title: Comparative effectiveness of induction therapy for human immunodeficiency virus-associated cryptococcal meningitis: a network meta-analysis.
abstract: Background.  Multiple international treatment guidelines recommend amphotericin-based combination regimens for induction therapy of cryptococcal meningitis. Yet, only 1 trial has reported a mortality benefit for combination amphotericin-flucytosine, and none have reported a mortality benefit for combination amphotericin-fluconazole. Methods.  We conducted a Bayesian network meta-analysis to estimate the comparative effectiveness of recommended induction therapies for HIV-associated cryptococcal meningitis. We searched PubMed and Cochrane CENTRAL for clinical reports of induction therapy for HIV-associated cryptococcal meningitis. We extracted or calculated early (two-week) and late (six to 12-week) mortality by treatment arm for the following induction regimens: amphotericin B alone, amphotericin B + flucytosine, amphotericin B + triazoles, amphotericin B + flucytosine +triazoles, triazoles alone, triazoles + flucytosine, liposomal amphotericin B, and amphotericin B + other medicines. Results.  In the overall sample (35 studies, n = 2483), we found no evidence of decreased mortality from addition of flucytosine or triazoles to amphotericin B, compared with amphotericin B alone. Although we did find a nonsignificant benefit for addition of flucytosine to amphotericin B in studies including participants with altered levels of consciousness, we did not identify a benefit for combination therapy in restricted analyses in either resource-rich or resource-limited settings, studies conducted before or after 2004, and studies restricted to a high dose of amphotericin B and fluconazole. Conclusions.  Given considerations of drug availability and toxicity, there is an important need for additional data to clarify which populations are most likely to benefit from combination therapies for human immunodeficiency virus-associated cryptococcal meningitis.
authors.affiliation: Harvard Medical School , Boston, Massachusetts.
authors.forename: Jeffrey I
authors.initials: JI
authors.lastname: Campbell
authors.affiliation: Faculty of Health Sciences , University of Ottawa ; School of Population and Public Health , University of British Columbia , Vancouver , Canada.
authors.forename: Steve
authors.initials: S
authors.lastname: Kanters
authors.affiliation: Laboratory of Clinical Infectious Diseases , National Institutes of Health , Bethesda, Maryland.
authors.forename: John E
authors.initials: JE
authors.lastname: Bennett
authors.affiliation: Faculty of Health Sciences , McMaster University , Hamilton , Canada.
authors.forename: Kristian
authors.initials: K
authors.lastname: Thorlund
authors.affiliation: Harvard Medical School , Boston, Massachusetts ; Chester M. Pierce, MD Division of Global Psychiatry , Massachusetts General Hospital , Boston ; Mbarara University of Science and Technology , Uganda.
authors.forename: Alexander C
authors.initials: AC
authors.lastname: Tsai
authors.affiliation: Faculty of Health Sciences , University of Ottawa ; Stanford Prevention Research Center , Stanford University , California.
authors.forename: Edward J
authors.initials: EJ
authors.lastname: Mills
authors.affiliation: Harvard Medical School , Boston, Massachusetts ; Division of Infectious Disease, Department of Medicine , Massachusetts General Hospital , Boston.
authors.forename: Mark J
authors.initials: MJ
authors.lastname: Siedner
keywords: HIV/AIDS; cryptococcal meningitis; induction therapy; network meta-analysis; therapeutics