A randomized, double-blind, placebo-controlled clinical trial of fluconazole as early empiric treatment of coccidioidomycosis pneumonia (Valley Fever) in adults presenting with community-acquired pneumonia in endemic areas (FLEET-Valley Fever)

Julia A Messina; Eileen K Maziarz; John Galgiani; Jonathan T Truong; Aung K Htoo; Arash Heidari; Royce H Johnson; Aneesh T Narang; Fariba M Donovan; Marion Ewell; Antonino Catanzaro; George R Thompson 3rd; Neil M Ampel; John R Perfect; Susanna Naggie; Emmanuel B Walter

doi:10.1016/j.conctc.2021.100851

A randomized, double-blind, placebo-controlled clinical trial of fluconazole as early empiric treatment of coccidioidomycosis pneumonia (Valley Fever) in adults presenting with community-acquired pneumonia in endemic areas (FLEET-Valley Fever)

Contemp Clin Trials Commun. 2021 Oct 14:24:100851. doi: 10.1016/j.conctc.2021.100851. eCollection 2021 Dec.

Authors

Julia A Messina¹, Eileen K Maziarz¹, John Galgiani², Jonathan T Truong³, Aung K Htoo⁴, Arash Heidari⁵, Royce H Johnson⁵, Aneesh T Narang⁶, Fariba M Donovan⁷, Marion Ewell⁸, Antonino Catanzaro⁹, George R Thompson 3rd¹⁰, Neil M Ampel¹¹, John R Perfect¹, Susanna Naggie^{1

12}, Emmanuel B Walter^{1

12

13}

Affiliations

¹ Duke University School of Medicine, Durham, NC, USA.
² Valley Fever Center for Excellence, University of Arizona, Tucson, AZ, USA.
³ Southern California Kaiser Permanente, Antelope Valley, CA, USA.
⁴ Southern California Kaiser Permanente, Kern County, CA, USA.
⁵ Valley Fever Institute, Kern Medical, Bakersfield, CA, USA.
⁶ Banner University Medical Center Phoenix, Phoenix, AZ, USA.
⁷ Banner University Medical Center Tuscon, Tuscon, AZ, USA.
⁸ Emmes, Rockville, MD, USA.
⁹ University of California San Diego Medical Center, San Diego, CA, USA.
¹⁰ University of California Davis School of Medicine, Sacramento, CA, USA.
¹¹ University of Arizona, Tucson, AZ, USA.
¹² Duke Clinical Research Institute, Durham, NC, USA.
¹³ Duke Human Vaccine Institute, Durham, NC, USA.

Abstract

Introduction: Coccidioidomycosis is a fungal infection endemic in the southwestern United States (US). Primary pulmonary coccidioidomycosis (PPC) is a leading cause of community-acquired pneumonia (CAP) in this region, although its diagnosis is often delayed, leading to lag in antifungal treatment and subsequent morbidity. The impact of early empiric antifungal therapy as part of treatment for CAP in endemic areas on clinical outcomes is unknown.

Methods: Phase IV randomized, double-blind, placebo-controlled trial in individuals aged 18 years or older with CAP who met all eligibility criteria in Coccidioides endemic regions in the US. Eligible participants with CAP were randomized to receive either fluconazole (400 mg daily) or matching placebo for 42 days and were subsequently monitored for clinical resolution of their illness.

Objectives: The primary objective was to assess the clinical response of early empiric antifungal therapy with fluconazole through Day 22 in subjects with PPC who were adherent to the study intervention. Secondary objectives included: assessments of the impact of early empiric antifungal therapy with fluconazole through Day 22 and 43 in subjects with PPC regardless of adherence, comparisons of the clinical response and its individual components over time by treatment group in subjects with PPC, assessments of days lost from work or school, hospitalization, and all-cause mortality.

Discussion: This trial was halted early due to slow enrollment (72 participants in one year, 33 received fluconazole and 39 received placebo). Of those enrolled, eight (11%) met the study definition of PPC. The study design and challenges are discussed.

Keywords: Coccidioidomycosis; Community-acquired pneumonia; Valley fever.

Grants and funding

T32 AI100851/AI/NIAID NIH HHS/United States