Ontology highlight
ABSTRACT: Background
Recent artemisinin-combination therapy failures in Cambodia prompted a search for alternatives. Atovaquone-proguanil (AP), a safe, effective treatment for multidrug-resistant Plasmodium falciparum (P.f.), previously demonstrated additive effects in combination with artesunate (AS).Methods
Patients with P.f. or mixed-species infection (n = 205) in Anlong Veng (AV; n = 157) and Kratie (KT; n = 48), Cambodia, were randomized open-label 1:1 to a fixed-dose 3-day AP regimen +/-3 days of co-administered artesunate (ASAP). Single low-dose primaquine (PQ, 15 mg) was given on day 1 to prevent gametocyte-mediated transmission.Results
Polymerase chain reaction-adjusted adequate clinical and parasitological response at 42 days was 90% for AP (95% confidence interval [CI], 82%-95%) and 92% for ASAP (95% CI, 83%-96%; P = .73). The median parasite clearance time was 72 hours for ASAP in AV vs 56 hours in KT (P < .001) and was no different than AP alone. At 1 week postprimaquine, 7% of the ASAP group carried microscopic gametocytes vs 29% for AP alone (P = .0001). Nearly all P.f. isolates had C580Y K13 propeller artemisinin resistance mutations (AV 99%; KT 88%). Only 1 of 14 treatment failures carried the cytochrome bc1 (Pfcytb) atovaquone resistance mutation, which was not present at baseline. P.f. isolates remained atovaquone sensitive in vitro but cycloguanil resistant, with a triple P.f. dihydrofolate reductase mutation.Conclusions
Atovaquone-proguanil remained marginally effective in Cambodia (≥90%) with minimal Pfcytb mutations observed. Treatment failures in the presence of ex vivo atovaquone sensitivity and adequate plasma levels may be attributable to cycloguanil and/or artemisinin resistance. Artesunate co-administration provided little additional blood-stage efficacy but reduced post-treatment gametocyte carriage in combination with AP beyond single low-dose primaquine.
SUBMITTER: Wojnarski M
PROVIDER: S-EPMC6736354 | biostudies-literature | 2019 Sep
REPOSITORIES: biostudies-literature
Wojnarski Mariusz M Lon Chanthap C Vanachayangkul Pattaraporn P Gosi Panita P Sok Somethy S Rachmat Agus A Harrison Dustin D Berjohn Catherine M CM Spring Michele M Chaoratanakawee Suwanna S Ittiverakul Mali M Buathong Nillawan N Chann Soklyda S Wongarunkochakorn Saowaluk S Waltmann Andreea A Kuntawunginn Worachet W Fukuda Mark M MM Burkly Hana H Heang Vireak V Heng Thay Keang TK Kong Nareth N Boonchan Threechada T Chum Bolin B Smith Philip P Vaughn Andrew A Prom Satharath S Lin Jessica J Lek Dysoley D Saunders David D
Open forum infectious diseases 20190904 9
<h4>Background</h4>Recent artemisinin-combination therapy failures in Cambodia prompted a search for alternatives. Atovaquone-proguanil (AP), a safe, effective treatment for multidrug-resistant <i>Plasmodium falciparum</i> (<i>P.f.</i>), previously demonstrated additive effects in combination with artesunate (AS).<h4>Methods</h4>Patients with <i>P.f.</i> or mixed-species infection (n = 205) in Anlong Veng (AV; n = 157) and Kratie (KT; n = 48), Cambodia, were randomized open-label 1:1 to a fixed- ...[more]