipeg, and the University of Alberta, Edmonton (I.S.S.) - all in Canada
| | - Elizabeth C Okafor
- From the University of Minnesota (D.R.B., M.F.P., A.S.B., K.A.P., S.M.L., E.C.O., C.P.S., A.A.N., M.R.N., M.A., N.W.E., R.R., K.H.H.) and M Health Fairview Investigational Drug Service Pharmacy (D.L.), Minneapolis; and the Research Institute of the McGill University Health Centre and the Clinical Practice Assessment Unit, Department of Medicine, McGill University, Montreal (M.P.C., E.G.M., T.C.L.), the Department of Internal Medicine, University of Manitoba (S.A.L., L.J.M., G.D., N.M., R.Z.), the Research Institute in Oncology and Hematology, CancerCare Manitoba, University of Manitoba (R.Z.), and the George and Fay Yee Centre for Healthcare Innovation (L.E.K.), Winnipeg, and the University of Alberta, Edmonton (I.S.S.) - all in Canada
| | - Caleb P Skipper
- From the University of Minnesota (D.R.B., M.F.P., A.S.B., K.A.P., S.M.L., E.C.O., C.P.S., A.A.N., M.R.N., M.A., N.W.E., R.R., K.H.H.) and M Health Fairview Investigational Drug Service Pharmacy (D.L.), Minneapolis; and the Research Institute of the McGill University Health Centre and the Clinical Practice Assessment Unit, Department of Medicine, McGill University, Montreal (M.P.C., E.G.M., T.C.L.), the Department of Internal Medicine, University of Manitoba (S.A.L., L.J.M., G.D., N.M., R.Z.), the Research Institute in Oncology and Hematology, CancerCare Manitoba, University of Manitoba (R.Z.), and the George and Fay Yee Centre for Healthcare Innovation (L.E.K.), Winnipeg, and the University of Alberta, Edmonton (I.S.S.) - all in Canada
| | - Alanna A Nascene
- From the University of Minnesota (D.R.B., M.F.P., A.S.B., K.A.P., S.M.L., E.C.O., C.P.S., A.A.N., M.R.N., M.A., N.W.E., R.R., K.H.H.) and M Health Fairview Investigational Drug Service Pharmacy (D.L.), Minneapolis; and the Research Institute of the McGill University Health Centre and the Clinical Practice Assessment Unit, Department of Medicine, McGill University, Montreal (M.P.C., E.G.M., T.C.L.), the Department of Internal Medicine, University of Manitoba (S.A.L., L.J.M., G.D., N.M., R.Z.), the Research Institute in Oncology and Hematology, CancerCare Manitoba, University of Manitoba (R.Z.), and the George and Fay Yee Centre for Healthcare Innovation (L.E.K.), Winnipeg, and the University of Alberta, Edmonton (I.S.S.) - all in Canada
| | - Melanie R Nicol
- From the University of Minnesota (D.R.B., M.F.P., A.S.B., K.A.P., S.M.L., E.C.O., C.P.S., A.A.N., M.R.N., M.A., N.W.E., R.R., K.H.H.) and M Health Fairview Investigational Drug Service Pharmacy (D.L.), Minneapolis; and the Research Institute of the McGill University Health Centre and the Clinical Practice Assessment Unit, Department of Medicine, McGill University, Montreal (M.P.C., E.G.M., T.C.L.), the Department of Internal Medicine, University of Manitoba (S.A.L., L.J.M., G.D., N.M., R.Z.), the Research Institute in Oncology and Hematology, CancerCare Manitoba, University of Manitoba (R.Z.), and the George and Fay Yee Centre for Healthcare Innovation (L.E.K.), Winnipeg, and the University of Alberta, Edmonton (I.S.S.) - all in Canada
| | - Mahsa Abassi
- From the University of Minnesota (D.R.B., M.F.P., A.S.B., K.A.P., S.M.L., E.C.O., C.P.S., A.A.N., M.R.N., M.A., N.W.E., R.R., K.H.H.) and M Health Fairview Investigational Drug Service Pharmacy (D.L.), Minneapolis; and the Research Institute of the McGill University Health Centre and the Clinical Practice Assessment Unit, Department of Medicine, McGill University, Montreal (M.P.C., E.G.M., T.C.L.), the Department of Internal Medicine, University of Manitoba (S.A.L., L.J.M., G.D., N.M., R.Z.), the Research Institute in Oncology and Hematology, CancerCare Manitoba, University of Manitoba (R.Z.), and the George and Fay Yee Centre for Healthcare Innovation (L.E.K.), Winnipeg, and the University of Alberta, Edmonton (I.S.S.) - all in Canada
| | - Nicole W Engen
- From the University of Minnesota (D.R.B., M.F.P., A.S.B., K.A.P., S.M.L., E.C.O., C.P.S., A.A.N., M.R.N., M.A., N.W.E., R.R., K.H.H.) and M Health Fairview Investigational Drug Service Pharmacy (D.L.), Minneapolis; and the Research Institute of the McGill University Health Centre and the Clinical Practice Assessment Unit, Department of Medicine, McGill University, Montreal (M.P.C., E.G.M., T.C.L.), the Department of Internal Medicine, University of Manitoba (S.A.L., L.J.M., G.D., N.M., R.Z.), the Research Institute in Oncology and Hematology, CancerCare Manitoba, University of Manitoba (R.Z.), and the George and Fay Yee Centre for Healthcare Innovation (L.E.K.), Winnipeg, and the University of Alberta, Edmonton (I.S.S.) - all in Canada
| | - Matthew P Cheng
- From the University of Minnesota (D.R.B., M.F.P., A.S.B., K.A.P., S.M.L., E.C.O., C.P.S., A.A.N., M.R.N., M.A., N.W.E., R.R., K.H.H.) and M Health Fairview Investigational Drug Service Pharmacy (D.L.), Minneapolis; and the Research Institute of the McGill University Health Centre and the Clinical Practice Assessment Unit, Department of Medicine, McGill University, Montreal (M.P.C., E.G.M., T.C.L.), the Department of Internal Medicine, University of Manitoba (S.A.L., L.J.M., G.D., N.M., R.Z.), the Research Institute in Oncology and Hematology, CancerCare Manitoba, University of Manitoba (R.Z.), and the George and Fay Yee Centre for Healthcare Innovation (L.E.K.), Winnipeg, and the University of Alberta, Edmonton (I.S.S.) - all in Canada
| | - Derek LaBar
- From the University of Minnesota (D.R.B., M.F.P., A.S.B., K.A.P., S.M.L., E.C.O., C.P.S., A.A.N., M.R.N., M.A., N.W.E., R.R., K.H.H.) and M Health Fairview Investigational Drug Service Pharmacy (D.L.), Minneapolis; and the Research Institute of the McGill University Health Centre and the Clinical Practice Assessment Unit, Department of Medicine, McGill University, Montreal (M.P.C., E.G.M., T.C.L.), the Department of Internal Medicine, University of Manitoba (S.A.L., L.J.M., G.D., N.M., R.Z.), the Research Institute in Oncology and Hematology, CancerCare Manitoba, University of Manitoba (R.Z.), and the George and Fay Yee Centre for Healthcare Innovation (L.E.K.), Winnipeg, and the University of Alberta, Edmonton (I.S.S.) - all in Canada
| | - Sylvain A Lother
- From the University of Minnesota (D.R.B., M.F.P., A.S.B., K.A.P., S.M.L., E.C.O., C.P.S., A.A.N., M.R.N., M.A., N.W.E., R.R., K.H.H.) and M Health Fairview Investigational Drug Service Pharmacy (D.L.), Minneapolis; and the Research Institute of the McGill University Health Centre and the Clinical Practice Assessment Unit, Department of Medicine, McGill University, Montreal (M.P.C., E.G.M., T.C.L.), the Department of Internal Medicine, University of Manitoba (S.A.L., L.J.M., G.D., N.M., R.Z.), the Research Institute in Oncology and Hematology, CancerCare Manitoba, University of Manitoba (R.Z.), and the George and Fay Yee Centre for Healthcare Innovation (L.E.K.), Winnipeg, and the University of Alberta, Edmonton (I.S.S.) - all in Canada
| | - Lauren J MacKenzie
- From the University of Minnesota (D.R.B., M.F.P., A.S.B., K.A.P., S.M.L., E.C.O., C.P.S., A.A.N., M.R.N., M.A., N.W.E., R.R., K.H.H.) and M Health Fairview Investigational Drug Service Pharmacy (D.L.), Minneapolis; and the Research Institute of the McGill University Health Centre and the Clinical Practice Assessment Unit, Department of Medicine, McGill University, Montreal (M.P.C., E.G.M., T.C.L.), the Department of Internal Medicine, University of Manitoba (S.A.L., L.J.M., G.D., N.M., R.Z.), the Research Institute in Oncology and Hematology, CancerCare Manitoba, University of Manitoba (R.Z.), and the George and Fay Yee Centre for Healthcare Innovation (L.E.K.), Winnipeg, and the University of Alberta, Edmonton (I.S.S.) - all in Canada
| | - Glen Drobot
- From the University of Minnesota (D.R.B., M.F.P., A.S.B., K.A.P., S.M.L., E.C.O., C.P.S., A.A.N., M.R.N., M.A., N.W.E., R.R., K.H.H.) and M Health Fairview Investigational Drug Service Pharmacy (D.L.), Minneapolis; and the Research Institute of the McGill University Health Centre and the Clinical Practice Assessment Unit, Department of Medicine, McGill University, Montreal (M.P.C., E.G.M., T.C.L.), the Department of Internal Medicine, University of Manitoba (S.A.L., L.J.M., G.D., N.M., R.Z.), the Research Institute in Oncology and Hematology, CancerCare Manitoba, University of Manitoba (R.Z.), and the George and Fay Yee Centre for Healthcare Innovation (L.E.K.), Winnipeg, and the University of Alberta, Edmonton (I.S.S.) - all in Canada
| | - Nicole Marten
- From the University of Minnesota (D.R.B., M.F.P., A.S.B., K.A.P., S.M.L., E.C.O., C.P.S., A.A.N., M.R.N., M.A., N.W.E., R.R., K.H.H.) and M Health Fairview Investigational Drug Service Pharmacy (D.L.), Minneapolis; and the Research Institute of the McGill University Health Centre and the Clinical Practice Assessment Unit, Department of Medicine, McGill University, Montreal (M.P.C., E.G.M., T.C.L.), the Department of Internal Medicine, University of Manitoba (S.A.L., L.J.M., G.D., N.M., R.Z.), the Research Institute in Oncology and Hematology, CancerCare Manitoba, University of Manitoba (R.Z.), and the George and Fay Yee Centre for Healthcare Innovation (L.E.K.), Winnipeg, and the University of Alberta, Edmonton (I.S.S.) - all in Canada
| | - Ryan Zarychanski
- From the University of Minnesota (D.R.B., M.F.P., A.S.B., K.A.P., S.M.L., E.C.O., C.P.S., A.A.N., M.R.N., M.A., N.W.E., R.R., K.H.H.) and M Health Fairview Investigational Drug Service Pharmacy (D.L.), Minneapolis; and the Research Institute of the McGill University Health Centre and the Clinical Practice Assessment Unit, Department of Medicine, McGill University, Montreal (M.P.C., E.G.M., T.C.L.), the Department of Internal Medicine, University of Manitoba (S.A.L., L.J.M., G.D., N.M., R.Z.), the Research Institute in Oncology and Hematology, CancerCare Manitoba, University of Manitoba (R.Z.), and the George and Fay Yee Centre for Healthcare Innovation (L.E.K.), Winnipeg, and the University of Alberta, Edmonton (I.S.S.) - all in Canada
| | - Lauren E Kelly
- From the University of Minnesota (D.R.B., M.F.P., A.S.B., K.A.P., S.M.L., E.C.O., C.P.S., A.A.N., M.R.N., M.A., N.W.E., R.R., K.H.H.) and M Health Fairview Investigational Drug Service Pharmacy (D.L.), Minneapolis; and the Research Institute of the McGill University Health Centre and the Clinical Practice Assessment Unit, Department of Medicine, McGill University, Montreal (M.P.C., E.G.M., T.C.L.), the Department of Internal Medicine, University of Manitoba (S.A.L., L.J.M., G.D., N.M., R.Z.), the Research Institute in Oncology and Hematology, CancerCare Manitoba, University of Manitoba (R.Z.), and the George and Fay Yee Centre for Healthcare Innovation (L.E.K.), Winnipeg, and the University of Alberta, Edmonton (I.S.S.) - all in Canada
| | - Ilan S Schwartz
- From the University of Minnesota (D.R.B., M.F.P., A.S.B., K.A.P., S.M.L., E.C.O., C.P.S., A.A.N., M.R.N., M.A., N.W.E., R.R., K.H.H.) and M Health Fairview Investigational Drug Service Pharmacy (D.L.), Minneapolis; and the Research Institute of the McGill University Health Centre and the Clinical Practice Assessment Unit, Department of Medicine, McGill University, Montreal (M.P.C., E.G.M., T.C.L.), the Department of Internal Medicine, University of Manitoba (S.A.L., L.J.M., G.D., N.M., R.Z.), the Research Institute in Oncology and Hematology, CancerCare Manitoba, University of Manitoba (R.Z.), and the George and Fay Yee Centre for Healthcare Innovation (L.E.K.), Winnipeg, and the University of Alberta, Edmonton (I.S.S.) - all in Canada
| | - Emily G McDonald
- From the University of Minnesota (D.R.B., M.F.P., A.S.B., K.A.P., S.M.L., E.C.O., C.P.S., A.A.N., M.R.N., M.A., N.W.E., R.R., K.H.H.) and M Health Fairview Investigational Drug Service Pharmacy (D.L.), Minneapolis; and the Research Institute of the McGill University Health Centre and the Clinical Practice Assessment Unit, Department of Medicine, McGill University, Montreal (M.P.C., E.G.M., T.C.L.), the Department of Internal Medicine, University of Manitoba (S.A.L., L.J.M., G.D., N.M., R.Z.), the Research Institute in Oncology and Hematology, CancerCare Manitoba, University of Manitoba (R.Z.), and the George and Fay Yee Centre for Healthcare Innovation (L.E.K.), Winnipeg, and the University of Alberta, Edmonton (I.S.S.) - all in Canada
| | - Radha Rajasingham
- From the University of Minnesota (D.R.B., M.F.P., A.S.B., K.A.P., S.M.L., E.C.O., C.P.S., A.A.N., M.R.N., M.A., N.W.E., R.R., K.H.H.) and M Health Fairview Investigational Drug Service Pharmacy (D.L.), Minneapolis; and the Research Institute of the McGill University Health Centre and the Clinical Practice Assessment Unit, Department of Medicine, McGill University, Montreal (M.P.C., E.G.M., T.C.L.), the Department of Internal Medicine, University of Manitoba (S.A.L., L.J.M., G.D., N.M., R.Z.), the Research Institute in Oncology and Hematology, CancerCare Manitoba, University of Manitoba (R.Z.), and the George and Fay Yee Centre for Healthcare Innovation (L.E.K.), Winnipeg, and the University of Alberta, Edmonton (I.S.S.) - all in Canada
| | - Todd C Lee
- From the University of Minnesota (D.R.B., M.F.P., A.S.B., K.A.P., S.M.L., E.C.O., C.P.S., A.A.N., M.R.N., M.A., N.W.E., R.R., K.H.H.) and M Health Fairview Investigational Drug Service Pharmacy (D.L.), Minneapolis; and the Research Institute of the McGill University Health Centre and the Clinical Practice Assessment Unit, Department of Medicine, McGill University, Montreal (M.P.C., E.G.M., T.C.L.), the Department of Internal Medicine, University of Manitoba (S.A.L., L.J.M., G.D., N.M., R.Z.), the Research Institute in Oncology and Hematology, CancerCare Manitoba, University of Manitoba (R.Z.), and the George and Fay Yee Centre for Healthcare Innovation (L.E.K.), Winnipeg, and the University of Alberta, Edmonton (I.S.S.) - all in Canada
| | - Kathy H Hullsiek
- From the University of Minnesota (D.R.B., M.F.P., A.S.B., K.A.P., S.M.L., E.C.O., C.P.S., A.A.N., M.R.N., M.A., N.W.E., R.R., K.H.H.) and M Health Fairview Investigational Drug Service Pharmacy (D.L.), Minneapolis; and the Research Institute of the McGill University Health Centre and the Clinical Practice Assessment Unit, Department of Medicine, McGill University, Montreal (M.P.C., E.G.M., T.C.L.), the Department of Internal Medicine, University of Manitoba (S.A.L., L.J.M., G.D., N.M., R.Z.), the Research Institute in Oncology and Hematology, CancerCare Manitoba, University of Manitoba (R.Z.), and the George and Fay Yee Centre for Healthcare Innovation (L.E.K.), Winnipeg, and the University of Alberta, Edmonton (I.S.S.) - all in Canada
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Pullen MF, Skipper CP, Hullsiek KH, Bangdiwala AS, Pastick KA, Okafor EC, Lofgren SM, Rajasingham R, Engen NW, Galdys A, Williams DA, Abassi M, Boulware DR. Symptoms of COVID-19 Outpatients in the United States. Open Forum Infect Dis 2020; 7:ofaa271. [PMID: 33117855 PMCID: PMC7337847 DOI: 10.1093/ofid/ofaa271] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 06/24/2020] [Indexed: 01/08/2023] Open
Abstract
Background Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is a novel pathogen causing the current worldwide coronavirus disease 2019 (COVID-19) pandemic. Due to insufficient diagnostic testing in the United States, there is a need for clinical decision-making algorithms to guide testing prioritization. Methods We recruited participants nationwide for a randomized clinical trial. We categorized participants into 3 groups: (1) those with confirmed SARS-CoV-2 infection, (2) those with probable SARS-CoV-2 infection (pending test or not tested but with a confirmed COVID-19 contact), and (3) those with possible SARS-CoV-2 infection (pending test or not tested and with a contact for whom testing was pending or not performed). We compared the frequency of self-reported symptoms in each group and categorized those reporting symptoms in early infection (0-2 days), midinfection (3-5 days), and late infection (>5 days). Results Among 1252 symptomatic persons screened, 316 had confirmed, 393 had probable, and 543 had possible SARS-CoV-2 infection. In early infection, those with confirmed and probable SARS-CoV-2 infection shared similar symptom profiles, with fever most likely in confirmed cases (P = .002). Confirmed cases did not show any statistically significant differences compared with unconfirmed cases in symptom frequency at any time point. The most commonly reported symptoms in those with confirmed infection were cough (82%), fever (67%), fatigue (62%), and headache (60%), with only 52% reporting both fever and cough. Conclusions Symptomatic persons with probable SARS-CoV-2 infection present similarly to those with confirmed SARS-CoV-2 infection. There was no pattern of symptom frequency over time.
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Affiliation(s)
- Matthew F Pullen
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Caleb P Skipper
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Kathy H Hullsiek
- School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Ananta S Bangdiwala
- School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Katelyn A Pastick
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Elizabeth C Okafor
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Sarah M Lofgren
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Radha Rajasingham
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Nicole W Engen
- School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Alison Galdys
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Darlisha A Williams
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Mahsa Abassi
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - David R Boulware
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA.,School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
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Pastick KA, Okafor EC, Wang F, Lofgren SM, Skipper CP, Nicol MR, Pullen MF, Rajasingham R, McDonald EG, Lee TC, Schwartz IS, Kelly LE, Lother SA, Mitjà O, Letang E, Abassi M, Boulware DR. Review: Hydroxychloroquine and Chloroquine for Treatment of SARS-CoV-2 (COVID-19). Open Forum Infect Dis 2020; 7:ofaa130. [PMID: 32363212 PMCID: PMC7184359 DOI: 10.1093/ofid/ofaa130] [Citation(s) in RCA: 134] [Impact Index Per Article: 33.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 04/13/2020] [Indexed: 12/12/2022] Open
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a rapidly emerging viral infection causing coronavirus disease 2019 (COVID-19). Hydroxychloroquine and chloroquine have garnered unprecedented attention as potential therapeutic agents against COVID-19 following several small clinical trials, uncontrolled case series, and public figure endorsements. While there is a growing body of scientific data, there is also concern for harm, particularly QTc prolongation and cardiac arrhythmias. Here, we perform a rapid narrative review and discuss the strengths and limitations of existing in vitro and clinical studies. We call for additional randomized controlled trial evidence prior to the widespread incorporation of hydroxychloroquine and chloroquine into national and international treatment guidelines.
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Affiliation(s)
- Katelyn A Pastick
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | | | - Fan Wang
- Department of Experimental and Clinical Pharmacology, University of Minnesota, Minneapolis, Minnesota
| | - Sarah M Lofgren
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Caleb P Skipper
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Melanie R Nicol
- Department of Experimental and Clinical Pharmacology, University of Minnesota, Minneapolis, Minnesota
| | - Matthew F Pullen
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Radha Rajasingham
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Emily G McDonald
- Clinical Practice Assessment Unit, Department of Medicine, McGill University Health Centre, Montreal, Canada
| | - Todd C Lee
- Clinical Practice Assessment Unit, Department of Medicine, McGill University Health Centre, Montreal, Canada
| | - Ilan S Schwartz
- Division of Infectious Diseases, Department of Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta
| | - Lauren E Kelly
- Department of Pediatrics and Child Health, Department of Pharmacology, University of Manitoba, Winnipeg, Canada
| | - Sylvain A Lother
- Department of Medicine, Sections of Critical Care and Infectious Diseases, University of Manitoba, Winnipeg, Canada
| | - Oriol Mitjà
- Fight AIDS and Inf Dis Foundation, Hospital Germans Trias i Pujol, Barcelona, Spain
| | - Emili Letang
- Department of Infectious Diseases, Hospital del Mar/Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
- ISGlobal, Barcelona Institute for Global Health, Universitat de Barcelona, Barcelona, Spain
| | - Mahsa Abassi
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - David R Boulware
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
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Tugume L, Rhein J, Hullsiek KH, Mpoza E, Kiggundu R, Ssebambulidde K, Schutz C, Taseera K, Williams DA, Abassi M, Muzoora C, Musubire AK, Meintjes G, Meya DB, Boulware DR. HIV-Associated Cryptococcal Meningitis Occurring at Relatively Higher CD4 Counts. J Infect Dis 2020; 219:877-883. [PMID: 30325463 DOI: 10.1093/infdis/jiy602] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 10/10/2018] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Cryptococcal meningitis can occur in persons with less-apparent immunosuppression. We evaluated clinical characteristics and outcomes of persons with HIV-related Cryptococcus presenting with higher CD4 counts. METHODS We enrolled 736 participants from 2 prospective cohorts in Uganda and South Africa from November 2010 to May 2017. We compared participants with CD4 <50, 50-99, or ≥100 cells/μL by clinical characteristics, cerebrospinal fluid (CSF) parameters, and 18-week survival. RESULTS Among first episode of cryptococcosis, 9% presented with CD4 ≥100 cells/μL. Participants with CD4 ≥100 cells/μL presented more often with altered mental status (52% vs 39%; P = .03) despite a 10-fold lower initial median CSF fungal burden of 7850 (interquartile range [IQR] 860-65500) versus 79000 (IQR 7400-380000) colony forming units/mL (P < .001). Participants with CD4 ≥100 cells/μL had higher median CSF levels of interferon-gamma, interleukin (IL)-6, IL-8, and IL-13, and lower monocyte chemokine, CCL2 (P < .01 for each). Death within 18 weeks occurred in 47% with CD4 <50, 35% with CD4 50-99, and 40% with CD4 ≥100 cells/μL (P = .04). CONCLUSION HIV-infected individuals developing cryptococcal meningitis with CD4 ≥100 cells/μL presented more frequently with altered mental status despite having 10-fold lower fungal burden and with greater Th2 (IL-13) immune response. Higher CD4 count was protective despite an increased propensity for immune-mediated damage, consistent with damage-response framework. CLINICAL TRIAL REGISTRATION NCT01075152 and NCT01802385.
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Affiliation(s)
- Lillian Tugume
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Joshua Rhein
- Infectious Diseases Institute, Makerere University, Kampala, Uganda.,University of Minnesota, Minneapolis
| | | | - Edward Mpoza
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Reuben Kiggundu
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | | | | | - Darlisha A Williams
- Infectious Diseases Institute, Makerere University, Kampala, Uganda.,University of Minnesota, Minneapolis
| | - Mahsa Abassi
- Infectious Diseases Institute, Makerere University, Kampala, Uganda.,University of Minnesota, Minneapolis
| | | | - Abdu K Musubire
- Infectious Diseases Institute, Makerere University, Kampala, Uganda.,University of Minnesota, Minneapolis
| | | | - David B Meya
- Infectious Diseases Institute, Makerere University, Kampala, Uganda.,School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda.,University of Minnesota, Minneapolis
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28
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Alhadab AA, Rhein J, Tugume L, Musubire A, Williams DA, Abassi M, Nicol MR, Meya DB, Boulware DR, Brundage RC. Pharmacokinetics-pharmacodynamics of sertraline as an antifungal in HIV-infected Ugandans with cryptococcal meningitis. J Pharmacokinet Pharmacodyn 2019; 46:565-576. [PMID: 31584146 PMCID: PMC7004416 DOI: 10.1007/s10928-019-09657-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 09/25/2019] [Indexed: 01/16/2023]
Abstract
The ASTRO-CM dose-finding pilot study investigated the role of adjunctive sertraline for the treatment of HIV-associated cryptococcal meningitis in HIV-infected Ugandan patients. The present study is a post hoc pharmacokinetic-pharmacodynamic analysis of the ASTRO-CM pilot study to provide insight into sertraline exposure-response-outcome relationships. We performed a population pharmacokinetic analysis using sertraline plasma concentration data and correlated various predicted PK-PD indices with the percentage change in log10 CFU/mL from baseline. Sertraline clearance was 1.95-fold higher in patients receiving antiretroviral (ART), resulting in 49% lower drug exposure. To quantify the clinical benefit of sertraline, we estimated rates of fungal clearance from cerebrospinal fluid (CSF) of ASTRO-CM patients using Poisson model and compared the clearance rates to a historical control study (COAT) in which patients received standard Cryptococcus therapy of amphotericin B (0.7-1.0 mg/kg per day) and fluconazole (800 mg/day) without sertraline. Adjunctive sertraline significantly increased CSF fungal clearance rate compared to COAT trial and sertraline effect was dose-independent with no covariate found to affect fungal clearance including ART. Study findings suggest sertraline response could be mediated by different mechanisms than directly inhibiting the initiation of protein translation as previously suggested; this is supported by the prediction of unbound sertraline concentrations is unlikely to reach MIC concentrations in the brain. Study findings also recommend against the use of higher doses of sertraline, especially those greater than the maximum FDA-approved daily dose (200 mg/day), since they unlikely provide any additional benefits and come with greater costs and risk of adverse events.
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Affiliation(s)
- Ali A Alhadab
- Oncology Clinical Pharmacology, Pfizer Inc., 10555 Science Center Dr #2423C, La Jolla, San Diego, CA, 92121, USA.
| | - Joshua Rhein
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Lillian Tugume
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Abdu Musubire
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
- Department of Medicine, Makerere University, Kampala, Uganda
| | - Darlisha A Williams
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Mahsa Abassi
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Melanie R Nicol
- Department of Experimental and Clinical Pharmacology, 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
- Department of Medicine, Makerere University, Kampala, Uganda
| | - David R Boulware
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Richard C Brundage
- Department of Experimental and Clinical Pharmacology, University of Minnesota, Minneapolis, MN, USA
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Pastick KA, Bangdiwala AS, Abassi M, Flynn AG, Morawski BM, Musubire AK, Eneh PC, Schutz C, Taseera K, Rhein J, Hullsiek KH, Nicol MR, Vidal JE, Nakasujja N, Meintjes G, Muzoora C, Meya DB, Boulware DR. Seizures in Human Immunodeficiency Virus-Associated Cryptococcal Meningitis: Predictors and Outcomes. Open Forum Infect Dis 2019; 6:ofz478. [PMID: 32042847 PMCID: PMC7001112 DOI: 10.1093/ofid/ofz478] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 11/02/2019] [Indexed: 01/24/2023] Open
Abstract
Background Seizures commonly occur in patients with cryptococcal meningitis, yet risk factors and outcomes related to seizures are not well described. Methods We performed post hoc analyses on participants prospectively enrolled in 3 separate human immunodeficiency virus (HIV)-associated cryptococcal meningitis clinical trials during 2010-2017. Documentation of seizures at presentation or during hospitalization and antiseizure medication receipt identified participants with seizures. We summarized participant characteristics by seizure status via Kruskal-Wallis and χ 2 tests. Cox proportional hazards models analyzed the relationship between seizures and mortality. We compared mean quantitative neurocognitive performance Z (QNPZ-8) scores, and individual domain z-scores, at 3-months using independent t tests. Results Among 821 HIV-infected cryptococcal meningitis participants, 28% (231 of 821) experienced seizures: 15.5% (127 of 821) experienced seizures at presentation, and 12.7% (104 of 821) experienced incident seizures. Participants with seizures at presentation had a significantly lower Glasgow coma scale ([GCS] <15; P < .001), CD4 count (<50 cells/mcL; P = .02), and higher cerebrospinal fluid (CSF) opening pressure (>25 cm H2O; P = .004) when compared with participants who never experienced seizures. Cerebrospinal fluid fungal burden was higher among those with seizures at presentation (125 000 Cryptococcus colony-forming units [CFU]/mL CSF) and with seizures during follow-up (92 000 CFU/mL) compared with those who never experienced seizures (36 000 CFU/mL, P < .001). Seizures were associated with increased 10-week mortality (adjusted hazard ratio = 1.45; 95% confidence interval, 1.11-1.89). Participants with seizures had lower neurocognitive function at 3 months (QNPZ-8 = -1.87) compared with those without seizures (QNPZ-8 = -1.36; P < .001). Conclusions Seizures were common in this HIV-associated cryptococcal meningitis cohort and were associated with decreased survival and neurocognitive function.
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Affiliation(s)
- Katelyn A Pastick
- University of Minnesota, Minneapolis, Minnesota, USA.,Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | - Mahsa Abassi
- University of Minnesota, Minneapolis, Minnesota, USA.,Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | | | - Abdu K Musubire
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | - Charlotte Schutz
- Wellcome Center for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Kabanda Taseera
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Joshua Rhein
- University of Minnesota, Minneapolis, Minnesota, USA.,Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | | | - Jose E Vidal
- Instituto de Infectologia Emilio Ribas, São Paulo, São Paulo, Brazil.,Divisão de Moléstias Infecciosas e Parasitárias, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | | | - Graeme Meintjes
- Wellcome Center for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, Cape Town, South Africa.,Division of Infectious Diseases and HIV Medicine, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Conrad Muzoora
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - David B Meya
- University of Minnesota, Minneapolis, Minnesota, USA.,Infectious Diseases Institute, Makerere University, Kampala, Uganda
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30
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Chesdachai S, Rajasingham R, Nicol MR, Meya D, Bongomin F, Abassi M, Skipper C, Kwizera R, Rhein J, Boulware D. 2120. Minimum Inhibitory Concentration Distribution of Fluconazole against Cryptococcus Species and the Fluconazole Exposure Prediction Model. Open Forum Infect Dis 2019. [PMCID: PMC6809647 DOI: 10.1093/ofid/ofz360.1800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background Fluconazole is lifesaving for the treatment and prevention of cryptococcosis; however, optimal dosing is unknown. Initial fluconazole doses of 100 mg to 2000 mg/day have been used. Prevalence of fluconazole non-susceptible Cryptococcus is increasing over time, risking the efficacy of long-established standard dosing. Based on current minimum inhibitory concentration (MIC) distribution, we modeled fluconazole concentration and area under the curve (AUC) relative to MIC to propose a rational fluconazole dosing strategy. Methods First, we conducted a systematic review using the MEDLINE database for reports of fluconazole MIC distribution against clinical Cryptococcus isolates. Second, we utilized fluconazole concentrations from 92 Ugandans who received fluconazole 800 mg/day coupled with fluconazole’s known pharmacokinetics to predict plasma fluconazole concentrations for doses ranging from 100 mg to 2000 mg via linear regression. Third, the fluconazole AUC above MIC ratio were calculated using Monte Carlo simulation and using the MIC distribution elucidated during the systemic review. Results We summarized 21 studies with 11,094 clinical Cryptococcus isolates. MICs were normally distributed with geometric mean of 3.4 mg/mL, median (MIC50) of 4 mg/mL, and 90th percentile (MIC90) of 16 mg/mL. The median MIC50 trended upwards from 4 mg/mL in 2000–2012 to 8 mg/mL in 2014–2018. Predicted sub-therapeutic fluconazole concentrations (below MIC) would occur in 38% with 100 mg, 20% with 200 mg, and 8% with 400 mg. AUC/MIC ratio > 100 would occur in 53% for 400 mg, 74% for 800 mg, 84% for 1200 mg, and 88% for 1,600 mg. Conclusion Currently recommended fluconazole doses may be inadequate for cryptococcosis. Further clinical studies are needed for rational fluconazole dose selection. ![]()
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Disclosures All authors: No reported disclosures.
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Affiliation(s)
| | | | | | - David Meya
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Kampala, Uganda
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31
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Chesdachai S, Engen N, Rhein J, Tugume L, kiiza. Kandole T, Abassi M, Williams DA, Skipper C, Hullsiek KH, kisekka. Musubire A, Meya D, Boulware D. 1716. Baseline Serum C-Reactive Protein Level Predicts Mortality in Cryptococcal Meningitis. Open Forum Infect Dis 2019. [PMCID: PMC6809027 DOI: 10.1093/ofid/ofz360.1579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Background C-reactive protein (CRP) is an acute-phase protein produced by the liver in response to systemic inflammation. CRP is a helpful surrogate biomarker widely used in various infections, particularly for following the progression and resolution of infection. We aimed to determine the association between baseline CRP level and cryptococcal meningitis outcome. Methods We reviewed 168 prospectively enrolled HIV-infected Ugandans with confirmed first-episode cryptococcal meningitis. Baseline serum samples collected within 5 days from diagnosis had CRP levels measured and categorized into quartiles. We compared baseline serum CRP with 18-week survival using unadjusted time-to-event analysis. Results Of 168 participants, the first quartile of baseline serum CRP was 83.6 mg/L. Baseline CD4 count, HIV viral load, and cerebrospinal fluid results did not differ by quartile. Participants with CRP > 49.5 mg/L more likely presented with Glasgow Coma Scale <15 (P = 0.03). The 18-week mortality rate was 54.8% (46/84) in the highest two quartile CRP groups (49.5 mg/L), 40.5% (17/42) in the mid-range CRP group (29–49.5 mg/L), and 14.3% (6/42) in the low CRP group (<29 mg/L) (P < 0.001) (Figure 1). Conclusion Higher baseline serum CRP is associated with increased mortality in HIV-infected individuals with first-episode cryptococcal meningitis. The serum CRP could be a surrogate marker for undiagnosed co-infections or may reflect immune dysregulation leading to worse outcomes in persons with advanced AIDS and concomitant cryptococcal meningitis. Additional studies investigating more specific inflammatory biomarkers and the longitudinal trend in CRP with effective therapy would be informative. ![]()
Disclosures All authors: No reported disclosures.
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Affiliation(s)
| | - Nicole Engen
- School of Public Health, University of Minnesota, Minneapolis, Minnesota
| | | | - Lillian Tugume
- Infectious Diseases Institute Makerere University, Kampala, Uganda
| | | | | | | | | | | | | | - David Meya
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
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32
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Chesdachai S, Rajasingham R, Nicol MR, Meya DB, Bongomin F, Abassi M, Skipper C, Kwizera R, Rhein J, Boulware DR. Minimum Inhibitory Concentration Distribution of Fluconazole against Cryptococcus Species and the Fluconazole Exposure Prediction Model. Open Forum Infect Dis 2019; 6:5550889. [PMID: 31420668 PMCID: PMC6767974 DOI: 10.1093/ofid/ofz369] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Fluconazole is lifesaving for treatment and prevention of cryptococcosis; however, optimal dosing is unknown. Initial fluconazole doses of 100mg to 2000mg/day have been used. Prevalence of fluconazole non-susceptible Cryptococcus is increasing over time, risking the efficacy of long-established standard dosing. Based on current minimum inhibitory concentration (MIC) distribution, we modeled fluconazole concentration and area under the curve (AUC) relative to MIC to propose a rational fluconazole dosing strategy. METHODS First, we conducted a systematic review using MEDLINE database for reports of fluconazole MIC distribution against clinical Cryptococcus isolates. Second, we utilized fluconazole concentrations from 92 Ugandans who received fluconazole 800mg/day coupled with fluconazole's known pharmacokinetics to predict plasma fluconazole concentrations for doses ranging from 100mg to 2000mg via linear regression. Third, the fluconazole AUC above MIC ratio were calculated using Monte Carlo simulation and using the MIC distribution elucidated during the systemic review. RESULTS We summarized 21 studies with 11,049 clinical Cryptococcus isolates. MICs were normally distributed with geometric mean of 3.4 μg/mL, median (MIC50) of 4 μg/mL, and 90th percentile (MIC90) of 16 μg/mL. The median MIC50 trended upwards from 4 μg/mL in 2000-2012 to 8 μg/mL in 2014-2018. Predicted sub-therapeutic fluconazole concentrations (below MIC) would occur in 40% with 100mg, 21% with 200mg, and 9% with 400mg. AUC/MIC ratio >100 would occur in 53% for 400mg, 74% for 800mg, 83% for 1200mg, and 88% for 1600mg. CONCLUSIONS Currently recommended fluconazole doses may be inadequate for cryptococcosis. Further clinical studies are needed for rational fluconazole dose selection.
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Affiliation(s)
| | - Radha Rajasingham
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Melanie R Nicol
- College of Pharmacy, Department of Experimental and Clinical Pharmacology, University of Minnesota, Minneapolis, MN, USA
| | - David B Meya
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Felix Bongomin
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Gulu University, Gulu, Uganda
| | - Mahsa Abassi
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Caleb Skipper
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Richard Kwizera
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Joshua Rhein
- 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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Rhein J, Huppler Hullsiek K, Tugume L, Nuwagira E, Mpoza E, Evans EE, Kiggundu R, Pastick KA, Ssebambulidde K, Akampurira A, Williams DA, Bangdiwala AS, Abassi M, Musubire AK, Nicol MR, Muzoora C, Meya DB, Boulware DR. Adjunctive sertraline for HIV-associated cryptococcal meningitis: a randomised, placebo-controlled, double-blind phase 3 trial. Lancet Infect Dis 2019; 19:843-851. [PMID: 31345462 PMCID: PMC7041360 DOI: 10.1016/s1473-3099(19)30127-6] [Citation(s) in RCA: 82] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 02/18/2019] [Accepted: 03/04/2019] [Indexed: 01/26/2023]
Abstract
BACKGROUND Identifying new antifungals for cryptococcal meningitis is a priority given the inadequacy of current therapy. Sertraline has previously shown in vitro and in vivo activity against cryptococcus. We aimed to assess the efficacy and cost-effectiveness of adjunctive sertraline in adults with HIV-associated cryptococcal meningitis compared with placebo. METHODS In this double-blind, randomised, placebo-controlled trial, we recruited HIV-positive adults with cryptococcal meningitis from two hospitals in Uganda. Participants were randomly assigned (1:1) to receive standard therapy with 7-14 days of intravenous amphotericin B (0·7-1·0 mg/kg per day) and oral fluconazole (starting at 800 mg/day) with either adjunctive sertraline or placebo. Sertraline was administered orally or via nasogastric tube at a dose of 400 mg/day for 2 weeks, followed by 200 mg/day for 12 weeks, then tapered off over 3 weeks. The primary endpoint was 18-week survival, analysed by intention-to-treat. This study is registered with ClinicalTrials.gov, number NCT01802385. FINDINGS Between March 9, 2015, and May 29, 2017, we screened 842 patients with suspected meningitis and enrolled 460 of a planned 550 participants, at which point the trial was stopped for futility. Three patients in the sertraline group and three patients in the placebo group were lost to follow-up and therefore discontinued before study end. At 18 weeks, 120 (52%) of 229 patients in the sertraline group and 106 (46%) of 231 patients in the placebo group had died (hazard ratio 1·21, 95% CI 0·93-1·57; p=0·15). The fungal clearance rate from cerebrospinal fluid was similar between groups (0·43 -log10 CFU/mL per day [95% CI 0·37-0·50] in the sertraline group vs 0·47 -log10 CFU/mL per day [0·40-0·54] in the placebo group; p=0·59), as was occurrence of grade 4 or 5 adverse events (72 [31%] of 229 vs 75 [32%] of 231; p=0·98), most of which were associated with amphotericin B toxicity. INTERPRETATION Sertraline did not reduce mortality and should not be used to treat patients with HIV-associated cryptococcal meningitis. The reasons for sertraline inactivity appear to be multifactorial and might be associated with insufficient duration of therapeutic sertraline concentrations. FUNDING National Institutes of Health and Medical Research Council, Wellcome Trust.
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Affiliation(s)
- Joshua Rhein
- University of Minnesota, Minneapolis, MN, USA,Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | - Lillian Tugume
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Edwin Nuwagira
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Edward Mpoza
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Emily E. Evans
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Reuben Kiggundu
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Katelyn A. Pastick
- University of Minnesota, Minneapolis, MN, USA,Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | | | - Darlisha A. Williams
- University of Minnesota, Minneapolis, MN, USA,Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | - Mahsa Abassi
- University of Minnesota, Minneapolis, MN, USA,Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Abdu K. Musubire
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | - Conrad Muzoora
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - David B. Meya
- University of Minnesota, Minneapolis, MN, USA,Infectious Diseases Institute, Makerere University, Kampala, Uganda,School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
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34
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Skipper C, Abassi M, Boulware DR. Diagnosis and Management of Central Nervous System Cryptococcal Infections in HIV-Infected Adults. J Fungi (Basel) 2019; 5:jof5030065. [PMID: 31330959 PMCID: PMC6787675 DOI: 10.3390/jof5030065] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 07/15/2019] [Accepted: 07/17/2019] [Indexed: 11/24/2022] Open
Abstract
Cryptococcal meningitis persists as a significant source of morbidity and mortality in persons with HIV/AIDS, particularly in sub-Saharan Africa. Despite increasing access to antiretrovirals, persons presenting with advanced HIV disease remains common, and Cryptococcus remains the most frequent etiology of adult meningitis. We performed a literature review and herein present the most up-to-date information on the diagnosis and management of cryptococcosis. Recent advances have dramatically improved the accessibility of timely and affordable diagnostics. The optimal initial antifungal management has been newly updated after the completion of a landmark clinical trial. Beyond antifungals, the control of intracranial pressure and mitigation of toxicities remain hallmarks of effective treatment. Cryptococcal meningitis continues to present challenging complications and continued research is needed.
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Affiliation(s)
- Caleb Skipper
- Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA.
| | - Mahsa Abassi
- Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA
| | - David R Boulware
- Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA
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Abassi M, Sacktor N. Letter to the Editor. J Neurovirol 2019; 25:897-898. [PMID: 31278534 DOI: 10.1007/s13365-019-00774-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 05/29/2019] [Accepted: 06/12/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Mahsa Abassi
- University of Minnesota, Minneapolis, MN, 55455, USA. .,Infectious Diseases Institute, Kampala, Uganda.
| | - Ned Sacktor
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Ssebambulidde K, Bangdiwala AS, Kwizera R, Kandole TK, Tugume L, Kiggundu R, Mpoza E, Nuwagira E, Williams DA, Lofgren SM, Abassi M, Musubire AK, Cresswell FV, Rhein J, Muzoora C, Hullsiek KH, Boulware DR, Meya DB. Symptomatic Cryptococcal Antigenemia Presenting as Early Cryptococcal Meningitis With Negative Cerebral Spinal Fluid Analysis. Clin Infect Dis 2019; 68:2094-2098. [PMID: 30256903 PMCID: PMC6541705 DOI: 10.1093/cid/ciy817] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Accepted: 09/18/2018] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Individuals with cryptococcal antigenemia are at high risk of developing cryptococcal meningitis if untreated. The progression and timing from asymptomatic infection to cryptococcal meningitis is unclear. We describe a subpopulation of individuals with neurologic symptomatic cryptococcal antigenemia but negative cerebral spinal fluid (CSF) studies. METHODS We evaluated 1201 human immunodeficiency virus-seropositive individuals hospitalized with suspected meningitis in Kampala and Mbarara, Uganda. Baseline characteristics and clinical outcomes of participants with neurologic-symptomatic cryptococcal antigenemia and negative CSF cryptococcal antigen (CrAg) were compared to participants with confirmed CSF CrAg+ cryptococcal meningitis. Additional CSF testing included microscopy, fungal culture, bacterial culture, tuberculosis culture, multiplex FilmArray polymerase chain reaction (PCR; Biofire), and Xpert MTB/Rif. RESULTS We found 56% (671/1201) of participants had confirmed CSF CrAg+ cryptococcal meningitis and 4% (54/1201) had neurologic symptomatic cryptococcal antigenemia with negative CSF CrAg. Of those with negative CSF CrAg, 9% (5/54) had Cryptococcus isolated on CSF culture (n = 3) or PCR (n = 2) and 11% (6/54) had confirmed tuberculous meningitis. CSF CrAg-negative patients had lower proportions with CSF pleocytosis (16% vs 26% with ≥5 white cells/μL) and CSF opening pressure >200 mmH2O (16% vs 71%) compared with CSF CrAg-positive patients. No cases of bacterial or viral meningitis were detected by CSF PCR or culture. In-hospital mortality was similar between symptomatic cryptococcal antigenemia (32%) and cryptococcal meningitis (31%; P = .91). CONCLUSIONS Cryptococcal antigenemia with meningitis symptoms was the third most common meningitis etiology. We postulate this is early cryptococcal meningoencephalitis. Fluconazole monotherapy was suboptimal despite Cryptococcus-negative CSF. Further studies are warranted to understand the clinical course and optimal management of this distinct entity. CLINICAL TRIALS REGISTRATION NCT01802385.
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Affiliation(s)
- Kenneth Ssebambulidde
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Ananta S Bangdiwala
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis
| | - Richard Kwizera
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Tadeo Kiiza Kandole
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Lillian Tugume
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Reuben Kiggundu
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Edward Mpoza
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Edwin Nuwagira
- Department of Internal Medicine, Mbarara University of Science and Technology, Uganda
| | - Darlisha A Williams
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis
| | - Sarah M Lofgren
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis
| | - Mahsa Abassi
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis
| | - Abdu K Musubire
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
- Department of Medicine, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Fiona V Cresswell
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Joshua Rhein
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis
| | - Conrad Muzoora
- Department of Internal Medicine, Mbarara University of Science and Technology, Uganda
| | - Kathy Huppler Hullsiek
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis
| | - David R Boulware
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis
| | - David B Meya
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis
- Department of Medicine, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
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Rhein J, Hullsiek KH, Evans EE, Tugume L, Nuwagira E, Ssebambulidde K, Kiggundu R, Mpoza E, Musubire AK, Bangdiwala AS, Bahr NC, Williams DA, Abassi M, Muzoora C, Meya DB, Boulware DR. Detrimental Outcomes of Unmasking Cryptococcal Meningitis With Recent ART Initiation. Open Forum Infect Dis 2018; 5:ofy122. [PMID: 30094292 PMCID: PMC6080052 DOI: 10.1093/ofid/ofy122] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2016] [Accepted: 05/21/2018] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Increased antiretroviral therapy (ART) availability has been associated with more patients developing cryptococcosis after ART initiation. Despite this changing epidemiology, data regarding cryptococcal meningitis in those already receiving ART are limited. We compared clinical presentations and outcomes among ART-naïve and ART-experienced Ugandans. METHODS We prospectively enrolled 605 HIV-infected persons with first-episode cryptococcal meningitis from August 2013 to May 2017 who received amphotericin-based combination therapy. We classified participants by ART status and ART duration and compared groups for 2-week survival. RESULTS Overall, 46% (281/605) of participants were receiving ART at presentation. Compared with those not receiving ART, those receiving ART had higher CD4 counts (P < .001) and lower cerebrospinal fluid fungal burdens (P < .001). Of those receiving ART, 56% (156/281) initiated ART within 6 months, and 18% (51/281) initiated ART within 14 days. Two-week mortality did not differ by ART status (27% in both ART-naïve and ART-experienced%; P > .99). However, 47% (24/51) of those receiving ART for ≤14 days died within 2 weeks, compared with 19% (20/105) of those receiving ART for 15-182 days and 26% (32/125) of those receiving ART for >6 months (P < .001). Among persons receiving ART for >6 months, 87% had HIV viral loads >1000 copies/mL. CONCLUSIONS Cryptococcosis after ART initiation is common in Africa. Patients initiating ART who unmask cryptococcal meningitis are at a high risk of death. Immune recovery in the setting of central nervous system infection is detrimental, and management of this population requires further study. Implementing pre-ART cryptococcal antigen screening is urgently needed to prevent cryptococcal meningitis after ART initiation.
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Affiliation(s)
- Joshua Rhein
- University of Minnesota, Minneapolis, Minneapolis
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | - Emily E Evans
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Lillian Tugume
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Edwin Nuwagira
- Mbarara University of Science and Technology, Mbarara, Uganda
| | | | - Reuben Kiggundu
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Edward Mpoza
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Abdu K Musubire
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | - Nathan C Bahr
- University of Minnesota, Minneapolis, Minneapolis
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Darlisha A Williams
- University of Minnesota, Minneapolis, Minneapolis
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Mahsa Abassi
- University of Minnesota, Minneapolis, Minneapolis
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Conrad Muzoora
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - David B Meya
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
- School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
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Diehl JW, Hullsiek KH, Okirwoth M, Stephens N, Abassi M, Rhein J, Meya DB, Boulware DR, Musubire AK. Cerebral Oximetry for Detecting High-mortality Risk Patients with Cryptococcal Meningitis. Open Forum Infect Dis 2018; 5:ofy105. [PMID: 29942819 PMCID: PMC6007269 DOI: 10.1093/ofid/ofy105] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Accepted: 05/07/2018] [Indexed: 11/13/2022] Open
Abstract
Background Cryptococcus is the commonest cause of adult meningitis in Africa, with 50%–70% experiencing increased intracranial pressure. Cerebral oximetry is a noninvasive near-infrared spectroscopy technology to monitor percent regional cerebral tissue oxygenation (rSO2). We assessed if cerebral oximetry predicts meningitis mortality. Methods We performed cerebral oximetry within 14 days of cryptococcal meningitis diagnosis on 121 Ugandans from April 2016 to September 2017. We evaluated baseline rSO2 association with mortality by multivariable logistic regression and correlation with other clinical factors. We compared groups formed by initial rSO2 <30% vs ≥30% for longitudinal change with mixed effects models. We measured change in %rSO2 before and after lumbar puncture (LP). Results The median initial rSO2 (interquartile range) was 36% (29%–42%), and it was <30% in 29% (35/121). For 30-day mortality, the unadjusted odds ratio (per 5% increase in rSO2) was 0.73 (95% confidence interval [CI], 0.58 to 0.91; P = .005). Those with initial rSO2 <30% had 3.4 (95% CI, 1.5 to 8.0) higher odds of 30-day mortality than those with initial rSO2 ≥30%. Hemoglobin correlated with initial rSO2 (rho = .54; P < .001), but rSO2 did not correlate with pulse oximetry, intracranial pressure, cerebral perfusion pressure, or quantitative cerebrospinal fluid culture, and rSO2 was unchanged pre/post–lumbar punctures. The longitudinal rSO2 measurements change was 15% (95% CI, 12% to 18%) lower in the group with initial rSO2 <30%. Conclusions Individuals with cryptococcal meningitis and low cerebral oximetry (rSO2 < 30%) have high mortality. Cerebral oximetry may be useful as a prognostic marker of mortality. Targeted interventions to improve rSO2 should be tested in trials to try to decrease mortality in meningitis.
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Affiliation(s)
- John W Diehl
- Infectious Disease Institute, Makerere University, Kampala, Uganda.,University of Minnesota, Minneapolis, Minnesota.,Emory University School of Medicine, Atlanta, Georgia
| | | | - Michael Okirwoth
- Infectious Disease Institute, Makerere University, Kampala, Uganda
| | | | - Mahsa Abassi
- Infectious Disease Institute, Makerere University, Kampala, Uganda.,University of Minnesota, Minneapolis, Minnesota
| | - Joshua Rhein
- Infectious Disease Institute, Makerere University, Kampala, Uganda.,University of Minnesota, Minneapolis, Minnesota
| | - David B Meya
- Infectious Disease Institute, Makerere University, Kampala, Uganda.,University of Minnesota, Minneapolis, Minnesota
| | | | - Abdu K Musubire
- Infectious Disease Institute, Makerere University, Kampala, Uganda.,University of Minnesota, Minneapolis, Minnesota
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Mpoza E, Mukaremera L, Kundura DA, Akampurira A, Luggya T, Tadeo KK, Pastick KA, Bridge SC, Tugume L, Kiggundu R, Musubire AK, Williams DA, Muzoora C, Nalintya E, Rajasingham R, Rhein J, Boulware DR, Meya DB, Abassi M. Evaluation of a point-of-care immunoassay test kit 'StrongStep' for cryptococcal antigen detection. PLoS One 2018; 13:e0190652. [PMID: 29304090 PMCID: PMC5755834 DOI: 10.1371/journal.pone.0190652] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Accepted: 12/18/2017] [Indexed: 12/04/2022] Open
Abstract
Background HIV-associated cryptococcal meningitis is the leading cause of adult meningitis in Sub-Saharan Africa, accounting for 15%–20% of AIDS-attributable mortality. The development of point-of-care assays has greatly improved the screening and diagnosis of cryptococcal disease. We evaluated a point-of-care immunoassay, StrongStep (Liming Bio, Nanjing, Jiangsu, China) lateral flow assay (LFA), for cryptococcal antigen (CrAg) detection in cerebrospinal fluid (CSF) and plasma. Methods We retrospectively tested 143 CSF and 77 plasma samples collected from HIV-seropositive individuals with suspected meningitis from 2012–2016 in Uganda. We prospectively tested 90 plasma samples collected from HIV-seropositive individuals with CD4 cell count <100 cells/μL from 2016–2017 as part of a cryptococcal antigenemia screening program. The StrongStep CrAg was tested against a composite reference standard of positive Immy CrAg LFA (Immy, Norman, OK, USA) or CSF culture with statistical comparison by McNemar’s test. Results StrongStep CrAg had a 98% (54/55) sensitivity and 90% (101/112) specificity in plasma (P = 0.009, versus reference standard). In CSF, the StrongStep CrAg had 100% (101/101) sensitivity and 98% (41/42) specificity (P = 0.99). Adjusting for the cryptococcal antigenemia prevalence of 9% in Uganda and average cryptococcal meningitis prevalence of 37% in Sub-Saharan Africa, the positive predictive value of the StrongStep CrAg was 50% in plasma and 96% in CSF. Conclusions We found the StrongStep CrAg LFA to be a sensitive assay, which unfortunately lacked specificity in plasma. In lower prevalence settings, a majority of positive results from blood would be expected to be false positives.
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Affiliation(s)
- Edward Mpoza
- Infectious Diseases Institute, Kampala, Uganda
- * E-mail:
| | - Liliane Mukaremera
- Infectious Diseases Institute, Kampala, Uganda
- University of Minnesota, Minneapolis, Minnesota, United States of America
| | | | | | - Tonny Luggya
- Department of Microbiology, Makerere University, Kampala, Uganda
| | | | - Katelyn A. Pastick
- University of Minnesota, Minneapolis, Minnesota, United States of America
| | - Sarah C. Bridge
- University of Minnesota, Minneapolis, Minnesota, United States of America
| | | | | | | | - Darlisha A. Williams
- Infectious Diseases Institute, Kampala, Uganda
- University of Minnesota, Minneapolis, Minnesota, United States of America
| | - Conrad Muzoora
- Mbarara University of Science and Technology, Mbarara, Uganda
| | | | - Radha Rajasingham
- University of Minnesota, Minneapolis, Minnesota, United States of America
| | - Joshua Rhein
- Infectious Diseases Institute, Kampala, Uganda
- University of Minnesota, Minneapolis, Minnesota, United States of America
| | - David R. Boulware
- University of Minnesota, Minneapolis, Minnesota, United States of America
| | - David B. Meya
- Infectious Diseases Institute, Kampala, Uganda
- University of Minnesota, Minneapolis, Minnesota, United States of America
| | - Mahsa Abassi
- Infectious Diseases Institute, Kampala, Uganda
- University of Minnesota, Minneapolis, Minnesota, United States of America
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40
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Abassi M, Rhein J, Meya DB, Boulware DR. Cryptococcal Disease in the Era of "Test and Treat": Is There Cause for Concern? Open Forum Infect Dis 2017; 5:ofx274. [PMID: 29372172 PMCID: PMC5777480 DOI: 10.1093/ofid/ofx274] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Accepted: 12/24/2017] [Indexed: 01/01/2023] Open
Abstract
Treatment of cryptococcosis requires deferred initiation of antiretroviral therapy (ART). Early ART initiation may be detrimental in the context of cryptococcal infection by increasing the risk of immune reconstitution inflammatory syndrome (IRIS). We present 3 cases where early ART initiation in the presence of unrecognized cryptococcal disease had fatal outcomes.
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Affiliation(s)
- Mahsa Abassi
- Infectious Diseases Institute, Kampala, Uganda.,University of Minnesota, Minneapolis, Minnesota
| | - Joshua Rhein
- Infectious Diseases Institute, Kampala, Uganda.,University of Minnesota, Minneapolis, Minnesota
| | - David B Meya
- Infectious Diseases Institute, Kampala, Uganda.,University of Minnesota, Minneapolis, Minnesota.,School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
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Mpoza E, Rhein J, Abassi M. Emerging fluconazole resistance: Implications for the management of cryptococcal meningitis. Med Mycol Case Rep 2017; 19:30-32. [PMID: 29234588 PMCID: PMC5723366 DOI: 10.1016/j.mmcr.2017.11.004] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 11/24/2017] [Indexed: 12/27/2022] Open
Abstract
We present the case of an HIV-seropositive individual with cryptococcal meningitis who was found to have a fluconazole resistant strain of Cryptococcus neoformans. The individual required multiple rounds of amphotericin and fluconazole 800-1200 mg after several episodes of clinical relapse. Cerebrospinal fluid sterilization was achieved and maintained with high doses of fluconazole. This case demonstrates the emerging dilemma of increasing rates of fluconazole resistance in Cryptococcus and the clinical difficulties in meningitis management.
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Affiliation(s)
- Edward Mpoza
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Joshua Rhein
- Infectious Diseases Institute, Makerere University, Kampala, Uganda.,University of Minnesota, 420 Delaware Street SE, Minneapolis 55455, USA
| | - Mahsa Abassi
- Infectious Diseases Institute, Makerere University, Kampala, Uganda.,University of Minnesota, 420 Delaware Street SE, Minneapolis 55455, USA
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Lofgren S, Montgomery M, Yueh N, Namudde A, Rhein J, Abassi M, Musubire A, Meya D, Boulware D. Hearing Loss in Cryptococcal Meningitis Survivors. Open Forum Infect Dis 2017. [PMCID: PMC5632230 DOI: 10.1093/ofid/ofx163.709] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Hearing loss is a known complication cryptococcal meningitis (CM); however, there is a paucity of data. We aimed to describe hearing loss in CM survivors.
Methods
We assessed hearing via audiometry 8 and 18 weeks after diagnosis of CM in Kampala, Uganda from 2015-2016. We measured at 0.5, 1, 2, 4 Hz. Normal hearing was defined as minimum hearing level at <25 decibels (dB), mild at 25-39, moderate hearing at 40–69, severe at 70–89, and profound hearing loss at 90+ dB. We compared clinical factors, fungal burden, and CSF parameters to evaluate for factors associated with improvement (change in hearing loss category).
Results
We evaluated hearing symptoms via audiogram at week 8 (n = 117) and week 18 (n = 98). At 8-weeks, 6 (5%) participants had normal hearing, 36 (31%) had mild hearing loss, 72 (62%) had moderate hearing loss, 3 (3%) had severe hearing loss and none had profound hearing loss. Of those with moderate/severe/profound loss at week 8, 63 (54%) had mixed conductive + sensorineural hearing loss, 15 (13%) had sensorineural hearing loss, and 14 (12%) had conductive hearing loss. An additional 19 (16%) had sensorineural loss but unknown air conduction, and 3 (3%) did not have sensorineural loss but unknown air conduction. We compared risk factors for hearing loss summarized in Table 1. We assessed 66 participants who had repeated audiograms at week 8 and week 18. Of those 31 (47%) had no change, 30 (45%) had improvement and 5 (8%) had worsening.
Conclusion
Moderate/severe hearing loss was common 8 weeks after diagnosis of CM. More than half had mixed hearing loss and 20% had conductive hearing loss which represents a higher incidence than noted in other types of meningitis. The data is complicated by advanced HIV. Further research is needed evaluating immunologic factors causes hearing impairment in those who survived CM.
Disclosures
All authors: No reported disclosures.
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Affiliation(s)
- Sarah Lofgren
- Department of Medicine, Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, Minnesota
| | | | - Nathan Yueh
- University of Minnesota, Minneapolis, Minnesota
| | | | - Joshua Rhein
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Mahsa Abassi
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | | | - David Meya
- Infectious Disease Institute, Makerere University, Kampala, Uganda
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Lofgren S, Hullsiek KH, Morawski BM, Nabeta HW, Kiggundu R, Taseera K, Musubire A, Schutz C, Abassi M, Bahr NC, Tugume L, Muzoora C, Williams DA, Rolfes MA, Velamakanni SS, Rajasingham R, Meintjes G, Rhein J, Meya DB, Boulware DR. Differences in Immunologic Factors Among Patients Presenting with Altered Mental Status During Cryptococcal Meningitis. J Infect Dis 2017; 215:693-697. [PMID: 28329080 PMCID: PMC5388270 DOI: 10.1093/infdis/jix033] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Accepted: 01/17/2017] [Indexed: 11/13/2022] Open
Abstract
Altered mental status in cryptococcal meningitis results in poorer survival, but underlying causes of altered mentation are poorly understood. Within two clinical trials, we assessed risk factors for altered mental status (GCS score<15) considering baseline clinical characteristics, CSF cytokines/chemokines, and antiretroviral therapy. Among 326 enrolled participants, 97 (30%) had GCS<15 and these patients had lower median CSF cryptococcal antigen titers (P = .042) and CCL2 (P = .005) but higher opening pressures (320 vs. 269 mm H2O; P = .016), IL-10 (P = .044), and CCL3 (P = .008) compared with persons with GCS=15. Altered mental status may be associated with host immune response rather than Cryptococcus burden.
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Affiliation(s)
- Sarah Lofgren
- University of Minnesota, Minneapolis, MN, USA.,Infectious Disease Institute, Makerere University, Kampala, Uganda
| | | | | | - Henry W Nabeta
- Infectious Disease Institute, Makerere University, Kampala, Uganda
| | - Reuben Kiggundu
- Infectious Disease Institute, Makerere University, Kampala, Uganda
| | - Kabanda Taseera
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Abdu Musubire
- Infectious Disease Institute, Makerere University, Kampala, Uganda
| | | | - Mahsa Abassi
- University of Minnesota, Minneapolis, MN, USA.,Infectious Disease Institute, Makerere University, Kampala, Uganda
| | - Nathan C Bahr
- University of Minnesota, Minneapolis, MN, USA.,University of Kansas, Kansas City, KS, USA
| | - Lillian Tugume
- Infectious Disease Institute, Makerere University, Kampala, Uganda
| | - Conrad Muzoora
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Darlisha A Williams
- University of Minnesota, Minneapolis, MN, USA.,Infectious Disease Institute, Makerere University, Kampala, Uganda
| | | | | | | | | | - Joshua Rhein
- University of Minnesota, Minneapolis, MN, USA.,Infectious Disease Institute, Makerere University, Kampala, Uganda
| | - David B Meya
- University of Minnesota, Minneapolis, MN, USA.,Infectious Disease Institute, Makerere University, Kampala, Uganda
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Lofgren S, Abassi M, Rhein J, Boulware DR. Recent advances in AIDS-related cryptococcal meningitis treatment with an emphasis on resource limited settings. Expert Rev Anti Infect Ther 2017; 15:331-340. [PMID: 28111998 PMCID: PMC5602588 DOI: 10.1080/14787210.2017.1285697] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Recent advances in the treatment and prevention of cryptococcal meningitis have the potential to decrease AIDS-related deaths. Areas covered: Targeted screening for asymptomatic cryptococcal antigenemia in persons with AIDS is a cost effective method for reducing early mortality in patients on antiretroviral therapy. For persons with symptomatic cryptococcal meningitis, optimal initial management with amphotericin and flucytosine improves survival compared to alternative therapies; however, amphotsericin is difficult to administer and flucytosine has not been available in middle or low income countries, where cryptococcal meningitis is most prevalent. Expert commentary: Improved care for cryptococcal meningitis patients in resource-limited settings is possible, and new treatment possibilities are emerging.
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Affiliation(s)
- Sarah Lofgren
- a Division of Infectious Diseases & International Medicine, Department of Medicine , University of Minnesota , Minneapolis , MN , USA
- b Infectious Disease Institute, Makerere University , Kampala , Uganda
| | - Mahsa Abassi
- a Division of Infectious Diseases & International Medicine, Department of Medicine , University of Minnesota , Minneapolis , MN , USA
- b Infectious Disease Institute, Makerere University , Kampala , Uganda
| | - Joshua Rhein
- a Division of Infectious Diseases & International Medicine, Department of Medicine , University of Minnesota , Minneapolis , MN , USA
- b Infectious Disease Institute, Makerere University , Kampala , Uganda
| | - David R Boulware
- a Division of Infectious Diseases & International Medicine, Department of Medicine , University of Minnesota , Minneapolis , MN , USA
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45
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Abassi M, Morawski BM, Nakigozi G, Nakasujja N, Kong X, Meya DB, Robertson K, Gray R, Wawer MJ, Sacktor N, Boulware DR. Cerebrospinal fluid biomarkers and HIV-associated neurocognitive disorders in HIV-infected individuals in Rakai, Uganda. J Neurovirol 2016; 23:369-375. [PMID: 27995575 DOI: 10.1007/s13365-016-0505-9] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Revised: 11/21/2016] [Accepted: 12/01/2016] [Indexed: 01/11/2023]
Abstract
In the USA, increased cerebrospinal fluid (CSF) inflammatory cytokines have been observed in antiretroviral therapy (ART)-naive, HIV-seropositive individuals with HIV-associated neurocognitive disorder (HAND). We characterized the relationship between HAND and CSF biomarker expression in ART-naive, HIV-seropositive individuals in Rakai, Uganda. We analyzed CSF of 78 HIV-seropositive, ART-naive Ugandan adults for 17 cytokines and 20 neurodegenerative biomarkers via Luminex multiplex assay. These adults underwent neurocognitive assessment to determine their degree of HAND. We compared biomarker concentrations between high and low CD4 groups and across HAND classifications, adjusting for multiple comparisons. Individuals with CD4 <200 cells/μL (N = 38) had elevated levels of CSF Interleukin (IL)-2, IL-12, granulocyte-macrophage colony-stimulating factor (GM-CSF), TNF-α, matrix metalloproteinase (MMP)-1, MMP-7, and S100 calcium-binding protein B (S100B) and lower levels of amyloid β42. Individuals with CD4 351-500 cells/μL (N = 40) had significantly higher CSF levels of interleukin (IL)-1β, amyloid β42, and soluble receptor for advanced glycation end products (sRAGE). Increasing levels of S100B, platelet-derived growth factor-AA (PDGF-AA), brain-derived neurotrophic factor (BDNF), and sRAGE were associated with decreased odds of mild neurocognitive disorder (n = 22) or HIV-associated dementia (n = 15) compared with normal function (n = 30) or asymptomatic neurocognitive impairment (n = 11). Increased levels of interferon (IFN)-γ were associated with increased odds of mild neurocognitive impairment or HIV-associated dementia relative to normal or asymptomatic neurocognitive impairment. Proinflammatory CSF cytokines, chemokines, and neurodegenerative biomarkers were present in increasing concentrations with advanced immunosuppression and may play a role in the development of HAND. The presence of select CNS biomarkers may also play a protective role in the development of HAND.
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Affiliation(s)
- Mahsa Abassi
- University of Minnesota, Minneapolis, MN
- Infectious Diseases Institute, Kampala, Uganda
| | - Bozena M Morawski
- University of Minnesota, Minneapolis, MN
- Infectious Diseases Institute, Kampala, Uganda
| | | | - Noeline Nakasujja
- Infectious Diseases Institute, Kampala, Uganda
- Makerere University, Kampala, Uganda
| | - Xiangrong Kong
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - David B Meya
- University of Minnesota, Minneapolis, MN
- Infectious Diseases Institute, Kampala, Uganda
- Makerere University, Kampala, Uganda
| | | | - Ronald Gray
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Maria J Wawer
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Ned Sacktor
- Johns Hopkins University School of Medicine, Baltimore, MD
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Tugume L, Morawski BM, Abassi M, Bahr NC, Kiggundu R, Nabeta HW, Hullsiek KH, Taseera K, Musubire AK, Schutz C, Muzoora C, Williams DA, Rolfes MA, Meintjes G, Rhein J, Meya DB, Boulware DR. Prognostic implications of baseline anaemia and changes in haemoglobin concentrations with amphotericin B therapy for cryptococcal meningitis. HIV Med 2016; 18:13-20. [PMID: 27126930 DOI: 10.1111/hiv.12387] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2016] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Anaemia represents a common toxicity with amphotericin B-based induction therapy in HIV-infected persons with cryptococcal meningitis. We sought to examine the impact of amphotericin-related anaemia on survival. METHODS We used data from Ugandan and South African trial participants to characterize the variation of haemoglobin concentrations from diagnosis to 12 weeks post-diagnosis. Anaemia severity was classified based on the haemoglobin concentration at cryptococcal meningitis diagnosis, and nadir haemoglobin values during amphotericin induction. Cox proportional hazard models were used to estimate 2- and 10-week mortality risk. We also estimated 10-week mortality risk among participants with nadir haemoglobin < 8.5 g/dL during amphotericin induction and who survived ≥ 2 weeks post-enrolment. RESULTS The median haemoglobin concentration at meningitis diagnosis was 11.5 g/dL [interquartile range (IQR) 9.7-13 g/dL; n = 311] with a mean decline of 4.2 g/dL [95% confidence interval (CI) -4.6 to -3.8; P < 0.001; n = 148] from diagnosis to nadir value among participants with baseline haemoglobin ≥ 8.5 g/dL. The median haemoglobin concentration was 8.1 g/dL (IQR 6.5-9.5 g/dL) at 2 weeks, increasing to 9.4 g/dL (IQR 8.2-10.9 g/dL) by 4 weeks and continuing to increase to 12 weeks. Among participants with haemoglobin < 8.5 g/dL at diagnosis, mortality risk was elevated at 2 weeks [hazard ratio (HR) 2.7; 95% CI 1.5-4.9; P < 0.01] and 10 weeks (HR 1.8; 95% CI 1.1-2.2; P = 0.03), relative to those with haemoglobin ≥ 8.5 g/dL. New-onset anaemia occurring with amphotericin therapy did not have a statistically significant association with 10-week mortality (HR 2.0; 95% CI 0.5-9.1; P = 0.4). CONCLUSIONS Amphotericin induced significant haemoglobin declines, which were mostly transient and did not impact 10-week mortality. Individuals with moderate to life-threatening anaemia at baseline had a higher mortality risk at 2 and 10 weeks post-enrolment.
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Affiliation(s)
- L Tugume
- Infectious Disease Institute, Makerere University, Kampala, Uganda
| | - B M Morawski
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN, USA.,Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - M Abassi
- Infectious Disease Institute, Makerere University, Kampala, Uganda.,Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - N C Bahr
- Infectious Disease Institute, Makerere University, Kampala, Uganda.,Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN, USA.,Center for Infectious Diseases & Microbiology Translational Research, University of Minnesota, Minneapolis, MN, USA
| | - R Kiggundu
- Infectious Disease Institute, Makerere University, Kampala, Uganda
| | - H W Nabeta
- Infectious Disease Institute, Makerere University, Kampala, Uganda
| | - K H Hullsiek
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - K Taseera
- Department of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - A K Musubire
- Infectious Disease Institute, Makerere University, Kampala, Uganda.,Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - C Schutz
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Disease and Molecular Medicine and Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - C Muzoora
- Department of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - D A Williams
- Infectious Disease Institute, Makerere University, Kampala, Uganda.,Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - M A Rolfes
- Epidemiologic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - G Meintjes
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Disease and Molecular Medicine and Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.,Department of Medicine, Imperial College London, London, UK
| | - J Rhein
- Infectious Disease Institute, Makerere University, Kampala, Uganda.,Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - D B Meya
- Infectious Disease Institute, Makerere University, Kampala, Uganda.,Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN, USA.,Department of Medicine, Faculty of Health Sciences, Makerere University, Kampala, Uganda
| | - D R Boulware
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN, USA.,Center for Infectious Diseases & Microbiology Translational Research, University of Minnesota, Minneapolis, MN, USA
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Rhein J, Morawski BM, Hullsiek KH, Nabeta HW, Kiggundu R, Tugume L, Musubire A, Akampurira A, Smith KD, Alhadab A, Williams DA, Abassi M, Bahr NC, Velamakanni SS, Fisher J, Nielsen K, Meya DB, Boulware DR. Efficacy of adjunctive sertraline for the treatment of HIV-associated cryptococcal meningitis: an open-label dose-ranging study. Lancet Infect Dis 2016; 16:809-818. [PMID: 26971081 PMCID: PMC4927382 DOI: 10.1016/s1473-3099(16)00074-8] [Citation(s) in RCA: 138] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Revised: 01/29/2016] [Accepted: 01/29/2016] [Indexed: 12/17/2022]
Abstract
Background Cryptococcus is the most common cause of adult meningitis in Africa. We evaluated the activity of adjunctive sertraline, previously demonstrated to have in vitro and in vivo activity against Cryptococcus. Methods We enrolled 172 HIV-infected Ugandans with cryptococcal meningitis from August 2013 through August 2014 into an open-label dose-finding study to assess safety and microbiologic efficacy. Sertraline 100–400mg/day was added to standard therapy of amphotericin + fluconazole 800mg/day. We evaluated early fungicidal activity via Cryptococcus cerebrospinal fluid (CSF) clearance rate, sertraline pharmacokinetics, and in vitro susceptibility. Findings Participants receiving any sertraline dose averaged a CSF clearance rate of −0·37 (95%CI: −0·41, −0·33) colony forming units (CFU)/mL/day. Incidence of paradoxical immune reconstitution inflammatory syndrome (IRIS) was 5% (2/43) and relapse was 0% through 12-weeks. Sertraline reached steady state concentrations in plasma by day 7, with median steady-state concentrations of 201 ng/mL (IQR, 90–300; n=49) with 200mg/day and 399 ng/mL (IQR, 279–560; n=30) with 400mg/day. Plasma concentrations reached 83% of steady state levels by day 3. The median projected steady state brain tissue concentration at 200mg/day was 3·7 (IQR, 2·0–5·7) mcg/mL and 6·8 (IQR, 4·6–9·7) mcg/mL at 400mg/day. Minimum inhibitory concentrations were ≤2 mcg/mL for 27% (35/128), ≤4 mcg/mL for 84% (108/128), ≤6 mcg/mL for 91% (117/128), and ≤8 mcg/mL for 100% of 128 Cryptococcus isolates. Interpretation Sertraline had faster cryptococcal CSF clearance, decreased IRIS, and decreased relapse compared with historical experiences. Sertraline reaches therapeutic levels in a clinical setting. This inexpensive and off-patent oral medication is a promising adjunctive antifungal therapy. Funding National Institutes of Health, Grand Challenges Canada.
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Affiliation(s)
- Joshua Rhein
- University of Minnesota, Minneapolis, MN, USA; Infectious Disease Institute, Makerere University, Kampala, Uganda.
| | | | | | - Henry W Nabeta
- Infectious Disease Institute, Makerere University, Kampala, Uganda
| | - Reuben Kiggundu
- Infectious Disease Institute, Makerere University, Kampala, Uganda
| | - Lillian Tugume
- Infectious Disease Institute, Makerere University, Kampala, Uganda
| | - Abdu Musubire
- Infectious Disease Institute, Makerere University, Kampala, Uganda
| | | | | | - Ali Alhadab
- University of Minnesota, Minneapolis, MN, USA
| | - Darlisha A Williams
- University of Minnesota, Minneapolis, MN, USA; Infectious Disease Institute, Makerere University, Kampala, Uganda
| | - Mahsa Abassi
- University of Minnesota, Minneapolis, MN, USA; Infectious Disease Institute, Makerere University, Kampala, Uganda
| | - Nathan C Bahr
- University of Minnesota, Minneapolis, MN, USA; Infectious Disease Institute, Makerere University, Kampala, Uganda
| | | | | | | | - David B Meya
- University of Minnesota, Minneapolis, MN, USA; Infectious Disease Institute, Makerere University, Kampala, Uganda; Department of Medicine, Makerere University, Kampala, Uganda
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Abassi M, Rhein J, Morawski B, Hullsiek KH, Tugume L, Nabeta H, Kiggundu R, Akampurira A, Williams D, Meya D, Boulware D. Enhanced Consolidation Therapy With High-Dose Fluconazole and Sertraline Ameliorates Negative Outcomes Associated With Persistent Cerebrospinal Fluid Culture Positivity in Cryptococcal Meningitis. Open Forum Infect Dis 2015. [DOI: 10.1093/ofid/ofv133.507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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49
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Tugume L, Morawski B, Abassi M, Bahr N, Kiggundu R, Nabeta H, Hullsiek KH, Kabanda T, Musubire A, Schutz C, Muzoora C, Williams D, Rolfes M, Meintjes G, Rhein J, Meya D, Boulware D. Development of Anemia and Changes in Hemoglobin Concentrations With Amphotericin B Therapy for Cryptococcal Meningitis. Open Forum Infect Dis 2015. [DOI: 10.1093/ofid/ofv133.1240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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50
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Lofgren S, Hullsiek KH, Morawski B, Nabeta H, Kiggundu R, Taseera K, Musubire A, Schutz C, Abassi M, Bahr N, Tugume L, Muzoora C, Williams D, Rolfes M, Meintjes G, Rhein J, Meya D, Boulware D. Differences in Immunologic Factors Among Those Presenting With Altered Mental Status in Cryptococcal Meningitis. Open Forum Infect Dis 2015. [DOI: 10.1093/ofid/ofv133.1239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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