Single-Dose Liposomal Amphotericin B Treatment for Cryptococcal Meningitis.
AIDS-Related Opportunistic Infections
/ drug therapy
Administration, Oral
Africa South of the Sahara
Amphotericin B
/ administration & dosage
Antifungal Agents
/ administration & dosage
Drug Administration Schedule
Drug Therapy, Combination
Fluconazole
/ administration & dosage
Flucytosine
/ administration & dosage
HIV Infections
/ complications
Meningitis, Cryptococcal
/ drug therapy
Journal
The New England journal of medicine
ISSN: 1533-4406
Titre abrégé: N Engl J Med
Pays: United States
ID NLM: 0255562
Informations de publication
Date de publication:
24 03 2022
24 03 2022
Historique:
entrez:
23
3
2022
pubmed:
24
3
2022
medline:
31
3
2022
Statut:
ppublish
Résumé
Cryptococcal meningitis is a leading cause of human immunodeficiency virus (HIV)-related death in sub-Saharan Africa. Whether a treatment regimen that includes a single high dose of liposomal amphotericin B would be efficacious is not known. In this phase 3 randomized, controlled, noninferiority trial conducted in five African countries, we assigned HIV-positive adults with cryptococcal meningitis in a 1:1 ratio to receive either a single high dose of liposomal amphotericin B (10 mg per kilogram of body weight) on day 1 plus 14 days of flucytosine (100 mg per kilogram per day) and fluconazole (1200 mg per day) or the current World Health Organization-recommended treatment, which includes amphotericin B deoxycholate (1 mg per kilogram per day) plus flucytosine (100 mg per kilogram per day) for 7 days, followed by fluconazole (1200 mg per day) for 7 days (control). The primary end point was death from any cause at 10 weeks; the trial was powered to show noninferiority at a 10-percentage-point margin. A total of 844 participants underwent randomization; 814 were included in the intention-to-treat population. At 10 weeks, deaths were reported in 101 participants (24.8%; 95% confidence interval [CI], 20.7 to 29.3) in the liposomal amphotericin B group and 117 (28.7%; 95% CI, 24.4 to 33.4) in the control group (difference, -3.9 percentage points); the upper boundary of the one-sided 95% confidence interval was 1.2 percentage points (within the noninferiority margin; P<0.001 for noninferiority). Fungal clearance from cerebrospinal fluid was -0.40 log Single-dose liposomal amphotericin B combined with flucytosine and fluconazole was noninferior to the WHO-recommended treatment for HIV-associated cryptococcal meningitis and was associated with fewer adverse events. (Funded by the European and Developing Countries Clinical Trials Partnership and others; Ambition ISRCTN number, ISRCTN72509687.).
Sections du résumé
BACKGROUND
Cryptococcal meningitis is a leading cause of human immunodeficiency virus (HIV)-related death in sub-Saharan Africa. Whether a treatment regimen that includes a single high dose of liposomal amphotericin B would be efficacious is not known.
METHODS
In this phase 3 randomized, controlled, noninferiority trial conducted in five African countries, we assigned HIV-positive adults with cryptococcal meningitis in a 1:1 ratio to receive either a single high dose of liposomal amphotericin B (10 mg per kilogram of body weight) on day 1 plus 14 days of flucytosine (100 mg per kilogram per day) and fluconazole (1200 mg per day) or the current World Health Organization-recommended treatment, which includes amphotericin B deoxycholate (1 mg per kilogram per day) plus flucytosine (100 mg per kilogram per day) for 7 days, followed by fluconazole (1200 mg per day) for 7 days (control). The primary end point was death from any cause at 10 weeks; the trial was powered to show noninferiority at a 10-percentage-point margin.
RESULTS
A total of 844 participants underwent randomization; 814 were included in the intention-to-treat population. At 10 weeks, deaths were reported in 101 participants (24.8%; 95% confidence interval [CI], 20.7 to 29.3) in the liposomal amphotericin B group and 117 (28.7%; 95% CI, 24.4 to 33.4) in the control group (difference, -3.9 percentage points); the upper boundary of the one-sided 95% confidence interval was 1.2 percentage points (within the noninferiority margin; P<0.001 for noninferiority). Fungal clearance from cerebrospinal fluid was -0.40 log
CONCLUSIONS
Single-dose liposomal amphotericin B combined with flucytosine and fluconazole was noninferior to the WHO-recommended treatment for HIV-associated cryptococcal meningitis and was associated with fewer adverse events. (Funded by the European and Developing Countries Clinical Trials Partnership and others; Ambition ISRCTN number, ISRCTN72509687.).
Identifiants
pubmed: 35320642
doi: 10.1056/NEJMoa2111904
pmc: PMC7612678
mid: EMS143842
doi:
Substances chimiques
Antifungal Agents
0
liposomal amphotericin B
0
Amphotericin B
7XU7A7DROE
Fluconazole
8VZV102JFY
Flucytosine
D83282DT06
Banques de données
ISRCTN
['ISRCTN72509687']
Types de publication
Clinical Trial, Phase III
Equivalence Trial
Journal Article
Multicenter Study
Randomized Controlled Trial
Research Support, Non-U.S. Gov't
Langues
eng
Sous-ensembles de citation
IM
Pagination
1109-1120Subventions
Organisme : Wellcome Trust
ID : 098316
Pays : United Kingdom
Organisme : Wellcome Trust
ID : 203135
Pays : United Kingdom
Organisme : Wellcome Trust
ID : 211360/Z/18/Z
Pays : United Kingdom
Organisme : Medical Research Council
ID : MR/N023005/1
Pays : United Kingdom
Organisme : Medical Research Council
ID : G1001760
Pays : United Kingdom
Organisme : Wellcome Trust
Pays : United Kingdom
Organisme : Medical Research Council
ID : MR/P006922/1
Pays : United Kingdom
Organisme : Department of Health
ID : RP-2017-08-ST2-012
Pays : United Kingdom
Organisme : NINDS NIH HHS
ID : R01 NS086312
Pays : United States
Organisme : Medical Research Council
ID : MC_PC_MR/P006922/1
Pays : United Kingdom
Organisme : Wellcome Trust
ID : 206007
Pays : United Kingdom
Organisme : Medical Research Council
ID : MR/V033417/1
Pays : United Kingdom
Organisme : Medical Research Council
ID : MR/P020526/1
Pays : United Kingdom
Organisme : Wellcome Trust
ID : 214321
Pays : United Kingdom
Organisme : FIC NIH HHS
ID : K01 TW010268
Pays : United States
Investigateurs
J Goodall
(J)
K Lechiile
(K)
N Mawoko
(N)
T Mbangiwa
(T)
J Milburn
(J)
R Mmipi
(R)
C Muthoga
(C)
P Ponatshego
(P)
I Rulaganyang
(I)
K Seatla
(K)
N Tlhako
(N)
K Tsholo
(K)
S April
(S)
A Bekiswa
(A)
L Boloko
(L)
H Bookholane
(H)
T Crede
(T)
L Davids
(L)
R Goliath
(R)
S Hlungulu
(S)
R Hoffman
(R)
H Kyepa
(H)
N Masina
(N)
D Maughan
(D)
T Mnguni
(T)
S Moosa
(S)
T Morar
(T)
M Mpalali
(M)
J Naude
(J)
I Oliphant
(I)
S Sayed
(S)
L Sebesho
(L)
M Shey
(M)
L Swanepoel
(L)
M Chasweka
(M)
W Chimang'anga
(W)
T Chimphambano
(T)
E Dziwani
(E)
E Gondwe
(E)
A Kadzilimbile
(A)
S Kateta
(S)
E Kossam
(E)
C Kukacha
(C)
B Lipenga
(B)
J Ndaferankhande
(J)
M Ndalama
(M)
R Shah
(R)
A Singini
(A)
K Stott
(K)
A Zambasa
(A)
T Banda
(T)
T Chikaonda
(T)
G Chitulo
(G)
L Chiwoko
(L)
N Chome
(N)
M Gwin
(M)
T Kachitosi
(T)
B Kamanga
(B)
M Kazembe
(M)
E Kumwenda
(E)
M Kumwenda
(M)
C Maya
(C)
W Mhango
(W)
C Mphande
(C)
L Msumba
(L)
T Munthali
(T)
D Ngoma
(D)
S Nicholas
(S)
L Simwinga
(L)
A Stambuli
(A)
G Tegha
(G)
J Zambezi
(J)
C Ahimbisibwe
(C)
A Akampurira
(A)
A Alice
(A)
F Cresswell
(F)
J Gakuru
(J)
D Kiiza
(D)
J Kisembo
(J)
R Kwizera
(R)
F Kugonza
(F)
E Laker
(E)
T Luggya
(T)
A Lule
(A)
A Musubire
(A)
R Muyise
(R)
O Namujju
(O)
J Ndyetukira
(J)
L Nsangi
(L)
M Okirwoth
(M)
A Sadiq
(A)
K Tadeo
(K)
A Tukundane
(A)
D Williams
(D)
L Atwine
(L)
P Buzaare
(P)
M Collins
(M)
N Emily
(N)
C Inyakuwa
(C)
S Kariisa
(S)
J Mwesigye
(J)
S Niwamanya
(S)
A Rodgers
(A)
J Rukundo
(J)
I Rwomushana
(I)
M Ssemusu
(M)
G Stead
(G)
K Boyd
(K)
S Gondo
(S)
P Kufa
(P)
E Makaha
(E)
C Moyo
(C)
T Mtisi
(T)
S Mudzingwa
(S)
T Mwarumba
(T)
T Zinyandu
(T)
A Alanio
(A)
F Dromer
(F)
A Sturny-Leclere
(A)
P Griffin
(P)
S Hafeez
(S)
Commentaires et corrections
Type : CommentIn
Type : CommentIn
Informations de copyright
Copyright © 2022 Massachusetts Medical Society.
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