Targeted Treatment of Early Cryptococcal Infection in HIV-infected Patients

HIV感染者早期隐球菌感染的靶向治疗

• 批准号: 8779847
• 负责人: Ana-Claire Lew Meyer
• 金额: $ 6.14万
• 依托单位: YALE UNIVERSITY
• 依托单位国家: 美国
• 财政年份: 2011
• 资助国家: 美国
• 起止时间: 2011-09-30 至 2015-12-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/8779847
• 关键词: Targeted; Treatment; Early; Cryptococcal; Infection

DESCRIPTION (provided by applicant): In sub-Saharan Africa and southeast Asia, invasive cryptococcal disease is the second most common life- threatening opportunistic infection after tuberculosis and is responsible for up to 20% of deaths. As anti- retroviral and antifungal therapies become more available in resource-limited settings, there has been growing interest in developing new approaches to improve outcomes from invasive cryptococcal infection. Since invasive cryptococcal disease primarily affects HIV-individuals with advanced immunosuppression, one potential strategy to identify early cryptococcal infection in resource-limited settings is to screen asymptomatic individuals with advanced HIV-related immunosuppression for serum cryptococcal antigen (CrAg) as they enter outpatient HIV care and treatment programs. Several observational cohort studies have demonstrated that this approach clearly identifies a population at high risk of cryptococcal meningitis and death and is a feasible screening method for resource-limited settings. However, screening with serum CrAg alone without additional diagnostic studies identifies a heterogeneous clinical population with early cryptococcal infection, many of whom already have sub-clinical meningeal infection or fungemia. Although the mainstay of anti-cryptococcal therapy in resource-limited settings is monotherapy with oral fluconazole, preliminary evidence suggests this is not an effective treatment in a heterogeneous population of individuals with early cryptococcal infection. Thus, there is a critical need for potent therapies that are effective in a heterogeneous population of HIV-infected individuals with advanced immunosuppression and early cryptococcal infection and which can be safely administered in resource-limited settings. Although there are no randomized controlled trials of therapies for early cryptococcal infection, combination therapy with oral high-dose fluconazole and flucytosine has shown promise in small clinical trials for the treatment of cryptococcal meningitis. In this open-label Phase IIb randomized controlled clinical trial based at Family AIDS Care and Education Services (FACES) in Western Kenya, we will determine the safety and estimate the efficacy of combination therapy with oral flucytosine and fluconazole as compared to fluconazole monotherapy for the treatment of early cryptococcal infection in HIV-infected individuals with advanced immunosuppression who have no signs of meningitis or severe, systemic cryptococcal infection. In a sub-sample of trial participants, we will conduct additional diagnostic studies to further characterize the nature of early cryptococcal infection in our setting. Finally, through a new research collaboration which builds on existing relationships, we will conduct a series of activities intended to build research capacity in Kenya at the University of Nairobi and FACES.

描述（由申请人提供）：在撒哈拉以南非洲和东南亚，侵袭性隐球菌病是仅次于结核病的第二种最常见的危及生命的机会性感染，导致高达20%的死亡。随着抗逆转录病毒和抗真菌疗法在资源有限的环境中变得更加可用，人们越来越关注开发新的方法来改善侵袭性隐球菌感染的结果。由于侵袭性隐球菌病主要影响晚期免疫抑制的HIV个体，因此在资源有限的环境中识别早期隐球菌感染的一种潜在策略是在无症状的晚期HIV相关免疫抑制个体进入门诊HIV护理和治疗计划时筛查血清隐球菌抗原（CrAg）。几项观察性队列研究表明，这种方法清楚地识别出隐球菌脑膜炎和死亡的高风险人群，是资源有限环境中可行的筛查方法。 然而，仅用血清CrAg进行筛查而不进行额外的诊断研究，可以识别出具有早期隐球菌感染的异质性临床人群，其中许多人已经患有亚临床脑膜感染或真菌血症。虽然在资源有限的情况下，抗隐球菌治疗的主要方法是口服氟康唑单药治疗，但初步证据表明，在早期隐球菌感染的异质人群中，这不是一种有效的治疗方法。因此，迫切需要在具有晚期免疫抑制和早期隐球菌感染的HIV感染个体的异质群体中有效并且可以在资源有限的环境中安全施用的有效疗法。虽然没有早期隐球菌感染治疗的随机对照试验，但口服大剂量氟康唑和氟胞嘧啶的联合治疗在小型临床试验中显示出治疗隐球菌脑膜炎的前景。 在这项基于肯尼亚西部家庭艾滋病护理和教育服务（FACES）的开放标签IIb期随机对照临床试验中，我们将确定口服氟胞嘧啶和氟康唑联合治疗与氟康唑单药治疗相比的安全性和疗效，用于治疗晚期免疫抑制的HIV感染者的早期隐球菌感染，这些患者没有脑膜炎或严重脑膜炎的迹象，系统性隐球菌感染在试验参与者的子样本中，我们将进行额外的诊断研究，以进一步表征早期隐球菌感染的性质。 在我们的环境中感染。最后，通过在现有关系基础上开展新的研究合作，我们将在肯尼亚内罗毕大学和FACES开展一系列旨在建设研究能力的活动。