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Single-Dose Liposomal Amphotericin B Treatment for Cryptococcal Meningitis. 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 log10 colony-forming units (CFU) per milliliter per day in the liposomal amphotericin B group and -0.42 log10 CFU per milliliter per day in the control group. Fewer participants had grade 3 or 4 adverse events in the liposomal amphotericin B group than in the control group (50.0% vs. 62.3%). 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.).

The study design has been described previously26 and is provided in the full study protocol available as Supplementary Material at nejm.org. HIV-positive adults (≧18 years) with a first episode of cryptococcal meningitis, diagnosed by positive India Ink or cryptococcal antigen (CrAg lateral flow assay, IMMY, Norman, Oklahoma, USA) in CSF, were recruited from eight Hospitals: Princess Marina Hospital, Gaborone, Botswana; Queen Elizabeth Central Hospital, Blantyre and Kamuzu Central Hospital, Lilongwe, Malawi; Mitchells Plain Hospital and Khayelitsha Hospital, Cape Town, South Africa; Kiruddu National Referral Hospital, Kampala and Mbarara Regional Referral Hospital, Mbarara, Uganda; and Parirenyatwa Central Hospital, Harare, Zimbabwe. Participants were excluded if they had received more than two doses of either amphotericin or treatment dose fluconazole (≧800mg) prior to screening, declined consent or in cases of impaired capacity to consent had no legal representative to consent on their behalf, were pregnant, breast-feeding, taking contraindicated concomitant drugs, or had any previous adverse reaction to the study drugs. Late exclusion criteria, put in place to enable rapid enrolment of critically unwell participants pending baseline blood test results, were alanine transaminase (ALT) >5 times the upper limit of normal (>200 IU/L), polymorphonuclear leukocytes (PMNs) <500 x 106/L or platelets <50,000 x 106/L.

action to the study drugs. Late exclusion criteria, put in place to enable rapid enrolment of critically unwell participants pending baseline blood test results, were alanine transaminase (ALT) >5 times the upper limit of normal (>200 IU/L), polymorphonuclear leukocytes (PMNs) <500 x 106/L or platelets <50,000 x 106/L. Participants were individually randomized to either (i) single dose L-AmB 10mg/kg (AmBisome, Gilead Sciences Inc.) plus 14 days of flucytosine 100mg/kg/day and fluconazole 1200mg/day (the “AmBisome” group, a three-drug regimen27), or (ii) amphotericin B deoxycholate (1mg/kg/day) plus flucytosine (100mg/kg/day) for seven days, followed by fluconazole 1200mg/day on days 8-14 (the “control” group, a two-drug regimen), using a computer-generated randomization list with block sizes of four and six, stratified by site, in a 1:1 ratio. Randomization was performed electronically within a bespoke Electronic Data Capture tool in which the allocation sequence was concealed from all study investigators involved in participant recruitment. Treatment group allocation was provided to recruiting teams after consent and enrolment. Allocation was open label. AmBisome was donated by Gilead Sciences Inc; amphotericin B deoxycholate was purchased from Bristol Myers Squibb; flucytosine was purchased from Mylan; and fluconazole was purchased from Cipla/Medopharm. At sites where the Pfizer Diflucan Partnership Program was operational, donated Pfizer fluconazole was used if available. All participants were treated in hospital for a minimum of seven days. L-AmB 10 mg/kg was given in 1 liter of 5% dextrose over 2 hours, and amphotericin B deoxycholate 1 mg/kg in 1 liter of 5% dextrose over 4 hours. Participants received 1L of intravenous normal saline prior to any amphotericin dose, plus further IV fluids of at least one additional liter each day of amphotericin therapy. Potassium and magnesium supplements were given on each day participants received amphotericin and then for two additional days. Oral medications were given by nasogastric tube if participants were unable to swallow. Laboratory blood tests were monitored regularly during the first two weeks and again at week 4 (schedule provided in Supplementary Appendix Table S1). Lumbar punctures were performed at diagnosis, day 7, and day 14 for quantitative cryptococcal cultures. Participants with raised intracranial pressure received additional daily therapeutic lumbar punctures until the pressure was controlled to <20 cm H2O.

at week 4 (schedule provided in Supplementary Appendix Table S1). Lumbar punctures were performed at diagnosis, day 7, and day 14 for quantitative cryptococcal cultures. Participants with raised intracranial pressure received additional daily therapeutic lumbar punctures until the pressure was controlled to <20 cm H2O. Participants were followed in outpatient clinics for 10 weeks and contacted telephonically at week 16. If participants missed clinic appointments the trial teams traced them either telephonically or in person. After the 2-week induction period all participants received fluconazole 800mg/day for 8 weeks and 200mg/day thereafter. Antiretroviral therapy was initiated, re-initiated or switched at weeks 4-6 and was chosen in accordance with National Guidelines. The primary endpoint was all-cause mortality within 10 weeks after randomization. Secondary end points included: the rate of CSF fungal clearance over the 14 days of induction therapy; the proportion of participants in each arm developing clinical and DAIDS laboratory-defined grade 3/4 adverse events; and median absolute or percentage change from baseline in laboratory defined parameters.

omization. Secondary end points included: the rate of CSF fungal clearance over the 14 days of induction therapy; the proportion of participants in each arm developing clinical and DAIDS laboratory-defined grade 3/4 adverse events; and median absolute or percentage change from baseline in laboratory defined parameters. The protocol was approved by the London School of Hygiene and Tropical Medicine Research Ethics Committee and by all the site ethics committees and national regulatory bodies. All participants provided written informed consent. In those with abnormal mental status, written consent was obtained from the next-of-kin, and the participants were re-consented on recovery of capacity to consent. An Independent Data Monitoring Committee monitored the study and reviewed the trial data regularly. The trial funder, suppliers and drug manufacturers had no role in the study design, data collection, analysis, interpretation, or manuscript presentation. The authors vouch for the accuracy and completeness of the data and for the adherence of the trial to the trial protocol.

tudy and reviewed the trial data regularly. The trial funder, suppliers and drug manufacturers had no role in the study design, data collection, analysis, interpretation, or manuscript presentation. The authors vouch for the accuracy and completeness of the data and for the adherence of the trial to the trial protocol. Assuming a 35% 10-week mortality in both arms, a sample size of 390 per arm (780 in total) was calculated to have 90% power to detect an upper limit of the one-sided 95% confidence interval (CI) of the absolute difference in percentages risks to be within 10% (the specified non-inferiority margin). The primary analysis was based on the intention-to-treat population, defined as all randomized study participants who did not meet any late exclusion criteria. A generalized linear model with a binomial distribution was used to calculate mortality differences.

ks to be within 10% (the specified non-inferiority margin). The primary analysis was based on the intention-to-treat population, defined as all randomized study participants who did not meet any late exclusion criteria. A generalized linear model with a binomial distribution was used to calculate mortality differences. We performed two sensitivity analyses. First, a per-protocol analysis was performed excluding participants who missed more than one day of any single treatment in the first two weeks or more than two weeks of fluconazole consolidation treatment between weeks 2 and 10. Second, we performed adjusted analyses adjusting for pre-specified covariates: site, age, sex, baseline Glasgow Coma Scale, CD4 count, CSF cryptococcal colony forming units/mL, antiretroviral therapy status, hemoglobin and CSF opening pressure. Analysis of log-transformed longitudinal CSF fungal counts was performed using a linear mixed-effects model, in which undetectable measurements were left-censored.28 Adverse event analyses were reported for a safety population consisting of all participants who received one or more doses of study medication. Analyses were conducted using SAS® (version 9.4). See Supplementary Appendix for full statistical analysis plan.

Participants were individually randomized to either (i) single dose L-AmB 10mg/kg (AmBisome, Gilead Sciences Inc.) plus 14 days of flucytosine 100mg/kg/day and fluconazole 1200mg/day (the “AmBisome” group, a three-drug regimen27), or (ii) amphotericin B deoxycholate (1mg/kg/day) plus flucytosine (100mg/kg/day) for seven days, followed by fluconazole 1200mg/day on days 8-14 (the “control” group, a two-drug regimen), using a computer-generated randomization list with block sizes of four and six, stratified by site, in a 1:1 ratio. Randomization was performed electronically within a bespoke Electronic Data Capture tool in which the allocation sequence was concealed from all study investigators involved in participant recruitment. Treatment group allocation was provided to recruiting teams after consent and enrolment. Allocation was open label. AmBisome was donated by Gilead Sciences Inc; amphotericin B deoxycholate was purchased from Bristol Myers Squibb; flucytosine was purchased from Mylan; and fluconazole was purchased from Cipla/Medopharm. At sites where the Pfizer Diflucan Partnership Program was operational, donated Pfizer fluconazole was used if available. All participants were treated in hospital for a minimum of seven days. L-AmB 10 mg/kg was given in 1 liter of 5% dextrose over 2 hours, and amphotericin B deoxycholate 1 mg/kg in 1 liter of 5% dextrose over 4 hours. Participants received 1L of intravenous normal saline prior to any amphotericin dose, plus further IV fluids of at least one additional liter each day of amphotericin therapy. Potassium and magnesium supplements were given on each day participants received amphotericin and then for two additional days. Oral medications were given by nasogastric tube if participants were unable to swallow. Laboratory blood tests were monitored regularly during the first two weeks and again at week 4 (schedule provided in Supplementary Appendix Table S1). Lumbar punctures were performed at diagnosis, day 7, and day 14 for quantitative cryptococcal cultures. Participants with raised intracranial pressure received additional daily therapeutic lumbar punctures until the pressure was controlled to <20 cm H2O.

at week 4 (schedule provided in Supplementary Appendix Table S1). Lumbar punctures were performed at diagnosis, day 7, and day 14 for quantitative cryptococcal cultures. Participants with raised intracranial pressure received additional daily therapeutic lumbar punctures until the pressure was controlled to <20 cm H2O. Participants were followed in outpatient clinics for 10 weeks and contacted telephonically at week 16. If participants missed clinic appointments the trial teams traced them either telephonically or in person. After the 2-week induction period all participants received fluconazole 800mg/day for 8 weeks and 200mg/day thereafter. Antiretroviral therapy was initiated, re-initiated or switched at weeks 4-6 and was chosen in accordance with National Guidelines.

The primary endpoint was all-cause mortality within 10 weeks after randomization. Secondary end points included: the rate of CSF fungal clearance over the 14 days of induction therapy; the proportion of participants in each arm developing clinical and DAIDS laboratory-defined grade 3/4 adverse events; and median absolute or percentage change from baseline in laboratory defined parameters.

The protocol was approved by the London School of Hygiene and Tropical Medicine Research Ethics Committee and by all the site ethics committees and national regulatory bodies. All participants provided written informed consent. In those with abnormal mental status, written consent was obtained from the next-of-kin, and the participants were re-consented on recovery of capacity to consent. An Independent Data Monitoring Committee monitored the study and reviewed the trial data regularly. The trial funder, suppliers and drug manufacturers had no role in the study design, data collection, analysis, interpretation, or manuscript presentation. The authors vouch for the accuracy and completeness of the data and for the adherence of the trial to the trial protocol.

Assuming a 35% 10-week mortality in both arms, a sample size of 390 per arm (780 in total) was calculated to have 90% power to detect an upper limit of the one-sided 95% confidence interval (CI) of the absolute difference in percentages risks to be within 10% (the specified non-inferiority margin). The primary analysis was based on the intention-to-treat population, defined as all randomized study participants who did not meet any late exclusion criteria. A generalized linear model with a binomial distribution was used to calculate mortality differences. We performed two sensitivity analyses. First, a per-protocol analysis was performed excluding participants who missed more than one day of any single treatment in the first two weeks or more than two weeks of fluconazole consolidation treatment between weeks 2 and 10. Second, we performed adjusted analyses adjusting for pre-specified covariates: site, age, sex, baseline Glasgow Coma Scale, CD4 count, CSF cryptococcal colony forming units/mL, antiretroviral therapy status, hemoglobin and CSF opening pressure. Analysis of log-transformed longitudinal CSF fungal counts was performed using a linear mixed-effects model, in which undetectable measurements were left-censored.28 Adverse event analyses were reported for a safety population consisting of all participants who received one or more doses of study medication. Analyses were conducted using SAS® (version 9.4). See Supplementary Appendix for full statistical analysis plan.

From January 2018 to February 2021, 844 participants were randomized (Figure 1). Of these, 30 were excluded as: 24 met the pre-defined late exclusion criteria (13 due to low platelets, 4 due to low neutrophils, 2 due to raised ALT, 3 with low platelets and low neutrophils, and 1 with low platelets and raised ALT, Supplementary Appendix Table S2), 5 did not have cryptococcal meningitis, and 1 was HIV negative – leaving 814 participants in the intention-to-treat population. None were lost to follow up. A further 30 participants were excluded from the per-protocol population (20 missed more than one day of treatment in the first two weeks, 6 received incorrect treatment, and 4 missed more than two weeks of fluconazole consolidation treatment between weeks 2 and 10; full listing in Supplementary Appendix Table S2). Baseline characteristics were similar in both arms (Table 1).

col population (20 missed more than one day of treatment in the first two weeks, 6 received incorrect treatment, and 4 missed more than two weeks of fluconazole consolidation treatment between weeks 2 and 10; full listing in Supplementary Appendix Table S2). Baseline characteristics were similar in both arms (Table 1). In the intention-to-treat analysis, the proportion who died at 10 weeks was 24.8% (101 of 407; 95% CI, 20.7-29.3%) in the AmBisome group compared with 28.7% (117 of 407; 95% CI, 24.4-33.4%) in the control group (Table 2 and Figure 2A). The absolute difference in 10-week mortality risk between the AmBisome arm and control arm was -3.9% and the upper limit of the one-sided 95% confidence interval for this mortality risk difference was 1.2%, within the pre-specified 10% non-inferiority margin (p-value for non-inferiority <0.001)(Figure 2B). In the per-protocol analysis, mortality risk at 10 weeks was 24.5% (95 of 388; 95% CI, 20.3-29.1%) in the AmBisome group compared with 28.5% (113 of 396; 95% CI, 24.1-33.3%) in the control group, with a 10-week mortality risk difference of -4.1%, and upper limit of one-sided 95% confidence interval 1.1%. Results were consistent across protocol defined adjusted analyses (Table 2, Figure 2B) and key sub-group analyses (Supplementary Appendix Table S3).

28.5% (113 of 396; 95% CI, 24.1-33.3%) in the control group, with a 10-week mortality risk difference of -4.1%, and upper limit of one-sided 95% confidence interval 1.1%. Results were consistent across protocol defined adjusted analyses (Table 2, Figure 2B) and key sub-group analyses (Supplementary Appendix Table S3). Mortality risk at 2 weeks, 4 weeks, and 16 weeks is shown in Supplementary Appendix Table S3. The AmBisome group was non-inferior to the control group at the 10% margin at each of these time-points in both intention-to-treat and per-protocol populations. In a pre-specified superiority analysis at the 10-week time-point, the reduction in mortality risk in the AmBisome group compared with the control group did not reach statistical significance in the unadjusted analyses (risk difference -3.9%; 95% CI, -10.0% to 2.2%;), but was statistically significant in adjusted analysis (risk difference - 5.7%; 95% CI, -11.4% to -0.04%) when adjusting for co-variates associated with cryptococcal mortality. Outcomes of time-to-event analyses of mortality risk using Cox regression are shown in Supplementary Appendix Table S4, with no significant differences between groups (Figure 2B). The mean rate of fungal clearance from the CSF was -0.40 log10 CFU/ml/day in the AmBisome group and -0.42 log10 CFU/ml/day in the control group, difference in mean rates of 0.017 log10 CFU/ml/day; (95% CI, -0.001 to 0.036)(Table 2B and Supplementary Appendix Figure S2).

Mortality risk at 2 weeks, 4 weeks, and 16 weeks is shown in Supplementary Appendix Table S3. The AmBisome group was non-inferior to the control group at the 10% margin at each of these time-points in both intention-to-treat and per-protocol populations. In a pre-specified superiority analysis at the 10-week time-point, the reduction in mortality risk in the AmBisome group compared with the control group did not reach statistical significance in the unadjusted analyses (risk difference -3.9%; 95% CI, -10.0% to 2.2%;), but was statistically significant in adjusted analysis (risk difference - 5.7%; 95% CI, -11.4% to -0.04%) when adjusting for co-variates associated with cryptococcal mortality. Outcomes of time-to-event analyses of mortality risk using Cox regression are shown in Supplementary Appendix Table S4, with no significant differences between groups (Figure 2B). The mean rate of fungal clearance from the CSF was -0.40 log10 CFU/ml/day in the AmBisome group and -0.42 log10 CFU/ml/day in the control group, difference in mean rates of 0.017 log10 CFU/ml/day; (95% CI, -0.001 to 0.036)(Table 2B and Supplementary Appendix Figure S2). Paradoxical IRIS was reported in 3.7% (15 of 407) participants in the AmBisome group and 4.7% (19 of 407) in the control group (Supplementary Appendix Table S6). There were no cases of culture-positive relapse in the AmBisome arm. One case of relapse occurred in a participant who had received full induction therapy within the control group and initially cleared Cryptococcus from the CSF but had subsequent poor adherence to consolidation phase fluconazole. Overall, during the initial 10 weeks of follow up 17.4% (71 of 407) of participants were re-admitted to hospital at least once in the AmBisome arm and 17.4% (71 of 407) in the control arm (Supplementary Appendix Table S7).

d Cryptococcus from the CSF but had subsequent poor adherence to consolidation phase fluconazole. Overall, during the initial 10 weeks of follow up 17.4% (71 of 407) of participants were re-admitted to hospital at least once in the AmBisome arm and 17.4% (71 of 407) in the control arm (Supplementary Appendix Table S7). In the safety population, including all randomized participants who received one or more doses of study medication, within the initial 21 days of treatment there were 382 grade 3 or 4 adverse events among 210/420 (50.0%) of participants randomized into the AmBisome group and 579 grade 3 or 4 adverse events among 263/422 (62.3%) participants randomized into the control group (p<0.001). Table 3 gives a summary of clinical and laboratory adverse events, with a detailed listing in Supplementary Appendix Table S8. Potentially life threatening (grade 4) adverse events occurred in significantly fewer participants in the AmBisome group than the control group (21.7% [91 of 420] vs. 30.1% [127 of 422], p=0.005). Grade 3 or 4 anemia developed in 13.3% (56 of 420) of participants in the AmBisome group compared to 39.1% (165 of 422) in the control group (p<0.001). The mean decrease in hemoglobin over the first week of the induction period was 0.3g/dL in the AmBisome group and 1.9g/dL in the control group (p<0.001); 7.6% (32 of 420) of participants in the AmBisome group received a blood transfusion, compared to 18.0% (76 of 422) of participants in the control group. A grade 3 or 4 increase in creatinine developed in 5.2% (22 of 420) of participants in the AmBisome group compared to 5.9% (25 of 422) in the control group. The mean relative increase in serum creatinine from baseline to day 7 was 20.2% in the Ambisome group and 49.7% in the control group (p<0.001). Thrombophlebitis requiring antibiotic therapy occurred in 1.9% (8 of 420) of participants in the AmBisome group and 6.7% (28 of 422) of participants in the control group (p=0.001). There was a low frequency of grade 4 thrombocytopenia, neutropenia, and elevated alanine aminotransferase in both AmBisome and control groups.

In the intention-to-treat analysis, the proportion who died at 10 weeks was 24.8% (101 of 407; 95% CI, 20.7-29.3%) in the AmBisome group compared with 28.7% (117 of 407; 95% CI, 24.4-33.4%) in the control group (Table 2 and Figure 2A). The absolute difference in 10-week mortality risk between the AmBisome arm and control arm was -3.9% and the upper limit of the one-sided 95% confidence interval for this mortality risk difference was 1.2%, within the pre-specified 10% non-inferiority margin (p-value for non-inferiority <0.001)(Figure 2B). In the per-protocol analysis, mortality risk at 10 weeks was 24.5% (95 of 388; 95% CI, 20.3-29.1%) in the AmBisome group compared with 28.5% (113 of 396; 95% CI, 24.1-33.3%) in the control group, with a 10-week mortality risk difference of -4.1%, and upper limit of one-sided 95% confidence interval 1.1%. Results were consistent across protocol defined adjusted analyses (Table 2, Figure 2B) and key sub-group analyses (Supplementary Appendix Table S3).

Mortality risk at 2 weeks, 4 weeks, and 16 weeks is shown in Supplementary Appendix Table S3. The AmBisome group was non-inferior to the control group at the 10% margin at each of these time-points in both intention-to-treat and per-protocol populations. In a pre-specified superiority analysis at the 10-week time-point, the reduction in mortality risk in the AmBisome group compared with the control group did not reach statistical significance in the unadjusted analyses (risk difference -3.9%; 95% CI, -10.0% to 2.2%;), but was statistically significant in adjusted analysis (risk difference - 5.7%; 95% CI, -11.4% to -0.04%) when adjusting for co-variates associated with cryptococcal mortality. Outcomes of time-to-event analyses of mortality risk using Cox regression are shown in Supplementary Appendix Table S4, with no significant differences between groups (Figure 2B).

The mean rate of fungal clearance from the CSF was -0.40 log10 CFU/ml/day in the AmBisome group and -0.42 log10 CFU/ml/day in the control group, difference in mean rates of 0.017 log10 CFU/ml/day; (95% CI, -0.001 to 0.036)(Table 2B and Supplementary Appendix Figure S2).

Paradoxical IRIS was reported in 3.7% (15 of 407) participants in the AmBisome group and 4.7% (19 of 407) in the control group (Supplementary Appendix Table S6). There were no cases of culture-positive relapse in the AmBisome arm. One case of relapse occurred in a participant who had received full induction therapy within the control group and initially cleared Cryptococcus from the CSF but had subsequent poor adherence to consolidation phase fluconazole. Overall, during the initial 10 weeks of follow up 17.4% (71 of 407) of participants were re-admitted to hospital at least once in the AmBisome arm and 17.4% (71 of 407) in the control arm (Supplementary Appendix Table S7).

In the safety population, including all randomized participants who received one or more doses of study medication, within the initial 21 days of treatment there were 382 grade 3 or 4 adverse events among 210/420 (50.0%) of participants randomized into the AmBisome group and 579 grade 3 or 4 adverse events among 263/422 (62.3%) participants randomized into the control group (p<0.001). Table 3 gives a summary of clinical and laboratory adverse events, with a detailed listing in Supplementary Appendix Table S8. Potentially life threatening (grade 4) adverse events occurred in significantly fewer participants in the AmBisome group than the control group (21.7% [91 of 420] vs. 30.1% [127 of 422], p=0.005). Grade 3 or 4 anemia developed in 13.3% (56 of 420) of participants in the AmBisome group compared to 39.1% (165 of 422) in the control group (p<0.001). The mean decrease in hemoglobin over the first week of the induction period was 0.3g/dL in the AmBisome group and 1.9g/dL in the control group (p<0.001); 7.6% (32 of 420) of participants in the AmBisome group received a blood transfusion, compared to 18.0% (76 of 422) of participants in the control group. A grade 3 or 4 increase in creatinine developed in 5.2% (22 of 420) of participants in the AmBisome group compared to 5.9% (25 of 422) in the control group. The mean relative increase in serum creatinine from baseline to day 7 was 20.2% in the Ambisome group and 49.7% in the control group (p<0.001). Thrombophlebitis requiring antibiotic therapy occurred in 1.9% (8 of 420) of participants in the AmBisome group and 6.7% (28 of 422) of participants in the control group (p=0.001). There was a low frequency of grade 4 thrombocytopenia, neutropenia, and elevated alanine aminotransferase in both AmBisome and control groups.

This trial showed that induction therapy with a single 10 mg/kg dose of liposomal amphotericin B (AmBisome) with oral flucytosine and fluconazole was non-inferior to the WHO recommended standard-of-care of one week of amphotericin B deoxycholate given with flucytosine and was associated with significantly fewer adverse events. This clinical trial of cryptococcal meningitis was conducted in a range of settings across five countries in southern and eastern Africa with no loss to follow-up, giving generalizability to high HIV prevalent African settings (Supplementary Appendix Table S9). The 10-week mortality of 24.8% seen in the AmBisome group of our trial is among the lowest reported from a major cryptococcal meningitis trial in Africa, despite more than a quarter of participants presenting with very severe disease and abnormal baseline mental status. Our trial demonstrates that both strategies of single-dose AmBisome and short-course amphotericin B deoxycholate treatment with flucytosine are capable of reducing 10-week mortality from cryptococcal meningitis to below 30%, a significant improvement on the rates of 40-45% reported with 2-week amphotericin B-based regimens in trials from resource limited settings,12,29-31 and is consistent with the relatively favorable outcomes with the 1-week amphotericin B deoxycholate plus flucytosine regimen that were reported in the ACTA trial.12

30%, a significant improvement on the rates of 40-45% reported with 2-week amphotericin B-based regimens in trials from resource limited settings,12,29-31 and is consistent with the relatively favorable outcomes with the 1-week amphotericin B deoxycholate plus flucytosine regimen that were reported in the ACTA trial.12 The trial builds on the phase-II data24 that a single 10mg/kg dose of AmBisome is effective at clearing Cryptococcus from the CSF. Single high-dose AmBisome with flucytosine and fluconazole matched the fungicidal activity of seven days of amphotericin B deoxycholate, at 1 mg/kg, plus flucytosine. In addition, the single high-dose AmBisome treatment regimen was better tolerated than the one-week amphotericin B deoxycholate regimen, with fewer adverse events overall, fewer life-threatening grade 4 events, fewer episodes of grade 3 or 4 anemia, a reduced need for blood transfusion, and less thrombophlebitis. This reflects the known improved drug toxicity-profile of liposomal amphotericin B compared to amphotericin B deoxycholate.13,15 Within this trial we administered pre-emptive fluid and electrolytes to all participants to reduce the risk of amphotericin B-related toxicity, adopted an intensive blood monitoring schedule, and actively managed adverse events when they occurred. The reality of routine care in resource-limited settings is that the necessary resources are often not available to implement this toxicity reduction and intensive monitoring and management approach.

elated toxicity, adopted an intensive blood monitoring schedule, and actively managed adverse events when they occurred. The reality of routine care in resource-limited settings is that the necessary resources are often not available to implement this toxicity reduction and intensive monitoring and management approach. A further potential benefit of the AmBisome regimen is that it may be possible to shorten the length of hospital stay needed to safely administer effective treatment. For the evaluation of safety in this trial, our protocol required all participants to be admitted to hospital for seven days of inpatient monitoring. However, when scaled-up in real-world situations, earlier discharge will likely be possible in a proportion of participants. A cost-effectiveness comparison is underway. Given our results, a single high dose liposomal amphotericin B approach may be worth investigating in the treatment of other systemic fungal infections prevalent in resource-limited settings, such as histoplasmosis and talaromycosis.32,33 Our trial was open label, and clinical management of the critically unwell participants with advanced HIV disease was complex. However, both the primary endpoint of all-cause mortality and the key safety endpoints of laboratory confirmed toxicities were objectively measured, and a consistent approach to HIV and ART management agreed by the investigators and applied throughout the study (see Supplementary Appendix Table S10), avoiding differential management or outcome assessment by study arm.

rtality and the key safety endpoints of laboratory confirmed toxicities were objectively measured, and a consistent approach to HIV and ART management agreed by the investigators and applied throughout the study (see Supplementary Appendix Table S10), avoiding differential management or outcome assessment by study arm. In conclusion, a single, high-dose of AmBisome given with flucytosine and fluconazole was non-inferior to the current WHO recommended standard of care for cryptococcal meningitis and offers a practical, easier-to-administer and better-tolerated treatment for the management for HIV-associated cryptococcal meningitis. Continued efforts to ensure access to AmBisome and flucytosine are needed to enable implementation of this treatment.