SToP-Crypto: Safety Study of Fluconazole in Combination With Flucytosine for the Treatment of Early Cryptococcal Infection
Study Details
Study Description
Brief Summary
The purpose of this study is to determine if treatment with two medicines in combination (fluconazole and flucytosine) is safe as compared with one medicine alone (fluconazole) for the treatment of an early infection with a fungus called cryptococcus.
Condition or Disease | Intervention/Treatment | Phase |
---|---|---|
|
Phase 2 |
Detailed Description
Currently there is wide variation in practice and little evidence to guide the treatment of early cryptococcal infection in HIV-infected individuals with advanced immunosuppression. However, epidemiologic studies suggest that this may be a promising novel approach to decrease the mortality due to cryptococcal meningitis (CM), the second leading cause of death among HIV-infected individuals in many resource-limited settings. Screening asymptomatic HIV-infected individuals with advanced immunosuppression for serum cryptococcal antigen (CrAg) clearly identifies a population at high risk of CM 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. The mainstay of anti-cryptococcal therapy in resource-limited settings is oral fluconazole though preliminary evidence suggests this is not an effective treatment. Thus, there is a critical need for potent therapies that (1) can be safely administered in resource-limited settings and (2) are effective in a heterogeneous population of HIV-infected individuals with advanced immunosuppression and early cryptococcal infection who are initiating anti-retroviral therapy (ART).
This single center, open-label, randomized Phase IIb study is being conducted to assess the safety and estimate the efficacy of oral fluconazole in combination with flucytosine for the treatment of early cryptococcal infection. The study will be based at two sites supported by Family AIDS Care and Education Services (FACES) in Western Kenya. A consecutive sample of 100 HIV-infected adults with CD4 cell count ≤100 cells/µl and serum CrAg titer ≥1:2 who have no signs or symptoms of severe, systemic cryptococcal infection will be enrolled. At enrollment, specimens from participants will be cultured for evidence of Cryptococcus neoformans. Individuals who meet inclusion and exclusion criteria and consent to participate in the study will be randomized to combination therapy with oral fluconazole (1200mg/day) plus flucytosine (100mg/kg/day) or fluconazole alone for the fourteen days of therapy. Subsequently both groups will receive anti-retroviral therapy as well as fluconazole 800mg/day for 8 weeks followed by 200mg/day. The primary safety endpoint will be the incidence of treatment-related adverse events and serious adverse events. The primary efficacy endpoint will be survival at 12 weeks.
In addition, we will offer additional diagnostic testing and aim for 50% participation, approximately 25 individuals from each arm. We will perform a battery of diagnostic tests including chest radiography, fungal cultures in blood, sputum, urine, stool and cerebrospinal fluid (CSF), cryptococcal antigen testing in the CSF, and gram stain, Ziehls-Nielsen stain and India Ink staining of CSF sediment. Anti-fungal susceptibility testing via broth microdilution and polymerase chain reaction serotyping and mating type analysis will be performed on clinical isolates.
Study Design
Arms and Interventions
Arm | Intervention/Treatment |
---|---|
Experimental: 5FC plus fluconazole Combination therapy with oral fluconazole and flucytosine |
Drug: Flucytosine and fluconazole
Flucytosine 100mg/kg/day in 4 divided doses orally for 14 days given in combination with fluconazole 1200mg orally once daily for 14 days, followed by 800mg orally once daily for 8 weeks, followed by 200mg orally once daily
Other Names:
|
Active Comparator: fluconazole alone Fluconazole monotherapy |
Drug: Fluconazole
fluconazole 1200mg orally once daily for 14 days, followed by 800mg orally once daily for 8 weeks, followed by 200mg orally once daily
Other Names:
|
Outcome Measures
Primary Outcome Measures
- Number of Participants Alive at 12 Weeks [12 weeks]
Secondary Outcome Measures
- Number of Participants Alive at 2 Weeks [2 weeks]
- Survival at 24 Weeks [24 weeks]
- Number of Individuals Who Develop Cryptococcal Meningitis [24 weeks]
Clinical meningitis AND at least one of the following: cryptococcal antigen in the cerebrospinal fluid (CSF), cryptococcal organisms on India Ink stain, or fungal culture of CSF. Clinical meningitis will be defined as: fever>39.0°C, AND severe headache, AND At least one of the following: meningismus, photophobia, new onset seizure, focal neurological deficit localizable to the central nervous system papilledema confusion, delirium, or decreased level of consciousness.
- Number of Individuals Who Develop Immune Reconstitution Inflammatory Syndrome Due to Cryptococcus [24 weeks]
Individuals who develop clinical meningitis without evidence of fungal, bacterial, or parasitic (e.g. malaria) organisms in the cerebrospinal fluid. Clinical meningitis will be defined as: fever>39.0°C, AND severe headache, AND At least one of the following: meningismus, photophobia, new onset seizure, focal neurological deficit localizable to the central nervous system papilledema confusion, delirium, or decreased level of consciousness.
- Achieve Targeted Recruitment, Retention and Adherence Rates [24 weeks]
- Proportion of Individuals Requiring Treatment Discontinuation [4 weeks]
- Proportion of Individuals Requiring Dose Reduction [24 weeks]
- Number of Individuals With Treatment Related Adverse Events [24 weeks]
- Number of Individuals With Treatment Related Serious Adverse Events [24 weeks]
- Cryptococcal Meningitis-free Survival at 24 Weeks [24 weeks]
Clinical meningitis AND at least one of the following: cryptococcal antigen in the cerebrospinal fluid (CSF), cryptococcal organisms on India Ink stain, or fungal culture of CSF. Clinical meningitis will be defined as: fever>39.0°C, AND severe headache, AND At least one of the following: meningismus, photophobia, new onset seizure, focal neurological deficit localizable to the central nervous system papilledema confusion, delirium, or decreased level of consciousness.
Eligibility Criteria
Criteria
Inclusion Criteria:
-
Able and willing to give informed consent
-
Age > 18 years
-
HIV infection as confirmed by HIV-antibody test as per Kenyan guidelines
-
CD4+ T-cell count ≤100 cells/µl
-
Serum CrAg titer≥1:2
-
Able to travel to district hubs (Sindo District Hospital, Lumumba Health Centre) for regular study visits
Exclusion Criteria:
-
clinical meningitis:
-
clinical sepsis:
-
hemiparesis, aphasia, visual field deficit or other finding on neurological examination localizable to the central nervous system
-
a history of culture proven or suspected (cryptococcal antigen present) cryptococcal meningitis
-
a history of stroke or other infection of the central nervous system
-
a seizure within the last 2 months
-
currently taking or ever taken antiretroviral therapy
-
currently taking anti-tuberculous therapy
-
currently or recently (<2 months) prescribed fluconazole, itraconazole, clotrimazole troches, amphotericin or other oral anti-fungal medications
-
pregnant or breast-feeding
-
alanine aminotransferase concentration more than 3 times the upper limit of normal
-
neutrophil count <1000x103 cells/mL
-
hemoglobin <8g/dL
-
platelet count <100,000x 103 platelets/mL
-
creatinine clearance ≤50 ml/min
-
individuals with active heavy alcohol use or active recreational drug use
Contacts and Locations
Locations
Site | City | State | Country | Postal Code | |
---|---|---|---|---|---|
1 | Family AIDS Care and Education Services | Kisumu | Nyanza | Kenya | |
2 | Family AIDS Care and Education Services | Sindo | Nyanza | Kenya |
Sponsors and Collaborators
- Yale University
- National Institute of Neurological Disorders and Stroke (NINDS)
- Kenya Medical Research Institute
- Bausch Health Americas, Inc.
- University of Nairobi
Investigators
- Principal Investigator: Ana-Claire L Meyer, MD, MSHS, University of California, San Francisco
- Principal Investigator: Mark A Jacobson, MD, University of California, San Francisco
- Principal Investigator: Judith K Kwasa, MBChB MMed, University of Nairobi
Study Documents (Full-Text)
None provided.More Information
Publications
None provided.- 1307012426
- R21NS077858-01
Study Results
Participant Flow
Recruitment Details | |
---|---|
Pre-assignment Detail |
Arm/Group Title | 5FC Plus Fluconazole | Fluconazole Alone |
---|---|---|
Arm/Group Description | Combination therapy with oral fluconazole and flucytosine Flucytosine and fluconazole: Flucytosine 100mg/kg/day in 4 divided doses orally for 14 days given in combination with fluconazole 1200mg orally once daily for 14 days, followed by 800mg orally once daily for 8 weeks, followed by 200mg orally once daily | Fluconazole monotherapy Fluconazole: fluconazole 1200mg orally once daily for 14 days, followed by 800mg orally once daily for 8 weeks, followed by 200mg orally once daily |
Period Title: Overall Study | ||
STARTED | 3 | 3 |
COMPLETED | 3 | 3 |
NOT COMPLETED | 0 | 0 |
Baseline Characteristics
Arm/Group Title | 5FC Plus Fluconazole | Fluconazole Alone | Total |
---|---|---|---|
Arm/Group Description | Combination therapy with oral fluconazole and flucytosine Flucytosine and fluconazole: Flucytosine 100mg/kg/day in 4 divided doses orally for 14 days given in combination with fluconazole 1200mg orally once daily for 14 days, followed by 800mg orally once daily for 8 weeks, followed by 200mg orally once daily | Fluconazole monotherapy Fluconazole: fluconazole 1200mg orally once daily for 14 days, followed by 800mg orally once daily for 8 weeks, followed by 200mg orally once daily | Total of all reporting groups |
Overall Participants | 3 | 3 | 6 |
Age (years) [Median (Full Range) ] | |||
Median (Full Range) [years] |
36
|
31
|
33.5
|
Sex: Female, Male (Count of Participants) | |||
Female |
1
33.3%
|
1
33.3%
|
2
33.3%
|
Male |
2
66.7%
|
2
66.7%
|
4
66.7%
|
Region of Enrollment (participants) [Number] | |||
Kenya |
3
100%
|
3
100%
|
6
100%
|
CD4+ T-cell Count (cells/microliter) [Median (Full Range) ] | |||
Median (Full Range) [cells/microliter] |
22
|
13
|
17
|
Outcome Measures
Title | Number of Participants Alive at 12 Weeks |
---|---|
Description | |
Time Frame | 12 weeks |
Outcome Measure Data
Analysis Population Description |
---|
[Not Specified] |
Arm/Group Title | 5FC Plus Fluconazole | Fluconazole Alone |
---|---|---|
Arm/Group Description | Combination therapy with oral fluconazole and flucytosine Flucytosine and fluconazole: Flucytosine 100mg/kg/day in 4 divided doses orally for 14 days given in combination with fluconazole 1200mg orally once daily for 14 days, followed by 800mg orally once daily for 8 weeks, followed by 200mg orally once daily | Fluconazole monotherapy Fluconazole: fluconazole 1200mg orally once daily for 14 days, followed by 800mg orally once daily for 8 weeks, followed by 200mg orally once daily |
Measure Participants | 3 | 3 |
Number [participants] |
2
66.7%
|
2
66.7%
|
Title | Number of Participants Alive at 2 Weeks |
---|---|
Description | |
Time Frame | 2 weeks |
Outcome Measure Data
Analysis Population Description |
---|
[Not Specified] |
Arm/Group Title |
---|
Arm/Group Description |
Title | Survival at 24 Weeks |
---|---|
Description | |
Time Frame | 24 weeks |
Outcome Measure Data
Analysis Population Description |
---|
[Not Specified] |
Arm/Group Title |
---|
Arm/Group Description |
Title | Number of Individuals Who Develop Cryptococcal Meningitis |
---|---|
Description | Clinical meningitis AND at least one of the following: cryptococcal antigen in the cerebrospinal fluid (CSF), cryptococcal organisms on India Ink stain, or fungal culture of CSF. Clinical meningitis will be defined as: fever>39.0°C, AND severe headache, AND At least one of the following: meningismus, photophobia, new onset seizure, focal neurological deficit localizable to the central nervous system papilledema confusion, delirium, or decreased level of consciousness. |
Time Frame | 24 weeks |
Outcome Measure Data
Analysis Population Description |
---|
[Not Specified] |
Arm/Group Title |
---|
Arm/Group Description |
Title | Number of Individuals Who Develop Immune Reconstitution Inflammatory Syndrome Due to Cryptococcus |
---|---|
Description | Individuals who develop clinical meningitis without evidence of fungal, bacterial, or parasitic (e.g. malaria) organisms in the cerebrospinal fluid. Clinical meningitis will be defined as: fever>39.0°C, AND severe headache, AND At least one of the following: meningismus, photophobia, new onset seizure, focal neurological deficit localizable to the central nervous system papilledema confusion, delirium, or decreased level of consciousness. |
Time Frame | 24 weeks |
Outcome Measure Data
Analysis Population Description |
---|
[Not Specified] |
Arm/Group Title |
---|
Arm/Group Description |
Title | Achieve Targeted Recruitment, Retention and Adherence Rates |
---|---|
Description | |
Time Frame | 24 weeks |
Outcome Measure Data
Analysis Population Description |
---|
[Not Specified] |
Arm/Group Title |
---|
Arm/Group Description |
Title | Proportion of Individuals Requiring Treatment Discontinuation |
---|---|
Description | |
Time Frame | 4 weeks |
Outcome Measure Data
Analysis Population Description |
---|
[Not Specified] |
Arm/Group Title |
---|
Arm/Group Description |
Title | Proportion of Individuals Requiring Dose Reduction |
---|---|
Description | |
Time Frame | 24 weeks |
Outcome Measure Data
Analysis Population Description |
---|
[Not Specified] |
Arm/Group Title |
---|
Arm/Group Description |
Title | Number of Individuals With Treatment Related Adverse Events |
---|---|
Description | |
Time Frame | 24 weeks |
Outcome Measure Data
Analysis Population Description |
---|
[Not Specified] |
Arm/Group Title |
---|
Arm/Group Description |
Title | Number of Individuals With Treatment Related Serious Adverse Events |
---|---|
Description | |
Time Frame | 24 weeks |
Outcome Measure Data
Analysis Population Description |
---|
[Not Specified] |
Arm/Group Title |
---|
Arm/Group Description |
Title | Cryptococcal Meningitis-free Survival at 24 Weeks |
---|---|
Description | Clinical meningitis AND at least one of the following: cryptococcal antigen in the cerebrospinal fluid (CSF), cryptococcal organisms on India Ink stain, or fungal culture of CSF. Clinical meningitis will be defined as: fever>39.0°C, AND severe headache, AND At least one of the following: meningismus, photophobia, new onset seizure, focal neurological deficit localizable to the central nervous system papilledema confusion, delirium, or decreased level of consciousness. |
Time Frame | 24 weeks |
Outcome Measure Data
Analysis Population Description |
---|
[Not Specified] |
Arm/Group Title |
---|
Arm/Group Description |
Adverse Events
Time Frame | ||||
---|---|---|---|---|
Adverse Event Reporting Description | ||||
Arm/Group Title | 5FC Plus Fluconazole | Fluconazole Alone | ||
Arm/Group Description | Combination therapy with oral fluconazole and flucytosine Flucytosine and fluconazole: Flucytosine 100mg/kg/day in 4 divided doses orally for 14 days given in combination with fluconazole 1200mg orally once daily for 14 days, followed by 800mg orally once daily for 8 weeks, followed by 200mg orally once daily | Fluconazole monotherapy Fluconazole: fluconazole 1200mg orally once daily for 14 days, followed by 800mg orally once daily for 8 weeks, followed by 200mg orally once daily | ||
All Cause Mortality |
||||
5FC Plus Fluconazole | Fluconazole Alone | |||
Affected / at Risk (%) | # Events | Affected / at Risk (%) | # Events | |
Total | / (NaN) | / (NaN) | ||
Serious Adverse Events |
||||
5FC Plus Fluconazole | Fluconazole Alone | |||
Affected / at Risk (%) | # Events | Affected / at Risk (%) | # Events | |
Total | 0/3 (0%) | 0/3 (0%) | ||
Other (Not Including Serious) Adverse Events |
||||
5FC Plus Fluconazole | Fluconazole Alone | |||
Affected / at Risk (%) | # Events | Affected / at Risk (%) | # Events | |
Total | 3/3 (100%) | 2/3 (66.7%) | ||
Blood and lymphatic system disorders | ||||
Neutropenia | 2/3 (66.7%) | 2 | 1/3 (33.3%) | 1 |
Gastrointestinal disorders | ||||
Nausea | 0/3 (0%) | 0 | 1/3 (33.3%) | 1 |
Vomiting | 0/3 (0%) | 0 | 1/3 (33.3%) | 1 |
General disorders | ||||
Unintentional Weight Loss | 1/3 (33.3%) | 1 | 0/3 (0%) | 0 |
Limitations/Caveats
More Information
Certain Agreements
Principal Investigators are NOT employed by the organization sponsoring the study.
The only disclosure restriction on the PI is that the sponsor can review results communications prior to public release and can embargo communications regarding trial results for a period that is less than or equal to 60 days. The sponsor cannot require changes to the communication and cannot extend the embargo.
Results Point of Contact
Name/Title | Dr. Ana-Claire Meyer |
---|---|
Organization | Yale University |
Phone | 203-737-8372 |
ana-claire.meyer@yale.edu |
- 1307012426
- R21NS077858-01