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Ikematsu H, Hayden FG, Kawaguchi K, Kinoshita M, de Jong MD, Lee N, Takashima S, Noshi T, Tsuchiya K, Uehara T. Baloxavir Marboxil for Prophylaxis against Influenza in Household Contacts. N Engl J Med 2020; 383:309-320. [PMID: 32640124 DOI: 10.1056/nejmoa1915341] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [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] [Indexed: 11/19/2022]
Abstract
BACKGROUND Baloxavir marboxil (baloxavir) is a polymerase acidic protein (PA) endonuclease inhibitor with clinical efficacy in the treatment of uncomplicated influenza, including in outpatients at increased risk for complications. The postexposure prophylactic efficacy of baloxavir in the household setting is unclear. METHODS We conducted a multicenter, double-blind, randomized, placebo-controlled trial to evaluate the postexposure prophylactic efficacy of baloxavir in household contacts of index patients with confirmed influenza during the 2018-2019 season in Japan. The participants were assigned in a 1:1 ratio to receive either a single dose of baloxavir or placebo. The primary end point was clinical influenza, as confirmed by reverse-transcriptase-polymerase-chain-reaction testing, over a period of 10 days. The occurrence of baloxavir-selected PA substitutions associated with reduced susceptibility was assessed. RESULTS A total of 752 household contacts of 545 index patients were randomly assigned to receive baloxavir or placebo. Among the index patients, 95.6% had influenza A virus infection, 73.6% were younger than 12 years of age, and 52.7% received baloxavir. Among the participants who could be evaluated (374 in the baloxavir group and 375 in the placebo group), the percentage in whom clinical influenza developed was significantly lower in the baloxavir group than in the placebo group (1.9% vs. 13.6%) (adjusted risk ratio, 0.14; 95% confidence interval [CI], 0.06 to 0.30; P<0.001). Baloxavir was effective in high-risk, pediatric, and unvaccinated subgroups of participants. The risk of influenza infection, regardless of symptoms, was lower with baloxavir than with placebo (adjusted risk ratio, 0.43; 95% CI, 0.32 to 0.58). The incidence of adverse events was similar in the two groups (22.2% in the baloxavir group and 20.5% in the placebo group). In the baloxavir group, the viral PA substitutions I38T/M or E23K were detected in 10 (2.7%) and 5 (1.3%) participants, respectively. No transmission of these variants from baloxavir-treated index patients to participants in the placebo group was detected; however, several instances of transmission to participants in the baloxavir group could not be ruled out. CONCLUSIONS Single-dose baloxavir showed significant postexposure prophylactic efficacy in preventing influenza in household contacts of patients with influenza. (Funded by Shionogi; Japan Primary Registries Network number, JapicCTI-184180.).
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Affiliation(s)
- Hideyuki Ikematsu
- From Ricerca Clinica, Fukuoka (H.I.), and Shionogi, Osaka (K.K., M.K., S.T., T.N., K.T., T.U.) - both in Japan; the Division of Infectious Diseases and International Health, Department of Medicine, University of Virginia School of Medicine, Charlottesville (F.G.H.); the Department of Medical Microbiology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam (M.D.J.); and the Division of Infectious Diseases, Department of Medicine, University of Alberta, Edmonton, Canada (N.L.)
| | - Frederick G Hayden
- From Ricerca Clinica, Fukuoka (H.I.), and Shionogi, Osaka (K.K., M.K., S.T., T.N., K.T., T.U.) - both in Japan; the Division of Infectious Diseases and International Health, Department of Medicine, University of Virginia School of Medicine, Charlottesville (F.G.H.); the Department of Medical Microbiology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam (M.D.J.); and the Division of Infectious Diseases, Department of Medicine, University of Alberta, Edmonton, Canada (N.L.)
| | - Keiko Kawaguchi
- From Ricerca Clinica, Fukuoka (H.I.), and Shionogi, Osaka (K.K., M.K., S.T., T.N., K.T., T.U.) - both in Japan; the Division of Infectious Diseases and International Health, Department of Medicine, University of Virginia School of Medicine, Charlottesville (F.G.H.); the Department of Medical Microbiology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam (M.D.J.); and the Division of Infectious Diseases, Department of Medicine, University of Alberta, Edmonton, Canada (N.L.)
| | - Masahiro Kinoshita
- From Ricerca Clinica, Fukuoka (H.I.), and Shionogi, Osaka (K.K., M.K., S.T., T.N., K.T., T.U.) - both in Japan; the Division of Infectious Diseases and International Health, Department of Medicine, University of Virginia School of Medicine, Charlottesville (F.G.H.); the Department of Medical Microbiology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam (M.D.J.); and the Division of Infectious Diseases, Department of Medicine, University of Alberta, Edmonton, Canada (N.L.)
| | - Menno D de Jong
- From Ricerca Clinica, Fukuoka (H.I.), and Shionogi, Osaka (K.K., M.K., S.T., T.N., K.T., T.U.) - both in Japan; the Division of Infectious Diseases and International Health, Department of Medicine, University of Virginia School of Medicine, Charlottesville (F.G.H.); the Department of Medical Microbiology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam (M.D.J.); and the Division of Infectious Diseases, Department of Medicine, University of Alberta, Edmonton, Canada (N.L.)
| | - Nelson Lee
- From Ricerca Clinica, Fukuoka (H.I.), and Shionogi, Osaka (K.K., M.K., S.T., T.N., K.T., T.U.) - both in Japan; the Division of Infectious Diseases and International Health, Department of Medicine, University of Virginia School of Medicine, Charlottesville (F.G.H.); the Department of Medical Microbiology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam (M.D.J.); and the Division of Infectious Diseases, Department of Medicine, University of Alberta, Edmonton, Canada (N.L.)
| | - Satoru Takashima
- From Ricerca Clinica, Fukuoka (H.I.), and Shionogi, Osaka (K.K., M.K., S.T., T.N., K.T., T.U.) - both in Japan; the Division of Infectious Diseases and International Health, Department of Medicine, University of Virginia School of Medicine, Charlottesville (F.G.H.); the Department of Medical Microbiology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam (M.D.J.); and the Division of Infectious Diseases, Department of Medicine, University of Alberta, Edmonton, Canada (N.L.)
| | - Takeshi Noshi
- From Ricerca Clinica, Fukuoka (H.I.), and Shionogi, Osaka (K.K., M.K., S.T., T.N., K.T., T.U.) - both in Japan; the Division of Infectious Diseases and International Health, Department of Medicine, University of Virginia School of Medicine, Charlottesville (F.G.H.); the Department of Medical Microbiology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam (M.D.J.); and the Division of Infectious Diseases, Department of Medicine, University of Alberta, Edmonton, Canada (N.L.)
| | - Kenji Tsuchiya
- From Ricerca Clinica, Fukuoka (H.I.), and Shionogi, Osaka (K.K., M.K., S.T., T.N., K.T., T.U.) - both in Japan; the Division of Infectious Diseases and International Health, Department of Medicine, University of Virginia School of Medicine, Charlottesville (F.G.H.); the Department of Medical Microbiology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam (M.D.J.); and the Division of Infectious Diseases, Department of Medicine, University of Alberta, Edmonton, Canada (N.L.)
| | - Takeki Uehara
- From Ricerca Clinica, Fukuoka (H.I.), and Shionogi, Osaka (K.K., M.K., S.T., T.N., K.T., T.U.) - both in Japan; the Division of Infectious Diseases and International Health, Department of Medicine, University of Virginia School of Medicine, Charlottesville (F.G.H.); the Department of Medical Microbiology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam (M.D.J.); and the Division of Infectious Diseases, Department of Medicine, University of Alberta, Edmonton, Canada (N.L.)
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Hayden FG, Sugaya N, Hirotsu N, Lee N, de Jong MD, Hurt AC, Ishida T, Sekino H, Yamada K, Portsmouth S, Kawaguchi K, Shishido T, Arai M, Tsuchiya K, Uehara T, Watanabe A. Baloxavir Marboxil for Uncomplicated Influenza in Adults and Adolescents. N Engl J Med 2018; 379:913-923. [PMID: 30184455 DOI: 10.1056/nejmoa1716197] [Citation(s) in RCA: 515] [Impact Index Per Article: 85.8] [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] [Indexed: 12/22/2022]
Abstract
BACKGROUND Baloxavir marboxil is a selective inhibitor of influenza cap-dependent endonuclease. It has shown therapeutic activity in preclinical models of influenza A and B virus infections, including strains resistant to current antiviral agents. METHODS We conducted two randomized, double-blind, controlled trials involving otherwise healthy outpatients with acute uncomplicated influenza. After a dose-ranging (10 to 40 mg) placebo-controlled trial, we undertook a placebo- and oseltamivir-controlled trial of single, weight-based doses of baloxavir (40 or 80 mg) in patients 12 to 64 years of age during the 2016-2017 season. The dose of oseltamivir was 75 mg twice daily for 5 days. The primary efficacy end point was the time to alleviation of influenza symptoms in the intention-to-treat infected population. RESULTS In the phase 2 trial, the median time to alleviation of influenza symptoms was 23.4 to 28.2 hours shorter in the baloxavir groups than in the placebo group (P<0.05). In the phase 3 trial, the intention-to-treat infected population included 1064 patients; 84.8 to 88.1% of patients in each group had influenza A(H3N2) infection. The median time to alleviation of symptoms was 53.7 hours (95% confidence interval [CI], 49.5 to 58.5) with baloxavir, as compared with 80.2 hours (95% CI, 72.6 to 87.1) with placebo (P<0.001). The time to alleviation of symptoms was similar with baloxavir and oseltamivir. Baloxavir was associated with greater reductions in viral load 1 day after initiation of the regimen than placebo or oseltamivir. Adverse events were reported in 20.7% of baloxavir recipients, 24.6% of placebo recipients, and 24.8% of oseltamivir recipients. The emergence of polymerase acidic protein variants with I38T/M/F substitutions conferring reduced susceptibility to baloxavir occurred in 2.2% and 9.7% of baloxavir recipients in the phase 2 trial and phase 3 trial, respectively. CONCLUSIONS Single-dose baloxavir was without evident safety concerns, was superior to placebo in alleviating influenza symptoms, and was superior to both oseltamivir and placebo in reducing the viral load 1 day after initiation of the trial regimen in patients with uncomplicated influenza. Evidence for the development of decreased susceptibility to baloxavir after treatment was also observed. (Funded by Shionogi; JapicCTI number, 153090, and CAPSTONE-1 ClinicalTrials.gov number, NCT02954354 .).
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Affiliation(s)
- Frederick G Hayden
- From the Department of Medicine, University of Virginia School of Medicine, Charlottesville (F.G.H.); the Department of Pediatrics, Keiyu Hospital, Yokohama (N.S.), Hirotsu Clinic, Kawasaki (N.H.), the Department of Respiratory Medicine, Kurashiki Central Hospital, Kurashiki (T.I.), Sekino Hospital, Tokyo (H.S.), Tsuchiura Beryl Clinic, Tsuchiura (K.Y.), Shionogi, Osaka (K.K., T.S., M.A., K.T., T.U.), and the Research Division for Development of Anti-Infective Agents, Institute of Development, Aging, and Cancer, Tohoku University, Sendai (A.W.) - all in Japan; the Division of Infectious Diseases, Department of Medicine, University of Alberta, Edmonton, Canada (N.L.); the Department of Medical Microbiology, Academic Medical Center, University of Amsterdam, Amsterdam (M.D.J.); the Department of Microbiology and Immunology, University of Melbourne, at the Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia (A.C.H.); and Shionogi, Florham Park, NJ (S.P.)
| | - Norio Sugaya
- From the Department of Medicine, University of Virginia School of Medicine, Charlottesville (F.G.H.); the Department of Pediatrics, Keiyu Hospital, Yokohama (N.S.), Hirotsu Clinic, Kawasaki (N.H.), the Department of Respiratory Medicine, Kurashiki Central Hospital, Kurashiki (T.I.), Sekino Hospital, Tokyo (H.S.), Tsuchiura Beryl Clinic, Tsuchiura (K.Y.), Shionogi, Osaka (K.K., T.S., M.A., K.T., T.U.), and the Research Division for Development of Anti-Infective Agents, Institute of Development, Aging, and Cancer, Tohoku University, Sendai (A.W.) - all in Japan; the Division of Infectious Diseases, Department of Medicine, University of Alberta, Edmonton, Canada (N.L.); the Department of Medical Microbiology, Academic Medical Center, University of Amsterdam, Amsterdam (M.D.J.); the Department of Microbiology and Immunology, University of Melbourne, at the Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia (A.C.H.); and Shionogi, Florham Park, NJ (S.P.)
| | - Nobuo Hirotsu
- From the Department of Medicine, University of Virginia School of Medicine, Charlottesville (F.G.H.); the Department of Pediatrics, Keiyu Hospital, Yokohama (N.S.), Hirotsu Clinic, Kawasaki (N.H.), the Department of Respiratory Medicine, Kurashiki Central Hospital, Kurashiki (T.I.), Sekino Hospital, Tokyo (H.S.), Tsuchiura Beryl Clinic, Tsuchiura (K.Y.), Shionogi, Osaka (K.K., T.S., M.A., K.T., T.U.), and the Research Division for Development of Anti-Infective Agents, Institute of Development, Aging, and Cancer, Tohoku University, Sendai (A.W.) - all in Japan; the Division of Infectious Diseases, Department of Medicine, University of Alberta, Edmonton, Canada (N.L.); the Department of Medical Microbiology, Academic Medical Center, University of Amsterdam, Amsterdam (M.D.J.); the Department of Microbiology and Immunology, University of Melbourne, at the Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia (A.C.H.); and Shionogi, Florham Park, NJ (S.P.)
| | - Nelson Lee
- From the Department of Medicine, University of Virginia School of Medicine, Charlottesville (F.G.H.); the Department of Pediatrics, Keiyu Hospital, Yokohama (N.S.), Hirotsu Clinic, Kawasaki (N.H.), the Department of Respiratory Medicine, Kurashiki Central Hospital, Kurashiki (T.I.), Sekino Hospital, Tokyo (H.S.), Tsuchiura Beryl Clinic, Tsuchiura (K.Y.), Shionogi, Osaka (K.K., T.S., M.A., K.T., T.U.), and the Research Division for Development of Anti-Infective Agents, Institute of Development, Aging, and Cancer, Tohoku University, Sendai (A.W.) - all in Japan; the Division of Infectious Diseases, Department of Medicine, University of Alberta, Edmonton, Canada (N.L.); the Department of Medical Microbiology, Academic Medical Center, University of Amsterdam, Amsterdam (M.D.J.); the Department of Microbiology and Immunology, University of Melbourne, at the Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia (A.C.H.); and Shionogi, Florham Park, NJ (S.P.)
| | - Menno D de Jong
- From the Department of Medicine, University of Virginia School of Medicine, Charlottesville (F.G.H.); the Department of Pediatrics, Keiyu Hospital, Yokohama (N.S.), Hirotsu Clinic, Kawasaki (N.H.), the Department of Respiratory Medicine, Kurashiki Central Hospital, Kurashiki (T.I.), Sekino Hospital, Tokyo (H.S.), Tsuchiura Beryl Clinic, Tsuchiura (K.Y.), Shionogi, Osaka (K.K., T.S., M.A., K.T., T.U.), and the Research Division for Development of Anti-Infective Agents, Institute of Development, Aging, and Cancer, Tohoku University, Sendai (A.W.) - all in Japan; the Division of Infectious Diseases, Department of Medicine, University of Alberta, Edmonton, Canada (N.L.); the Department of Medical Microbiology, Academic Medical Center, University of Amsterdam, Amsterdam (M.D.J.); the Department of Microbiology and Immunology, University of Melbourne, at the Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia (A.C.H.); and Shionogi, Florham Park, NJ (S.P.)
| | - Aeron C Hurt
- From the Department of Medicine, University of Virginia School of Medicine, Charlottesville (F.G.H.); the Department of Pediatrics, Keiyu Hospital, Yokohama (N.S.), Hirotsu Clinic, Kawasaki (N.H.), the Department of Respiratory Medicine, Kurashiki Central Hospital, Kurashiki (T.I.), Sekino Hospital, Tokyo (H.S.), Tsuchiura Beryl Clinic, Tsuchiura (K.Y.), Shionogi, Osaka (K.K., T.S., M.A., K.T., T.U.), and the Research Division for Development of Anti-Infective Agents, Institute of Development, Aging, and Cancer, Tohoku University, Sendai (A.W.) - all in Japan; the Division of Infectious Diseases, Department of Medicine, University of Alberta, Edmonton, Canada (N.L.); the Department of Medical Microbiology, Academic Medical Center, University of Amsterdam, Amsterdam (M.D.J.); the Department of Microbiology and Immunology, University of Melbourne, at the Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia (A.C.H.); and Shionogi, Florham Park, NJ (S.P.)
| | - Tadashi Ishida
- From the Department of Medicine, University of Virginia School of Medicine, Charlottesville (F.G.H.); the Department of Pediatrics, Keiyu Hospital, Yokohama (N.S.), Hirotsu Clinic, Kawasaki (N.H.), the Department of Respiratory Medicine, Kurashiki Central Hospital, Kurashiki (T.I.), Sekino Hospital, Tokyo (H.S.), Tsuchiura Beryl Clinic, Tsuchiura (K.Y.), Shionogi, Osaka (K.K., T.S., M.A., K.T., T.U.), and the Research Division for Development of Anti-Infective Agents, Institute of Development, Aging, and Cancer, Tohoku University, Sendai (A.W.) - all in Japan; the Division of Infectious Diseases, Department of Medicine, University of Alberta, Edmonton, Canada (N.L.); the Department of Medical Microbiology, Academic Medical Center, University of Amsterdam, Amsterdam (M.D.J.); the Department of Microbiology and Immunology, University of Melbourne, at the Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia (A.C.H.); and Shionogi, Florham Park, NJ (S.P.)
| | - Hisakuni Sekino
- From the Department of Medicine, University of Virginia School of Medicine, Charlottesville (F.G.H.); the Department of Pediatrics, Keiyu Hospital, Yokohama (N.S.), Hirotsu Clinic, Kawasaki (N.H.), the Department of Respiratory Medicine, Kurashiki Central Hospital, Kurashiki (T.I.), Sekino Hospital, Tokyo (H.S.), Tsuchiura Beryl Clinic, Tsuchiura (K.Y.), Shionogi, Osaka (K.K., T.S., M.A., K.T., T.U.), and the Research Division for Development of Anti-Infective Agents, Institute of Development, Aging, and Cancer, Tohoku University, Sendai (A.W.) - all in Japan; the Division of Infectious Diseases, Department of Medicine, University of Alberta, Edmonton, Canada (N.L.); the Department of Medical Microbiology, Academic Medical Center, University of Amsterdam, Amsterdam (M.D.J.); the Department of Microbiology and Immunology, University of Melbourne, at the Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia (A.C.H.); and Shionogi, Florham Park, NJ (S.P.)
| | - Kota Yamada
- From the Department of Medicine, University of Virginia School of Medicine, Charlottesville (F.G.H.); the Department of Pediatrics, Keiyu Hospital, Yokohama (N.S.), Hirotsu Clinic, Kawasaki (N.H.), the Department of Respiratory Medicine, Kurashiki Central Hospital, Kurashiki (T.I.), Sekino Hospital, Tokyo (H.S.), Tsuchiura Beryl Clinic, Tsuchiura (K.Y.), Shionogi, Osaka (K.K., T.S., M.A., K.T., T.U.), and the Research Division for Development of Anti-Infective Agents, Institute of Development, Aging, and Cancer, Tohoku University, Sendai (A.W.) - all in Japan; the Division of Infectious Diseases, Department of Medicine, University of Alberta, Edmonton, Canada (N.L.); the Department of Medical Microbiology, Academic Medical Center, University of Amsterdam, Amsterdam (M.D.J.); the Department of Microbiology and Immunology, University of Melbourne, at the Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia (A.C.H.); and Shionogi, Florham Park, NJ (S.P.)
| | - Simon Portsmouth
- From the Department of Medicine, University of Virginia School of Medicine, Charlottesville (F.G.H.); the Department of Pediatrics, Keiyu Hospital, Yokohama (N.S.), Hirotsu Clinic, Kawasaki (N.H.), the Department of Respiratory Medicine, Kurashiki Central Hospital, Kurashiki (T.I.), Sekino Hospital, Tokyo (H.S.), Tsuchiura Beryl Clinic, Tsuchiura (K.Y.), Shionogi, Osaka (K.K., T.S., M.A., K.T., T.U.), and the Research Division for Development of Anti-Infective Agents, Institute of Development, Aging, and Cancer, Tohoku University, Sendai (A.W.) - all in Japan; the Division of Infectious Diseases, Department of Medicine, University of Alberta, Edmonton, Canada (N.L.); the Department of Medical Microbiology, Academic Medical Center, University of Amsterdam, Amsterdam (M.D.J.); the Department of Microbiology and Immunology, University of Melbourne, at the Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia (A.C.H.); and Shionogi, Florham Park, NJ (S.P.)
| | - Keiko Kawaguchi
- From the Department of Medicine, University of Virginia School of Medicine, Charlottesville (F.G.H.); the Department of Pediatrics, Keiyu Hospital, Yokohama (N.S.), Hirotsu Clinic, Kawasaki (N.H.), the Department of Respiratory Medicine, Kurashiki Central Hospital, Kurashiki (T.I.), Sekino Hospital, Tokyo (H.S.), Tsuchiura Beryl Clinic, Tsuchiura (K.Y.), Shionogi, Osaka (K.K., T.S., M.A., K.T., T.U.), and the Research Division for Development of Anti-Infective Agents, Institute of Development, Aging, and Cancer, Tohoku University, Sendai (A.W.) - all in Japan; the Division of Infectious Diseases, Department of Medicine, University of Alberta, Edmonton, Canada (N.L.); the Department of Medical Microbiology, Academic Medical Center, University of Amsterdam, Amsterdam (M.D.J.); the Department of Microbiology and Immunology, University of Melbourne, at the Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia (A.C.H.); and Shionogi, Florham Park, NJ (S.P.)
| | - Takao Shishido
- From the Department of Medicine, University of Virginia School of Medicine, Charlottesville (F.G.H.); the Department of Pediatrics, Keiyu Hospital, Yokohama (N.S.), Hirotsu Clinic, Kawasaki (N.H.), the Department of Respiratory Medicine, Kurashiki Central Hospital, Kurashiki (T.I.), Sekino Hospital, Tokyo (H.S.), Tsuchiura Beryl Clinic, Tsuchiura (K.Y.), Shionogi, Osaka (K.K., T.S., M.A., K.T., T.U.), and the Research Division for Development of Anti-Infective Agents, Institute of Development, Aging, and Cancer, Tohoku University, Sendai (A.W.) - all in Japan; the Division of Infectious Diseases, Department of Medicine, University of Alberta, Edmonton, Canada (N.L.); the Department of Medical Microbiology, Academic Medical Center, University of Amsterdam, Amsterdam (M.D.J.); the Department of Microbiology and Immunology, University of Melbourne, at the Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia (A.C.H.); and Shionogi, Florham Park, NJ (S.P.)
| | - Masatsugu Arai
- From the Department of Medicine, University of Virginia School of Medicine, Charlottesville (F.G.H.); the Department of Pediatrics, Keiyu Hospital, Yokohama (N.S.), Hirotsu Clinic, Kawasaki (N.H.), the Department of Respiratory Medicine, Kurashiki Central Hospital, Kurashiki (T.I.), Sekino Hospital, Tokyo (H.S.), Tsuchiura Beryl Clinic, Tsuchiura (K.Y.), Shionogi, Osaka (K.K., T.S., M.A., K.T., T.U.), and the Research Division for Development of Anti-Infective Agents, Institute of Development, Aging, and Cancer, Tohoku University, Sendai (A.W.) - all in Japan; the Division of Infectious Diseases, Department of Medicine, University of Alberta, Edmonton, Canada (N.L.); the Department of Medical Microbiology, Academic Medical Center, University of Amsterdam, Amsterdam (M.D.J.); the Department of Microbiology and Immunology, University of Melbourne, at the Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia (A.C.H.); and Shionogi, Florham Park, NJ (S.P.)
| | - Kenji Tsuchiya
- From the Department of Medicine, University of Virginia School of Medicine, Charlottesville (F.G.H.); the Department of Pediatrics, Keiyu Hospital, Yokohama (N.S.), Hirotsu Clinic, Kawasaki (N.H.), the Department of Respiratory Medicine, Kurashiki Central Hospital, Kurashiki (T.I.), Sekino Hospital, Tokyo (H.S.), Tsuchiura Beryl Clinic, Tsuchiura (K.Y.), Shionogi, Osaka (K.K., T.S., M.A., K.T., T.U.), and the Research Division for Development of Anti-Infective Agents, Institute of Development, Aging, and Cancer, Tohoku University, Sendai (A.W.) - all in Japan; the Division of Infectious Diseases, Department of Medicine, University of Alberta, Edmonton, Canada (N.L.); the Department of Medical Microbiology, Academic Medical Center, University of Amsterdam, Amsterdam (M.D.J.); the Department of Microbiology and Immunology, University of Melbourne, at the Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia (A.C.H.); and Shionogi, Florham Park, NJ (S.P.)
| | - Takeki Uehara
- From the Department of Medicine, University of Virginia School of Medicine, Charlottesville (F.G.H.); the Department of Pediatrics, Keiyu Hospital, Yokohama (N.S.), Hirotsu Clinic, Kawasaki (N.H.), the Department of Respiratory Medicine, Kurashiki Central Hospital, Kurashiki (T.I.), Sekino Hospital, Tokyo (H.S.), Tsuchiura Beryl Clinic, Tsuchiura (K.Y.), Shionogi, Osaka (K.K., T.S., M.A., K.T., T.U.), and the Research Division for Development of Anti-Infective Agents, Institute of Development, Aging, and Cancer, Tohoku University, Sendai (A.W.) - all in Japan; the Division of Infectious Diseases, Department of Medicine, University of Alberta, Edmonton, Canada (N.L.); the Department of Medical Microbiology, Academic Medical Center, University of Amsterdam, Amsterdam (M.D.J.); the Department of Microbiology and Immunology, University of Melbourne, at the Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia (A.C.H.); and Shionogi, Florham Park, NJ (S.P.)
| | - Akira Watanabe
- From the Department of Medicine, University of Virginia School of Medicine, Charlottesville (F.G.H.); the Department of Pediatrics, Keiyu Hospital, Yokohama (N.S.), Hirotsu Clinic, Kawasaki (N.H.), the Department of Respiratory Medicine, Kurashiki Central Hospital, Kurashiki (T.I.), Sekino Hospital, Tokyo (H.S.), Tsuchiura Beryl Clinic, Tsuchiura (K.Y.), Shionogi, Osaka (K.K., T.S., M.A., K.T., T.U.), and the Research Division for Development of Anti-Infective Agents, Institute of Development, Aging, and Cancer, Tohoku University, Sendai (A.W.) - all in Japan; the Division of Infectious Diseases, Department of Medicine, University of Alberta, Edmonton, Canada (N.L.); the Department of Medical Microbiology, Academic Medical Center, University of Amsterdam, Amsterdam (M.D.J.); the Department of Microbiology and Immunology, University of Melbourne, at the Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia (A.C.H.); and Shionogi, Florham Park, NJ (S.P.)
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