Intensified Tuberculosis Treatment to Reduce the Mortality of Patients With Tuberculous Meningitis (INTENSE-TBM)
Tuberculous Meningitis
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About this trial
This is an interventional treatment trial for Tuberculous Meningitis focused on measuring Tuberculous Meningitis, Intensified treatment, High dose Rifampicin, Linezolid, Aspirin, Subsaharan Africa
Eligibility Criteria
Inclusion criteria:
- Age ≥ 15 years
- TBM defined as "definite", "probable" or "possible"
Signed Informed Consent
- Definite TBM = at least one of the following criteria: acid-fast bacilli seen in CSF microscopy, positive CSF M. tuberculosis culture, or positive CSF M. tuberculosis commercial nucleic acid amplification test.
- Probable TBM = total modified Marais score ≥12 when neuroimaging is available, or ≥10 when neuroimaging is not available (at least 2 points should come from CSF or cerebral imaging criteria).
- Possible TBM = total modified Marais 6-11 when neuroimaging is available, or 6-9 when neuroimaging is not available.
Exclusion criteria:
- > 5 days of TB treatment
- Renal failure (eGFR<30 ml/min, CKD-EPI formula).
- Neutrophil count < 0.6 x 109/L.
- Hemoglobin concentration < 8 g/dL.
- Total bilirubin > 2.6 times the Upper Limit of Normal
- Platelet count < 50 x 109/L.
- ALT > 5 times the Upper Limit of Normal.
- Clinical evidence of liver failure or decompensated cirrhosis.
- For women: more than 17 weeks pregnancy or breastfeeding.
- For patients without decrease level of consciousness (Glasgow Coma Scale = 15): Peripheral neuropathy scoring Grade 3 or above on the Brief Peripheral Neuropathy Score (BPNS).
- Documented M. tuberculosis resistance to rifampicin.
- Positive gram-stain, bacterial culture or cryptococcal antigen in the Cerebral Spinal Fluid.
- Evidence of active bleeding (hemoptysis, gastrointestinal bleeding, hematuria, intracranial bleeding).
- Inability to collect Cerebral Spinal Fluid, except for patients with confirmed tuberculosis (by rapid molecular test or culture) from another biological sample and clinical and/or CT scan evidence of meningitis.
- Major surgery within the last two weeks prior to inclusion.
- Ongoing chronic aspirin treatment (eg for cardiovascular risk).
- Current use of drugs contraindicated with study drugs and that cannot be safely stopped (see Appendix 1: Drugs contra-indicated with study drugs).
In available history from patients:
- Evidence of past intracranial bleeding.
- Evidence of past of peptic ulceration.
- Evidence of recent (< 3 month) gastrointestinal bleeding.
- Known hypersensitivity contraindicating the use of study drugs .
- Evidence of porphyria.
- Evidence of hyperuricemia or gout.
- Any reason which at the discretion of the investigator would compromise safety and cooperation in the trial.
Sites / Locations
- Cocody University Hospital
- Treichville University HospitalRecruiting
- Yopougon University Hospital
- University Hospital Joseph Raseta BefelatananaRecruiting
- University Hospital TambohobeRecruiting
- Morafeno University Hospital
- Kayelitsha District HospitalRecruiting
- Mitchells Plain HospitalRecruiting
- New Somerset HospitalRecruiting
- Dora Nginza HospitalRecruiting
- Livingstone and PE Central HospitalsRecruiting
- Mbarara Regional Reference HospitalRecruiting
- Regional Reference Hospital of KabaleRecruiting
Arms of the Study
Arm 1
Arm 2
Arm 3
Arm 4
Other
Other
Other
Other
WHO TBM treatment + placebo
WHO TBM treatment + aspirin
Intensified TBM treatment + placebo
Intensified TBM treatment + aspirin
Inclusion (D-0) to end of Week-8 (W-8): isoniazid 5 mg/kg/d + rifampicin 10 mg/kg/d + ethambutol 20 mg/kg/d + pyrazinamide 30 mg/kg/d + placebo of aspirin W-9 to W-40: isoniazid 5 mg/kg/d + rifampicin 10 mg/kg/d.
Inclusion (D-0) to end of Week-8 (W-8): isoniazid 5 mg/kg/d + rifampicin 10 mg/kg/d + ethambutol 20 mg/kg/d + pyrazinamide 30 mg/kg/d + aspirin 200 mg/d W-9 to W-40: isoniazid 5 mg/kg/d + rifampicin 10 mg/kg/d.
Inclusion (D-0) to end of Week-8 (W-8): high dose rifampicin (35 mg/kg/d) + high dose linezolid (1200 mg/d from D-0 to end of W-4, then 600 mg/d from W-5 to W-8) + isoniazid 5 mg/kg/d + ethambutol 20 mg/kg/d + pyrazinamide 30 mg/kg/d + placebo of aspirin W-9 to W-40: isoniazid 5 mg/kg/d + rifampicin 10 mg/kg/d.
Inclusion (D-0) to end of Week-8 (W-8): high dose rifampicin (35 mg/kg/d) + high dose linezolid (1200 mg/d from D-0 to end of W-4, then 600 mg/d from W-5 to W-8) + isoniazid 5 mg/kg/d + ethambutol 20 mg/kg/d + pyrazinamide 30 mg/kg/d + aspirin 200 mg/d W-9 to W-40: isoniazid 5 mg/kg/d + rifampicin 10 mg/kg/d.