Cryptococcal Meningitis Treatment: What’s on the horizon?

Tom HarrisonProfessor of Infectious Diseases, St Georges University of London21st July 2020

• Symptomatic meningitis: WHO (2018), SA HIV Clinicians Soc. (2019)Preferred: A short course (1 week) induction with AmB + 5FCAlternative: 2 weeks fluconazole 1200 mg/d + 5FC

both followed by fluconazole consolidation and maintenance and ART at 4-6 wks

• Early infection - Asymptomatic CrAg-positive cases identified during screening:

Recommend LP; if LP declined (majority of cases), or CSF CrAg negative: fluconazole 1200 mg/d 2 weeks, followed by fluconazole consolidation/maintenance and ART at 2 wks

Current recommendations

2AmB = amphotericin B deoxycholate; 5FC = flucytosine. ART antiretroviral treatment, CrAg = cryptococcal antigen, CSF = cerebrospinal fluid. The CQUIN Project Virtual Workshop on Advanced HIV Disease | July 28-29, 2020

Both based RCT mortality benefit data:Symptomatic meningitis - ACTAMolloy et al. NEJM 2018 378:1004long term follow-up data CID 2020;70:521 è

Current recommendations

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Screening – REMSTARTMfinanga, et al. Lancet 2015 385:2173-82ç

Approx half mortality benefit due screening

The future? Optimising use of Liposomal Amphotericin B: The AMBITION-CM trial

4

Liposomal amphotericin (L-AmB, Ambisome) – in prior trials, no more effective but less toxic (renal impairment, anaemia) than conventional amphotericin B deoxycholate; even longer half life; excellent brain levelsEven better suited than conventional AmB to short course high dose induction treatment (as used in ACTA) – aimed at loading brain compartmentIF one / few doses effective, could be cost effective due shorter admission, less monitoring; and feasible to implement

Phase II RCTSingle 10 mg/kg/d dose:Safe, safer than Deoxy AmBAs rapid clearance as dailydosing for 2 weeks

Jarvis et al Clin Infect Dis. 2019 Jan 18;68:393

The AMBITION-CM trial: Phase-III study – clinical endpoint non-inferiority trial

• Liposomal-AmB 10 mg/kg day 1 (single dose) plus 5FC plus fluconazole (for initial 2 weeks) vs

• Amphotericin B deoxycholate 1.0 mg/kg/d 7 days plus 5FC(“control arm” new WHO standard – from ACTA)

• All patients fluconazole 800 mg/d to 10 weeks, 200 mg/dthereafter. ART initiated 4-6 weeks

• Endpoints: Primary: All-cause mortality within 10 weeks• Secondary: Early Fungicidal Activity (EFA); 2-week mortality;tolerability and adverse events; cost-effectiveness

>650 of target of 850 participants already enrolled

Results expected early 2021

• Access to 5FC is increasing and costs of 5FC are coming down: UNITAID AHD programme (launched Jan 2019)South African access programme, 5FC in routine use from May 2019:

24% in-hospital mortality first 335 patients, with 1 week AmB+5FC regimen, compared with 35% from long term surveillance data in South Africa. Govender N et al ICASA Dec2019

• Major (Mylan) and multiple manufacturers committed

• Funding secured for development of easier to use modified release formulation that could be given twice rather than 4 x daily (EDCTP – DNDi and partners)

• In fact, progress since release of ACTA results showing that 5FC is an essential part of best treatment has been rapid

Wide access to Flucytosine, and Modified-Release Flucytosine

6The CQUIN Project Virtual Workshop on Advanced HIV Disease | July 28-29, 2020

• Those testing CrAg positive have continued high mortality, despite fluconazole

• And a significant proportion 30-40% CrAgpositives have subclinical CM (defined by +ve CSF CrAg) if they agree to LP

• A high CrAg titre predicts subclinical CM; and a high titre and subclinical CM are both associated with higher mortality

We need to study more effective antifungal therapy for those who are CrAg+ve, in the context of a bundle of diagnostics and ART adherence support for all

The future? More effective antifungal treatment for those testing CrAg-positive during screening

7The CQUIN Project Virtual Workshop on Advanced HIV Disease | July 28-29, 2020

M A J O R A R T I C L E

Autopsy Evidence of Cryptococcal Disease • CID 2019:XX (XX XXXX) • 1

Clinical Infectious Diseases

Received 22 January 2019; editorial decision 25 April 2019; accepted 7 June 2019; published online June 8, 2019.

Correspondence: R.  M. Wake, Centre for Healthcare-associated Infections, Antimicrobial Resistance and Mycoses, National Institute for Communicable Diseases, NICD, 1 Modderfontein Road, Johannesburg, 2131, South Africa (rmwake@gmail.com).

Clinical Infectious Diseases® 2019;XX(XX):1–8© The Author(s) 2019. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com.DOI: 10.1093/cid/ciz485

Cryptococcal-related Mortality Despite Fluconazole Preemptive Treatment in a Cryptococcal Antigen Screen-and-Treat ProgramRachel M. Wake,1,2 Nelesh P. Govender,1,3,4 Tanvier Omar,5,6 Carolina Nel,5,6 Ahmad Haeri Mazanderani,7,8 Aaron S. Karat,9 Nazir A. Ismail,10 Caroline T. Tiemessen,7,11 Joseph N. Jarvis,12,13,14 and Thomas S. Harrison2

1Centre for Healthcare-associated Infections, Antimicrobial Resistance and Mycoses, National Institute for Communicable Diseases, Johannesburg, South Africa; 2Institute of Infection & Immunity, St George’s University of London, United Kingdom; 3School of Pathology, University of the Witwatersrand, Johannesburg, 4Division of Medical Microbiology, University of Cape Town, 5Department of Anatomical Pathology, University of the Witwatersrand, 6Department of Pathology, National Health Laboratory Services, and 7Centre for HIV & STIs, National Institute for Communicable Diseases, Johannesburg, and 8Department of Medical Virology, University of Pretoria, South Africa; 9Tuberculosis Centre, London School of Hygiene & Tropical Medicine, United Kingdom; 10Centre for Tuberculosis, National Institute for Communicable Diseases, and 11Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; 12Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, United Kingdom; 13Botswana-UPenn Partnership, Gaborone; and 14Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia

Background. Cryptococcal antigen (CrAg) screening and treatment with preemptive fluconazole reduces the incidence of clin-ically evident cryptococcal meningitis in individuals living with advanced human immunodeficiency virus (HIV) disease. However, mortality remains higher in CrAg-positive than in CrAg-negative patients with similar CD4+ T-lymphocyte counts.

Methods. We conducted a cohort study to investigate causes of morbidity and mortality during 6 months of follow-up among asymptomatic CrAg-positive and CrAg-negative (ratio of 1:2) patients living with HIV with CD4 counts <100 cells/µL attending 2 hospitals in Johannesburg, South Africa. When possible, minimally invasive autopsy (MIA) was performed on participants who died.

Results. Sixty-seven CrAg-positive and 134 CrAg-negative patients were enrolled. Death occurred in 17/67 (25%) CrAg-positive and 12/134 (9%) CrAg-negative participants (hazard ratio for death, adjusted for CD4 count, 3.0; 95% confidence interval, 1.4–6.7; P = .006). Cryptococcal disease was an immediate or contributing cause of death in 12/17 (71%) CrAg-positive participants. Postmortem cryptococcal meningitis and pulmonary cryptococcosis were identified at MIA in all 4 CrAg-positive participants, 3 of whom had negative cerebrospinal fluid CrAg tests from lumbar punctures (LPs) at the time of CrAg screening.

Conclusions. Cryptococcal disease was an important cause of mortality among asymptomatic CrAg-positive participants de-spite LPs to identify and treat those with subclinical cryptococcal meningitis and preemptive fluconazole for those without men-ingitis. Thorough investigation for cryptococcal disease with LPs and blood cultures, prompt ART initiation, and more intensive antifungals may reduce mortality among asymptomatic CrAg-positive patients identified through screening.

Keywords. cryptococcus; acquired immunodeficiency syndrome; AIDS-related opportunistic infections; autopsy; cryptococcal meningitis.

Cryptococcal disease is a leading cause of AIDS-related death in sub-Saharan Africa [1]. Although cryptococcal antigen (CrAg) screening and preemptive treatment with fluconazole reduces the incidence of cryptococcal meningitis [2–5], individuals with cryptococcal antigenemia treated with fluconazole re-main at higher risk of death than individuals without crypto-coccal antigenemia with similar CD4+ T-lymphocyte (CD4) counts [2–4].

CrAg screen-and-treat strategies have been implemented in several countries where cryptococcal meningitis is a common opportunistic infection [6]. In South Africa, blood samples with CD4 counts <100 cells/µL are screened at central laboratories using the Immuno-mycologics (IMMY, Norman, OK) CrAg lateral flow assay (LFA). South African national guidelines stip-ulate that CrAg-positive patients are assessed for symptoms or signs of meningitis and, if present, investigated for cryptococcal meningitis with a lumbar puncture (LP). Asymptomatic patients are offered LPs if available at the screening site or nearby facility and started on preemptive fluconazole (800 mg daily for 2 weeks, followed by 400 mg daily for 2 months, and then 200 mg daily pending immune reconstitution) if cryptococcal meningitis is excluded or if LP is not performed. Antiretroviral therapy (ART) is delayed for 2 weeks in asymptomatic CrAg-positive patients and for 4–6 weeks if cryptococcal meningitis is diagnosed [7].

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6 • CID 2019:XX (XX XXXX) • Wake et al

(Table 2, Figure 2). Participants with cryptococcal antigenemia had 3.3 times increased risk of death (95% CI, 1.6–7.0; P < .001) compared to CrAg-negative participants. This association remained significant when adjusted for baseline CD4 count (<50 cells/µL; hazard ratio [HR], 3.0; 95% CI, 1.4–6.4; P =  .004) and if all those lost to follow-up were assumed to have died (HR, 2.4; 95% CI, 1.3–4.6; P =  .008). Of other baseline variables assessed, only active TB at the time of enrollment was associated with mor-tality (HR, 2.6; 95% CI, 1.2–5.4; P = .01). Among CrAg-positive participants, death was associated with having a higher plasma CrAg titer (HR, 3.5 if titer >160 vs ≤160; 95% CI, 1.4–9.2; P = .009) but not with baseline cryptococcal disease. Time from CrAg test to death was a median 26 (IQR, 14–52) days in CrAg-positive and 70 (IQR, 37–95) days in CrAg-negative participants (P = .02).

MIA Results

MIAs were performed on 4 CrAg-positive and 2 CrAg-negative participants (Supplementary Table 2 and Figure 1). Postmortem cryptococcal meningitis was diagnosed in all 4 CrAg-positive participants by CSF CrAg test (plus culture for 1). Three of the participants had had negative LPs at the time of CrAg screening (7, 25, and 32 days prior to death); all became confused prior to death. The other participant died following treatment for subclinical cryptococcal meningitis. Cryptococcal pneumonia was identified histologically in lung tissue at MIA. BAL CrAg tests were posi-tive in all 4 CrAg-positive participants. Although multiple other pathologies were identified from autopsy samples, there was no ev-idence of cryptococcal disease in either CrAg-negative participant.

Causes of Death

Cryptococcosis was an immediate (n  =  5) or contributing (n = 7) cause of death in 12/17 (71%) CrAg-positive participants (8/12, 67% had cryptococcal meningitis) and no CrAg-negative participants. Of all 53 causes of death attributed (Supplementary

Table 1), cryptococcosis (12, 23%) was most common, followed by sepsis (11, 21%) and TB (8, 15%).

DISCUSSION

Cryptococcal antigenemia was a strong and independent pre-dictor of mortality among adults living with HIV without se-vere headache or reduced consciousness at the time of CrAg screening. This is consistent with previous studies that have found an increased mortality risk, irrespective of CD4 cell count and despite preemptive fluconazole treatment for CrAg-positive patients [2–4]. We found clinical and pathological evi-dence of cryptococcosis as a significant cause of morbidity and mortality among CrAg-positive participants; one-quarter had cryptococcal disease at the time of CrAg screening (19% had subclinical cryptococcal meningitis), 4 participants developed cryptococcal meningitis following negative baseline LPs, and more than two-thirds of deaths were attributed to cryptococ-cosis as an immediate or contributing cause.

Our findings emphasize the need to thoroughly investigate asymptomatic CrAg-positive patients for cryptococcal disease with LPs and blood cultures. However, we found that several cryptococcal-related deaths occurred despite the exclusion of cryptococcal disease at the time of screening. This indicates that fluconazole monotherapy, which is known to be subop-timal treatment for cryptococcal meningitis [14–17], is also in-adequate for preventing deaths among CrAg-positive patients; enhanced treatment strategies are needed.

One approach would be to use adjunctive antifungal treat-ment for all CrAg-positive patients or for those with higher blood CrAg titers, identified by quantitative CrAg assays [18, 19]. We found blood CrAg titers of >160 to be predictive of death, consistent with previous studies [5, 20, 21]. Adjunctive treatment options include flucytosine (shown to be effective for treating cryptococcal meningitis in the Advancing Cryptococcal meningitis Treatment for Africa (ACTA) trial [22]) or a single dose of 10  mg/kg liposomal amphotericin (effective fungi-cidal activity in CSF [23] and currently in a phase 3 trial for treating cryptococcal meningitis [24]). Both treatments are safe and feasible to administer in outpatient settings; randomized, controlled trials are required to establish if they would reduce mortality in asymptomatic CrAg-positive patients.

Delayed ART commencement may have contributed to increased mortality in CrAg-positive participants. Delay was longer in participants without subclinical cryptococcal menin-gitis, despite fluconazole being started relatively promptly after CrAg screening. Although point-of-care CrAg testing might im-prove linkage to ART [25–29], continued health worker educa-tion is imperative to ensure CrAg-positive patients initiate ART after the recommended 14 days of fluconazole 800 mg daily.

Previous studies have suggested that excess mortality among CrAg-positive patients might be explained by increased

Adjusted hazard ratio = 3.0

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Figure 2. Kaplan–Meier curve showing mortality estimates in CrAg-positive and CrAg-negative patients within 6 months, adjusted for baseline CD4 T-lymphocyte count. Abbreviations: CI, confidence interval; CrAg, cryptococcal antigen.

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More effective antifungal treatment for those testing CrAg-positive: EFFECT and ACACIA trials

8The CQUIN Project Virtual Workshop on Advanced HIV Disease | July 28-29, 2020

• EFFECT trial – funded MRC WT DFID Global Health Trials• From ACTA we know Fluconazole plus flucytosine (2 wks) is safe and

effective and could be sustainable, cost-effective oral option for CrAg +ve, that may preclude need for LP and i/v Rx

• South Africa, Tanzania, pragmatic trial, within screening programmes• 600 asymptomatic CrAg positive randomised to: • Fluconazole vs Fluconazole + flucytosine (first 2 wks)• All participants: ART adherence support, TB diagnostics

• ACACIA trial - Single Dose iv Liposomal Amphotericin for Asymptomatic Cryptococcal Antigenemia (ACACIA)Uganda, enrolling 2019 - 2023

Stratified management for those testing CrAg-positive according to CrAg titre

9The CQUIN Project Virtual Workshop on Advanced HIV Disease | July 28-29, 2020

Semi-quantitative tests are in development:IMMY CrAgSQ (negative, 1+ to 4+)Jarvis et al J. Clin. Microbiol. Online 27 May 2020 èBut may not be as easy to use in routine care as standard CrAg LFA - Depends relative intensity different test bands

Biosynex Crypto PS (negative, 1+, 2+)Simple to use But sensitivity and specificity sub-optimal compared IMMY LFA. Tenforde et al, unpublished

Nevertheless prospect is that more aggressive antifungal treatment could be directed at those with higher blood titre, at greatest risk of poor outcome. EFFECT and ACACIA can be analyzed by titre in retrospectin order to guide management pathways

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