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Safety of Daily Co-Trimoxazole in Pregnancy in an Area
of Changing Malaria Epidemiology: A Phase 3b
Randomized Controlle d Clinical Trial
Christine Manyando
1,5
*, Eric M. Njunju
1,5
, David Mwakazanga
1
, Gershom Chongwe
1
,
Rhoda Mkandawire
2
, Davies Champo
1
, Modest Mulenga
1
, Maaike De Crop
3
, Yves Claeys
3
,
Raffaella M. Ravinetto
3,6
, Ch antal van Overmeir
3
, Umberto D’ Alessandro
3,4
, Jean-Pierre Van
geertruyden
5
1 Tropical Diseases Research Centre, Ndola, Zambia, 2 Choma District Health Management Team, Choma, Zambia, 3 Institute of Tropical Medicine, Antwerp, Belgium,
4 Medical Research Council, Fajara, The Gambia, 5 International Health Unit, University of Antwerp, Antwerp, Belgium, 6 Department of Pharmaceutical and
Pharmacological Sciences, KU Leuven, Leuven, Belgium
Abstract
Introduction:
Antibiotic therapy during pregnancy may be beneficial and impacts positively on the reduction of adverse
pregnancy outcomes. No studies have been done so far on the effects of daily Co-trimoxazole (CTX) prophylaxis on birth
outcomes. A phase 3b randomized trial was conducted to establish that daily CTX in pregnancy is not inferior to SP
intermittent preventive treatment (IPT) in reducing placental malaria; preventing peripheral parasitaemia; preventing
perinatal mortality and also improving birth weight. To establish its safety on the offspring by measuring the gestational
age and birth weight at delivery, and compare the safety and efficacy profile of CTX to that of SP.
Methods:
Pregnant women (HIV infected and uninfected) attending antenatal clinic were randomized to receive either daily
CTX or sulfadoxine-pyrimethamine as per routine IPT. Safety was assessed using standard and pregnancy specific
measurements. Women were followed up monthly until delivery and then with their offspring up to six weeks after delivery.
Results:
Data from 346 pregnant women (CTX = 190; SP = 156) and 311 newborns (CTX = 166 and SP = 145) showed that
preterm deliveries (CTX 3.6%; SP 3.0%); still births (CTX 3.0%; SP 2.1%), neonatal deaths (CTX 0%; SP 1.4%), and spontaneous
abortions (CTX 0.6%; SP 0%) were similar between study arms. The low birth weight rates were 9% for CTX and 13% for SP.
There were no birth defects reported. Both drug exposure groups had full term deliveries with similar birth weights (mean
of 3.1 Kg). The incidence and severity of AEs in the two groups were comparable.
Conclusion:
Exposure to daily CTX in pregnancy may not be associated with particular safety risks in terms of birth
outcomes such as preterm deliveries, still births, neonatal deaths and spontaneous abortions compared to SP. However,
more data are required on CTX use in pregnant women both among HIV infected and un-infected individuals.
Trial Registration:
Clinicaltrials.gov NCT00711906.
Citation: Manyando C, Njunju EM, Mwakazanga D, Chongwe G, Mkandawire R, et al. (2014) Safety of Daily Co-Trimoxazole in Pregnancy in an Area of Changing
Malaria Epidemiology: A Phase 3b Randomized Controlled Clinical Trial. PLoS ONE 9(5): e96017. doi:10.1371/journal.pone.0096017
Editor: Philip Bejon, Kenya Medical Research Institute (KEMRI), Kenya
Received January 13, 2014; Accepted March 31, 2014; Published May 15, 2014
Copyright: ß 2014 Manyando et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: The study was funded under a program for institutional capacity strengthening, funded by the Belgian Development Cooperation and coordinated by
the Institute of Tropical Medicine in Antwerp. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the
manuscript.
Competing Interests: The authors have declared that no competing interests exist.
* E-mail: cmanyando@yahoo.com
Introduction
Malaria is one of the most important causes of morbidity and
mortality worldwide, with children and pregnant women being the
most severely affected groups [1]. In low transmission areas, all
pregnant women have little or no pre-existing immunity and
malaria can evolve towards severe disease with a higher risk of
maternal and perinatal mortality. Foetal and perinatal loss can be
as high as 60–70% [2–6]. In high transmission areas, primigrav-
idae are more at risk than multigravidae and malaria infection is
associated with maternal anaemia, low birth weight (LBW) and
stillbirth [7,8]. Annually, malaria during pregnancy is estimated to
account for 5% of the cases of severe anaemia in pregnant women,
approximately 35% of preventable low birth weight, 3–8% of
infant mortality and 5,000 to 200,000 infant deaths [9].
Anaemia, malnutrition and HIV infection are also common
events in malaria endemic areas and contribute to LBW. HIV
infection in pregnancy is associated with an increased risk of
malaria infection and higher parasite densities [10–12]. The risk
increment is more pronounced in multigravidae than in primi-
PLOS ONE | www.plosone.org 1 May 2014 | Volume 9 | Issue 5 | e96017
gravidae, indicating that HIV-1 hinders the development of
immunity [10,13,14]. HIV-1 infection is also associated with lower
birth weight [15], higher infant mortality and a 4-fold greater risk
of malaria attack in the new-born [16]. The increased risk of
placental malaria in HIV infected mothers is also associated with a
higher post-natal mortality [17]. The risk of anaemia suggests a
synergistic interaction between HIV and malaria, placing dually
infected women at very high risk of developing severe anaemia
[18,19].
The World Health Organization (WHO) recommends a
package of interventions for the prevention and control of malaria
in pregnancy. This comprises intermittent preventive treatment
(IPTp), use of insecticide treated materials (ITMs) [20,21], and
rapid access to effective case management for malaria illness and
anaemia [22]. Prevention with efficacious antimalarials can reduce
the incidence of placental malaria, LBW and maternal anaemia
[23,24]. IPTp with sulfadoxine/pyrimethamine (IPTp-SP) has
been proven to be an effective strategy to reduce the burden of
malaria during pregnancy. It is based on administering at least 2
treatment doses of SP to pregnant women after quickening
(around 18–20 weeks) at the Antenatal Care (ANC) centres
[25].The dose of SP should be given at not less than one month
interval as stipulated in the updated WHO IPTp guidelines, which
recommends IPTp at every scheduled antenatal visit [26]. HIV-1
infection may decrease the efficacy of IPTp-SP but 2 or more
doses of SP in the second and third trimester still reduce peripheral
and placental malaria, and maternal anaemia, including severe
anaemia, and increase birth weights [27,28]. Unfortunately, the
beneficial effect of IPTp-SP is currently threatened by increasing
resistance to SP. Therefore, other antimalarials to be used as IPTp
are currently investigated.
Cotrimoxazole (CTX) has been used for treating malaria in
children; recently, its daily use by non-pregnant HIV-infected
adults was associated with 70% reduction in the incidence of
clinical malaria [18,29,30]. Antibiotic therapy during pregnancy
may be beneficial and reduce some adverse pregnancy outcomes
[31]. CTX prophylaxis significantly improves birth outcomes in
HIV infected women with ,200 CD4 cells/ml with reduction of
chorionamnionitis, prematurity and neonatal mortality [32]. A
study conducted in Zambia using historical controls concluded
that antenatal provision of CTX was beneficial for HIV-infected
pregnant women with low CD4 count but not in women with $
200 CD4 cells/ml [32]. However, it is important to note that this
study was conducted in an area of very low malaria risk; CTX may
have had a different impact if malaria transmission had been
substantial. Though daily CTX could be considered as a potential
alternative for IPTp-SP, no information on its effectiveness in
preventing malaria infection during pregnancy and its conse-
quences (maternal anaemia and LBW) is available [33].
A clinical trial comparing the protective efficacy of daily CTX
versus IPTp-SP in pregnant women was carried out in southern
Zambia. Its primary objective was to test the hypothesis that CTX
prophylaxis is not inferior to SP prophylaxis in reducing placental
malaria. The secondary objectives were to evaluate efficacy of
CTX prophylaxis in preventing malaria peripheral parasitaemia,
perinatal mortality and in improving birth weight; to establish the
safety on the offspring by measuring the gestational age and birth
weight at delivery, and also to compare the safety and efficacy of
CTX prophylaxis to that of SP based on these parameters. The
study participants were stratified by HIV status in order to follow
the national preventive guidelines, taking note of the fact that
pregnant women with CD4 count ,200 cells/ml (at the time of the
trial as this has now been revised to ,350 cells/ml) are given daily
CTX and should not receive SP-IPTp. However, at the time of
implementation and thanks to the coordinated efforts for malaria
control, malaria transmission had become extremely low to the
extent that the study was prematurely stopped because it would
not have had sufficient power to meet the original objectives.
However, before interrupting the study, several pregnant women
were included and received either daily CTX or IPTp-SP in a 1:1
ratio. This provided the opportunity to report the safety of daily
CTX in an area of low malaria endemicity.
Methods
Study Area
Choma district is located in the Southern Province of Zambia.
Though malaria continued to be a key focus of public health
services in Choma as is the case in Zambia, there has been large
scale up of antimalarial interventions and considerable progress in
control of disease in recent years [22,34]. The malaria burden
decreased, in a population of 12 million, from 3.3 million reported
cases and 9,369 deaths in 2003 to 2.9 million cases and 3,862
deaths in 2009 [22].
The changing epidemiology was documented in Livingstone,
less that 200 km from Choma, where the number of malaria cases
declined from 8000 per quarter between 2004 and 2007[35] to
only 65 cases in the third quarter of 2008. Reported malaria
deaths declined from 60 in 2004 to zero in 2009 [35]. As Choma
and Livingstone are in the same epidemiological zone, these
reports retrospectively confirm that in 2009 the malaria risk in
Choma had decreased to an extremely low level and support the
decision of interrupting the clinical trial prematurely.
Decision to Stop the Trial in Choma
The study was initiated in Choma area in January, 2009, shortly
after a large observational study that was recruiting pregnant
women with history of clinical malaria and receiving antimalarial
treatment had just been concluded. The screening for the trial (the
Malcotrim study) included peripheral blood smear analysis. After 6
months of patient recruitment a review of the data on the
screening smear results revealed that only 4 of the 421 screened
patients had a malaria infection. This prompted the study director
in liaison with entire investigational team to inform the ethical
review committee at the Tropical Diseases Research Centre
(TDRC) and the National Ethical Review Committee, the sponsor
as well as the Zambia Medicines Regulatory Authority of the
extremely low malaria prevalence in the study area. As the risk of
malaria infection in pregnant women was much lower than
expected, the trial would not have had sufficient power to provide
the required answer, i.e. non-inferiority of the CTX arm in
preventing placental malaria as compared to SP intermittent
preventive treatment. The issue of changing the study site was
discussed also with the DSMB that received and reviewed on a
quarterly basis (unless differently requested by the DSMB
members) the updates on screening and recruitment and on losses
to follow-up, as well as the quarterly SAE reports routinely sent
also to the Ethical Committees. In addition, Serious Adverse
Events were also reported on a case-by-case basis, unless
differently requested by the DSMB members, in order to allow
them to promptly comment on specific events. The decision to
move the study site to another location known to have high
malaria transmission was taken by the research team in
consultation with the DSMB, ethics committees, the Regulatory
authority and the sponsor.
Safety of Daily Cotrimoxazole in Pregnancy: A Randomized Trial
PLOS ONE | www.plosone.org 2 May 2014 | Volume 9 | Issue 5 | e96017
Study Participants
Pregnant women between 16 and 28 weeks of gestation
attending the antenatal clinic of the Shampande Health Centre
or Choma Hospital in Choma District, accepting to be tested for
HIV and willing to participate in the study were enrolled. The
inclusion criteria were absence of symptoms consistent with
malaria at the time of recruitment (determined by asking them;
a positive blood smear was not an exclusion criterion although all
women found with a malaria infection at the time of recruitment
were also asked if they had any symptoms of malaria), willingness
to deliver at the health facility and willingness to adhere to study
requirements, e.g. monthly visits to the antenatal clinic. Exclusion
criteria were history of allergy to sulpha drugs, history or presence
of major illnesses likely to influence pregnancy outcome such as
diabetes, severe renal or heart disease or active tuberculosis; intent
to move outside the study catchment area before delivery, severe
anaemia (Hb, 7 g/dl) and previous history of unfavourable
pregnancy outcome (such as but not limited to pre-eclampsia,
caesarean section, stillbirth). Recruitment was conducted from
February to September, 2009.
Ethical Considerations
The study was sponsored by the Institute of Tropical Medicine,
Antwerp. It was approved by the Institutional Review Board at the
Institute of Tropical Medicine, Antwerp, and the Ethics commit-
tees at the University of Antwerp and at the Tropical Diseases
Research Centre, Ndola, Zambia. These bodies also approved the
Amendment 1.0 of 25 March 2009, which was issued to align the
study to the new management practices for prevention of mother
to child transmission (PMTCT) in Zambia (pregnant women to be
treated with anti-retroviral therapy (ART) if their CD4 count was
,350 cells/ml). All patients were informed about the study before
they were asked to sign the informed consent. Each study
participant was assigned a unique patient code that was used for
all subsequent forms in the study, so that confidentiality of all
subjects was guaranteed. A no fault study insurance was taken to
indemnify possible damage linked to a subjects participation in the
study. The trial was registered in the Clinicaltrials.gov registry,
identifier: NCT00711906, URL: http://clinicaltrial.gov/ct2/
show/NCT00711906.
Study Design
This was a phase 3 randomized open label clinical trial whose
planned primary endpoint was placental malaria. (The protocol
for this trial and supporting CONSORT checklist are available as
supporting information; see CONSORT Checklist S1 and
Protocol S1). The sample size calculation for the HIV negative
population was determined by assuming the prevalence of
placenta malaria at 10% in both groups with assumptions that
CTX prophylaxis was considered equivalent to SP if the two-sided
95% confidence interval was below 15% (90% power was required
for the primary hypothesis). Therefore, 788 pregnant women per
Figure 1. Study Design.
doi:10.1371/journal.pone.0096017.g001
Safety of Daily Cotrimoxazole in Pregnancy: A Randomized Trial
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treatment arm were required with an assumed loss to follow up of
10%. For HIV positive women with CD4 count $200 cells/ml,
similar assumptions were considered though the two-sided 95%
confidence interval was expected to be below 20%. Therefore, 260
pregnant women per treatment arm were required with an
assumed loss to follow up of 10%. Therefore, total sample size
initially planned for the study was 2,096 pregnant women.
The study stratification by HIV status to correspond to the
study hypothesis and objectives (as the study aimed at describing
differences in pregnancy outcomes by HIV status) is shown in
figure 1.
All HIV negative and HIV positive with CD4 count $200
cells/ml were randomized to either three monthly doses of SP–IPT
(a product of Roche, Fansidar) or daily CTX prophylaxis (2 tablets
of 400 mg of sulphamethoxazole and 80 mg of trimethoprim; a
product of Roche, Bactrim). Therefore, the study intervention and
randomization did not vary by HIV status in these two groups of
women. Nevertheless, HIV positive pregnant women with CD4
count ,200 cells/ml and complying with all other entry criteria
were recruited in an observational cohort as they had to be given 2
tablets of CTX prophylaxis daily and antiretroviral treatment as
per standard guidelines. In Zambia CTX prophylaxis for these
women is part of the routine ANC care since November, 2003, in
accordance with the WHO policy [37]. Thus, those women
already on CTX prophylaxis and/or ARV treatment and
complying with all other entry criteria were also recruited in this
observational cohort.
At enrolment, a standardized questionnaire to collect demo-
graphic information, history of malaria episodes, past medical and
obstetric history was administered. Other risk factors (such as
smoking and drinking) that may affect pregnancy outcome were
directly recorded in the Case Record Form (CRF). The
socioeconomic status was also assessed on the basis of some key
household parameters and a physical examination was performed.
Laboratory tests at baseline included thick and thin blood smears
for the diagnosis of malaria infection and measurement of
haemoglobin. IPTp-SP administration was directly observed while
CTX intake was supervised only for the first dose, the rest being
taken at home until the next monthly visit when participants were
reviewed.
Randomization
The randomization was stratified by HIV status. Eligible
women were randomized to one of the two arms according to a
pre-defined randomization list prepared at ITM, Antwerp.
Participants were assigned sequential study numbers which were
matched with numbered envelopes containing the arm allocation
that were opened by the study nurses only after recruitment of the
study subject. There was no blinding as each of the study drugs
was openly administered.
Study Procedures
Women attended the antenatal clinic monthly for assessment of
efficacy and safety parameters. Safety parameters included adverse
events (AEs), serious adverse events (SAEs) and concomitant
medications. During the monthly visits, physical examination,
including foetal viability, was performed, information on bed net
use was recorded, the study drugs provided, and compliance
assessed by means of drug accountability. A blood sample for
haemoglobin measurement (only once early in the third trimester,
between 30–34 weeks), blood film for malaria parasites and a filter
paper for later molecular biological assessments were collected (for
efficacy assessment). Urine was analysed for glucose, proteins and
blood using a dipstick urine test. At delivery, similar information as
Figure 2. Trial Profile.
doi:10.1371/journal.pone.0096017.g002
Safety of Daily Cotrimoxazole in Pregnancy: A Randomized Trial
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that collected at monthly visits was collected, including any AEs,
SAEs and use of concomitant medication. In addition, a placenta
blood sample for a thick blood film and later molecular analysis
(filter paper) was collected from the maternal surface of the
placenta. A biopsy was also obtained.
Women and their babies were seen at one and six weeks post-
delivery. Pregnancy specific assessments included rates of stillbirth
(.28 weeks gestation), neonatal mortality (#28 days of birth),
maternal mortality (up to 6 weeks post delivery), spontaneous
abortion (#28 weeks gestation), stillbirth, preterm delivery (#37
completed weeks), incidence of low birth weight, gestational age at
delivery (estimated from the last menstrual period [LMP], or by a
developmental score [36], if the LMP was unknown), incidence of
major and minor birth defects. Any infections that the patients
reported (or were treated for) were also recorded.
Data Management and Quality Control
Data were initially collected in a standardized source document
template, and then entered into an electronic case report form
(eCRF) using Macro 3.0 (InferMed Ltd, United Kingdom), a
CFR21Part11 compliant software with an in built audit trail,
password control and electronic signature. Each individual
involved in this process (the data manager, data entry clerk,
investigator and monitor) had a unique password-protected
database user profile.
The eCRF comprised a data entry interface which was an exact
but electronic copy of the source document (SD) and incorporated
pre-programmed checks and warnings for inconsistencies, omis-
sion and commission errors. Data were entered with single data
entry and then verified by the investigators who confirmed it with
an electronic signature. A study monitor performed several
external monitoring visits throughout the study, during which
partial source data verification (SDV) was done. In case of
inconsistencies, queries were raised in the eCRF. All findings were
discussed with the entire study team at the end of each visit, so that
corrective actions could be taken, and similar errors could be
prevented in the future. Similarly, the investigators based at
TDRC also performed SDV to resolve inconsistencies and answer
queries raised by monitors and TDRC based data managers along
with the study team on a monthly basis. In addition, a manual
review of the database was done on key variables such as safety-
and endpoint data. The system was set up on offline laptops and
had a facility for uploading and saving data at a central server at
the ITM. The data were extracted into SAS 9.2 (SAS Institute
Inc., Cary, NC, USA) for formatting and statistical analyses.
Statistical Analyses
Statistical analyses were based on the intention-to-treat princi-
ple (ITT). For continuous variables, tests of the normality of their
distributions were done. Descriptive statistics means, medians,
modes and standard deviations were determined as appropriate.
Table 1. Baseline, clinical and socio-economic characteristics of all patients.
Exposure groups
a
Cotrimoxazole (CTX Sulphadoxine-pyrimethamine (SP)
Baseline and clinical Characteristics N
b{
Mean Standard deviation N
b{
Mean Standard deviation
Age 181 24.8 5.6 165 25.1 5.6
Weight (Kg) 181 60.2 10.4 165 60.2 10.3
Height (M) 181 159.5 11.3 163 159.8 5.7
Gestational age (wks) 181 18.2. 3.0 163 19.3 4.0
Systolic pressure 181 108.7 11.1 165 106.9 10.4
Diastolic pressure 181 68.8 9.7 165 68.0 9.1
Haemoglobin (g/dl) 181 12.1 1.3 165 12.0 1.4
Gravidity 180 2.0 2.0 164 2.0 2.0
Socio-economic Characteristics N
b
% 95% CI N
b
% 95% CI
Married 154 81.5 75.2, 86.8 114 73.1 64.9, 79.4
Single 34 18.0 12.8, 24.2 41 26.3 19.4, 43.7
Able to read 176 93.1 88.5, 96.3 143 91.7 85.5, 95.0
Able to write 180 95.2 91.2, 97.8 149 95.5 90.2, 97.8
That own house of residence 73 38.6 31.7, 46.0 61 39.1 31.2, 47.0
That rent house of residence 115 60.8 53.5, 67.8 94 60.3 51.8, 67.6
Using electricity for power 70 37.0 30.1, 44.4 51 32.7 25.2, 40.4
Using wood and charcoal for power 115 60.8 53.5, 67.8 103 66.0 57.6, 73.0
Using communal taps and pumps for water 121 64.0 56.7, 70.9 104 66.7 58.3, 73.6
Using taps inside house for water 46 24.3 18.4, 31.1 44 28.2 21.2, 35.7
Using wells for water 19 10.1 6.2, 15.3 7 4.5 1.8, 9.0
a
Exposure groups represent the treatment given for prevention of malaria; Kg = Kilograms; M = meters; wks = weeks.
b
Enrolled pregnant women who gave informed consent,
{
Numbers varying due to missing values.
doi:10.1371/journal.pone.0096017.t001
Safety of Daily Cotrimoxazole in Pregnancy: A Randomized Trial
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Table 2. Overall Pregnancy outcomes by exposure group.
Characteristic
Overall population HIV negative population
HIV positive population
(CD4$200cell/ ml)
HIV positive population (CD4,200cell/
ml)
CTX (N = 166) SP (N = 145) CTX (N = 129) SP (N = 121) CTX (N = 26) SP (N = 24) CTX (N = 11)
SP (Not Applicable-
(N/A))
Pregnancy outcomes n % n % n % n % n % n % N %
--
Full-term normal deliveries* 150 90.4 130 89.6 118 91.5 108 89.2 25 96.2 22 91.7 7 63.6 - -
Preterm deliveries 6 3.6 4 2.8 5 3.9 4 3.3 0 0 0 0 1 9.1 - -
Spontaneous abortions 1 0.6 0 0 1 0.8 0 0 0 0 0 0 0 0 - -
Stillbirths 5 3.0 3 2.1 2 1.6 1 0.8 1 3.8 2 8.3 2 18.2 - -
Caesarean sections 4 2.4 6 4.1 3 2.3 6 5.0 0 0 0 0 1 9.1 - -
Neonatal deaths 0 0 2 1.4 0 0 2 1.7 0 0 0 0 0 0 - -
CTX (N = 161
1
) SP (N = 142
**
) CTX (N = 127
**
) SP (N = 120
**
) CTX (N = 25**) SP (N = 22
**
) CTX (N = 9) SP (N/A)
Infant outcome n % n % n % n % n % n % n % - -
Low birth-weight 15 9.3 9 6.3 12 9.4 7 5.8 2 8.0 2 9.1 1 9.1 - -
Normal infant 146 90.7 133 93.7 115 90.6 113 94.2 23 92.0 20 90.9 8 90.9 - -
1
Live births including one set of twins;
**Live births only;
*Full-term normal deliveries = spontaneous vaginal deliveries at gestational age $37 completed weeks; N/A-Not applicable.
doi:10.1371/journal.pone.0096017.t002
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Frequency and percentage distributions were computed for
discrete variables. Additionally, asymptotic 95% confidence
intervals (95% CI) for means of continuous variables were
determined. Clopper-Pearson exact 95% confidence intervals
were determined for percentage distributions of count variables.
Missing data were assumed ignorable and thus all statistical
analyses included only complete cases. Maternal and foetal
outcomes such as still births and neonatal deaths; spontaneous
abortions (#28 weeks gestation); preterm deliveries (,37 com-
pleted weeks); neonatal mortality (within 28 days after birth) and
birth weight, including LBW (,2,500 grams), were outcomes of
interest.
For each of these variables, the treatment arms were analyzed
per stratum (i.e. HIV status).
Results
The Trial Profile
Four hundred and twenty one pregnant women were screened,
346 met the entry criteria and one additional patient was recruited
among those whose baseline visit was at delivery (Figure 2).
Gestational age #16 weeks or $28 weeks was the most frequent
reason for non-enrolment in the study. Two hundred and eighty
(280) HIV negative women and 52 HIV positive women with CD4
count $200/ml were randomized to either CTX (140 and 27
respectively) or SP (140 and 25 respectively). The 14 HIV positive
pregnant women with CD4 count ,200/ml continued on daily
CTX according to the National guidelines for prevention of
opportunistic infections in HIV infected pregnant women [37].
Due to loss to follow up and consent withdrawal (Figure 2), 166
pregnant women in the CTX arm and 145 in SP arm were
analyzed at delivery.
Demographic and Clinical Characteristics
Baseline characteristics including age, weight, height and
gestational age were similar between treatment arms (Table 1).
Most of women were married (although about a fifth of them
declared to be single) and literate (Table 1). There was no
difference in mean blood pressure and haemoglobin at baseline
between study arms (Table 1).
Pregnancy Outcomes
Most pregnancy outcomes were spontaneous vaginal deliveries
at gestational age of $37 weeks, with over 89% of the total
deliveries between the 2 arms (Table 2). There were 10 preterm
deliveries, 6 (3.6%) in the CTX and 4 (2.8%) in the SP arm, and
few adverse pregnancy outcomes and neonatal deaths, with no
difference between the study arms (table 2). Among the 10
caesarean sections, half of them were due to cephalo-pelvic
disproportion (CPD). The rest were due to transverse lie (1), foetal
distress (1), breech presentation (1) and pre-eclampsia (2).
No congenital malformation was detected. There were 24 (8%)
LBW babies, 15 (9.3%) in the CTX group and 9 (6.3%) in SP
group (table 2). The mean birth-weight did not differ between
study arms (3.1 kg; SD = 0.5) (Table 3). Pregnancy outcomes,
including mean birth weight, did not differ by HIV status nor in
HIV infected women by CD4 count (,200 cells/ml) (Tables 2 and
3). It is important to note that subgroup analyses were intended to
be purely descriptive and were not powered for between-groups
comparisons.
General Safety Outcomes
A total of 61 AEs were observed in the 346 enrolled patients and
there was no difference between study arms (Table 4). Most AEs
were mild, i.e. 19 of the 61 (31.2%, with 9 from CTX arm and 10
from SP arm), and moderate 24 (39.3%) (12 AEs on CTX arm and
12 from the SP arm). Almost all these were either definitely
unrelated or unlikely related to the study drug. Those reported to
be severe and life threatening were 11 (18.0%) and 7 (11.5%),
respectively and almost all were reported as SAEs (Table 4).
Thirty three AEs were defined as SAEs (Table 4) and included 9
preterm deliveries and 10 caesarean sections. Two preterm
deliveries in the CTX arm were classified as possibly related to
the study drug by the attending physicians who performed the
causality assessment, while 4 were unlikely to be related. Both
patients were HIV negative and the reason for considering them as
SAEs was related to the hospitalization.
Efficacy Outcomes
There were only 2 patients on the CTX arm and 1 on the SP
arm who had malaria positive peripheral smears at the end of
follow up of the 347 pregnant women recruited. During the
screening phase no patients were declared ineligible due to
confirmed clinical malaria (with positive peripheral smear).
Among the women screened, there were only 4 out of the 421
that were found to have malaria infection.
Among the placenta blood samples collected on filter paper and
analysed by PCR, only 1 sample out of 214 was positive for
malaria. Placenta histopathology was also performed and only one
sample out of 214 had malaria pigment. This positive sample by
histopathology was the same as the placenta blood positive by
PCR analysis.
Discussion
For all HIV-infected adults, including pregnant women, with
CD4 cell counts below a given threshold, WHO recommends the
use of CTX to prevent opportunistic infections [37]. However, the
Table 3. Birth-weight profiles across the exposure groups.
CTX SP Total
Birth weight in kilograms n** Mean (SD) n** Mean (SD) n** Mean (SD)
Overall cohort 161 3.1 (60.5) 142 3.1 (60.5) 303 3.1 (60.5)
HIV negative population 127 3.1 (60.5) 120 3.2 (60.5) 247 3.1 (60.5)
HIV positive CD4.200 cells/ml 25 3.1 (6 0.5) 22 3.2 (60.5) 47 3.1 (60.5)
HIV positive CD4,200 cells/ml 9 2.9 (6 0.5) - - 9 2.9 (60.5)
**Live births only;
SD = Standard deviation.
doi:10.1371/journal.pone.0096017.t003
Safety of Daily Cotrimoxazole in Pregnancy: A Randomized Trial
PLOS ONE | www.plosone.org 7 May 2014 | Volume 9 | Issue 5 | e96017
Table 4. Common adverse events by exposure group.
ADVERSE EVENTS AND SERIOUS ADVERSE EVENTS
Exposure group
CTX SP Total
1.0 Adverse events reporting by MedDRA Primary System Organ Class: preferred term
1.1 Infections and infestations
1
Malaria 213
Respiratory Tract infection 112
Urinary Tract Infection 202
Vaginal candidosis 202
PROM/Threatened abortion 112
1.2 Nervous system and other disorders
1
Headache 202
General body pains 202
Gastro-intestinal disorders 134
Hypertension 325
General (Weakness, Fever, hypotension) 224
2.0 Serious adverse events reported and their causal relationship to study drug
Serious adverse Event Causal relationship CTX SP Total
2.1. Preterm deliveries U 439
D 00
P 20
2.1. IUFD and stillbirth Unlikely 2 2 8
Definitely unlikely 1 1
possible 2 0
2.3. Caesarean section U 2110
D 25
P 00
2.4. Spontaneous abortion Unlikely 1 0 1
Definitely unlikely 0 0
possible 0 0
2.5. Neonatal death U 002
D 01
P 01
2.6. Pre-eclampsia Unlikely 1 0 1
Definitely unlikely 0 0
possible 0 0
2.7. Septicaemia with empetigo U 001
D 01
P 00
2.8. Tendinitis Unlikely 1 0 1
Definitely unlikely 0 0
possible 0 0
Subtotal SAEs 18 15 33
TOTAL (SAEs and AEs) 36 25 61
U = Unlikely related, D = Definitely unrelated, P = Possibly related; IUFD = Intrauterine Foetal death;
1
Mainly mild/moderate severity; PROM = Premature rupture of membranes.
doi:10.1371/journal.pone.0096017.t004
Safety of Daily Cotrimoxazole in Pregnancy: A Randomized Trial
PLOS ONE | www.plosone.org 8 May 2014 | Volume 9 | Issue 5 | e96017
recommendation also states that pregnant women should not
receive SP as IPTp together with CTX prophylaxis. There is
evidence that CTX is also an effective antimalarial [33][38],
though the effect of daily CTX prophylaxis during pregnancy on
malaria and birth outcomes has not been investigated in HIV-
infected or uninfected pregnant women [33][39]. This was the
reason for carrying out in Choma, Zambia, the clinical trial
described here.
The trial was aimed at determining the protective efficacy of
daily CTX against malaria, both in HIV infected and uninfected
pregnant women. Nevertheless, after starting the trial, it became
obvious that the risk of malaria infection in the study area had
decreased substantially, to the extent that that the trial could not
answer the primary question on the protective efficacy of CTX
prophylaxis. Therefore, the trial was prematurely terminated
though a substantial number of pregnant women had already been
recruited. This provided the opportunity of investigating the safety
of CTX prophylaxis in an area of extremely low malaria
transmission.
Short term treatments with CTX (10–14 days) have been
associated with birth defects when administered during the first
trimester [40]. In this study, CTX was administered in the second
and third trimester and pregnant women were prospectively
followed up. Antifolates such as trimethoprim have been known to
cause folate deficiency during pregnancy [41] and dietary folate
deficiency during the last two trimesters of pregnancy has been
linked to preterm delivery and maternal anaemia [42–44].
However, in our study daily CTX was not associated with a
higher occurrence of adverse pregnancy outcomes and was well
tolerated, irrespective of the HIV status. Besides pregnancy related
AEs, the other most commonly reported AEs and SAEs were
infections and infestations. There was no observable difference in
relation to the severity assessment between the study arms and the
causality link patterns of the AEs on the CTX arm were
comparable to those on the SP arm. Though no birth defect
was reported, the sample size was small and probably inadequate
to capture rare events, particularly those not immediately visible
such as congenital heart disease and other internal organ related
defects.
The rate of preterm deliveries using the LMP did not differ
between the CTX (combined group of HIV negative and positive
mothers) and SP arm. Similarly, the occurrence of preterm
deliveries, stillbirths, neonatal mortality, spontaneous abortions
and low birth weight among the HIV uninfected and infected with
CD4 count $200 cells/ml women did not differ between study
arms. For both study arms and irrespective of HIV status, the
majority of the infants had birth weights consistent with full term
delivery. These results are comparable to the findings from a
cohort study conducted in the same study area [45] which
observed still birth and neonatal death rates of about 2%, and a
higher preterm delivery rate (17%) for SP than that (2.1%)
observed in this study. However, our findings are based on the
sub-analysis of a sample size not sufficiently powered to interpret
between group comparisons but rather intended to be purely
descriptive of the outcomes. Nevertheless, even if the planned
number of pregnant women had been recruited, the study may not
have been able to detect rare adverse events. It is important to
note that as our findings here do not show an increase in safety
risks associated with CTX, we do not suggest that they are
conclusive of evidence of absence as explained by Altman et al
[46].
After stopping this trial, a similar trial (COTRIMAL –
ClinTrialsGov number: NCT 01053325) was set up in an area
of high malaria transmission and data are currently being
analysed. Therefore, more information on the safety and efficacy
of CTX against malaria will be made available in due course.
Conclusions
Exposure to CTX during the latter part of pregnancy may not
be associated with increased safety risks when compared to SP.
However, considering the increasing resistance to SP, which is the
drug currently used for IPTp, and the need to prevent
opportunistic infections in HIV infected pregnant women by
administering daily CTX, there is need of exploring the possible
role CTX may have in preventing malaria in pregnant women,
both HIV infected and uninfected.
Supporting Information
Checklist S1 CONSORT Checklist.
(DOC)
Protocol S1 Trial Protocol.
(DOC)
Acknowledgments
We are grateful to the our patients for their participation in the study; the
study midwives Grace Chulu, Zodwa Hamweene, Alice Changuba, Lucia
Adams, Siphiwe Mwaba, Ida Nyanga; to the secretarial staff on the study,
Adah Biemba, Iness M. Simukonde and Esther Mashinde; laboratory staff,
Skitter Makwelele and Peter Mbewe. Thanks also to Joris Menten, Tom
Koyen, Danielle Van Melle, Celine Schurmans, Greta Gondol, Evi
Pockele and Harry Van Loen at the Institute of Tropical Medicine in
Antwerp.
Author Contributions
Conceived and designed the experiments: CM JPVG EMN UDA.
Performed the experiments: CM EMN GC JPVG UDA DM DC RM
MDC YC CVO RMR. Analyzed the data: CM DM JPVG UDA.
Contributed reagents/materials/analysis tools: DM CVO YC DC MM
JPVG UDA. Wrote the paper: CM JPVG UDA. Critical review of
manuscript: CM EMN GC RM MDC YC RMR JPVG UDA.
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