Clinical Infectious Diseases最新文献

Background: In this phase 3 trial of an investigational maternal respiratory syncytial virus prefusion F protein-based vaccine (RSVPreF3-Mat), a higher rate of preterm birth was observed in the vaccine (6.8%) versus the placebo group (4.9%). Trial enrollment and vaccination were stopped. Results of investigations into this safety signal were reported previously. Here, we describe end-of-trial efficacy, immunogenicity, and safety results.

Methods: Women 18-49 years old were randomized 2:1 to receive 1 dose of RSVPreF3-Mat (n = 3557) or placebo (n = 1771) at 240/7-340/7 weeks' gestation. Primary outcomes were any and severe medically assessed RSV-associated lower respiratory tract disease (MA-RSV-LRTD) in infants until 6 months postbirth and safety until 12 months postbirth. Other efficacy outcomes were evaluated, along with immunogenicity (until 6 months postpartum/birth) and safety in mothers and infants.

Results: Efficacy (with 95% credible interval) in infants until 6 months postbirth was 65.5% (37.5%-82.0%) against any MA-RSV-LRTD, 69.0% (33.0%-87.6%) against severe MA-RSV-LRTD, and 50.1% (-3.6% to 75.8%) against RSV hospitalization; it waned over time thereafter. Efficacy against MA-RSV-LRTD was 47.8% (-25.8% to 77.3%) in low- and middle-income and 75.9% (46.1%-91.5%) in high-income countries. RSVPreF3-Mat induced a substantial increase in RSV-A neutralization titers in mothers, with efficient transplacental transfer of antibodies that persisted in infants until at least 6 months postbirth.

Conclusions: Consistent with the high titers of transplacentally transferred antibodies, this trial suggests a reduced risk of any/severe MA-RSV-LRTD and RSV hospitalization until 6 months postbirth in infants born to mothers immunized with RSVPreF3-Mat during pregnancy. However, vaccine development was terminated due to an identified preterm birth risk. Clinical Trials Registration. NCT04605159.

Background: The impact of pharmacokinetic variability of cabotegravir (CAB) and rilpivirine (RPV) long-acting (LA) injectable therapy on virological outcomes remains controversial. This study aimed to characterize the variability of CAB and RPV trough concentrations (Ctrough) and to identify the predictors of suboptimal exposure and virologic failure (VF) in a large real-world cohort.

Methods: We conducted a multicenter observational study including people with human immunodeficiency virus type 1 (HIV-1) initiating LA-CAB/RPV as maintenance therapy from January to December 2022, in whom CAB and RPV plasma Ctrough were determined as part of therapeutic drug monitoring (TDM).

Results: A total of 1674 CAB and 1687 RPV Ctrough measurements were collected from 736 people with HIV-1 (PWH). Significant interindividual variability in concentrations was observed. At month 1/month 3, 20%-30% of PWH had Ctrough <1120 ng/mL for CAB and 32 ng/mL for RPV. Predictors of lower Ctrough were body mass index (BMI) ≥30 kg/m2 and female sex at month 1, and only male sex at steady state. After a median follow-up of 12 (interquartile range, 9-16) months, VF occurred in 2.5% of PWH. At month 6 and month 12, VF was significantly associated with the presence of at least 2 risk factors (obesity, suboptimal Ctrough) (odds ratio [OR], 4.6, P = .047; OR, 5.15, P = .014), and CD4 nadir (OR, 0.56, P = .008; OR, 0.5, P = .001).

Conclusions: Our large real-world study confirms significant variability in CAB and RPV exposure, with BMI and sex as key predictors of lower Ctrough. Suboptimal CAB and RPV Ctrough, particularly in people with obesity, increases the risk of VF during the first year of treatment, highlighting the usefulness of TDM in clinical practice.

Background: Recent trials have demonstrated that shortened 4-month treatment durations are effective for the majority of people with tuberculosis (TB). However, there is a population of patients with TB who require longer treatment durations. Prospectively identifying those who require shorter versus longer treatment durations would support evaluation and implementation of optimized regimens.

Methods: We analyzed data from the RIFASHORT TB treatment-shortening noninferiority trial to define a TB phenotype classification. The RIFASHORT trial primary outcome was reanalyzed using the protocol-defined noninferiority criterion of 8 percentage points, stratifying by those classified as having limited or extensive disease.

Results: Xpert MTB/RIF semiquantitative bacterial burden in combination with TB disease involvement grading on chest X-ray achieved the strongest differentiation between relapse and nonrelapse. The extensive disease TB phenotype (high semiquantitative bacterial burden and extensive TB disease on X-ray) accounted for one-quarter of the RIFASHORT trial population and more than half of all posttreatment TB relapses (13/23). For the limited TB disease phenotype (a semiquantitative bacterial burden other than high or no extensive TB disease on X-ray), the experimental 4-month 1200-mg rifampicin-containing regimen met the protocol-defined noninferiority criterion in both modified intention-to-treat (adjusted risk difference: -1.3%; 95% CI, -6.7% to 4.0%) and per protocol analyses (1.7%; 95% CI, -3.8% to 7.1%).

Conclusions: The TB phenotype classification derived here successfully identified three-quarters of RIFASHORT trial participants for whom a 4-month 1200-mg rifampicin regimen was noninferior to the 6-month standard of care. A definitive phase III randomized trial of disease-stratified rifampicin-based TB treatment is justified.

Background: Approximately 95% of people infected with Mycobacterium tuberculosis do not progress to tuberculosis (TB) disease. Identifying key determinants of TB progression could focus prevention efforts.

Methods: Contacts of pulmonary TB patients were enrolled in a prospective multi-center cohort study (Regional Prospective Observational Research in Tuberculosis [RePORT]-Brazil) from 2015 to 2019 and followed for 24 months. Empirical review and least absolute shrinkage and selection operator (LASSO) regression, using baseline clinical and laboratory information, were used as dimension reduction techniques to determine factors for inclusion in prediction models. Models were created for: (1) all contacts, (2) contacts interferon-gamma release assay (IGRA)-positive at baseline, and (3) IGRA-positive contacts who did not receive TB preventive therapy (TPT; <30 days isoniazid). Internal validation was performed using bootstrapping.

Results: Among 1846 contacts of 619 TB index patients, 25 (1.4%) progressed to TB. No TPT was a risk factor for progression to TB among all contacts (mixed-effects adjusted hazard ratio [aHR] = 16.55, 95% confidence interval [CI]: 2.22-124.45). Internal validation with all contacts yielded an area under the receiver operating characteristic curve of 0.80 (95% CI: .72-.86]. Body mass index (BMI) was inversely associated with increased risk of progressing to active TB among IGRA-positive contacts who did not receive TPT (aHR = 0.89, 95% CI: .80-.99). Interferon-gamma release assay-positive contacts with BMI <25 kg/m2 had a 4.14-fold (95% CI: 1.17-14.67) higher risk of progression to TB than IGRA-positive contacts with BMI ≥25 kg/m2: 8.4% versus 2.1%, respectively.

Conclusions: Body mass index <25 kg/m2, a readily available biomarker, identified IGRA-positive close TB contacts at high risk of progressing to TB disease. Prioritizing this high-risk group for TB preventive therapy could improve TB prevention efforts. BMI <25 kg/m², a readily available biomarker, identified IGRA-positive close contacts at high risk for progression to TB in a large observational Brazilian cohort. Prioritizing this high-risk group for TB preventive therapy could significantly improve TB prevention efforts.

Background: Dolutegravir (DTG)/lamivudine dual therapy (DT) has demonstrated noninferiority to triple therapy (TT) in the GEMINI trials. Although the population with ≤200 CD4 cells/mm3 had a lower response rate, this was unrelated to virological failure. This trial evaluated the antiviral activity of dolutegravir/lamivudine among antiretroviral therapy (ART)-naive patients with human immunodeficiency virus (HIV) with a CD4 count ≤200 cells/mm3.

Methods: DOLCE is a randomized, hypothesis-based, open-label, multicenter study l, assessing the antiviral efficacy of DTG/3TC at week 48 in treatment-naive people with HIV (PWH) with CD4 counts ≤200 cells/mm3. Participants were randomly assigned in a 2:1 ratio to receive DTG/3TC as a single tablet regimen or DTG plus Tenofovir disoproxil fumarate (TDF)/XTC: Emtricitabine or lamivudine (FTC or 3TC). The primary endpoint was the proportion of participants with pVL <50 copies/mL at week 48 (Food and Drug Administration snapshot analysis intent-to-treat exposed population). This report presents results at week 48.

Results: Baseline characteristics were similar in both arms. In the DT arm, median CD4 cell count was 109 cells/mm (interquartile range [IQR]: 49-177) and median pVL was 180,000 copies/mL (IQR: 53 309-468 691); 45.4% had CD4 <100 cells/mm3, and 61.4% had pVL >100 000 copies/mL. CDC (Centers for Disease Control and Prevention) stage C: 31.4%. At week 48, virological suppression (pVL <50 copies/mL) was achieved 82.2% in the DT (125/152), and the CD4 count increased by +200 cells/mm3. Per-protocol analysis showed a response rate of 91.9%. Severe adverse events (n = 17) were reported in 15 of 152 participants (11.1%).

Conclusions: Dolutegravir/3TC demonstrated high efficacy in a population with low CD4 counts and high viral load. This study adds information regarding the efficacy and safety of DTG/3TC, regardless of baseline CD4 counts and viral load.

Clinical trials registration: NCT04880395.

Background: Modern assays for the detection of Chlamydia trachomatis (CT) rely on nucleic acid amplification testing (NAAT) of DNA or ribosomal RNA. However, it is also known that both viable ("living") and non-viable ("dead") CT can be detected by NAAT. Multiple laboratory techniques to measure CT viability have emerged.

Methods: We searched PubMed, EMBASE, Scopus, and Dimensions as well as conference abstracts for entries between January 2000 and May 2023. We included any studies that measured CT viability among NAAT-positive samples. Viability assays include enhanced cell culture, direct fluorescent antibody (DFA), messenger RNA (mRNA) detection via digital droplet polymerase chain reaction (PCR, ddPCR), viability PCR (V-PCR), and real-time PCR measuring RNA-to-DNA ratio (RDR) (eg, InSignia®). A meta-analysis was performed on the proportions of non-viable CT by anatomical site.

Results: We screened 31 342 records and included 16 studies in the analysis. The pooled proportions of non-viable CT by site were: 33% (95% confidence interval [CI]: 19%-47%) in rectal swabs (8 studies), 17% (95% CI: 7%-27%) in cervical swabs (6 studies), 15% (95% CI: 6%-25%) in vaginal swabs (6 studies), and 11% (95% CI: 9%-17%) in urine/urethral swabs (2 studies).

Conclusions: All included studies found that a proportion of NAAT-detected CT is non-viable. The findings have far-reaching implications for screening programs and studies evaluating new STI tests and antimicrobial regimens.