Effect of phenobarbital on seizure frequency and mortality in childhood cerebral malaria: a randomised, controlled intervention study

BACKGROUND

Seizures commonly complicate cerebral malaria and are associated with an increased risk of death and neurological sequelae. We undertook a randomised study to assess the efficacy of intramuscular phenobarbital in preventing seizures in childhood cerebral malaria.

METHODS

Children with cerebral malaria admitted to one hospital in Kilifi, Kenya, were randomly assigned a single intramuscular dose of phenobarbital (20 mg/kg) or identical placebo. Clinical tolerance was assessed at the start of the trial, with particular reference to respiratory depression and hypotension. Seizures were timed and recorded, and treated in a standard way. Plasma phenobarbital concentrations were measured. Analyses were by intention to treat.

FINDINGS

440 children with cerebral malaria were admitted to the hospital; 100 were not recruited to the study. Of the remaining 340, 170 received phenobarbital and 170 placebo. The drug was adequately absorbed and well tolerated. Seizure frequency was significantly lower in the phenobarbital group than in the placebo group (18 [11%] vs 46 [27%] children had three or more seizures of any duration; odds ratio 0.32 [95% CI 0.18-0.58]) but mortality was doubled (30 [18%] vs 14 [8%] deaths; 2.39 [1.28-4.64]). The frequency of respiratory arrest was higher in the phenobarbital group than in the placebo group, and mortality was greatly increased in children who received phenobarbital plus three or more doses of diazepam (odds ratio 31.7 [1.2-814]).

INTERPRETATION

In children with cerebral malaria, phenobarbital 20 mg/kg provides highly effective seizure prophylaxis but is associated with an unacceptable increase in mortality. Use of this dose cannot, therefore, be recommended.

Combined antiviral treatment in HIV infection. Is it value for money?

There is compelling evidence that combinations of antiretroviral drugs are significantly more effective than monotherapy and appear, at least in the short run, to offset problems caused by the rapid emergence of drug resistance which is characteristic of human immunodeficiency virus (HIV) infection.1,2 The routine prescribing of combination antiretroviral therapy appears to have contributed to a fall in HIV-related in-patient admissions, mortality and morbidity, with a concomitant increase in pharmacy costs. In this paper we have attempted to determine to what extent the reduction in direct hospital costs (reduced in-patient admissions, diagnostic tests and management of complications) will offset the considerably increased pharmacy costs; by using Markhov modelling procedures together with locally gathered costs data.

Cost effectiveness of single-dose nevirapine regimen for mothers and babies to decrease vertical HIV-1 transmission in sub-Saharan Africa

BACKGROUND

Identification of economical interventions to decrease HIV-1 transmission to children is an urgent public-health priority in sub-Saharan Africa. We assessed the cost effectiveness of the HIVNET 012 nevirapine regimen.

METHODS

We assessed cost effectiveness in a hypothetical cohort of 20,000 pregnant women in sub-Saharan Africa. Our main outcome measures were programme cost, paediatric HIV-1 cases averted, cost per case averted, and cost per disability-adjusted life-year (DALY). We compared HIVNET 012 with other short-course antiretroviral regimens. We also compared two implementation strategies: counselling and HIV-1 testing before treatment (targeted treatment), or nevirapine for all pregnant women (universal treatment, no counselling and testing). We did univariate and multivariate sensitivity analyses.

FINDINGS

For universal treatment with 30% HIV-1 seroprevalence, the HIVNET 012 regimen would avert 603 cases of HIV-1 in babies, cost US$83,333, and generate 15,862 DALYs. The associated cost-effectiveness ratios were $138 per case averted or $5.25 per DALY. At 15% seroprevalence, the universal treatment option would cost $83,333 and avert 302 cases at $276 per case averted or $10.51 per DALY. For targeted treatment at 30% seroprevalence, HIVNET 012 would cost $141,922 and avert 476 cases at $298 per case averted or $11.29 per DALY. With seroprevalence higher than 3.0% for universal and 4.5% for targeted treatment, the HIVNET 012 regimen was likely to be as cost effective as other public-health interventions. The cost effectiveness of HIVNET 012 was robust under a wide range of parameters in the sensitivity analysis.

INTERPRETATION

The HIVNET 012 regimen can be highly cost-effective in high seroprevalence settings. In lower seroprevalence areas, when multidose regimens are not cost effective, nevirapine therapy could have a major public-health impact at a reasonable cost.

Intrapartum and neonatal single-dose nevirapine compared with zidovudine for prevention of mother-to-child transmission of HIV-1 in Kampala, Uganda: HIVNET 012 randomised trial

BACKGROUND

The AIDS Clinical Trials Group protocol 076 zidovudine prophylaxis regimen for HIV-1-infected pregnant women and their babies has been associated with a significant decrease in vertical HIV-1 transmission in non-breastfeeding women in developed countries. We compared the safety and efficacy of short-course nevirapine or zidovudine during labour and the first week of life.

METHODS

From November, 1997, to April, 1999, we enrolled 626 HIV-1-infected pregnant women at Mulago Hospital in Kampala, Uganda. We randomly assigned mothers nevirapine 200 mg orally at onset of labour and 2 mg/kg to babies within 72 h of birth, or zidovudine 600 mg orally to the mother at onset of labour and 300 mg every 3 h until delivery, and 4 mg/kg orally twice daily to babies for 7 days after birth. We tested babies for HIV-1 infection at birth, 6-8 weeks, and 14-16 weeks by HIV-1 RNA PCR. We assessed HIV-1 transmission and HIV-1-free survival with Kaplan-Meier analysis.

FINDINGS

Nearly all babies (98.8%) were breastfed, and 95.6% were still breastfeeding at age 14-16 weeks. The estimated risks of HIV-1 transmission in the zidovudine and nevirapine groups were: 10.4% and 8.2% at birth (p=0.354); 21.3% and 11.9% by age 6-8 weeks (p=0.0027); and 25.1% and 13.1% by age 14-16 weeks (p=0.0006). The efficacy of nevirapine compared with zidovudine was 47% (95% CI 20-64) up to age 14-16 weeks. The two regimens were well tolerated and adverse events were similar in the two groups.

INTERPRETATION

Nevirapine lowered the risk of HIV-1 transmission during the first 14-16 weeks of life by nearly 50% in a breastfeeding population. This simple and inexpensive regimen could decrease mother-to-child HIV-1 transmission in less-developed countries.

Assessment of drug resistance to the malaria parasite in residents of Kampala, Uganda

OBJECTIVE

To assess drug-resistance of the malaria parasite in elite residents of Kampala city, Uganda.

DESIGN

Recruited into the study were patients with complaints of fever, backache and headache or general malaise and body joint pains, could recall their previous treatment for the current complaints and could show laboratory reports indicating presence of malaria parasites. Blood was taken from those patients and examined for malaria parasites.

SETTING

Kampala Diagnostic and Imaging Consultants Clinic, Kampala, Uganda from 1994 to 1997.

RESULTS

Out of 268 patients, 27%, 26%, 12%, 11%, 6%, 6% and 5% strains of malaria parasites were respectively resistant to chloroquine, quinine, metakelfin, fansidar, halfan, artenam and camoquine. Double drug resistance was also observed in the patients who had taken chloroquine and quinine (21%), chloroquine and fansidar (16%) and quinine and fansidar (10%) out of 86. Some strains exhibited resistance to chloroquine, quinine and fansidar (12.6%) out of 71. R III was observed in 17 strains of malaria parasites, eight of them were for chloroquine, four for fansidar and three for quinine. Twenty-six patients had frequent recurrence of malaria lasting for over one year.

CONCLUSION

One third of Plasmodium falciparum strains by 1997 had acquired resistance to chloroquine and quinine and some were gradually acquiring multi-drug resistance, leading to frequent recurrence of malaria and use of many different types of antimalarials.

Comparative efficacy and safety of chloroquine and alternative antimalarial drugs: a meta-analysis from six African countries

OBJECTIVE

To evaluate the safety and efficacy of the currently used antimalarial drugs in six African countries.

DESIGN

A meta-analysis.

MAIN OUTCOME MEASURES

The role of efficacy, safety and cost on the selection of antimalarial drugs.

RESULTS

The comparative efficacy study showed that amodiaquine (with > 90% cure rate) was superior to chloroquine and sulphadoxine-pyrimethamine at seven days schedule. The efficacy of amodiaquine was also observed to be comparable to that of mefloquine and halofantrine. The parasite clearance time (PCT) of these drugs ranged between two days and a week and the fever clearance time (FCT) was within 48 hours. The recrudescence rate at D14-D21 was found to be 12-17% in chloroquine and amodiaquine, while sulphadoxine-pyrimethamine showed a trend similar to halofantrine and mefloquine (0-12% recrudescence rate). Similarly, a big difference was also noted in the cost of the different antimalarial drugs. The pharmacokinetic data, however, showed that they are of similar profile, except in adverse features and contraindications, and values like their half-life (t1/2) where the long (t1/2) in drugs like sulphadoxine-pyrimethamine endows them with suppressive-cure feature, especially against recrudescent strains. Nevertheless, as these data are obtained from resident population in Africa, who however naive are exposed to few malaria challenges in their life, the results should not be directly extrapolated to total non immunes such as visitors from Europe.

CONCLUSION

The choice of alternative antimalarial drugs should be mainly based on their relative efficacy, safety and cost.

Drug resistant tuberculosis in prisons in Azerbaijan: case study

OBJECTIVES

To document the existence of drug resistance in a tuberculosis treatment programme that adheres strictly to the DOTS principles (directly observed treatment, short course) and to determine the extent of drug resistance in a prison setting in one of the republics of the former Soviet Union.

DESIGN

Case study.

SETTING

Central Penitentiary Hospital in Baku, the referral centre for tuberculosis patients from all prisons in Azerbaijan.

SUBJECTS

Prisoners with tuberculosis: 28 selected patients not responding clinically or bacteriologically to the standard treatment (group 1) and 38 consecutive patients at admission to the programme (group 2).

MAIN OUTCOME MEASURES

Drug resistance of Mycobacterium tuberculosis strains grown from sputum.

RESULTS

All the non-responding patients (group 1) had strains resistant to at least one drug. 25 (89%) of the non-responding patients and nine (24%) of the consecutive patients had M tuberculosis strains resistant to both rifampicin and isoniazid. A further 17 patients in group 2 had strains resistant to one or more first line drugs.

CONCLUSIONS

Drug resistant M tuberculosis strains are common in prisons in Azerbaijan. Tuberculosis problems tend to be worse in prisons, but prisoners and former prisoners may have an important role in the transmission of tuberculosis, particularly of drug resistant forms, in the community. National programmes to control tuberculosis will have to take into account and address the problems in prisons to ensure their success.

Drug resistance among malaria and other parasites

Recent decades have witnessed the emergence and spread of parasites resistant to standard drug therapies, particularly malaria. Chloroquine-resistant Plasmodium falciparum has now spread to most malarial areas, and resistance to other antimalarial drugs, including mefloquine and sulfadoxine-pyrimethamine, have become significant problems in some parts of Southeast Asia and South America. Chloroquine-resistant P. vivax is well established in Papua New Guinea and Indonesia and has been reported in other areas. Trichomonas and Giardia infections resistant to metronidazole have also been documented. This article reviews the current status of drug resistance among parasites, particularly malaria, and offers strategies for managing patients with these infections.

Ivermectin in onchocerciasis control in the forest zone of Cote d'Ivoire

Ivermectin (Mectizan MK-933) is an efficient microfilaricidal drug used for mass treatment by the Onchocerciasis Control Programme (OCP) in the savanna zones of West Africa. Some populations of the forest zone of Côte d'Ivoire have very high microfilarial loads, so it was decided to treat some of these populations with ivermectin, in order to avoid an eventual reinfestation of the protected savanna areas. A pilot campaign was carried out in a small stream catchment area where onchocerciasis transmission is usually high. The whole population was treated orally with ivermectin (200 micrograms/kg of body weight), with the exception of children under 5 years of age, pregnant women and people who were ill. The results showed a very high efficiency of ivermectin in the treatment of onchocerciasis in the forest zone. The prevalence rate of microfilaria dropped from 60.1 to 33.2%. The community microfilarial load was reduced from 29.7 to 5.6 microfilariae per skin snip. To maintain this effect, the authors recommend regular treatment of all new comers into the area.

Randomised placebo-controlled trial of iron supplementation and malaria chemoprophylaxis for prevention of severe anaemia and malaria in Tanzanian infants

BACKGROUND

Malaria and anaemia, especially that due to iron deficiency, are two leading causes of morbidity worldwide. Little is known about the relative contribution of Plasmodium falciparum infection and iron deficiency to the aetiology of anaemia in malaria-endemic areas. We undertook a randomised comparison of different strategies for control of anaemia and malaria in infants, including an assessment of the effect of iron supplementation on malaria susceptibility.

METHODS

832 infants born at one hospital in a malaria-hyperendemic area of Tanzania between January and October, 1995, were randomly assigned to group DI, receiving daily oral iron (2 mg/kg daily) plus weekly Deltaprim (3.125 mg pyrimethamine plus 25 mg dapsone); group IP, receiving iron plus weekly placebo; group DP, receiving daily placebo plus weekly Deltaprim; or group PP. supplementation was given from 8 to 24 weeks of age, and the weekly chemoprophylaxis from 8 to 48 weeks. The frequency of severe anaemia (packed-cell volume < 25%) and malaria episodes was assessed through a combination of passive case detection and cross-sectional surveys.

FINDINGS

The groups that received iron supplementation had a lower frequency of severe anaemia than those that did not receive iron (0.62 vs 0.87 cases per person-year; protective efficacy 28.8% [95% CI 6.3-45.8). Iron supplementation had no effect on the frequency of malaria (0.87 vs 1.00 cases per person-year; protective efficacy 12.8% [-12.8 to 32.5]). The groups that received malaria prophylaxis had lower frequencies of both severe anaemia (0.45 vs 1.04 episodes per person-year; protective efficacy 57.3% [43.0-67.9]) and malaria (0.53 vs 1.34 episodes per person-year; protective efficacy 60.5% [48.2-69.9]) than the groups that did not receive prophylaxis. After the end of the intervention period, children who had received malaria chemoprophylaxis had higher rates of severe anaemia and malaria than non-chemoprophylaxis groups (relative risks 2.2 [1.3-3.7] and 1.8 [1.3-2.6]).

INTERPRETATION

Malaria chemoprophylaxis during the first year of life was effective in prevention of malaria and anaemia but apparently impaired the development of natural immunity. Iron supplementation was effective in preventing severe anaemia without increasing susceptibility to malaria. Our findings support iron supplementation of infants to prevent iron-deficiency anaemia, even in malaria-endemic areas.

Effect of paracetamol on parasite clearance time in Plasmodium falciparum malaria

BACKGROUND

Routine antipyretic therapy in children with infectious diseases has long been the source of controversy. Each year, in addition to antimalarial medication, millions of children with Plasmodium falciparum malaria receive paracetamol to reduce fever. However, the usefulness of this practice has not been proven.

METHODS

In a randomised trial in Lambaréné, Gabon, 50 children with P falciparum malaria were treated with intravenous quinine, and received either mechanical antipyresis alone, or in combination with paracetamol. Rectal body temperature and parasitaemia were recorded every 6 h for 4 days. Plasma concentrations and inducible concentrations of tumour necrosis factor (TNF) and interleukin-6 were measured every 24 h. In addition, production of oxygen radicals was measured in both groups.

FINDINGS

The mean fever clearance time was 32 h for children treated with paracetamol and 43 h for those who received mechanical antipyresis alone; however, this 11 h difference was not significant (95% CI -2 to 24 h; p = 0.176). Parasite clearance time was significantly prolonged in patients who received paracetamol with a difference of 16 h (8-24 h; p = 0.004). Plasma concentrations of TNF and interleukin-6 were similar in both groups during the study. However, the induced concentrations of TNF, and the production of oxygen radicals, were significantly lower in children treated with paracetamol than those who received mechanical antipyresis alone.

INTERPRETATION

These data suggest that paracetamol has no antipyretic benefits over mechanical antipyresis alone in P falciparum malaria. Moreover, paracetamol prolongs parasite clearance time, possibly by decreased production of TNF and oxygen radicals.

Comparison of 3, 5 and 7 days' treatment with Quinimax for falciparum malaria in Guinea-Bissau

For treatment of malaria, the World Health Organization recommends 10 mg of quinine per kg body-weight 3 times a day for at least 7 d. In Guinea-Bissau, as in several other African countries, a 3 d treatment regimen (10 mg/kg twice daily) is currently used. We therefore compared the 3 d treatment period with periods of 5 and 7 d. A total of 145 children with clinical malaria due to monoinfection with Plasmodium falciparum, with > or = 20 parasites per 200 leucocytes, were treated with intramuscular Quinimax 10 mg per kg body-weight twice daily for 3, 5 or 7 d. The children were then examined once weekly for 4 weeks. Following the 3 d treatment regimen, 34 of 43 children (79%) had parasitaemia on day 28 or before; following the 5 d treatment regimen, 36 of 40 children (90%) did so; and following the 7 d treatment regimen, 7 of 62 children (11%) were parasitaemic at that time. This study thus suggests that the currently recommended 3 d Quinimax treatment regimen in Guinea-Bissau for moderate and severe malaria is not effective.

Nitazoxanide in the treatment of cryptosporidial diarrhea and other intestinal parasitic infections associated with acquired immunodeficiency syndrome in tropical Africa

Eighteen patients hospitalized with intestinal parasitic infections associated with diarrhea and dehydration completed a study of nitazoxanide in the treatment of Cryptosporidium parvum and other intestinal parasitic infections. Seventeen of the 18 patients were positive for human immunodeficiency virus. Twelve patients were diagnosed with clinical Stage 4 acquired immunodeficiency syndrome (AIDS) according to the 1990 World Health Organization proposed clinical classification system and cryptosporidiosis. Nitazoxanide (500 mg tablets) were administered orally, one tablet twice a day for seven consecutive days. Cryptosporidium parvum oocysts were eradicated or reduced by more than 95% in seven of the 12 Stage 4 AIDS patients who completed the study based upon two post-treatment fecal examinations conducted on days 7 and 14 following the initiation of treatment. The elimination or reduction of C. parvum oocysts was associated with a complete resolution of diarrhea in four of the seven patients. The test drug was also effective against cases of Isospora belli, Entamoeba histolytica, Giardia lamblia, Ascaris lumbricoides, Enterobius vermicularis, Hymenolepis nana, and Dicrocoelium dentriticum. Treatment with nitazoxanide was well tolerated by the patients. There were no abnormalities in blood chemistry or hematology data that were considered to be attributable to nitazoxanide therapy. Transient episodes of vomiting were observed in four patients, all with Stage 4 AIDS and cryptosporidiosis, which resolved spontaneously without discontinuation of treatment and were not considered to be related to administration of nitazoxanide.

Short-course tuberculosis chemotherapy in rural Somalia

An 18-month study of tuberculosis patients treated using the 6-8-month short-course chemotherapy in Luuq district situated in the north-east of Gedo region in the south-west of Somalia is presented. From July 1994 to December 1995, 213 patients were passively identified, started on treatment and followed up. Sputum smear-positive patients were monitored using smear examination. The outcome of treatment for all patients was evaluated at the end of July 1996. An overall cure/treatment completed rate of 70% was achieved. The paper concludes that short-course chemotherapy under directly observed therapy is a useful tuberculosis control strategy, even in areas of conflict.

Antimicrobial susceptibilities of strains of Neisseria gonorrhoeae in Bangkok, Thailand: 1994-1995

BACKGROUND AND OBJECTIVES

Failure of uncomplicated gonococcal infections acquired in the Far East to respond to doses of ciprofloxacin and ofloxacin recommended by the Centers for Disease Control and Prevention have been identified in Australia, the United Kingdom, and the United States. In the Republic of the Philippines, 54.3% of strains exhibited decreased susceptibility to fluoroquinolones; 12% of strains were resistant to ciprofloxacin. This study was undertaken to compare the antimicrobial susceptibilities of gonococcal isolates in Bangkok, Thailand, with those in the Republic of the Philippines.

GOAL

To determine the frequency and diversity of antimicrobial resistance, particularly to fluoroquinolones, in gonococcal strains in Bangkok, Thailand.

STUDY DESIGN

Strains of Neisseria gonorrhoeae isolated from 101 patients with uncomplicated gonorrhea in Bangkok, Thailand, in July, 1994 (46 strains) and November, 1994 to July, 1995 (55 strains), were characterized by auxotype/serovar class, antimicrobial susceptibilities, and plasmid profile. Susceptibilities were determined to penicillin G, tetracycline, ceftriaxone, cefixime, cefoxitin, ciprofloxacin, ofloxacin, norfloxacin, erythromycin, kanamycin, and thiamphenicol.

RESULTS

Of 101 strains, 89.1% (90/101) were resistant to penicillin or tetracycline. Plasmid-mediated resistance to penicillin or tetracycline was identified in 33.7% (34/101) of the isolates: penicillinase-producing Neisseria gonorrhoeae (17.8%; 18/101), tetracycline-resistant Neisseria gonorrhoeae (7.9%; 8/101), and penicillinase-producing/tetracycline-resistant Neisseria gonorrhoeae (7.9%; 8/101). Most penicillinase-producing strains (96.2%; 25/26) possessed the 4.4-megadalton (Md) beta-lactamase plasmid; one strain possessed the 3.2-Md beta-lactamase plasmid. Chromosomally mediated resistance to penicillin and tetracycline was exhibited by 51.5% (52/101) of strains, and 4.0% (4/101) were tetracycline resistant. All strains were susceptible to spectinomycin. Of 21.8% (22/101) strains exhibiting decreased susceptibility to ciprofloxacin (minimal inhibitory concentration [MIC] > or = 0.125 microgram/ml), one strain (ciprofloxacin MIC, 0.5 microgram/ml; ciprofloxacin inhibition zone diameter of 23 mm) had MICs of 2.0 and 8.0 micrograms/ml for ofloxacin and norfloxacin, respectively, indicating resistance to these agents. Decreased susceptibility to ciprofloxacin was identified in strains with chromosomally mediated resistance to penicillin or tetracycline and in penicillinase-producing strains.

CONCLUSIONS

In Bangkok, Thailand, gonococcal isolates exhibit resistance to penicillin, tetracycline, kanamycin, and thiamphenicol. Decreased susceptibility to fluoroquinolones is emerging in a variety of strains of N. gonorrhoeae. Thus, all gonococcal infections should be treated with antimicrobial therapies known to be active against all gonococcal strains to reduce the spread of strains exhibiting decreased susceptibilities to fluoroquinolones.

Adherence to tuberculosis preventive therapy among HIV-infected persons in Chiang Rai, Thailand

OBJECTIVE

To determine the level of and reasons associated with adherence to tuberculosis preventive therapy among asymptomatic HIV-infected individuals in northern Thailand.

DESIGN

A prospective cohort study with a 9-month follow-up.

METHODS

A total of 412 HIV-infected persons were enrolled in a tuberculosis preventive therapy programme in a hospital. A 9-month isoniazid regimen was prescribed. Adherence was determined by pill count. Participants who missed a scheduled appointment for more than a month were interviewed. Five focus group discussion sessions were held among those who successfully completed the therapy.

RESULTS

Of the 412 participants, 69.4% (286) completed the 9-month regimen. The adherence rate, defined as the proportion of those who took more than 80% of pills, was 67.5% (n = 278). Sex, source of participants and history of physical symptoms were associated with adherence. A significant portion of defaults took place at the beginning of the therapy. Out-migration, denial of HIV status, and perceived side effects of isoniazid were frequently cited as reasons for non-adherence. For those adhering participants, the acceptance of personal HIV status, concern about children and family, and a good health provider relationship were important reasons motivating adherence. Several reminder systems were developed by the participants.

CONCLUSIONS

Although a isoniazid preventive therapy programme was shown to be feasible, further adjustments on the selection of participants, enrollment process, and follow-up system based on these findings are necessary to increase the adherence.

The management of asthma in children in Papua New Guinea

In the last decade advances in knowledge of the aetiology and pathogenesis of asthma, and the availability of metered-dose inhalers and nebulisers, has led to a change in emphasis in both the preventive and curative aspects of the management of children with asthma. Metered-dose inhalers are available in Papua New Guinea, and can be used successfully, with spacing devices, even in children less than 2 years of age. Inhaled beta-sympathomimetics, now widely available and relatively inexpensive, may be all that is required for the majority of children with infrequent episodic asthma. For those with frequent episodic and chronic asthma, preventive therapy with inhaled steroids is available and should be given wherever practicable. In the management of acute severe asthma inhaled beta-sympathomimetics should be combined with a short course of oral or parenteral steroids (covered with isoniazid in areas where tuberculosis is prevalent). Whilst asthma classically presents with wheeze, medical personnel should be aware of its other presentations. It is possible, and should be the aim, to achieve a very high level of control for the majority of asthmatic children using currently available therapy.

Systematic review of amodiaquine treatment in uncomplicated malaria

BACKGROUND

Opinion and policy over the use of amodiaquine for treating malaria vary. Amodiaquine is more palatable than chloroquine and may be more effective but serious adverse events have been reported in travellers taking it as prophylaxis. It is not recommended as first-line treatment. In the light of the global debate over the use of this drug, we conducted a systematic review of the effectiveness and tolerability of amodiaquine in the treatment of uncomplicated falciparum malaria.

METHODS

This is a systematic review of published and unpublished randomised or pseudorandomised trials of amodiaquine. Observational reports were also systematically identified and reviewed to access evidence of serious adverse events.

FINDINGS

40 trials met the inclusion criteria. Symptomatic patients were enrolled in 24 studies in comparisons of amodiaquine (n = 1071) with chloroquine (n = 1097). Amodiaquine was significantly more effective than chloroquine, with odds ratios and 99% confidence intervals (OR [99% CI]) of 4.29 (3.30-5.58) on day 7 and 6.00 (3.97-9.06) on day 14. Time to parasite clearance was significantly shorter with amodiaquine and fever clearance times were marginally faster. Eight studies compared amodiaquine with chloroquine in asymptomatic parasitaemia, with effects on parasitological outcomes similar to those for symptomatic malaria. At twelve sites, 692 amodiaquine and 679 sulfadoxine/pyrimethamine (S/P) recipients were enrolled. The two drugs did not differ significantly on day 7 (OR 0.74 [0.48-1.15]) but the odds ratios favoured S/P on day 14 (OR 0.51 [0.28-0.93]) and on day 28 (OR 0.30 [0.16-0.55]). The time to parasitological clearance was similar in the two groups; fever clearance times were significantly shorter with amodiaquine. Tolerability was assessed for both comparative and non-comparative trials. The rates of adverse events in controlled trials were 10.7%, 8.8%, and 14.3% with amodiaquine, chloroquine, and S/P, respectively. No life-threatening adverse events and no significant shifts in laboratory indices were reported.

INTERPRETATION

This systematic review of published and unpublished trials supports the use of amodiaquine in the treatment of uncomplicated malaria. However, there is partial cross-resistance between chloroquine and amodiaquine, and monitoring of the effectiveness of this drug and surveillance for evidence of toxicity must continue.

Pneumocystis carinii pneumonia in human immunodeficiency virus infected patients in Bombay: diagnosed by bronchoalveolar lavage cytology and transbronchial lung biopsy

We report Pneumocystis carinii pneumonia (PCP) diagnosed by bronchoalveolar lavage cytology and transbronchial lung biopsy in three out of five human immunodeficiency virus (HIV) positive adult patients presenting with interstitial pneumonitis. One of these patients was serologically positive for HIV at the time of presentation and the remaining two patients were detected to be HIV positive on follow up after the diagnosis had been established. All the three patients were treated with co-trimoxazole. One patient recovered and was discharged; another patient improved with treatment but died after jugular vein cannulation and the third patient succumbed to cryptosporidial diarrhoea. The remaining two patients with non-specific interstitial pneumonitis treated with prednisolone and bronchodilators were recovered and were discharged from the hospital.

Malaria treatment and prevention in pregnancy: indications for use and adverse events associated with use of chloroquine or mefloquine

In sub-Saharan Africa, women frequently report a variety of symptoms during pregnancy, some of which indicate possible illness. Given the adverse impact of malaria in pregnancy, these events may be important for at least two reasons: it may be possible to use reported fever illness as a determinant of which women need an antimalarial intervention, and, it is possible that adverse symptoms following the antimalarial intervention may be important determinants of continued adherence to the prevention regimen. In a cohort of pregnant women enrolled at first antenatal clinic visit in rural Malawi, we evaluated reported fever, determined parasitemia, and placed the women on antimalarial regimens containing chloroquine (CQ) or mefloquine (MQ). We then systematically evaluated reported symptoms following antimalarial drug use after initial therapeutic doses and subsequent prophylactic doses, and monitored women throughout their pregnancy and at delivery. Among 4,187 enrolled women, 1,048 (25%) reported at least one febrile episode during pregnancy before their first antenatal clinic visit. Factors associated with this reported fever included low parity, enrollment in the rainy season, human immunodeficiency virus seropositivity, use of antimalarial prophylaxis before enrollment, high socioeconomic status, normal (compared to low) maternal height and weight, and literacy. Fever before the first antenatal clinic visit was reported by 24.4% of parasitemic women and 25.4% of aparasitemic women; the sensitivity and specificity of fever to identify parasitemic women was 24% and 71%, respectively. In contrast, the sensitivity and specificity of first or second pregnancy to identify parasitemic women was 71% and 57%, respectively. Among women on a CQ or MQ regimen, approximately 60% reported side effects (e.g., itching, dizziness, and gastrointestinal disturbances) after a treatment dose and approximately 25% reported side effects after a prophylactic dose; rates and types of symptoms reported were similar in the CQ and MQ groups. Few serious side effects were observed and rates of fetal loss were low and similar in the groups. Reliance on fever illness will be wholly inadequate to identify parasitemic women; therefore, our findings support existing World Health Organization recommendations that presumptive treatment and prevention regimens should be offered to all pregnant women. When resources are inadequate to offer antimalarial prophylaxis to all pregnant women, women in their first or second pregnancy may be a more appropriate target group than pregnant women with reported fever. Education regarding expected minor side effects may reduce rates of poor compliance and improve the effectiveness of the prevention effort.

Albendazole chemotherapy for treatment of diarrhoea in patients with AIDS in Zambia: a randomised double blind controlled trial

OBJECTIVE

To determine the value of short course, high dose albendazole chemotherapy in the treatment of persistent diarrhoea related to HIV in unselected patients in urban Zambia.

DESIGN

A randomised double blind placebo controlled trial of albendazole 800 mg twice daily for two weeks. Patients were monitored intensively for one month and followed for up to six months.

SETTING

Home care. AIDS services in Lusaka and Ndola.

PATIENTS

174 HIV seropositive patients with persistent diarrhoea (defined as loose but not bloody stools three or more times a day for three weeks or longer). No investigations were undertaken except HIV testing after counselling.

MAIN OUTCOME MEASURES

Proportion of time periods during which diarrhoea was experienced after completion of treatment; proportion of patients with full remission after completion of treatment; mortality.

RESULTS

The patients taking albendazole had diarrhoea on 29% fewer days than those taking placebo (P < 0.0001) in the two weeks after treatment. The benefit of albendazole was maintained over six months. In patients with a Karnofsky score of 50 to 70 (needing help with activities of daily living and unable to work, but not needing admission to hospital) diarrhoea was reduced by 50%. Remission was obtained in 26% of all patients who received albendazole (P = 0.004 against 9% receiving placebo), and this difference was maintained over six months (log rank test, P = 0.003). Albendazole had no effect on mortality. Minimal adverse effects were noted.

CONCLUSIONS

For HIV infected Zambians with diarrhoea of more than three weeks' duration albendazole offers substantial relief from symptoms and may be used empirically, without prior investigation.

Knowledge, attitude, practice, and prescribing pattern of oral rehydration therapy among private practitioners in Nigeria

To determine the knowledge, attitude, and practice of oral rehydration therapy (ORT) among private medical practitioners in Enugu, Nigeria, 91 doctors were interviewed using a structured questionnaire. All the doctors had heard of ORT and believed in its efficacy. The commonest source of information on ORT was the medical school (44%). Fifty percent would recommend salt-sugar solution (SSS) rather than oral rehydration solution (ORS). The main reason is its cost-effectiveness and easy availability. Only 55% of the respondents knew how to prepare SSS correctly. The percentage of doctors who prescribe smooth muscle relaxant (spasmolytic use rate) was 41%, and the commonest reason for its use was to reduce bowel movement. The influence of year of medical graduation on spasmolytic use was found to be statistically significant (p < 0.05). Antibiotics were commonly used, although most (76%) doctors believed that viral infections were a common cause of childhood diarrhoea. All the respondents would recommend continued breastfeeding during diarrhoeal episodes. The study revealed a high rate of inappropriate drug use and a deficiency in the knowledge and practice of ORT.

Arthritis associated with HIV infection in Zimbabwe

OBJECTIVE

To document the clinical and immunogenetic features of arthritis associated with heterosexually acquired human immunodeficiency virus (HIV) infection.

METHODS

All patients were assessed by a rheumatologist and standard laboratory tests were performed.

RESULTS

There were 3 common clinical presentations. (1) Oligo/polyarticular arthritis (22 men, 4 women). HIV infection had not previously been diagnosed in 24 of these patients but persistent generalized lymphadenopathy (85%) and weight loss (42%) were present. Joints commonly involved were ankles (65%) and knees (54%), often with associated enthesitis (31%) and dactylitis (23%). Followup data in 18 patients showed that arthritis resolved completely in 9 patients (one subsequently recurred), improved by >50% in 5 patients, was unremitting in 3 patients, and recurred frequently in one patient. None of 7 patients tested were HLA-B27 or B7 positive. (2) Reiter's syndrome (RS) (21 men, 3 women; incomplete RS 18 patients,complete RS 6 patients). Lymphadenopathy was present in 19 patients (79%) and 4 patients were previously known to have HIV infection. Involvement of knees (80%) and ankles (58%) was common, as were enthesitis (29%) and dactylitis (13%). Followup data in 21 patients showed that 14 resolved (5 with recurrences), 2 improved by >50%, and 5 had continued arthritis. HLA-B27 was not found in 13 patients tested but a cross reacting antigen was found in 6 patients. (3) Symmetrical polyarthritis (4 men, 4 women). Symmetrical arthritis of the wrists (8 patients) and peripheral interphalangeal (PIP) and metacarpophalangeal (MCP) joints (7), as well as lymphadenopathy (5), nodules (4), rheumatoid factor (3), and erosive radiographic changes (one patient) were seen. (4) Miscellaneous. Other types of arthritis included 3 patients with psoriasis and arthritis and one patient each with Behcet's disease, Salmonella septic arthritis, and secondary syphilis.

CONCLUSION

Arthritis associated with HIV in this population is most commonly characterized by oligoarticular, asymmetrical, large joint arthritis, with or without features of Reiter's syndrome, and is not associated with HLA-B27.

Treatment of multidrug-resistant tuberculosis in Thailand

Tuberculosis (TB) has remained the 5th leading cause of death in Thailand for several years. There has been a slight change in the total number of TB cases notified since 1985 when the first case of HIV infection was reported. Although there is an increase in the incidence of TB in HIV-infected cases, the percentage of multidrug-resistant tuberculosis (MDR-TB) in this group is the same as in the HIV-negative group (2.7%). The percentages of total initial drug resistance, four-drug resistance and MDR-TB have increased to 22.4, 1.4 and 4.8%, respectively. Comparable figures for acquired resistance are up to 2.5-, 10- and 6-fold, respectively. The rapid diagnosis and susceptibility pattern of MDR-TB are essential for improving therapeutic outcome. At present there is no defined standard regimen for MDR-TB and clinical practice has been to select a regimen of three to four sensitive or not previously exposed anti-TB drugs. Duration of treatment for 24-30 months depends on severity, previous therapy and the number of drug resistances. Surgery is suggested for persistent positive cases with localized lesions and a good cardiopulmonary reserve. The quinolone, ofloxacin, is a promising drug for MDR-TB, achieving a sputum conversion rate of 59-79%. A prospective study showed a success rate of 67% with no adverse effects. The current Bangkok multicenter trials on ofloxacin 600 mg daily combined with pyrazinamide, p-aminosalicylate, amikacin and ethambutol are ongoing. Good organization of ambulatory TB management combined with directly observed therapy will probably help to reduce the incidence of MDR-TB.

Treatment of diarrhoea in infants by medical doctors in Balochistan, Pakistan

Diarrhoea is an important public health problem in Balochistan, the westernmost province of Pakistan. Although the use of oral rehydration solutions (ORS) has been widely promoted, no studies have been reported on the actual uses of ORS in treating infant diarrhoea by the medical doctors in this region. The medical practices of 30 doctors in Balochistan were surveyed. The surveyors posed as the mothers of infants with diarrhoea. The questions asked by the doctors, the physical examinations performed, and the treatments prescribed were noted. The histories and physical examinations were incomplete, as performed by most practitioners. In addition, 80% of the doctors prescribed drugs, usually kaolin preparations to treat diarrhoea. However, 18 of the 30 (60%) practitioners also prescribed ORS for treating diarrhoea and most of them gave some recommendations about ORS use. It is concluded that many medical practitioners have incorporated ORS treatment into their practices. Ongoing educational programmes and refresher courses would likely improve the use of ORS further in this region.

Prescribing pattern by doctors for acute diarrhoea in children in Delhi, India

Parents (mostly mothers) of 264 children aged less than 5 years with acute watery diarrhoea were interviewed about their treatment profile before hospitalization in Delhi, India in 1993. Only 22% of the cases were given prescriptions for oral rehydration solutions (ORS), whereas a very high proportion (64%) of them were given drugs, including antibiotics and antidiarrhoeals and 40% were given intravenous fluids. The differences among the treatment groups were highly significant. The government and private doctors were equally responsible for the low rate of prescription of ORS. The confidence of health professionals in ORS appears to be very low. The findings suggest the need of a high-profile continuing education programme to encourage ORS prescription in Delhi.

Antimalarials during pregnancy: a cost-effectiveness analysis

Antenatal clinics (ANC) provide an avenue for interventions that promote maternal and infant health. In areas hyperendemic for Plasmodium falciparum, malaria infection during pregnancy contributes to low birth weight (LBW), which is the greatest risk factor for neonatal mortality. Using current data and costs from studies in Malawi, a decision-analysis model was constructed to predict the number of LBW cases prevented by three antimalarial regimens, in an area with a high prevalence of chloroquine (CQ)-resistant malaria. Factors considered included local costs of antimalarials, number of ANC visits, compliance with dispensed antimalarials, prevalence of placental malaria, and LBW incidence. For a hypothetical cohort of 10,000 women in their first or second pregnancy, a regimen consisting of one dose of sulfadoxine-pyrimethamine (SP) in the second trimester followed by a second dose at the beginning of the third trimester would prevent 205 cases of LBW at a cost of US$ 9.66 per case of LBW prevented. A regimen using a treatment dose of SP followed by CQ 300 mg (base) weekly would prevent 59 cases of LBW at a cost of $62 per case prevented, compared with only 30 cases of LBW prevented at a cost of $113 per case when the regimen involves initial treatment with CQ (25 mg/kg) followed by CQ 300 mg (base) weekly. In areas hyperendemic for CQ-resistant P. falciparum, a two-dose SP regimen is a cost-effective intervention to reduce LBW incidence and it should be included as part of the antenatal care package.