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Ali MZ, Dutt TS, MacNeill A, Walz A, Pearce C, Lam H, Philp J, Patterson J, Henao-Tamayo M, Lee RE, Liu J, Robertson GT, Hickey AJ, Meibohm B, Gonzalez-Juarrero M. A Modified BPaL Regimen for Tuberculosis Treatment replaces Linezolid with Inhaled Spectinamides. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2023.11.16.567434. [PMID: 38014249 PMCID: PMC10680823 DOI: 10.1101/2023.11.16.567434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
The Nix-TB clinical trial evaluated a new 6-month regimen containing three-oral- drugs; bedaquiline (B), pretomanid (Pa) and linezolid (L) (BPaL regimen) for treatment of tuberculosis (TB). This regimen achieved remarkable results as almost 90% of the multidrug resistant (MDR) or extensively drug resistant (XDR) TB participants were cured but many patients also developed severe adverse events (AEs). The AEs were associated with the long-term administration of the protein synthesis inhibitor linezolid. Spectinamide 1599 is also a protein synthesis inhibitor of Mycobacterium tuberculosis with an excellent safety profile but which lacks oral bioavailability. Here, we propose to replace L in the BPaL regimen with spectinamide (S) administered via inhalation and we demonstrate that inhaled spectinamide 1599, combined with BPa --BPaS regimen--has similar efficacy to that of BPaL regimen while simultaneously avoiding the L-associated AEs. The BPaL and BPaS regimens were compared in the BALB/c and C3HeB/FeJ murine chronic TB efficacy models. After 4-weeks of treatment, both regimens promoted equivalent bactericidal effect in both TB murine models. However, treatment with BPaL resulted in significant weight loss and the complete blood count suggested development of anemia. These effects were not similarly observed in mice treated with BPaS. BPaL and BPa, but no the BPaS treatment, also decreased myeloid to erythroid ratio suggesting the S in the BPaS regimen was able to recover this effect. Moreover, the BPaL also increased concentration of proinflammatory cytokines in bone marrow compared to mice receiving BPaS regimen. During therapy both regimens improved the lung lesion burden, reduced neutrophil and cytotoxic T cells counts while increased the number of B and helper and regulatory T cells. These combined data suggest that inhaled spectinamide 1599 combined with BPa is an effective TB regimen that avoids L-associated AEs. IMPORTANCE Tuberculosis (TB) is an airborne infectious disease that spreads via aerosols containing Mycobacterium tuberculosis (Mtb), the causative agent of TB. TB can be cured by administration of 3-4 drugs for 6-9 months but there are limited treatment options for patients infected with multidrug (MDR) and extensively resistant (XDR) strains of Mtb. BPaL is a new all-oral combination of drugs consisting of Bedaquiline (B), Pretomanid (Pa) and Linezolid (L). This regimen was able to cure ∼90% of MDR and XDR TB patients in clinical trials but many patients developed severe adverse events (AEs) associated to the long-term administration of linezolid. We evaluated a new regimen in which Linezolid in the BPaL regimen was replaced with inhaled spectinamide 1599. In the current study, we demonstrate that 4-weeks of treatment with inhaled spectinamide 1599 in combination with Bedaquiline and Pretomanid has equivalent efficacy to the BPaL drug combination and avoids the L-associated-AEs.
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Metcalfe JZ, Economou T, Naufal F, Kucukosmanoglu M, Kleiman R, Phillips PPJ, Conradie F. Validation of a Handheld 6-Lead Device for QT Interval Monitoring in Resource-Limited Settings. JAMA Netw Open 2024; 7:e2415576. [PMID: 38848063 PMCID: PMC11161846 DOI: 10.1001/jamanetworkopen.2024.15576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 04/08/2024] [Indexed: 06/10/2024] Open
Abstract
Importance Rifampin-resistant tuberculosis treatment regimens require electrocardiographic (ECG) monitoring due to the use of multiple QTc-prolonging agents. Formal 12-lead ECG devices represent a significant burden in resource-constrained clinics worldwide and a potential barrier to treatment scale-up in some settings. Objective To evaluate the diagnostic accuracy of a handheld 6-lead ECG device within resource-constrained clinics. Design, Setting, and Participants This diagnostic study was performed within a multicenter, pragmatic (broad eligibility criteria with no exclusions for randomized participants), phase 3 rifampin-resistant tuberculosis treatment trial (BEAT Tuberculosis [Building Evidence for Advancing New Treatment for Tuberculosis]) in South Africa. A total of 192 consecutive trial participants were assessed, and 191 were recruited for this substudy between January 21, 2021, and March 27, 2023. A low proportion (3 of 432 [0.7%]) of all screened trial participants were excluded due to a QTc interval greater than 450 milliseconds. Triplicate reference standard 12-lead ECG results were human calibrated with readers blinded to 6-lead ECG results. Main Outcomes and Measures Diagnostic accuracy, repeatability, and feasibility of a 6-lead ECG device. Results A total of 191 participants (median age, 36 years [IQR, 28-45 years]; 81 female participants [42.4%]; 91 participants [47.6%] living with HIV) with a median of 4 clinic visits (IQR, 3-4 visits) contributed 2070 and 2015 12-lead and 6-lead ECG assessments, respectively. Across 170 participants attending 489 total clinic visits where valid triplicate QTc measurements were available for both devices, the mean 12-lead QTc measurement was 418 milliseconds (range, 321-519 milliseconds), and the mean 6-lead QTc measurement was 422 milliseconds (range, 288-574 milliseconds; proportion of variation explained, R2 = 0.4; P < .001). At a QTc interval threshold of 500 milliseconds, the 6-lead ECG device had a negative predictive value of 99.8% (95% CI, 98.8%-99.9%) and a positive predictive value of 16.7% (95% CI, 0.4%-64.1%). The normal expected range of within-individual variability of the 6-lead ECG device was high (±50.2 milliseconds [coefficient of variation, 6.0%]) relative to the 12-lead ECG device (±22.0 milliseconds [coefficient of variation, 2.7%]). The mean (SD) increase in the 12-lead QTc measurement during treatment was 10.1 (25.8) milliseconds, with 0.8% of clinic visits (4 of 489) having a QTc interval of 500 milliseconds or more. Conclusions and Relevance This study suggests that simplified, handheld 6-lead ECG devices are effective triage tests that could reduce the need to perform 12-lead ECG monitoring in resource-constrained settings.
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Affiliation(s)
- John Z. Metcalfe
- Division of Pulmonary and Critical Care Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco
| | - Tamsin Economou
- Department of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Fahd Naufal
- Division of Pulmonary and Critical Care Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco
| | | | | | - Patrick P. J. Phillips
- Division of Pulmonary and Critical Care Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco
| | - Francesca Conradie
- Department of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
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Jones NT, Abadie R, Keller CL, Jones K, Ledet Iii LF, Fox JE, Klapper VG, Potharaju P, Siddaiah H, Kaye AM, Shekoohi S, Kaye AD, Varrassi G. Treatment and Toxicity Considerations in Tuberculosis: A Narrative Review. Cureus 2024; 16:e62698. [PMID: 39036175 PMCID: PMC11259524 DOI: 10.7759/cureus.62698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Accepted: 06/19/2024] [Indexed: 07/23/2024] Open
Abstract
Tuberculosis remains one of the most significant bacterial infections plaguing the medical community worldwide. The bacteria Mycobacterium tuberculosis retains the ability to manifest as an active infection, latent infection, miliary infection, or reactivation of latent infections in times of immunosuppression. Therefore, the medication regimen to treat the condition revolves around four medications, each with a mechanism that targets a different part of the bacteria. Isoniazid weakens the cell wall but produces neuropathy and hepatotoxicity as side effects. Rifampin interrupts protein synthesis but creates the opportunity for many drug-to-drug interactions and red-orange discolorations as side effects. Pyrazinamide is poorly understood, but it is believed to acidify the internal environment of the bacteria, with gout exacerbations and arthralgias as major side effects. Ethambutol also works as a bacteriostatic medication to interrupt the cell membrane; however, its mechanism is poorly understood. The most concerning side effect is optic neuropathy. The unfavorable side effect profile for tuberculosis treatment may contribute to the higher rates of medication noncompliance with therapy and needs to be addressed in the future.
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Affiliation(s)
- Nicholas T Jones
- School of Medicine, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Raegan Abadie
- School of Medicine, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Camryn L Keller
- School of Medicine, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Kamryn Jones
- School of Medicine, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Lloyd F Ledet Iii
- School of Medicine, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Julia E Fox
- School of Medicine, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Vincent G Klapper
- Department of Internal Medicine, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Pooja Potharaju
- Department of Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Harish Siddaiah
- Department of Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Adam M Kaye
- Department of Pharmacy Practice, Thomas J. Long School of Pharmacy and Health Sciences, University of the Pacific, Stockton, USA
| | - Sahar Shekoohi
- Department of Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Alan D Kaye
- Department of Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
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Ryckman TS, Schumacher SG, Lienhardt C, Sweeney S, Dowdy DW, Mirzayev F, Kendall EA. Economic implications of novel regimens for tuberculosis treatment in three high-burden countries: a modelling analysis. Lancet Glob Health 2024; 12:e995-e1004. [PMID: 38762299 PMCID: PMC11126367 DOI: 10.1016/s2214-109x(24)00088-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 01/24/2024] [Accepted: 02/21/2024] [Indexed: 05/20/2024]
Abstract
BACKGROUND With numerous trials investigating novel drug combinations to treat tuberculosis, we aimed to evaluate the extent to which future improvements in tuberculosis treatment regimens could offset potential increases in drug costs. METHODS In this modelling analysis, we used an ingredients-based approach to estimate prices at which novel regimens for rifampin-susceptible and rifampin-resistant tuberculosis treatment would be cost-neutral or cost-effective compared with standards of care in India, the Philippines, and South Africa. We modelled regimens meeting targets set in the WHO's 2023 Target Regimen Profiles (TRPs). Our decision-analytical model tracked cohorts of adults initiating rifampin-susceptible or rifampin-resistant tuberculosis treatment, simulating their health outcomes and costs accumulated during and following treatment under standard-of-care and novel regimen scenarios. Price thresholds included short-term cost-neutrality (considering only savings accrued during treatment), medium-term cost-neutrality (additionally considering savings from averted retreatments and secondary cases), and cost-effectiveness (incorporating willingness-to-pay for improved health outcomes). FINDINGS Total medium-term costs per person treated using standard-of-care regimens were estimated at US$450 (95% uncertainty interval 310-630) in India, $560 (350-860) in the Philippines, and $730 (530-1090) in South Africa for rifampin-susceptible tuberculosis (current drug costs $46) and $2100 (1590-2810) in India, $2610 (2090-3280) in the Philippines, and $3790 (3090-4630) in South Africa for rifampin-resistant tuberculosis (current drug costs $432). A rifampin-susceptible tuberculosis regimen meeting the optimal targets defined in the TRPs could be cost-neutral in the short term at drug costs of $140 (90-210) per full course in India, $230 (130-380) in the Philippines, and $280 (180-460) in South Africa. For rifampin-resistant tuberculosis, short-term cost-neutral thresholds were higher with $930 (720-1230) in India, $1180 (980-1430) in the Philippines, and $1480 (1230-1780) in South Africa. Medium-term cost-neutral prices were approximately $50-100 higher than short-term cost-neutral prices for rifampin-susceptible tuberculosis and $250-550 higher for rifampin-resistant tuberculosis. Health system cost-neutral prices that excluded patient-borne costs were 45-70% lower (rifampin-susceptible regimens) and 15-50% lower (rifampin-resistant regimens) than the cost-neutral prices that included patient costs. Cost-effective prices were substantially higher. Shorter duration was the most important driver of medium-term savings with novel regimens, followed by ease of adherence. INTERPRETATION Improved tuberculosis regimens, particularly shorter regimens or those that facilitate better adherence, could reduce overall costs, potentially offsetting higher prices. FUNDING WHO.
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Affiliation(s)
- Theresa S Ryckman
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | | | - Christian Lienhardt
- Institut de Recherche pour le Développement, Université de Montpellier, Montpellier, France; Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Sedona Sweeney
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - David W Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Emily A Kendall
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Evans D, Hirasen K, Casalme DJ, Gler MT, Gupta A, Juneja S. Cost and cost-effectiveness of BPaL regimen used in drug-resistant TB treatment in the Philippines. IJTLD OPEN 2024; 1:242-249. [PMID: 39021448 PMCID: PMC11249654 DOI: 10.5588/ijtldopen.24.0094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 04/24/2024] [Indexed: 07/20/2024]
Abstract
BACKGROUND In 2022, the WHO announced that the 6-month BPaL/M regimen should be used for drug-resistant TB (DR-TB). We estimate the patient and provider costs of BPaL compared to current standard-of-care treatment in the Philippines. METHODS Patients on BPaL under operational research, or 9-11-month standard short oral regimen (SSOR) and 18-21-month standard long oral regimen (SLOR) under programmatic conditions were interviewed using the WHO cross-sectional TB patient cost tool. Provider costs were assessed through a bottom-up and top-down costing analysis. RESULTS Total patient costs per treatment episode were lowest with BPaL (USD518.0) and increased with use of SSOR (USD825.8) and SLOR (USD1,023.0). Total provider costs per successful treatment were lowest with BPaL (USD1,994.5) and increased with SSOR (USD3,121.5) and SLOR (USD10,032.4). Compared to SSOR, BPaL treatment was cost-effective at even the lowest willingness to pay threshold. As expected, SLOR was the costliest and least effective regimen. CONCLUSIONS Costs incurred by patients on BPaL were 37% (95% CI 22-56) less than SSOR and 50% (95% CI 32-68) less than SLOR, while providers could save 36% (95% CI 21-56) to 80% (95% CI 64-93) per successful treatment, respectively. The study shows that treatment of DR-TB with BPaL was cost-saving for patients and cost-effective for the health system.
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Affiliation(s)
- D Evans
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg
| | - K Hirasen
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg
- Health Economics Division, Faculty of Health Sciences, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - D J Casalme
- TB-HIV Innovations and Research Foundation
- De La Salle Medical and Health Sciences Institute (DLSMHSI), Dasmariñas, Cavite, The Philippines
| | - M T Gler
- TB-HIV Innovations and Research Foundation
- De La Salle Medical and Health Sciences Institute (DLSMHSI), Dasmariñas, Cavite, The Philippines
| | - A Gupta
- TB Alliance, New York, NY, USA
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Stanley S, Spaulding CN, Liu Q, Chase MR, Ha DTM, Thai PVK, Lan NH, Thu DDA, Quang NL, Brown J, Hicks ND, Wang X, Marin M, Howard NC, Vickers AJ, Karpinski WM, Chao MC, Farhat MR, Caws M, Dunstan SJ, Thuong NTT, Fortune SM. Identification of bacterial determinants of tuberculosis infection and treatment outcomes: a phenogenomic analysis of clinical strains. THE LANCET. MICROBE 2024; 5:e570-e580. [PMID: 38734030 PMCID: PMC11229950 DOI: 10.1016/s2666-5247(24)00022-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 12/23/2023] [Accepted: 01/16/2024] [Indexed: 05/13/2024]
Abstract
BACKGROUND Bacterial diversity could contribute to the diversity of tuberculosis infection and treatment outcomes observed clinically, but the biological basis of this association is poorly understood. The aim of this study was to identify associations between phenogenomic variation in Mycobacterium tuberculosis and tuberculosis clinical features. METHODS We developed a high-throughput platform to define phenotype-genotype relationships in M tuberculosis clinical isolates, which we tested on a set of 158 drug-sensitive M tuberculosis strains sampled from a large tuberculosis clinical study in Ho Chi Minh City, Viet Nam. We tagged the strains with unique genetic barcodes in multiplicate, allowing us to pool the strains for in-vitro competitive fitness assays across 16 host-relevant antibiotic and metabolic conditions. Relative fitness was quantified by deep sequencing, enumerating output barcode read counts relative to input normalised values. We performed a genome-wide association study to identify phylogenetically linked and monogenic mutations associated with the in-vitro fitness phenotypes. These genetic determinants were further associated with relevant clinical outcomes (cavitary disease and treatment failure) by calculating odds ratios (ORs) with binomial logistic regressions. We also assessed the population-level transmission of strains associated with cavitary disease and treatment failure using terminal branch length analysis of the phylogenetic data. FINDINGS M tuberculosis clinical strains had diverse growth characteristics in host-like metabolic and drug conditions. These fitness phenotypes were highly heritable, and we identified monogenic and phylogenetically linked variants associated with the fitness phenotypes. These data enabled us to define two genetic features that were associated with clinical outcomes. First, mutations in Rv1339, a phosphodiesterase, which were associated with slow growth in glycerol, were further associated with treatment failure (OR 5·34, 95% CI 1·21-23·58, p=0·027). Second, we identified a phenotypically distinct slow-growing subclade of lineage 1 strains (L1.1.1.1) that was associated with cavitary disease (OR 2·49, 1·11-5·59, p=0·027) and treatment failure (OR 4·76, 1·53-14·78, p=0·0069), and which had shorter terminal branch lengths on the phylogenetic tree, suggesting increased transmission. INTERPRETATION Slow growth under various antibiotic and metabolic conditions served as in-vitro intermediate phenotypes underlying the association between M tuberculosis monogenic and phylogenetically linked mutations and outcomes such as cavitary disease, treatment failure, and transmission potential. These data suggest that M tuberculosis growth regulation is an adaptive advantage for bacterial success in human populations, at least in some circumstances. These data further suggest markers for the underlying bacterial processes that contribute to these clinical outcomes. FUNDING National Health and Medical Research Council/A∗STAR, National Institutes of Allergy and Infectious Diseases, National Institute of Child Health and Human Development, and the Wellcome Trust Fellowship in Public Health and Tropical Medicine.
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Affiliation(s)
- Sydney Stanley
- Department of Immunology and Infectious Diseases, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Caitlin N Spaulding
- Department of Immunology and Infectious Diseases, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Qingyun Liu
- Department of Immunology and Infectious Diseases, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Michael R Chase
- Department of Immunology and Infectious Diseases, Harvard T H Chan School of Public Health, Boston, MA, USA
| | | | | | | | - Do Dang Anh Thu
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Viet Nam
| | - Nguyen Le Quang
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Viet Nam
| | - Jessica Brown
- Department of Immunology and Infectious Diseases, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Nathan D Hicks
- Department of Immunology and Infectious Diseases, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Xin Wang
- Department of Immunology and Infectious Diseases, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Maximillian Marin
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA, USA; Department of Systems Biology, Harvard Medical School, Boston, MA, USA
| | - Nicole C Howard
- Department of Immunology and Infectious Diseases, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Andrew J Vickers
- Department of Immunology and Infectious Diseases, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Wiktor M Karpinski
- Department of Immunology and Infectious Diseases, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Michael C Chao
- Department of Immunology and Infectious Diseases, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Maha R Farhat
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA, USA; Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Maxine Caws
- Liverpool School of Tropical Medicine, Liverpool, UK; Birat Nepal Medical Trust, Kathmandu, Nepal
| | - Sarah J Dunstan
- Department of Infectious Diseases, University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Parkville, VIC, Australia
| | - Nguyen Thuy Thuong Thuong
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Viet Nam; Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Sarah M Fortune
- Department of Immunology and Infectious Diseases, Harvard T H Chan School of Public Health, Boston, MA, USA; Ragon Institute of MGH, MIT, and Harvard, Cambridge, MA, USA; Broad Institute of MIT and Harvard, Cambridge, MA, USA.
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Duffey M, Shafer RW, Timm J, Burrows JN, Fotouhi N, Cockett M, Leroy D. Combating antimicrobial resistance in malaria, HIV and tuberculosis. Nat Rev Drug Discov 2024; 23:461-479. [PMID: 38750260 DOI: 10.1038/s41573-024-00933-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/15/2024] [Indexed: 06/07/2024]
Abstract
Antimicrobial resistance poses a significant threat to the sustainability of effective treatments against the three most prevalent infectious diseases: malaria, human immunodeficiency virus (HIV) infection and tuberculosis. Therefore, there is an urgent need to develop novel drugs and treatment protocols capable of reducing the emergence of resistance and combating it when it does occur. In this Review, we present an overview of the status and underlying molecular mechanisms of drug resistance in these three diseases. We also discuss current strategies to address resistance during the research and development of next-generation therapies. These strategies vary depending on the infectious agent and the array of resistance mechanisms involved. Furthermore, we explore the potential for cross-fertilization of knowledge and technology among these diseases to create innovative approaches for minimizing drug resistance and advancing the discovery and development of new anti-infective treatments. In conclusion, we advocate for the implementation of well-defined strategies to effectively mitigate and manage resistance in all interventions against infectious diseases.
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Affiliation(s)
- Maëlle Duffey
- Medicines for Malaria Venture (MMV), R&D Department/Drug Discovery, ICC, Geneva, Switzerland
- The Global Antibiotic Research & Development Partnership, Geneva, Switzerland
| | - Robert W Shafer
- Department of Medicine/Infectious Diseases, Stanford University, Palo Alto, CA, USA
| | | | - Jeremy N Burrows
- Medicines for Malaria Venture (MMV), R&D Department/Drug Discovery, ICC, Geneva, Switzerland
| | | | | | - Didier Leroy
- Medicines for Malaria Venture (MMV), R&D Department/Drug Discovery, ICC, Geneva, Switzerland.
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Otto-Knapp R, Bauer T, Brinkmann F, Feiterna-Sperling C, Friesen I, Geerdes-Fenge H, Hartmann P, Häcker B, Heyckendorf J, Kuhns M, Lange C, Maurer FP, Nienhaus A, Priwitzer M, Richter E, Salzer HJF, Schoch OD, Schönfeld N, Schaberg T. Treatment of MDR, Pre-XDR, XDR, and Rifampicin-Resistant Tuberculosis or in Case of Intolerance to at Least Rifampicin in Austria, Germany, and Switzerland. Respiration 2024; 103:593-600. [PMID: 38810608 PMCID: PMC11373575 DOI: 10.1159/000539410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2024] [Accepted: 05/06/2024] [Indexed: 05/31/2024] Open
Abstract
Based on the assessment of new evidence, the World Health Organization (WHO) updated its guidelines for the treatment of drug-resistant tuberculosis (TB) in December 2022. The new recommendations and the latest study data made it necessary to update the existing guideline on the treatment of at least rifampicin-resistant TB (RR-TB) for the German-speaking countries, replacing the respective chapters of the treatment guidelines published in 2022. A shortened treatment of proven RR-TB and multidrug-resistant TB for at least 6 months using the fixed and non-modifiable drug combination of bedaquiline, pretomanid, linezolid, and moxifloxacin (BPaLM) is now also recommended for Austria, Germany, and Switzerland under certain conditions considering the existing barriers for the implementation of the new treatment regimen. For the treatment of pre-extensively drug-resistant (pre-XDR-) TB, an individualized treatment for 18 months continues to be the primary recommendation. The non-modifiable drug combination of bedaquiline, pretomanid, and linezolid (BPaL) may be used alternatively in selected pre-XDR-TB cases, provided that all prerequisites are met. The necessary requirements for using BPaLM and BPaL are presented in detail in this amendment to the consensus-based TB treatment guideline for adult patients.
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Affiliation(s)
- Ralf Otto-Knapp
- DZK German Central Committee against Tuberculosis e.V., Berlin, Germany
| | - Torsten Bauer
- DZK German Central Committee against Tuberculosis e.V., Berlin, Germany
- Lung Hospital Heckeshorn, Helios Klinikum Emil von Behring, Berlin, Germany
| | - Folke Brinkmann
- Division of Pneumology, Department of Pediatrics, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Cornelia Feiterna-Sperling
- Department of Paediatric Respiratory Medicine, Immunology and Critical Care Medicine, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Inna Friesen
- National Reference Center for Mycobacteria, Research Center Borstel, Leibniz Lung Center, Borstel, Germany
| | | | - Pia Hartmann
- Department of Clinical Infectiology, St. Vinzenz-Hospital, Cologne, Germany
| | - Brit Häcker
- DZK German Central Committee against Tuberculosis e.V., Berlin, Germany
| | - Jan Heyckendorf
- Department of Internal Medicine I, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Martin Kuhns
- National Reference Center for Mycobacteria, Research Center Borstel, Leibniz Lung Center, Borstel, Germany
| | - Christoph Lange
- Department of Clinical Infectiology, Research Center Borstel, Borstel, Germany
- DZIF German Center for Infection Research, Hamburg-Lübeck-Borstel-Riems, Hamburg, Germany
- Respiratory Medicine and International Health, Universität zu Lübeck, Lübeck, Germany
- Baylor College of Medicine and Texas Children's Hospital, Global TB Program, Houston, Texas, USA
| | - Florian P Maurer
- Department of Medical Microbiology, Virology and Hygiene, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Albert Nienhaus
- Institute for Health Services Research in Dermatology and Nursing (IVDP), Universitätsklinikum Hamburg Eppendorf (UKE), Hamburg, Germany
| | - Martin Priwitzer
- Public Health Department, Landeshauptstadt Stuttgart, Stuttgart, Germany
| | - Elvira Richter
- MVZ Labor Dr. Limbach and Colleagues GbR, Heidelberg, Germany
| | - Helmut J F Salzer
- Division of Infectious Diseases and Tropical Medicine, Department of Internal Medicine 4 - Pneumology, Kepler University Hospital, Linz, Austria
- Faculty of Medicine, Johannes Kepler Universität, Linz, Austria
- Ignaz Semmelweis Institute, Interuniversity Institute for Infection Research, Vienna, Austria
| | | | - Nicolas Schönfeld
- Lung Hospital Heckeshorn, Helios Klinikum Emil von Behring, Berlin, Germany
| | - Tom Schaberg
- DZK German Central Committee against Tuberculosis e.V., Berlin, Germany
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Zhong X, Lin A, Luo J, Li Y, Chen J, Ning C, Cao F. Clinical research progress of novel antituberculosis drugs on multidrug-resistant tuberculosis. Postgrad Med J 2024; 100:366-372. [PMID: 38200633 DOI: 10.1093/postmj/qgad140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Revised: 12/05/2023] [Accepted: 12/10/2023] [Indexed: 01/12/2024]
Abstract
Multidrug-resistant tuberculosis (MDR-TB) has become a critical challenge to public health, and the prevention and treatment of MDR-TB are of great significance in reducing the global burden of tuberculosis. How to improve the effectiveness and safety of chemotherapy for MDR-TB is a pressing issue that needs to be addressed in tuberculosis control efforts. This article provides a comprehensive review of the clinical application of new antituberculosis drugs in MDR-TB, aiming to provide a scientific basis for the prevention and treatment strategy of MDR-TB.
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Affiliation(s)
- Xinxin Zhong
- Department of Pulmonary and Critical Care Medicine, Red Cross Hospital of Yulin City, Yulin, Guangxi 537000, China
| | - Ao Lin
- Department of Cardiothoracic Surgery, Red Cross Hospital of Yulin City, Yulin, Guangxi 537000, China
| | - Jian Luo
- Department of Pulmonary and Critical Care Medicine, Red Cross Hospital of Yulin City, Yulin, Guangxi 537000, China
| | - Yeqin Li
- Department of Pulmonary and Critical Care Medicine, Red Cross Hospital of Yulin City, Yulin, Guangxi 537000, China
| | - Jinlan Chen
- Department of Pulmonary and Critical Care Medicine, Red Cross Hospital of Yulin City, Yulin, Guangxi 537000, China
| | - Chao Ning
- Department of Pulmonary and Critical Care Medicine, Red Cross Hospital of Yulin City, Yulin, Guangxi 537000, China
| | - Fu Cao
- Department of Pulmonary and Critical Care Medicine, Red Cross Hospital of Yulin City, Yulin, Guangxi 537000, China
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Arconada Alvarez SJ, Hoover AT, Greenleaf M, Ray SM, Schechter MC, Blumberg HM, Lam WA. "An app is just available at all times"-the process and outcomes of converting the Georgia Tuberculosis Reference Guide into a mobile application. PLoS One 2024; 19:e0298758. [PMID: 38753810 PMCID: PMC11098468 DOI: 10.1371/journal.pone.0298758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 01/31/2024] [Indexed: 05/18/2024] Open
Abstract
BACKGROUND The physical, paper-based Georgia TB Reference Guide has served as the clinical reference handbook on tuberculosis (TB) diagnostic and treatment guidelines for the state of Georgia in the United States. Supported by the Georgia Department of Public Health, the production of the 112-page palm-sized booklet was previously led by a team of Georgia-based TB experts at Emory University and printed every three-five years with updates to clinical management guidelines and TB consult contact information. However, the costs associated with editorial printing combined with delays in updating a static printed booklet with revised guidance hampered the utility of the tool. Considering the barriers with paper-based production and based on the beneficial use of apps to support the dissemination of clinical management guidance in other settings, the booklet was converted into a mobile application. This paper describes the process of developing a mobile app version of the Georgia TB Reference Guide in an easy-to-update and readily available format. METHODS We employed a user-centered design approach to develop the app, including a series of qualitative interviews and quantitative surveys. Participants included a mix of state officials and local TB experts. First, initial foundational interviews were conducted to conceptualize current utilization practices of both the paper and PDF versions of the tool. Second, the findings from the initial interviews were organized thematically and informed the design of the app, which was then beta tested by a round of previously unsampled TB experts as well as a re-sample from the initial interviews. Third, the designs were coded into developmental phases and beta tested among users of the current Georgia TB Reference Guide. Fourth, the app was published and downloaded by a pre-selected group of local users who provided answers to a follow-up survey after using the app for one month. Fifth, user growth, self-reported demographics, and app usage between February and July 2022 were recorded through automatic data metrics built into the app. RESULTS The paper copy Georgia TB Reference Guide usage themes included commonly referenced content, navigation paths, and desired features and content. The themes were converted into features and designs such as prioritizing commonly reviewed topics and guide customization with bookmarks and notes. Iterations of the designs were driven by feedback from TB experts and included home page featured content, improving content readability, and improving the search feature. The follow-up survey revealed a 90% preference for the app over the paper version of the guide. In the six months following the app's release, the app was downloaded by 281 individuals in the United States. The majority of downloads were in Georgia and the app also expanded organically to 19 other states. CONCLUSION The experience of converting the Georgia TB Reference Guide offers specific and effective steps to converting a medical reference guide into a mobile application tool that is readily available, easy to use, and easy to update. The organic dissemination of the app beyond the state of Georgia's borders within the first six months of app launch underscores desire among TB healthcare professionals for high-quality digital reference content outside the state. This experience offers clear outlines for replication in other contexts and demonstrates the utility of similar mobile medical reference tools.
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Affiliation(s)
- Santiago J. Arconada Alvarez
- Emory University School of Medicine, Atlanta, Georgia, United States of America
- AppHatchery, Georgia Clinical and Translational Science Alliance, Atlanta, Georgia, United States of America
| | - Alison T. Hoover
- Emory University School of Medicine, Atlanta, Georgia, United States of America
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Morgan Greenleaf
- Emory University School of Medicine, Atlanta, Georgia, United States of America
- AppHatchery, Georgia Clinical and Translational Science Alliance, Atlanta, Georgia, United States of America
| | - Susan M. Ray
- Emory University School of Medicine, Atlanta, Georgia, United States of America
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia, United States of America
- Grady Memorial Hospital, Atlanta, Georgia, United States of America
- Georgia Department of Public Health Tuberculosis Program, Atlanta, Georgia, United States of America
| | - Marcos C. Schechter
- Emory University School of Medicine, Atlanta, Georgia, United States of America
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia, United States of America
- Grady Memorial Hospital, Atlanta, Georgia, United States of America
- Georgia Department of Public Health Tuberculosis Program, Atlanta, Georgia, United States of America
| | - Henry M. Blumberg
- Emory University School of Medicine, Atlanta, Georgia, United States of America
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia, United States of America
- Grady Memorial Hospital, Atlanta, Georgia, United States of America
- Departments of Epidemiology and Global Health, Emory University Rollins School of Public Health, Atlanta, Georgia, United States of America
| | - Wilbur A. Lam
- Emory University School of Medicine, Atlanta, Georgia, United States of America
- AppHatchery, Georgia Clinical and Translational Science Alliance, Atlanta, Georgia, United States of America
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, United States of America
- Wallace H. Coulter Department of Biomedical Engineering, Emory University and Georgia Institute of Technology, Atlanta, Georgia, United States of America
- Aflac Cancer & Blood Disorders Center, Children’s Healthcare of Atlanta, Atlanta, Georgia, United States of America
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Lyons MA, Obregon-Henao A, Ramey ME, Bauman AA, Pauly S, Rossmassler K, Reid J, Karger B, Walter ND, Robertson GT. Use of multiple pharmacodynamic measures to deconstruct the Nix-TB regimen in a short-course murine model of tuberculosis. Antimicrob Agents Chemother 2024; 68:e0101023. [PMID: 38501805 PMCID: PMC11064538 DOI: 10.1128/aac.01010-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 02/23/2024] [Indexed: 03/20/2024] Open
Abstract
A major challenge for tuberculosis (TB) drug development is to prioritize promising combination regimens from a large and growing number of possibilities. This includes demonstrating individual drug contributions to the activity of higher-order combinations. A BALB/c mouse TB infection model was used to evaluate the contributions of each drug and pairwise combination in the clinically relevant Nix-TB regimen [bedaquiline-pretomanid-linezolid (BPaL)] during the first 3 weeks of treatment at human equivalent doses. The rRNA synthesis (RS) ratio, an exploratory pharmacodynamic (PD) marker of ongoing Mycobacterium tuberculosis rRNA synthesis, together with solid culture CFU counts and liquid culture time to positivity (TTP) were used as PD markers of treatment response in lung tissue; and their time-course profiles were mathematically modeled using rate equations with pharmacologically interpretable parameters. Antimicrobial interactions were quantified using Bliss independence and Isserlis formulas. Subadditive (or antagonistic) and additive effects on bacillary load, assessed by CFU and TTP, were found for bedaquiline-pretomanid and linezolid-containing pairs, respectively. In contrast, subadditive and additive effects on rRNA synthesis were found for pretomanid-linezolid and bedaquiline-containing pairs, respectively. Additionally, accurate predictions of the response to BPaL for all three PD markers were made using only the single-drug and pairwise effects together with an assumption of negligible three-way drug interactions. The results represent an experimental and PD modeling approach aimed at reducing combinatorial complexity and improving the cost-effectiveness of in vivo systems for preclinical TB regimen development.
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Affiliation(s)
- M. A. Lyons
- Department of Microbiology, Immunology and Pathology, Mycobacteria Research Laboratories, Colorado State University, Fort Collins, Colorado, USA
| | - A. Obregon-Henao
- Department of Microbiology, Immunology and Pathology, Mycobacteria Research Laboratories, Colorado State University, Fort Collins, Colorado, USA
| | - M. E. Ramey
- Department of Microbiology, Immunology and Pathology, Mycobacteria Research Laboratories, Colorado State University, Fort Collins, Colorado, USA
| | - A. A. Bauman
- Department of Microbiology, Immunology and Pathology, Mycobacteria Research Laboratories, Colorado State University, Fort Collins, Colorado, USA
| | - S. Pauly
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - K. Rossmassler
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - J. Reid
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - B. Karger
- Department of Microbiology, Immunology and Pathology, Mycobacteria Research Laboratories, Colorado State University, Fort Collins, Colorado, USA
| | - N. D. Walter
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Consortium for Applied Microbial Metrics, Aurora, Colorado, USA
- Rocky Mountain Regional VA Medical Center, Aurora, Colorado, USA
| | - G. T. Robertson
- Department of Microbiology, Immunology and Pathology, Mycobacteria Research Laboratories, Colorado State University, Fort Collins, Colorado, USA
- Consortium for Applied Microbial Metrics, Aurora, Colorado, USA
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Singh V. Tuberculosis treatment-shortening. Drug Discov Today 2024; 29:103955. [PMID: 38548262 DOI: 10.1016/j.drudis.2024.103955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Revised: 03/06/2024] [Accepted: 03/21/2024] [Indexed: 04/06/2024]
Abstract
Tuberculosis (TB) presents a significant global health concern, with ∼10 million people developing TB and 1.3 million people dying from the disease each year. The standard treatment regimen for drug-susceptible TB was between 6 and 9 months until recently, presenting a prolonged therapeutic duration compared with other infectious diseases. This is a long time for patients to adhere to the medication, consequently increasing the risk of developing drug-resistant Mycobacterium tuberculosis - a significant challenge in TB management globally. Therefore, the primary objective of contemporary TB drug development research is to shorten the treatment duration. This review comprehensively explores the strategies aimed at shortening TB treatment.
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Affiliation(s)
- Vinayak Singh
- Holistic Drug Discovery and Development (H3D) Centre, University of Cape Town, Rondebosch 7701, South Africa; South African Medical Research Council Drug Discovery and Development Research Unit, University of Cape Town, Rondebosch 7701, South Africa; Institute of Infectious Disease and Molecular Medicine (IDM), University of Cape Town, Observatory 7925, South Africa.
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Reza Yosofi A, Mesic A, Decroo T. Relapse after treatment with standardized all-oral short regimens for rifampicin-resistant tuberculosis (RR-TB): A systematic review and meta-analysis. J Clin Tuberc Other Mycobact Dis 2024; 35:100426. [PMID: 38468818 PMCID: PMC10926307 DOI: 10.1016/j.jctube.2024.100426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/13/2024] Open
Abstract
Background Treatment for rifampicin-resistant tuberculosis (RR-TB) has been shortened to 12 months or less, with duration depending on the regimen used and treatment response. Treatment shortening has the potential to increase the risk of relapse, with a new episode of RR-TB after cure or completion. The proportion of relapses after standardized all-oral short (12 months or less) RR-TB regimens has not yet been systematically reviewed, which is the main objective of this review. Methods This is a systematic review and meta-analysis. PubMed, Web of Science and Google scholar databases were systematically investigated to identify studies published between January 2018 and November 2023. Characteristics of studies, demographic data, baseline clinical condition, resistance profile, and definitions used for relapse, failure, and end-of-treatment outcomes are summarized in tables and graphs. Pooled proportions are estimated for relapse. Results A total of ten studies were included in this review and meta-analysis, representing 1792 participants. Seven studies were clinical trials and two were cohorts. Five studies investigated all-oral six-month regimens composed of bedaquiline, pretomanid, and linezolid (BPaL). The remaining studies assessed other standardized all-oral short regimens, with treatment duration between 6 and 12 months. Post-treatment follow-up (PTFU) duration ranged from 6 to 30 months. The pooled proportion estimate of relapse was 2·0% (95 % CI, 1·0-3·0%) for all and BPaL-based regimens. Treatment extension due to poor treatment response was poorly documented. Conclusion This review showed that the proportion of relapse in RR-TB patients treated with standardized short all-oral regimens was low. The low relapse proportion is similar to what was achieved for drug-susceptible Tuberculosis patients treated with first-line rifampicin-containing regimens. However, most data came from trial settings, and in some studies the post-treatment follow-up was short. Studies of large programmatic cohorts with longer post-treatment follow-up periods are needed to confirm the low relapse rate shown in the clinical trials.
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Affiliation(s)
- Ahmad Reza Yosofi
- Department of Clinical Sciences, Institute of Tropical Medicine (ITM) Antwerp, Belgium
| | - Anita Mesic
- Department of Clinical Sciences, Institute of Tropical Medicine (ITM) Antwerp, Belgium
| | - Tom Decroo
- Department of Clinical Sciences, Institute of Tropical Medicine (ITM) Antwerp, Belgium
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Mehta K, Balazki P, van der Graaf PH, Guo T, van Hasselt JGC. Predictions of Bedaquiline Central Nervous System Exposure in Patients with Tuberculosis Meningitis Using Physiologically based Pharmacokinetic Modeling. Clin Pharmacokinet 2024; 63:657-668. [PMID: 38530588 PMCID: PMC11106169 DOI: 10.1007/s40262-024-01363-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2024] [Indexed: 03/28/2024]
Abstract
BACKGROUND AND OBJECTIVE The use of bedaquiline as a treatment option for drug-resistant tuberculosis meningitis (TBM) is of interest to address the increased prevalence of resistance to first-line antibiotics. To this end, we describe a whole-body physiologically based pharmacokinetic (PBPK) model for bedaquiline to predict central nervous system (CNS) exposure. METHODS A whole-body PBPK model was developed for bedaquiline and its metabolite, M2. The model included compartments for brain and cerebrospinal fluid (CSF). Model predictions were evaluated by comparison to plasma PK time profiles following different dosing regimens and sparse CSF concentrations data from patients. Simulations were then conducted to compare CNS and lung exposures to plasma exposure at clinically relevant dosing schedules. RESULTS The model appropriately described the observed plasma and CSF bedaquiline and M2 concentrations from patients with pulmonary tuberculosis (TB). The model predicted a high impact of tissue binding on target site drug concentrations in CNS. Predicted unbound exposures within brain interstitial exposures were comparable with unbound vascular plasma and unbound lung exposures. However, unbound brain intracellular exposures were predicted to be 7% of unbound vascular plasma and unbound lung intracellular exposures. CONCLUSIONS The whole-body PBPK model for bedaquiline and M2 predicted unbound concentrations in brain to be significantly lower than the unbound concentrations in the lung at clinically relevant doses. Our findings suggest that bedaquiline may result in relatively inferior efficacy against drug-resistant TBM when compared with efficacy against drug-resistant pulmonary TB.
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Affiliation(s)
- Krina Mehta
- Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands.
| | | | - Piet H van der Graaf
- Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands
- Certara, Canterbury, UK
| | - Tingjie Guo
- Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands
| | - J G Coen van Hasselt
- Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands
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Negatu DA, Aragaw WW, Dartois V, Dick T. A pairwise approach to revitalize β-lactams for the treatment of TB. Antimicrob Agents Chemother 2024:e0003424. [PMID: 38690896 DOI: 10.1128/aac.00034-24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 04/07/2024] [Indexed: 05/03/2024] Open
Abstract
The dual β-lactam approach has been successfully applied to overcome target redundancy in nontuberculous mycobacteria. Surprisingly, this approach has not been leveraged for Mycobacterium tuberculosis, despite the high conservation of peptidoglycan synthesis. Through a comprehensive screen of oral β-lactam pairs, we have discovered that cefuroxime strongly potentiates the bactericidal activity of tebipenem and sulopenem-advanced clinical candidates-and amoxicillin, at concentrations achieved clinically. β-lactam pairs thus have the potential to reduce TB treatment duration.
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Affiliation(s)
- Dereje A Negatu
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, New Jersey, USA
- Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), Addis Ababa University, Addis Ababa, Ethiopia
| | - Wassihun Wedajo Aragaw
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, New Jersey, USA
| | - Véronique Dartois
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, New Jersey, USA
- Department of Medical Sciences, Hackensack Meridian School of Medicine, Nutley, New Jersey, USA
| | - Thomas Dick
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, New Jersey, USA
- Department of Medical Sciences, Hackensack Meridian School of Medicine, Nutley, New Jersey, USA
- Department of Microbiology and Immunology, Georgetown University, Washington, DC, USA
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Anand AB, Malur K, Sabnis GR, Mahajan AU. A case series of drug-induced torsades de pointes in patients on multidrug-resistant tuberculosis treatment: Beware the gift that conceals a blade. Heart Rhythm O2 2024; 5:324-326. [PMID: 38840757 PMCID: PMC11148482 DOI: 10.1016/j.hroo.2024.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024] Open
Affiliation(s)
- Abhinav B. Anand
- Department of Cardiology, King Edward Memorial Hospital and Seth G.S. Medical College, Mumbai, India
| | - Kruthi Malur
- Infectious Diseases, P.D. Hinduja Hospital and Medical Research Centre, Mumbai, India
| | - Girish R. Sabnis
- Department of Cardiology, King Edward Memorial Hospital and Seth G.S. Medical College, Mumbai, India
| | - Ajay U. Mahajan
- Department of Cardiology, King Edward Memorial Hospital and Seth G.S. Medical College, Mumbai, India
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Trauth J, Kantelhardt V, Usenko B, Knipper M, Kuhns M, Friesen I, Herold S. Bedaquiline, pretomanid and linezolid in multidrug-resistant and pre-extensively drug-resistant tuberculosis in refugees from Ukraine and Somalia in Germany. Eur Respir J 2024; 63:2400303. [PMID: 38636988 DOI: 10.1183/13993003.00303-2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 03/20/2024] [Indexed: 04/20/2024]
Affiliation(s)
- Janina Trauth
- Department of Medicine V - Infectious Diseases, Justus-Liebig-University Giessen, member of the German Lung Center (DZL) and the German Center for Infectious Diseases Research (DZIF), Giessen, Germany
| | - Vera Kantelhardt
- Department of Medicine V - Infectious Diseases, Justus-Liebig-University Giessen, member of the German Lung Center (DZL) and the German Center for Infectious Diseases Research (DZIF), Giessen, Germany
| | - Bohdan Usenko
- Department of Medicine V - Infectious Diseases, Justus-Liebig-University Giessen, member of the German Lung Center (DZL) and the German Center for Infectious Diseases Research (DZIF), Giessen, Germany
| | - Michael Knipper
- Global Health, Migration and Medical Humanities, University of Giessen, Giessen, Germany
| | - Martin Kuhns
- National and WHO Supranational Reference Laboratory for Tuberculosis, Research Center Borstel, Borstel, Germany
| | - Inna Friesen
- National and WHO Supranational Reference Laboratory for Tuberculosis, Research Center Borstel, Borstel, Germany
| | - Susanne Herold
- Department of Medicine V - Infectious Diseases, Justus-Liebig-University Giessen, member of the German Lung Center (DZL) and the German Center for Infectious Diseases Research (DZIF), Giessen, Germany
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Fan L, Yang M, Han YT, Ren F, Wang H, Ma JB, Zhu GH, Xiong YJ, Fan XX, Chen SX, Wu HY, Sun WW, Zhang SJ, Ke H, Cheng XH, Xu B, Chen Y, Chen C. Drug recommendation for optimization on treatment outcome for MDR/RR-TB based on a multi-center, large scale, retrospective cohort study in China. Expert Rev Anti Infect Ther 2024; 22:353-363. [PMID: 38251634 DOI: 10.1080/14787210.2024.2303032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 12/19/2023] [Indexed: 01/23/2024]
Abstract
OBJECTIVE With the change in drug-resistant pattern, MDR/RR-TB was faced with underlying changes in regimens. A multi-center, large-scale, retrospective study performed aims to provide a recommendation of drug selection on optimization of outcome for the patients. METHOD The study was conducted in six TB-specialized hospitals in China. Patients were included from 2018-2021 and followed up throughout the treatment. Using a multivarariable and propensity score-matched logistic regression analysis, we evaluated associations between outcomes and drug use, as well as clinical characteritics. RESULTS Of 3112 patients, 74.29% had treatment sucess, 14.52% lost to follow-up, 9.67% failure, and 1.51% died. Treatment success was positively associated with Bedaquiline(Bdq), Linezolid(Lzd), and Cycloserin(Cs). Capreomycin(Cm) increased the risk of unfavorable outcomes. other drugs such as Amikacin(Amk) and clofazimine had no significant effect on outcomes. If isolates were susceptible to fluoroquinolones(FQs), FQs could decrease the risk of unfavorable outcomes. CONCLUSIONS The recommendation order for the treatment of MDR/RR-TB is Bdq, Lzd, and Cs. FQs were decreased in use intensity. Injection drugs, whether Amk or Cm, are not recommended.
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Affiliation(s)
- Lin Fan
- Department of Tuberculosis, Shanghai Clinical Research Center for Tuberculosis, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai Clinical Research Center for Tuberculosis, Shanghai Key Lab of Tuberculosis, Shanghai, China
| | - Ming Yang
- Department of Tuberculosis, Public Health Clinical Center of Cheng Du, Chengdu, China
| | - Yu-Tong Han
- Department of Epidemiology, School of Public Health, Fudan University, Shanghai, China
- Key Laboratory of Health Technology Assessment, National Health Commission of the People's Republic of China (Fudan University), Shanghai, China
| | - Fei Ren
- Department of Tuberculosis, West Section of HangTian Avenue, Xi'an Chest Hospital, Xi'an, Shanxi Province, China
| | - Hua Wang
- Department of Tuberculosis, Anhui Chest Hospital, Hefei, Anhui, China
| | - Jin-Bao Ma
- Department of Tuberculosis, West Section of HangTian Avenue, Xi'an Chest Hospital, Xi'an, Shanxi Province, China
| | - Guo-Hui Zhu
- Department of Tuberculosis, Public Health Clinical Center of Cheng Du, Chengdu, China
| | - Yan-Jun Xiong
- Department of Tuberculosis, Anhui Chest Hospital, Hefei, Anhui, China
| | - Xin-Xin Fan
- Department of Tuberculosis, The Pulmonary Hospital of Fuzhou, Fu Zhou, Fujian Province, China
| | - Su-Xia Chen
- Department of Tuberculosis, The Pulmonary Hospital of Fuzhou, Fu Zhou, Fujian Province, China
| | - Hao-Yu Wu
- Department of Tuberculosis, Shenyang Tenth People's Hospital (Shenyang Chest Hospital), Shenyang, China
| | - Wen-Wen Sun
- Department of Tuberculosis, Shanghai Clinical Research Center for Tuberculosis, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai Clinical Research Center for Tuberculosis, Shanghai Key Lab of Tuberculosis, Shanghai, China
| | - Shao-Jun Zhang
- Department of Tuberculosis, Shanghai Clinical Research Center for Tuberculosis, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai Clinical Research Center for Tuberculosis, Shanghai Key Lab of Tuberculosis, Shanghai, China
| | - Hui Ke
- Department of Tuberculosis, Shanghai Clinical Research Center for Tuberculosis, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai Clinical Research Center for Tuberculosis, Shanghai Key Lab of Tuberculosis, Shanghai, China
| | - Xiao-Hong Cheng
- Department of Tuberculosis, The Pulmonary Hospital of Fuzhou, Fu Zhou, Fujian Province, China
| | - Biao Xu
- Department of Epidemiology, School of Public Health, Fudan University, Shanghai, China
- Key Laboratory of Health Technology Assessment, National Health Commission of the People's Republic of China (Fudan University), Shanghai, China
| | - Yu Chen
- Department of Tuberculosis, Shenyang Tenth People's Hospital (Shenyang Chest Hospital), Shenyang, China
| | - Chang Chen
- Department of Tuberculosis, Shanghai Clinical Research Center for Tuberculosis, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai Clinical Research Center for Tuberculosis, Shanghai Key Lab of Tuberculosis, Shanghai, China
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Yu W, Ju Y, Han X, Tian X, Ding J, Wang S, Hameed HMA, Gao Y, Li L, Li Y, Zhong N, Zhang T. Bactericidal and sterilizing activity of sudapyridine-clofazimine-TB47 combined with linezolid or pyrazinamide in a murine model of tuberculosis. Antimicrob Agents Chemother 2024:e0012424. [PMID: 38690893 DOI: 10.1128/aac.00124-24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 04/07/2024] [Indexed: 05/03/2024] Open
Abstract
As an obligate aerobe, Mycobacterium tuberculosis relies on its branched electron transport chain (ETC) for energy production through oxidative phosphorylation. Regimens targeting ETC exhibit promising potential to enhance bactericidal activity against M. tuberculosis and hold the prospect of shortening treatment duration. Our previous research demonstrated that the bacteriostatic drug candidate TB47 (T) inhibited the growth of M. tuberculosis by targeting the cytochrome bc1 complex and exhibited synergistic activity with clofazimine (C). Here, we found synergistic activities between C and sudapyridine (S), a structural analog of bedaquiline (B). S has shown similar anti-tuberculosis efficacy and may share a mechanism of action with B, which inhibits ATP synthesis and the energy metabolism of bacteria. We evaluated the efficacy of SCT in combination with linezolid (L) or pyrazinamide (Z) using a well-established murine model of tuberculosis. Compared to the BPa(pretomanid)L regimen, SCT and SCTL demonstrated similar bactericidal and sterilizing activities. There was no significant difference in activity between SCT and SCTL. In contrast, SCZ and SCTZ showed much higher activities, with none of the 15 mice experiencing relapse after 2 months of treatment with either SCZ or SCTZ. However, T did not contribute to the activity of the SCZ. Our findings emphasize the efficacy and the potential clinical significance of combination therapy with ETC inhibitors. Additionally, cross-resistance exists not only between S and B but also between S/B and C. This is supported by our findings, as spontaneous S-resistant mutants exhibited mutations in Rv0678, which are associated with cross-resistance to B and C.
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Affiliation(s)
- Wei Yu
- State Key Laboratory of Respiratory Disease, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, Guangzhou, China
- Guangdong-Hong Kong-Macao Joint Laboratory of Respiratory Infectious Diseases, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, Guangzhou, China
- China-New Zealand Joint Laboratory on Biomedicine and Health, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, Guangzhou, China
- Guangzhou National Laboratory, Guangzhou, China
| | - Yanan Ju
- State Key Laboratory of Respiratory Disease, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, Guangzhou, China
- Guangdong-Hong Kong-Macao Joint Laboratory of Respiratory Infectious Diseases, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, Guangzhou, China
- China-New Zealand Joint Laboratory on Biomedicine and Health, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, Guangzhou, China
- Division of Life Science and Medicine, School of Basic Medical Sciences, University of Science and Technology of China, Hefei, China
| | - Xingli Han
- State Key Laboratory of Respiratory Disease, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, Guangzhou, China
- Guangdong-Hong Kong-Macao Joint Laboratory of Respiratory Infectious Diseases, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, Guangzhou, China
- China-New Zealand Joint Laboratory on Biomedicine and Health, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, Guangzhou, China
- Medical School, University of Chinese Academy of Sciences, Beijing, China
| | - Xirong Tian
- State Key Laboratory of Respiratory Disease, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, Guangzhou, China
- Guangdong-Hong Kong-Macao Joint Laboratory of Respiratory Infectious Diseases, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, Guangzhou, China
- China-New Zealand Joint Laboratory on Biomedicine and Health, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, Guangzhou, China
- Medical School, University of Chinese Academy of Sciences, Beijing, China
| | - Jie Ding
- State Key Laboratory of Respiratory Disease, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, Guangzhou, China
- Guangdong-Hong Kong-Macao Joint Laboratory of Respiratory Infectious Diseases, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, Guangzhou, China
- China-New Zealand Joint Laboratory on Biomedicine and Health, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, Guangzhou, China
- Institute of Physical Science and Information Technology, Anhui University, Hefei, China
| | - Shuai Wang
- State Key Laboratory of Respiratory Disease, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, Guangzhou, China
- Guangdong-Hong Kong-Macao Joint Laboratory of Respiratory Infectious Diseases, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, Guangzhou, China
- China-New Zealand Joint Laboratory on Biomedicine and Health, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, Guangzhou, China
| | - H M Adnan Hameed
- State Key Laboratory of Respiratory Disease, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, Guangzhou, China
- Guangdong-Hong Kong-Macao Joint Laboratory of Respiratory Infectious Diseases, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, Guangzhou, China
- China-New Zealand Joint Laboratory on Biomedicine and Health, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, Guangzhou, China
| | - Yamin Gao
- State Key Laboratory of Respiratory Disease, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, Guangzhou, China
- Guangdong-Hong Kong-Macao Joint Laboratory of Respiratory Infectious Diseases, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, Guangzhou, China
- China-New Zealand Joint Laboratory on Biomedicine and Health, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, Guangzhou, China
| | - Lei Li
- Shanghai Jiatan Pharmatech Co., Ltd, a subsidiary of Guangzhou JOYO Pharma Ltd., Shanghai, China
| | - Yongguo Li
- Shanghai Jiatan Pharmatech Co., Ltd, a subsidiary of Guangzhou JOYO Pharma Ltd., Shanghai, China
| | - Nanshan Zhong
- Guangzhou National Laboratory, Guangzhou, China
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, The National Center for Respiratory Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Tianyu Zhang
- State Key Laboratory of Respiratory Disease, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, Guangzhou, China
- Guangdong-Hong Kong-Macao Joint Laboratory of Respiratory Infectious Diseases, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, Guangzhou, China
- China-New Zealand Joint Laboratory on Biomedicine and Health, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, Guangzhou, China
- Guangzhou National Laboratory, Guangzhou, China
- Division of Life Science and Medicine, School of Basic Medical Sciences, University of Science and Technology of China, Hefei, China
- Medical School, University of Chinese Academy of Sciences, Beijing, China
- Institute of Physical Science and Information Technology, Anhui University, Hefei, China
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Mesic A, Decuyper I, Ishaq S, Azizi T, Ziamal FH, Amiri S, Keus K, Thandar Pyae M, Mangal KM, Amirzada HK, Rasooli A, Aloudal MR, Daldar MZ, Decroo T. Short oral treatment regimens for rifampicin-resistant tuberculosis are safe and effective for young children: results from a field-based, non-randomised clinical trial from Kandahar, Afghanistan. Eur Respir J 2024; 63:2400436. [PMID: 38782466 PMCID: PMC11137330 DOI: 10.1183/13993003.00436-2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 04/23/2024] [Indexed: 05/25/2024]
Abstract
Clinical trials evaluating 9-month/7-drug and 6-month/4-drug all-oral treatment regimens for rifampicin-resistant (RR) tuberculosis (TB) showed that these are at least as effective and safer than previously used longer and injectable-containing regimens [1–4]. These findings have directly informed World Health Organization (WHO) guidelines for the treatment of adults with RR-TB, including those with pre-extensively drug-resistant TB (pre-XDR-TB; RR-TB with resistance to fluoroquinolones (FQ)) [5]. However, children were not included in these trials. In particular for children with pre-XDR-TB, severe TB disease or extrapulmonary TB (other than peripheral lymphadenitis), this has dire consequences. They are still treated with individualised 18-month regimens, which are not only longer, but also more toxic, less effective and with a higher pill burden than regimens for adults with a similar condition [5, 6]. Children have not equitably benefitted from improved RR-TB treatment shown to be efficacious in adults. This study from Afghanistan demonstrates short regimens are safe and effective in children, regardless of disease severity and resistance complexity. https://bit.ly/3UnWm43
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Affiliation(s)
- Anita Mesic
- Médecins Sans Frontières, Public Health Department, Amsterdam, The Netherlands
- Institute of Tropical Medicine, Department of Clinical Sciences, Antwerp, Belgium
| | - Ine Decuyper
- Institute of Tropical Medicine, Department of Clinical Sciences, Antwerp, Belgium
| | | | - Taiba Azizi
- Médecins Sans Frontières, Kandahar, Islamic Republic of Afghanistan
| | | | - Shirbaz Amiri
- Médecins Sans Frontières, Kandahar, Islamic Republic of Afghanistan
| | - Kees Keus
- Médecins Sans Frontières, Public Health Department, Amsterdam, The Netherlands
| | - Moe Thandar Pyae
- Médecins Sans Frontières, Kandahar, Islamic Republic of Afghanistan
| | - Khan Mohammed Mangal
- Ministry of Public Health, National Tuberculosis Program, Kabul, Islamic Republic of Afghanistan
| | - Hashim Khan Amirzada
- Ministry of Public Health, National Tuberculosis Program, Kabul, Islamic Republic of Afghanistan
| | - Assadullah Rasooli
- Ministry of Public Health, National Tuberculosis Program, Kabul, Islamic Republic of Afghanistan
| | | | - Mohammad Zaher Daldar
- Ministry of Public Health, National Tuberculosis Program, Kabul, Islamic Republic of Afghanistan
| | - Tom Decroo
- Institute of Tropical Medicine, Department of Clinical Sciences, Antwerp, Belgium
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James LP, Klaassen F, Sweeney S, Furin J, Franke MF, Yaesoubi R, Chesov D, Ciobanu N, Codreanu A, Crudu V, Cohen T, Menzies NA. Impact and cost-effectiveness of the 6-month BPaLM regimen for rifampicin-resistant tuberculosis in Moldova: A mathematical modeling analysis. PLoS Med 2024; 21:e1004401. [PMID: 38701084 PMCID: PMC11101189 DOI: 10.1371/journal.pmed.1004401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 05/17/2024] [Accepted: 04/10/2024] [Indexed: 05/05/2024] Open
Abstract
BACKGROUND Emerging evidence suggests that shortened, simplified treatment regimens for rifampicin-resistant tuberculosis (RR-TB) can achieve comparable end-of-treatment (EOT) outcomes to longer regimens. We compared a 6-month regimen containing bedaquiline, pretomanid, linezolid, and moxifloxacin (BPaLM) to a standard of care strategy using a 9- or 18-month regimen depending on whether fluoroquinolone resistance (FQ-R) was detected on drug susceptibility testing (DST). METHODS AND FINDINGS The primary objective was to determine whether 6 months of BPaLM is a cost-effective treatment strategy for RR-TB. We used genomic and demographic data to parameterize a mathematical model estimating long-term health outcomes measured in quality-adjusted life years (QALYs) and lifetime costs in 2022 USD ($) for each treatment strategy for patients 15 years and older diagnosed with pulmonary RR-TB in Moldova, a country with a high burden of TB drug resistance. For each individual, we simulated the natural history of TB and associated treatment outcomes, as well as the process of acquiring resistance to each of 12 anti-TB drugs. Compared to the standard of care, 6 months of BPaLM was cost-effective. This strategy was estimated to reduce lifetime costs by $3,366 (95% UI: [1,465, 5,742] p < 0.001) per individual, with a nonsignificant change in QALYs (-0.06; 95% UI: [-0.49, 0.03] p = 0.790). For those stopping moxifloxacin under the BPaLM regimen, continuing with BPaL plus clofazimine (BPaLC) provided more QALYs at lower cost than continuing with BPaL alone. Strategies based on 6 months of BPaLM had at least a 93% chance of being cost-effective, so long as BPaLC was continued in the event of stopping moxifloxacin. BPaLM for 6 months also reduced the average time spent with TB resistant to amikacin, bedaquiline, clofazimine, cycloserine, moxifloxacin, and pyrazinamide, while it increased the average time spent with TB resistant to delamanid and pretomanid. Sensitivity analyses showed 6 months of BPaLM to be cost-effective across a broad range of values for the relative effectiveness of BPaLM, and the proportion of the cohort with FQ-R. Compared to the standard of care, 6 months of BPaLM would be expected to save Moldova's national TB program budget $7.1 million (95% UI: [1.3 million, 15.4 million] p = 0.002) over the 5-year period from implementation. Our analysis did not account for all possible interactions between specific drugs with regard to treatment outcomes, resistance acquisition, or the consequences of specific types of severe adverse events, nor did we model how the intervention may affect TB transmission dynamics. CONCLUSIONS Compared to standard of care, longer regimens, the implementation of the 6-month BPaLM regimen could improve the cost-effectiveness of care for individuals diagnosed with RR-TB, particularly in settings with a high burden of drug-resistant TB. Further research may be warranted to explore the impact and cost-effectiveness of shorter RR-TB regimens across settings with varied drug-resistant TB burdens and national income levels.
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Affiliation(s)
- Lyndon P. James
- PhD Program in Health Policy, Harvard University, Cambridge, Massachusetts, United States of America
- Center for Health Decision Science, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Fayette Klaassen
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Sedona Sweeney
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Jennifer Furin
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Molly F. Franke
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Reza Yaesoubi
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut, United States of America
| | - Dumitru Chesov
- Discipline of Pneumology and Allergology, Nicolae Testemitanu State University of Medicine and Pharmacy, Chişinǎu, Moldova
- Clinical Infectious Diseases, Research Center Borstel, Borstel, Germany
| | - Nelly Ciobanu
- Chiril Draganiuc Institute of Phthisiopneumology, Chișinǎu, Moldova
| | | | - Valeriu Crudu
- Chiril Draganiuc Institute of Phthisiopneumology, Chișinǎu, Moldova
| | - Ted Cohen
- Department of Epidemiology and Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, United States of America
| | - Nicolas A. Menzies
- Center for Health Decision Science, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, United States of America
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, United States of America
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Dartois V, Dick T. Therapeutic developments for tuberculosis and nontuberculous mycobacterial lung disease. Nat Rev Drug Discov 2024; 23:381-403. [PMID: 38418662 PMCID: PMC11078618 DOI: 10.1038/s41573-024-00897-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/24/2024] [Indexed: 03/02/2024]
Abstract
Tuberculosis (TB) drug discovery and development has undergone nothing short of a revolution over the past 20 years. Successful public-private partnerships and sustained funding have delivered a much-improved understanding of mycobacterial disease biology and pharmacology and a healthy pipeline that can tolerate inevitable attrition. Preclinical and clinical development has evolved from decade-old concepts to adaptive designs that permit rapid evaluation of regimens that might greatly shorten treatment duration over the next decade. But the past 20 years also saw the rise of a fatal and difficult-to-cure lung disease caused by nontuberculous mycobacteria (NTM), for which the drug development pipeline is nearly empty. Here, we discuss the similarities and differences between TB and NTM lung diseases, compare the preclinical and clinical advances, and identify major knowledge gaps and areas of cross-fertilization. We argue that applying paradigms and networks that have proved successful for TB, from basic research to clinical trials, will help to populate the pipeline and accelerate curative regimen development for NTM disease.
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Affiliation(s)
- Véronique Dartois
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, NJ, USA.
- Department of Medical Sciences, Hackensack Meridian School of Medicine, Nutley, NJ, USA.
| | - Thomas Dick
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, NJ, USA
- Department of Medical Sciences, Hackensack Meridian School of Medicine, Nutley, NJ, USA
- Department of Microbiology and Immunology, Georgetown University, Washington, DC, USA
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Buglino JA, Ozakman Y, Hatch C, Benjamin A, Tan D, Glickman MS. Chalkophore mediated respiratory oxidase flexibility controls M. tuberculosis virulence. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.04.12.589290. [PMID: 38645185 PMCID: PMC11030325 DOI: 10.1101/2024.04.12.589290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/23/2024]
Abstract
Oxidative phosphorylation has emerged as a critical therapeutic vulnerability of M. tuberculosis, but it is unknown how M. tuberculosis and other pathogens maintain respiration during infection. M. tuberculosis synthesizes diisonitrile lipopeptide chalkophores that chelate copper tightly, but their role in host-pathogen interactions is also unknown. We demonstrate that M. tuberculosis chalkophores maintain the function of the heme-copper bcc:aa3 respiratory oxidase under copper limitation. Chalkophore deficient M. tuberculosis cannot survive, respire to oxygen, or produce ATP under copper deprivation in culture. M. tuberculosis lacking chalkophore biosynthesis is attenuated in mice, a phenotype that is severely exacerbated by loss of the CytBD alternative respiratory oxidase (encoded by cydAB), revealing a multilayered flexibility of the respiratory chain that maintains oxidative phosphorylation during infection. Taken together, these data demonstrate that chalkophores counter host inflicted copper deprivation and highlight that protection of cellular respiration is a critical virulence function in M. tuberculosis.
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Affiliation(s)
- John A. Buglino
- Immunology Program, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, New York 10065 USA
| | - Yaprak Ozakman
- Immunology Program, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, New York 10065 USA
| | - Chad Hatch
- Chemical Biology Program, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, New York 10065 USA
| | - Anna Benjamin
- Immunology Program, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, New York 10065 USA
| | - Derek Tan
- Chemical Biology Program, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, New York 10065 USA
- Tri-Institutional Research Program, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, New York 10065 USA
| | - Michael S. Glickman
- Immunology Program, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, New York 10065 USA
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Mikiashvili L, Kempker RR, Chakhaia TS, Bablishvili N, Avaliani Z, Lomtadze N, Schechter MC, Kipiani M. Impact of Prior Tuberculosis Treatment With New/Companion Drugs on Clinical Outcomes in Patients Receiving Concomitant Bedaquiline and Delamanid for Multidrug- and Rifampicin-Resistant Tuberculosis. Clin Infect Dis 2024; 78:1043-1052. [PMID: 37962987 PMCID: PMC11006115 DOI: 10.1093/cid/ciad694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Revised: 10/27/2023] [Accepted: 11/10/2023] [Indexed: 11/16/2023] Open
Abstract
BACKGROUND There are scarce data on the clinical outcomes of persons retreated with new/companion anti-tuberculosis (TB) drugs for multidrug- and rifampicin-resistant tuberculosis (MDR/RR-TB). We sought to evaluate the efficacy and safety of bedaquiline and delamanid containing regimens among patients with and without prior exposure to the new/companion drugs (bedaquiline, delamanid, linezolid, clofazimine, and fluoroquinolones). METHODS We conducted a retrospective cohort study among patients with pulmonary MDR/RR-TB in Georgia who received bedaquiline and delamanid combination as a part of a salvage regimen from November 2017 to December 2020 in a programmatic setting. RESULTS Among 106 persons with a median age of 39.5 years, 44 (41.5%) were previously treated with new/companion TB drugs. Patients with prior exposure to new/companion drugs had higher rates of baseline resistance compared to those without exposure to new/companion TB drugs (bedaquiline 15.2% vs 1.8%, linezolid 22.2% vs 16.7%). Sputum culture conversion rates among patients exposed and not exposed to new/companion drugs were 65.9% vs 98.0%, respectively (P < .001). Among patients with and without prior new/companion TB drug use, favorable outcome rates were 41.0% and 82.3%, respectively (P < .001). Treatment adherence in 32 (30.2%) patients was ≤80%. Five of 21 patients (23.8%) who had a baseline and repeat susceptibility test had acquired bedaquiline resistance. QTC/F prolongation (>500 ms) was rare (2.8%). CONCLUSIONS Prior exposure to new/companion TB drugs was associated with poor clinical outcomes and acquired drug resistance. Tailoring the TB regimen to each patient's drug susceptibility test results and burden of disease and enhancing adherence support may improve outcomes.
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Affiliation(s)
- L Mikiashvili
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - R R Kempker
- Department of Medicine, Division of Infectious Disease, Emory University School of Medicine, Atlanta, Georgia, USA
| | - T S Chakhaia
- School of Public Health, Georgia State University, Atlanta, Georgia, USA
| | - N Bablishvili
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Z Avaliani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - N Lomtadze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
- Department of Medicine, David Tvildiani Medical University, Tbilisi, Georgia
- Department of Medicine, The University of Georgia, Tbilisi, Georgia
| | - M C Schechter
- Department of Medicine, Division of Infectious Disease, Emory University School of Medicine, Atlanta, Georgia, USA
| | - M Kipiani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
- Department of Medicine, David Tvildiani Medical University, Tbilisi, Georgia
- Department of Medicine, The University of Georgia, Tbilisi, Georgia
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Niculescu AG, Mük GR, Avram S, Vlad IM, Limban C, Nuta D, Grumezescu AM, Chifiriuc MC. Novel strategies based on natural products and synthetic derivatives to overcome resistance in Mycobacterium tuberculosis. Eur J Med Chem 2024; 269:116268. [PMID: 38460268 DOI: 10.1016/j.ejmech.2024.116268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 02/09/2024] [Accepted: 02/18/2024] [Indexed: 03/11/2024]
Abstract
One of the biggest health challenges of today's world is the emergence of antimicrobial resistance (AMR), which renders conventional therapeutics insufficient and urgently demands the generation of novel antimicrobial strategies. Mycobacterium tuberculosis (M. tuberculosis), the pathogen causing tuberculosis (TB), is among the most successful bacteria producing drug-resistant infections. The versatility of M. tuberculosis allows it to evade traditional anti-TB agents through various acquired and intrinsic mechanisms, rendering TB among the leading causes of infectious disease-related mortality. In this context, researchers worldwide focused on establishing novel approaches to address drug resistance in M. tuberculosis, developing diverse alternative treatments with varying effectiveness and in different testing phases. Overviewing the current progress, this paper aims to briefly present the mechanisms involved in M. tuberculosis drug-resistance, further reviewing in more detail the under-development antibiotics, nanotechnological approaches, and natural therapeutic solutions that promise to overcome current treatment limitations.
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Affiliation(s)
- Adelina-Gabriela Niculescu
- Research Institute of the University of Bucharest, University of Bucharest, 90 Panduri Road, Bucharest, Romania; Department of Science and Engineering of Oxide Materials and Nanomaterials, National University of Science and Technology Politehnica Bucharest, 011061, Bucharest, Romania.
| | - Georgiana Ramona Mük
- Faculty of Biology, University of Bucharest, Splaiul Independenței 91-95, Bucharest, R-050095, Romania; St. Stephen's Pneumoftiziology Hospital, Șoseaua Ștefan cel Mare 11, Bucharest, 020122, Romania.
| | - Speranta Avram
- Faculty of Biology, University of Bucharest, Splaiul Independenței 91-95, Bucharest, R-050095, Romania.
| | - Ilinca Margareta Vlad
- Department of Pharmaceutical Chemistry, Faculty of Pharmacy, "Carol Davila" University of Medicine and Pharmacy, 6 Traian Vuia, 020956, Bucharest, Romania.
| | - Carmen Limban
- Department of Pharmaceutical Chemistry, Faculty of Pharmacy, "Carol Davila" University of Medicine and Pharmacy, 6 Traian Vuia, 020956, Bucharest, Romania.
| | - Diana Nuta
- Department of Pharmaceutical Chemistry, Faculty of Pharmacy, "Carol Davila" University of Medicine and Pharmacy, 6 Traian Vuia, 020956, Bucharest, Romania.
| | - Alexandru Mihai Grumezescu
- Research Institute of the University of Bucharest, University of Bucharest, 90 Panduri Road, Bucharest, Romania; Department of Science and Engineering of Oxide Materials and Nanomaterials, National University of Science and Technology Politehnica Bucharest, 011061, Bucharest, Romania.
| | - Mariana-Carmen Chifiriuc
- Research Institute of the University of Bucharest, University of Bucharest, 90 Panduri Road, Bucharest, Romania; Faculty of Biology, University of Bucharest, Splaiul Independenței 91-95, Bucharest, R-050095, Romania.
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Li SY, Tyagi S, Soni H, Betoudji F, Converse PJ, Mdluli K, Upton AM, Fotouhi N, Barros-Aguirre D, Ballell L, Jimenez-Navarro E, Nuermberger EL. Bactericidal and sterilizing activity of novel regimens combining bedaquiline or TBAJ-587 with GSK2556286 and TBA-7371 in a mouse model of tuberculosis. Antimicrob Agents Chemother 2024; 68:e0156223. [PMID: 38376228 PMCID: PMC10989019 DOI: 10.1128/aac.01562-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 01/27/2024] [Indexed: 02/21/2024] Open
Abstract
The combination of bedaquiline, pretomanid, and linezolid (BPaL) has become a preferred regimen for treating multidrug- and extensively drug-resistant tuberculosis (TB). However, treatment-limiting toxicities of linezolid and reports of emerging bedaquiline and pretomanid resistance necessitate efforts to develop new short-course oral regimens. We recently found that the addition of GSK2556286 increases the bactericidal and sterilizing activity of BPa-containing regimens in a well-established BALB/c mouse model of tuberculosis. Here, we used this model to evaluate the potential of new regimens combining bedaquiline or the more potent diarylquinoline TBAJ-587 with GSK2556286 and the DprE1 inhibitor TBA-7371, all of which are currently in early-phase clinical trials. We found the combination of bedaquiline, GSK2556286, and TBA-7371 to be more active than the first-line regimen and nearly as effective as BPaL in terms of bactericidal and sterilizing activity. In addition, we found that GSK2556286 and TBA-7371 were as effective as pretomanid and the novel oxazolidinone TBI-223 when either drug pair was combined with TBAJ-587 and that the addition of GSK2556286 increased the bactericidal activity of the TBAJ-587, pretomanid, and TBI-223 combination. We conclude that GSK2556286 and TBA-7371 have the potential to replace pretomanid, an oxazolidinone, or both components, in combination with bedaquiline or TBAJ-587.
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Affiliation(s)
- Si-Yang Li
- Center for Tuberculosis Research, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Sandeep Tyagi
- Center for Tuberculosis Research, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Heena Soni
- Center for Tuberculosis Research, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Fabrice Betoudji
- Center for Tuberculosis Research, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Paul J. Converse
- Center for Tuberculosis Research, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Khisimuzi Mdluli
- TB Alliance: Global Alliance for Tuberculosis Drug Development, New York, New York, USA
| | - Anna M. Upton
- TB Alliance: Global Alliance for Tuberculosis Drug Development, New York, New York, USA
| | - Nader Fotouhi
- TB Alliance: Global Alliance for Tuberculosis Drug Development, New York, New York, USA
| | - David Barros-Aguirre
- Global Health Medicines R&D, GlaxoSmithKline R&D Limited, Tres Cantos, Madrid, Spain
| | - Lluís Ballell
- Global Health Medicines R&D, GlaxoSmithKline R&D Limited, Tres Cantos, Madrid, Spain
| | - Elena Jimenez-Navarro
- Global Health Medicines R&D, GlaxoSmithKline R&D Limited, Tres Cantos, Madrid, Spain
| | - Eric L. Nuermberger
- Center for Tuberculosis Research, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Maure A, Lawarée E, Fiorentino F, Pawlik A, Gona S, Giraud-Gatineau A, Eldridge MJG, Danckaert A, Hardy D, Frigui W, Keck C, Gutierrez C, Neyrolles O, Aulner N, Mai A, Hamon M, Barreiro LB, Brodin P, Brosch R, Rotili D, Tailleux L. A host-directed oxadiazole compound potentiates antituberculosis treatment via zinc poisoning in human macrophages and in a mouse model of infection. PLoS Biol 2024; 22:e3002259. [PMID: 38683873 PMCID: PMC11081512 DOI: 10.1371/journal.pbio.3002259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 05/09/2024] [Accepted: 03/13/2024] [Indexed: 05/02/2024] Open
Abstract
Antituberculosis drugs, mostly developed over 60 years ago, combined with a poorly effective vaccine, have failed to eradicate tuberculosis. More worryingly, multiresistant strains of Mycobacterium tuberculosis (MTB) are constantly emerging. Innovative strategies are thus urgently needed to improve tuberculosis treatment. Recently, host-directed therapy has emerged as a promising strategy to be used in adjunct with existing or future antibiotics, by improving innate immunity or limiting immunopathology. Here, using high-content imaging, we identified novel 1,2,4-oxadiazole-based compounds, which allow human macrophages to control MTB replication. Genome-wide gene expression analysis revealed that these molecules induced zinc remobilization inside cells, resulting in bacterial zinc intoxication. More importantly, we also demonstrated that, upon treatment with these novel compounds, MTB became even more sensitive to antituberculosis drugs, in vitro and in vivo, in a mouse model of tuberculosis. Manipulation of heavy metal homeostasis holds thus great promise to be exploited to develop host-directed therapeutic interventions.
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Affiliation(s)
- Alexandra Maure
- Institut Pasteur, Université Paris Cité, CNRS UMR 6047, Unit for Integrated Mycobacterial Pathogenomics, Paris, France
| | - Emeline Lawarée
- Institut Pasteur, Université Paris Cité, CNRS UMR 6047, Unit for Integrated Mycobacterial Pathogenomics, Paris, France
| | - Francesco Fiorentino
- Department of Drug Chemistry and Technologies, Sapienza University of Rome, Rome, Italy
| | - Alexandre Pawlik
- Institut Pasteur, Université Paris Cité, CNRS UMR 6047, Unit for Integrated Mycobacterial Pathogenomics, Paris, France
| | - Saideep Gona
- Department of Genetic Medicine, University of Chicago, Chicago, Illinois, United States of America
| | | | | | - Anne Danckaert
- Institut Pasteur, Université Paris Cité, UTechS BioImaging-C2RT, Paris, France
| | - David Hardy
- Institut Pasteur, Université Paris Cité, Histopathology Platform, Paris, France
| | - Wafa Frigui
- Institut Pasteur, Université Paris Cité, CNRS UMR 6047, Unit for Integrated Mycobacterial Pathogenomics, Paris, France
| | - Camille Keck
- Institut Pasteur, Université Paris Cité, CNRS UMR 6047, Unit for Integrated Mycobacterial Pathogenomics, Paris, France
| | - Claude Gutierrez
- Institut de Pharmacologie et de Biologie Structurale, IPBS, Université de Toulouse, CNRS, UPS, Toulouse, France
| | - Olivier Neyrolles
- Institut de Pharmacologie et de Biologie Structurale, IPBS, Université de Toulouse, CNRS, UPS, Toulouse, France
| | - Nathalie Aulner
- Institut Pasteur, Université Paris Cité, UTechS BioImaging-C2RT, Paris, France
| | - Antonello Mai
- Department of Drug Chemistry and Technologies, Sapienza University of Rome, Rome, Italy
- Pasteur Institute, Cenci-bolognetti Foundation, Sapienza University of Rome, Rome, Italy
| | - Mélanie Hamon
- Institut Pasteur, Université Paris Cité, Chromatine et Infection unit, Paris, France
| | - Luis B. Barreiro
- Department of Genetic Medicine, University of Chicago, Chicago, Illinois, United States of America
| | - Priscille Brodin
- Université de Lille, CNRS, INSERM, CHU Lille, Institut Pasteur de Lille, U1019 - UMR 9017 - CIIL - Center for Infection and Immunity of Lille, Lille, France
| | - Roland Brosch
- Institut Pasteur, Université Paris Cité, CNRS UMR 6047, Unit for Integrated Mycobacterial Pathogenomics, Paris, France
| | - Dante Rotili
- Department of Drug Chemistry and Technologies, Sapienza University of Rome, Rome, Italy
| | - Ludovic Tailleux
- Institut Pasteur, Université Paris Cité, CNRS UMR 6047, Unit for Integrated Mycobacterial Pathogenomics, Paris, France
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Budak M, Via LE, Weiner DM, Barry CE, Nanda P, Michael G, Mdluli K, Kirschner D. A systematic efficacy analysis of tuberculosis treatment with BPaL-containing regimens using a multiscale modeling approach. CPT Pharmacometrics Syst Pharmacol 2024; 13:673-685. [PMID: 38404200 PMCID: PMC11015080 DOI: 10.1002/psp4.13117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 12/22/2023] [Accepted: 02/07/2024] [Indexed: 02/27/2024] Open
Abstract
Tuberculosis (TB) is a life-threatening infectious disease. The standard treatment is up to 90% effective; however, it requires the administration of four antibiotics (isoniazid, rifampicin, pyrazinamide, and ethambutol [HRZE]) over long time periods. This harsh treatment process causes adherence issues for patients because of the long treatment times and a myriad of adverse effects. Therefore, the World Health Organization has focused goals of shortening standard treatment regimens for TB in their End TB Strategy efforts, which aim to reduce TB-related deaths by 95% by 2035. For this purpose, many novel and promising combination antibiotics are being explored that have recently been discovered, such as the bedaquiline, pretomanid, and linezolid (BPaL) regimen. As a result, testing the number of possible combinations with all possible novel regimens is beyond the limit of experimental resources. In this study, we present a unique framework that uses a primate granuloma modeling approach to screen many combination regimens that are currently under clinical and experimental exploration and assesses their efficacies to inform future studies. We tested well-studied regimens such as HRZE and BPaL to evaluate the validity and accuracy of our framework. We also simulated additional promising combination regimens that have not been sufficiently studied clinically or experimentally, and we provide a pipeline for regimen ranking based on their efficacies in granulomas. Furthermore, we showed a correlation between simulation rankings and new marmoset data rankings, providing evidence for the credibility of our framework. This framework can be adapted to any TB regimen and can rank any number of single or combination regimens.
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Affiliation(s)
- Maral Budak
- Department of Microbiology and ImmunologyUniversity of Michigan Medical SchoolAnn ArborMichiganUSA
| | - Laura E. Via
- Tuberculosis Research Section, Laboratory of Clinical Immunology and MicrobiologyNational Institute of Allergy and Infectious Diseases (NIAID)BethesdaMarylandUSA
- Tuberculosis Imaging Program, Division of Intramural ResearchNIAIDBethesdaMarylandUSA
| | - Danielle M. Weiner
- Tuberculosis Research Section, Laboratory of Clinical Immunology and MicrobiologyNational Institute of Allergy and Infectious Diseases (NIAID)BethesdaMarylandUSA
- Tuberculosis Imaging Program, Division of Intramural ResearchNIAIDBethesdaMarylandUSA
| | - Clifton E. Barry
- Tuberculosis Research Section, Laboratory of Clinical Immunology and MicrobiologyNational Institute of Allergy and Infectious Diseases (NIAID)BethesdaMarylandUSA
- Centre for Infectious Diseases Research in AfricaInstitute of Infectious Disease and Molecular MedicineObservatoryRepublic of South Africa
- Department of MedicineUniversity of Cape TownObservatoryRepublic of South Africa
| | - Pariksheet Nanda
- Department of Microbiology and ImmunologyUniversity of Michigan Medical SchoolAnn ArborMichiganUSA
| | - Gabrielle Michael
- Molecular, Cellular and Developmental BiologyUniversity of MichiganAnn ArborMichiganUSA
| | - Khisimuzi Mdluli
- Bill & Melinda Gates Medical Research InstituteCambridgeMassachusettsUSA
| | - Denise Kirschner
- Department of Microbiology and ImmunologyUniversity of Michigan Medical SchoolAnn ArborMichiganUSA
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Gao J, Gao M, Du J, Pang Y, Mao G, Lounis N, Bakare N, Jiang Y, Zhan Y, Liu Y, Li L. A pragmatic randomized controlled trial to evaluate the efficacy and safety of an oral short-course regimen including bedaquiline for the treatment of patients with multidrug-resistant tuberculosis in China: study protocol for PROSPECT. Trials 2024; 25:227. [PMID: 38561815 PMCID: PMC10986125 DOI: 10.1186/s13063-024-07946-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Accepted: 01/18/2024] [Indexed: 04/04/2024] Open
Abstract
INTRODUCTION The lack of safe, effective, and simple short-course regimens (SCRs) for multidrug-resistant/rifampicin-resistant tuberculosis (MDR/RR-TB) treatment has significantly impeded TB control efforts in China. METHODS This phase 4, randomized, open-label, controlled, non-inferiority trial aims to assess the efficacy and safety of a 9-month all-oral SCR containing bedaquiline (BDQ) versus an all-oral SCR without BDQ for adult MDR-TB patients (18-65 years) in China. The trial design mainly mirrors that of the "Evaluation of a Standardized Treatment Regimen of Anti-Tuberculosis Drugs for Patients with MDR-TB" (STREAM) stage 2 study, while also incorporating programmatic data from South Africa and the 2019 consensus recommendations of Chinese MDR/RR-TB treatment experts. Experimental arm participants will receive a modified STREAM regimen C that replaces three group C drugs, ethambutol (EMB), pyrazinamide (PZA), and prothionamide (PTO), with two group B drugs, linezolid (LZD) and cycloserine (CS), while omitting high-dose isoniazid (INH) for confirmed INH-resistant cases. BDQ duration will be extended from 6 to 9 months for participants with Mycobacterium tuberculosis-positive sputum cultures at week 16. The control arm will receive a modified STREAM regimen B without high-dose INH and injectable kanamycin (KM) that incorporates experimental arm LZD and CS dosages, treatment durations, and administration methods. LZD (600 mg) will be given daily for ≥ 24 weeks as guided by observed benefits and harm. The primary outcome measures the proportion of participants with favorable treatment outcomes at treatment completion (week 40), while the same measurement taken at 48 weeks post-treatment completion is the secondary outcome. Assuming an α = 0.025 significance level (one-sided test), 80% power, 15% non-inferiority margin, and 10% lost to follow-up rate, each arm requires 106 participants (212 total) to demonstrate non-inferiority. DISCUSSION PROSPECT aims to assess the safety and efficacy of a BDQ-containing SCR MDR-TB treatment at seventeen sites across China, while also providing high-quality data to guide SCRs administration under the direction of the China National Tuberculosis Program for MDR-TB. Additionally, PROSPECT will explore the potential benefits of extending the administration of the 9-month BDQ-containing SCR for participants without sputum conversion by week 16. TRIAL REGISTRATION ClinicalTrials.gov NCT05306223. Prospectively registered on 16 March 2022 at https://clinicaltrials.gov/ct2/show/NCT05306223?term=NCT05306223&draw=1&rank=1 {2}.
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Affiliation(s)
- Jingtao Gao
- Clinical Center On TB, Beijing Chest Hospital, Capital Medical University/Beijing Tuberculosis & Thoracic Tumor Research Institute, Beijing, People's Republic of China
| | - Mengqiu Gao
- Department of Tuberculosis, Beijing Chest Hospital, Capital Medical University/Beijing Tuberculosis and Thoracic Tumor Research Institute, Beijing, 101149, People's Republic of China
| | - Jian Du
- Clinical Center On TB, Beijing Chest Hospital, Capital Medical University/Beijing Tuberculosis & Thoracic Tumor Research Institute, Beijing, People's Republic of China
| | - Yu Pang
- Department of Bacteriology and Immunology, Beijing Chest Hospital, Capital Medical University/Beijing Tuberculosis & Thoracic Tumor Research Institute, Beijing, 101149, People's Republic of China
| | - Gary Mao
- Janssen Global Public Health, Janssen Research & Development, Titusville, NJ, USA
| | | | - Nyasha Bakare
- Janssen Global Public Health, Janssen Research & Development, Titusville, NJ, USA
| | - Yanxin Jiang
- Janssen China Research & Development, Shanghai, People's Republic of China
| | - Ying Zhan
- Innovation Alliance On Tuberculosis Diagnosis and Treatment (Beijing) [IATB], Beijing, 101100, People's Republic of China
| | - Yuhong Liu
- Clinical Center On TB, Beijing Chest Hospital, Capital Medical University/Beijing Tuberculosis & Thoracic Tumor Research Institute, Beijing, People's Republic of China.
| | - Liang Li
- Clinical Center On TB, Beijing Chest Hospital, Capital Medical University/Beijing Tuberculosis & Thoracic Tumor Research Institute, Beijing, People's Republic of China.
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80
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Patil SM, Diorio AM, Kommarajula P, Kunda NK. A quality-by-design strategic approach for the development of bedaquiline-pretomanid nanoparticles as inhalable dry powders for TB treatment. Int J Pharm 2024; 653:123920. [PMID: 38387819 DOI: 10.1016/j.ijpharm.2024.123920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 01/30/2024] [Accepted: 02/18/2024] [Indexed: 02/24/2024]
Abstract
Tuberculosis (TB) is caused by Mycobacterium tuberculosis (M.tb) and is the second leading cause of death from an infectious disease globally. The disease mainly affects the lungs and forms granulomatous lesions that encapsulate the bacteria, making treating TB challenging. The current treatment includes oral administration of bedaquiline (BDQ) and pretomanid (PTD); however, patients suffer from severe systemic toxicities, low lung drug concentration, and non-adherence. In this study, we developed BDQ-PTD loaded nanoparticles as inhalable dry powders for pulmonary TB treatment using a Quality-by-Design (QbD) approach. The BDQ-PTD combination showed an additive/synergistic effect for M.tb inhibition in vitro, and the optimized drug ratio (1:4) was successfully loaded into polymeric nanoparticles (PLGA NPs). The QbD approach was implemented by identifying the quality target product profile (QTPPs), critical quality attributes (CQAs), and critical process parameters (CPPs) to develop efficient design space for dry powder preparation using spray drying. The three-factorial and three-level Box-Behnken Design was used to assess the effect of process parameters (CPPs) on product quality (CQAs). The Design of Experiments (DoE) analysis showed different regression models for product quality responses and helped optimize process parameters to meet QTPPs. The optimized dry powder showed excellent yield (72 ± 2 % w/w), high drug (BDQ-PTD) loading, low moisture content (<1% w/w), and spherical morphology. Further, aerosolization performance revealed the suitability of powder for deposition in the respiratory airways of the lungs (MMAD 2.4 µm and FPF > 75 %). In conclusion, the QbD approach helped optimize process parameters and develop dry powder with a suitable quality profile for inhalation delivery in TB patients.
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Affiliation(s)
- Suyash M Patil
- Department of Pharmaceutical Sciences, College of Pharmacy and Health Sciences, St. John's University, Jamaica, NY 11439, USA
| | - Alec M Diorio
- Department of Pharmaceutical Sciences, College of Pharmacy and Health Sciences, St. John's University, Jamaica, NY 11439, USA
| | - Parasharamulu Kommarajula
- Department of Pharmaceutical Sciences, College of Pharmacy and Health Sciences, St. John's University, Jamaica, NY 11439, USA
| | - Nitesh K Kunda
- Department of Pharmaceutical Sciences, College of Pharmacy and Health Sciences, St. John's University, Jamaica, NY 11439, USA.
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81
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Dheda K, Mirzayev F, Cirillo DM, Udwadia Z, Dooley KE, Chang KC, Omar SV, Reuter A, Perumal T, Horsburgh CR, Murray M, Lange C. Multidrug-resistant tuberculosis. Nat Rev Dis Primers 2024; 10:22. [PMID: 38523140 DOI: 10.1038/s41572-024-00504-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/16/2024] [Indexed: 03/26/2024]
Abstract
Tuberculosis (TB) remains the foremost cause of death by an infectious disease globally. Multidrug-resistant or rifampicin-resistant TB (MDR/RR-TB; resistance to rifampicin and isoniazid, or rifampicin alone) is a burgeoning public health challenge in several parts of the world, and especially Eastern Europe, Russia, Asia and sub-Saharan Africa. Pre-extensively drug-resistant TB (pre-XDR-TB) refers to MDR/RR-TB that is also resistant to a fluoroquinolone, and extensively drug-resistant TB (XDR-TB) isolates are additionally resistant to other key drugs such as bedaquiline and/or linezolid. Collectively, these subgroups are referred to as drug-resistant TB (DR-TB). All forms of DR-TB can be as transmissible as rifampicin-susceptible TB; however, it is more difficult to diagnose, is associated with higher mortality and morbidity, and higher rates of post-TB lung damage. The various forms of DR-TB often consume >50% of national TB budgets despite comprising <5-10% of the total TB case-load. The past decade has seen a dramatic change in the DR-TB treatment landscape with the introduction of new diagnostics and therapeutic agents. However, there is limited guidance on understanding and managing various aspects of this complex entity, including the pathogenesis, transmission, diagnosis, management and prevention of MDR-TB and XDR-TB, especially at the primary care physician level.
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Affiliation(s)
- Keertan Dheda
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and UCT Lung Institute & South African MRC/UCT Centre for the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa.
- Faculty of Infectious and Tropical Diseases, Department of Immunology and Infection, London School of Hygiene and Tropical Medicine, London, UK.
| | - Fuad Mirzayev
- Global Tuberculosis Programme, WHO, Geneva, Switzerland
| | - Daniela Maria Cirillo
- Emerging Bacterial Pathogens Unit, IRCCS San Raffaele Scientific Institute Milan, Milan, Italy
| | - Zarir Udwadia
- Department of Pulmonology, Hinduja Hospital & Research Center, Mumbai, India
| | - Kelly E Dooley
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kwok-Chiu Chang
- Tuberculosis and Chest Service, Centre for Health Protection, Department of Health, Hong Kong, SAR, China
| | - Shaheed Vally Omar
- Centre for Tuberculosis, National & WHO Supranational TB Reference Laboratory, National Institute for Communicable Diseases, a division of the National Health Laboratory Service, Johannesburg, South Africa
- Department of Molecular Medicine & Haematology, School of Pathology, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Anja Reuter
- Sentinel Project on Paediatric Drug-Resistant Tuberculosis, Boston, MA, USA
| | - Tahlia Perumal
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and UCT Lung Institute & South African MRC/UCT Centre for the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa
- Faculty of Infectious and Tropical Diseases, Department of Immunology and Infection, London School of Hygiene and Tropical Medicine, London, UK
| | - C Robert Horsburgh
- Department of Epidemiology, Boston University Schools of Public Health and Medicine, Boston, MA, USA
| | - Megan Murray
- Department of Epidemiology, Harvard Medical School, Boston, MA, USA
| | - Christoph Lange
- Division of Clinical Infectious Diseases, Research Center Borstel, Borstel, Germany
- German Center for Infection Research (DZIF), TTU-TB, Borstel, Germany
- Respiratory Medicine & International Health, University of Lübeck, Lübeck, Germany
- Department of Paediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
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82
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Hasan T, Medcalf E, Nyang'wa BT, Egizi E, Berry C, Dodd M, Foraida S, Gegia M, Li M, Mirzayev F, Morgan H, Motta I, Nguyen L, Schumacher S, Schlub T, Fox G. The Safety and Tolerability of Linezolid in Novel Short-Course Regimens Containing Bedaquiline, Pretomanid, and Linezolid to Treat Rifampicin-Resistant Tuberculosis: An Individual Patient Data Meta-analysis. Clin Infect Dis 2024; 78:730-741. [PMID: 37874021 PMCID: PMC10954324 DOI: 10.1093/cid/ciad653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Revised: 09/28/2023] [Accepted: 10/20/2023] [Indexed: 10/25/2023] Open
Abstract
BACKGROUND Effectiveness, safety, tolerability, and adherence are critical considerations in shifting to shorter tuberculosis (TB) regimens. Novel 6-month oral regimens that include bedaquiline (B), pretomanid (Pa), and linezolid (L), with or without a fourth drug, have been shown to be as or more effective than the established longer regimens for the treatment of multidrug-resistant/rifampicin-resistant TB (MDR/RR-TB). We aimed to evaluate the safety and tolerability of linezolid in BPaL-containing regimens for the treatment of MDR/RR-TB among recently completed clinical trials. METHODS A review and meta-analysis was undertaken including published and unpublished data from clinical trials, conducted between 2010 and 2021, that evaluated regimens containing BPaL for the treatment of MDR/RR-TB. Individual patient data were obtained. For each BPaL-containing regimen, we evaluated the frequency and severity of treatment-related adverse events. The risk difference of adverse events for each regimen was calculated, in comparison to patients assigned to receiving the lowest cumulative exposure of linezolid. RESULTS Data from 3 clinical trials investigating 8 unique BPaL-containing regimens were included, comprising a total of 591 participants. Adverse events were more frequent in groups randomized to a higher cumulative linezolid dose. Among patients who were randomized to a daily dose of 1200 mg linezolid, 68 of 195 (35%) experienced a grade 3-4 adverse event versus 89 of 396 (22%) patients receiving BPaL-containing regimens containing 600 mg linezolid. CONCLUSIONS Regimens containing BPaL were relatively well tolerated when they included a daily linezolid dose of 600 mg. These novel regimens promise to improve the tolerability of treatment for MDR/RR-TB.
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Affiliation(s)
- Tasnim Hasan
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Ellie Medcalf
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Bern-Thomas Nyang'wa
- Public Health Department, Médecins sans Frontières, Amsterdam, The Netherlands
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Erica Egizi
- TB Alliance Research and Development, New York City, USA
| | - Catherine Berry
- Manson Unit, Médecins sans Frontières, London, United Kingdom
| | - Matthew Dodd
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Salah Foraida
- TB Alliance Research and Development, New York City, USA
| | - Medea Gegia
- Global Tuberculosis Program, World Health Organization, Geneva, Switzerland
| | - Mengchun Li
- TB Alliance Research and Development, New York City, USA
| | - Fuad Mirzayev
- Global Tuberculosis Program, World Health Organization, Geneva, Switzerland
| | - Hannah Morgan
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Ilaria Motta
- Manson Unit, Médecins sans Frontières, London, United Kingdom
| | - Linh Nguyen
- Global Tuberculosis Program, World Health Organization, Geneva, Switzerland
| | - Samuel Schumacher
- Global Tuberculosis Program, World Health Organization, Geneva, Switzerland
| | - Tim Schlub
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Greg Fox
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
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83
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Krishnan S, Chaisson RE. US Guidelines Fall Short on Short-Course Tuberculosis-Preventive Therapy. Clin Infect Dis 2024; 78:514-517. [PMID: 37879092 PMCID: PMC10954328 DOI: 10.1093/cid/ciad659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 10/07/2023] [Accepted: 10/23/2023] [Indexed: 10/27/2023] Open
Abstract
The provision of tuberculosis-preventive therapy (TPT) to vulnerable populations is critical for global control. Shorter-course TPT regimens are highly effective and improve completion rates. Despite incorporation of 1 month of rifapentine and isoniazid into global guidelines, current US TPT guidelines do not include this as a recommended regimen, but should.
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Affiliation(s)
- Sonya Krishnan
- Center for Tuberculosis Research, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Richard E Chaisson
- Center for Tuberculosis Research, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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84
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Holger DJ, Althubyani A, Morrisette T, Rebold N, Tailor M. Updates in pulmonary drug-resistant tuberculosis pharmacotherapy: A focus on BPaL and BPaLM. Pharmacotherapy 2024; 44:268-282. [PMID: 38270468 DOI: 10.1002/phar.2909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 12/08/2023] [Accepted: 12/11/2023] [Indexed: 01/26/2024]
Abstract
Drug-resistant tuberculosis (TB) is a major public health concern and contributes to high morbidity and mortality. New evidence supports the use of shorter duration, all-oral regimens, which represent an encouraging treatment strategy for drug-resistant TB. As a result, the landscape of drug-resistant TB pharmacotherapy has drastically evolved regarding treatment principles and preferred agents. This narrative review focuses on the key updates of drug-resistant TB treatment, including the use of short-duration all-oral regimens, while calling attention to current gaps in knowledge that may be addressed in future observational studies.
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Affiliation(s)
- Dana J Holger
- Department of Pharmacy Practice, Barry and Judy Silverman College of Pharmacy, Nova Southeastern University, Fort Lauderdale, Florida, USA
- Department of Pharmacy Services, Memorial Hospital West, Pembroke Pines, Florida, USA
| | - Ali Althubyani
- Department of Pharmacy Services, St. Elizabeth's Medical Center, Boston, Massachusetts, USA
- Department of Pharmacy Practice, College of Pharmacy, University of Tabuk, Tabuk, Saudi Arabia
| | - Taylor Morrisette
- Department of Clinical Pharmacy & Outcomes Sciences, Medical University of South Carolina College of Pharmacy, Charleston, South Carolina, USA
- Department of Pharmacy Services, Medical University of South Carolina Health, Charleston, South Carolina, USA
| | - Nicholas Rebold
- Department of Clinical & Administrative Pharmacy Sciences, College of Pharmacy, Howard University, Washington, DC, USA
| | - Marylee Tailor
- Department of Pharmacy Practice, Barry and Judy Silverman College of Pharmacy, Nova Southeastern University, Fort Lauderdale, Florida, USA
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85
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Block AM, Wiegert PC, Namugenyi SB, Tischler AD. Transposon sequencing reveals metabolic pathways essential for Mycobacterium tuberculosis infection. PLoS Pathog 2024; 20:e1011663. [PMID: 38498580 PMCID: PMC10977890 DOI: 10.1371/journal.ppat.1011663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 03/28/2024] [Accepted: 02/26/2024] [Indexed: 03/20/2024] Open
Abstract
New drugs are needed to shorten and simplify treatment of tuberculosis caused by Mycobacterium tuberculosis. Metabolic pathways that M. tuberculosis requires for growth or survival during infection represent potential targets for anti-tubercular drug development. Genes and metabolic pathways essential for M. tuberculosis growth in standard laboratory culture conditions have been defined by genome-wide genetic screens. However, whether M. tuberculosis requires these essential genes during infection has not been comprehensively explored because mutant strains cannot be generated using standard methods. Here we show that M. tuberculosis requires the phenylalanine (Phe) and de novo purine and thiamine biosynthetic pathways for mammalian infection. We used a defined collection of M. tuberculosis transposon (Tn) mutants in essential genes, which we generated using a custom nutrient-rich medium, and transposon sequencing (Tn-seq) to identify multiple central metabolic pathways required for fitness in a mouse infection model. We confirmed by individual retesting and complementation that mutations in pheA (Phe biosynthesis) or purF (purine and thiamine biosynthesis) cause death of M. tuberculosis in the absence of nutrient supplementation in vitro and strong attenuation in infected mice. Our findings show that Tn-seq with defined Tn mutant pools can be used to identify M. tuberculosis genes required during mouse lung infection. Our results also demonstrate that M. tuberculosis requires Phe and purine/thiamine biosynthesis for survival in the host, implicating these metabolic pathways as prime targets for the development of new antibiotics to combat tuberculosis.
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Affiliation(s)
- Alisha M. Block
- Department of Microbiology and Immunology, University of Minnesota, Twin Cities Campus, Minneapolis, Minnesota, United States of America
| | - Parker C. Wiegert
- Department of Microbiology and Immunology, University of Minnesota, Twin Cities Campus, Minneapolis, Minnesota, United States of America
| | - Sarah B. Namugenyi
- Department of Microbiology and Immunology, University of Minnesota, Twin Cities Campus, Minneapolis, Minnesota, United States of America
| | - Anna D. Tischler
- Department of Microbiology and Immunology, University of Minnesota, Twin Cities Campus, Minneapolis, Minnesota, United States of America
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Pedersen OS, Butova T, Kapustnyk V, Miasoiedov V, Kuzhko M, Hryshchuk L, Kornaha S, Borovok N, Raznatovska O, Fedorec A, Bogomolov A, Tkhorovskiy M, Akymenko O, Klymenko I, Kulykova O, Karpenko Z, Shapoval T, Chursina N, Kondratyuk N, Parkhomenko O, Sazonenko I, Ostrovskyy M, Makoida I, Markovtsiy L, Skryp V, Lubenko V, Hrankina N, Bondarenko L, Hlynenko V, Dahl VN, Butov D. Treatment outcomes and risk factors for an unsuccessful outcome among patients with highly drug-resistant tuberculosis in Ukraine. Clin Microbiol Infect 2024; 30:360-367. [PMID: 38065363 DOI: 10.1016/j.cmi.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 11/28/2023] [Accepted: 12/02/2023] [Indexed: 12/26/2023]
Abstract
OBJECTIVES To describe demographics, clinical features, and treatment outcomes of patients with highly drug-resistant tuberculosis (TB) in Ukraine, and to evaluate risk factors for an unsuccessful outcome. METHODS Data from patients with multi-, pre-extensively, or extensively drug-resistant TB were collected prospectively from TB dispensaries in 15 out of 24 Ukrainian oblasts (regions) from 2020 to 2021. Treatment outcomes were evaluated using WHO definitions. Risk factors for an unsuccessful outcome were identified using a multivariable logistic regression model. RESULTS Among 1748 patients, the overall proportion of successful outcomes was 58% (95% confidence interval [95% CI] 56-60) (n = 1015/1748), ranging from 65% (95% CI: 62-69) (n = 531/814) for multidrug-resistant TB to 54% (95% CI: 49-58) (n = 301/563) for pre-extensively drug-resistant TB and 49% (95% CI: 44-55) (n = 183/371) for extensively drug-resistant TB. Results were similar across oblasts, with few exceptions. The strongest risk factors for an unsuccessful outcome were extensively drug-resistant TB (adjusted OR [aOR] 3.23; 95% CI: 1.88-5.53), total serum protein below 62 g/L in adults and below 57 g/L for children and adolescents (aOR 2.79; 95% CI: 1.93-4.04), psychiatric illness (aOR 2.79; 95% CI: 1.46-5.33), age at TB diagnosis >65 years (aOR 2.50; 95% CI: 1.42-4.42), and alcohol misuse (aOR 2.48; 95% CI: 1.89-3.26). DISCUSSION The overall proportion of successful outcomes among Ukrainians treated for highly drug-resistant TB was 58%, notably better compared with previous years, but still low for extensively drug-resistant TB. Risk factors for unsuccessful outcomes highlight that addressing socioeconomic factors in TB management is crucial. Efforts in maintaining TB dispensaries during and following the ongoing war are highly warranted.
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Affiliation(s)
- Ole Skouvig Pedersen
- Department of Respiratory Diseases and Allergy, Aarhus University Hospital, Aarhus, Denmark
| | - Tetiana Butova
- Outpatient Department, Merefa Central District Hospital, Merefa, Ukraine
| | | | | | - Mykhailo Kuzhko
- Department of Chemoresistant Tuberculosis, National Institute of Phthisiology and Pulmonology named after F. G. Yanovskyi NAMS of Ukraine, Kiev, Ukraine
| | - Leonid Hryshchuk
- Department of Internal Medicine Propedeutics and Phthisiology, I. Horbachevsky Ternopil National Medical University, Ternopil, Ukraine
| | - Svitlana Kornaha
- Department of Internal Medicine Propedeutics and Phthisiology, I. Horbachevsky Ternopil National Medical University, Ternopil, Ukraine
| | - Natalia Borovok
- Medical Department No. 3, Regional Anti-tuberculosis Dispensary No 1 in Kharkiv, Kharkiv, Ukraine
| | - Olena Raznatovska
- Phthisiology and Pulmonology, Zaporizhzhia State Medical and Pharmaceutical University, Zaporizhzhia, Ukraine
| | - Andrii Fedorec
- The Pulmonary Tuberculosis Department No. 2, Zaporizhzhia Regional Phthisiology and Pulmonology Clinical Treatment and Diagnostic Center, Zaporizhzhia, Ukraine
| | - Artemii Bogomolov
- Phthisiology, Clinical Immunology and Allergology, National Pirogov Memorial Medical University, Vinnytsya, Ukraine
| | - Mykhaylo Tkhorovskiy
- Phthisiology, Clinical Immunology and Allergology, National Pirogov Memorial Medical University, Vinnytsya, Ukraine
| | - Oleksandra Akymenko
- Medical Department No. 3, Regional Anti-tuberculosis Dispensary No 1 in Kharkiv, Kharkiv, Ukraine
| | | | - Olena Kulykova
- Outpatient Department, Regional Clinical Tuberculosis Dispensary, Kramatorsk, Ukraine
| | - Zhanna Karpenko
- Phthisiatry Center, Chernihiv Regional Hospital, Chernihiv, Ukraine
| | - Tetiana Shapoval
- Phthisiatry Center, Chernihiv Regional Hospital, Chernihiv, Ukraine
| | | | - Natalia Kondratyuk
- Bacteriological Laboratory, Volyn Regional Phthisiopulmonological Center, Lutsk, Ukraine
| | - Olha Parkhomenko
- Mykolaiv Regional Phthisio-pulmonological Medical Center, Mykolaiv, Ukraine
| | - Inna Sazonenko
- Phthisiology, Mykolaiv Regional Phthisiology and Pulmonology Medical Center, Mykolaiv, Ukraine
| | - Mykola Ostrovskyy
- Phthisiology and Pulmonology Rate of Occupational Diseases, Ivano-Frankivsk National Medical University, Ivano-Frankivsk, Ukraine
| | - Iryna Makoida
- Phthisiology and Pulmonology Rate of Occupational Diseases, Ivano-Frankivsk National Medical University, Ivano-Frankivsk, Ukraine
| | | | - Vasyl Skryp
- Center of Pulmonary Diseases, Uzhhorod, Ukraine
| | - Victoriya Lubenko
- Information and Analytical Department, Phthisiopulmonology Center, Kyiv, Ukraine
| | - Nataliia Hrankina
- Infectious Diseases and Phthisiology, Krivoy Rig Tuberculosis Dispensary, Dnipro, Ukraine
| | - Leonid Bondarenko
- Administration, Sumy Regional Clinical Anti-tuberculosis Dispensary, Sumy, Ukraine
| | - Valentyna Hlynenko
- Outpatient Department, Sumy Regional Clinical Anti-tuberculosis Dispensary, Sumy, Ukraine
| | - Victor Næstholt Dahl
- Department of Infectious Diseases, Aarhus University Hospital, Aarhus, Denmark; Center for Global Health, Aarhus University (GloHAU), Aarhus, Denmark; International Reference Laboratory of Mycobacteriology, Statens Serum Institut, Copenhagen, Denmark.
| | - Dmytro Butov
- Infectious Diseases and Phthisiology, Kharkiv National Medical University, Kharkiv, Ukraine
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Utpatel C, Zavaleta M, Rojas-Bolivar D, Mühlbach A, Picoy J, Portugal W, Esteve-Solé A, Alsina L, Miotto P, Bartholomeu DC, Sanchez J, Cuadros DF, Alarcon JO, Niemann S, Huaman MA. Prison as a driver of recent transmissions of multidrug-resistant tuberculosis in Callao, Peru: a cross-sectional study. LANCET REGIONAL HEALTH. AMERICAS 2024; 31:100674. [PMID: 38500964 PMCID: PMC10945431 DOI: 10.1016/j.lana.2024.100674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 01/01/2024] [Accepted: 01/03/2024] [Indexed: 03/20/2024]
Abstract
Background We sought to identify resistance patterns and key drivers of recent multidrug-resistant tuberculosis (MDR-TB) transmission in a TB-prevalent area in Peru. Methods Cross-sectional study including MDR Mycobacterium tuberculosis complex (Mtbc) strains identified in Callao-Peru between April 2017 and February 2019. Mtbc DNA was extracted for whole genome sequencing which was used for phylogenetic inference, clustering, and resistance mutation analyses. Clusters indicative of recent transmission were defined based on a strain-to-strain distance of ≤5 (D5) single nucleotide polymorphisms (SNPs). Epidemiologic factors linked to MDR-TB clustering were analyzed using Poisson regression. Findings 171 unique MDR-Mtbc strains were included; 22 (13%) had additional fluoroquinolone resistance and were classified as pre-XDR. Six strains (3.5%) harboured bedaquiline (BDQ) resistance mutations and were classified as MDR + BDQ. 158 (92%) Mtbc strains belonged to lineage 4 and 13 (8%) to lineage 2. Using a cluster threshold of ≤5 SNPs, 98 (57%) strains were grouped in one of the 17 D5 clusters indicative of recent transmission, ranging in size from 2 to the largest cluster formed by 53 4.3.3 strains (group_1). Lineage 4.3.3 strains showed the overall highest cluster rate (43%). In multivariate analyses, current or previous imprisonment was independently associated with being part of any MDR-TB transmission clusters (adjusted prevalence ratio [aPR], 1.45; 95% CI, 1.09-1.92). Interpretation Pre-XDR-TB emerged in more than 10% of the MDR-TB strains investigated. Transmission of 4.3.3 Mtbc strains especially of the dominant group_1 clone is a major driver of the MDR-TB epidemic in Callao. Current or previous imprisonment was linked to recent MDR-TB transmissions, indicating an important role of prisons in driving the MDR-TB epidemic. Funding This work was supported in part by the ERANet-LAC Network of the European Union, Latin America and the Caribbean Countries on Joint Innovation and Research Activities, and FONDECYT. Additional support was received from Leibniz Science Campus Evolutionary Medicine of the Lung, the Deutsche Forschungsgemeinschaft (German Research Foundation, under Germany's Excellence Strategy-EXC 2167 Precision Medicine in Inflammation), and the Research Training Group 2501 TransEvo.
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Affiliation(s)
- Christian Utpatel
- Molecular and Experimental Mycobacteriology, Research Center Borstel, Borstel, Germany
| | - Milagros Zavaleta
- Centro de Investigaciones Tecnológicas, Biomedicas y Medioambientales, Callao, Peru
| | - Daniel Rojas-Bolivar
- Centro de Investigaciones Tecnológicas, Biomedicas y Medioambientales, Callao, Peru
| | - Andreas Mühlbach
- Centro de Investigaciones Tecnológicas, Biomedicas y Medioambientales, Callao, Peru
| | - Janet Picoy
- Direccion Regional de Salud del Callao, Callao, Peru
| | | | - Ana Esteve-Solé
- Allergy and Clinical Immunology Department, Hospital Sant Joan de Déu Institut de Recerca Sant Joan de Déu, Universitat de Barcelona, Barcelona, Spain
| | - Laia Alsina
- Allergy and Clinical Immunology Department, Hospital Sant Joan de Déu Institut de Recerca Sant Joan de Déu, Universitat de Barcelona, Barcelona, Spain
| | - Paolo Miotto
- Emerging Bacterial Pathogens Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Daniella C. Bartholomeu
- Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Minas Gerais, Brazil
| | - Jorge Sanchez
- Centro de Investigaciones Tecnológicas, Biomedicas y Medioambientales, Callao, Peru
| | - Diego F. Cuadros
- Department of Geography and GIS, Health Geography and Disease Modeling Laboratory, University of Cincinnati, Cincinnati, USA
| | - Jorge O. Alarcon
- Centro de Investigaciones Tecnológicas, Biomedicas y Medioambientales, Callao, Peru
- Epidemiology Section, Instituto de Medicina Tropical, Universidad Nacional Mayor de San Marcos, Lima, Peru
| | - Stefan Niemann
- Molecular and Experimental Mycobacteriology, Research Center Borstel, Borstel, Germany
- German Center for Infection Research, Partner Site Hamburg-Lübeck-Borstel-Riems, Borstel, Germany
| | - Moises A. Huaman
- Centro de Investigaciones Tecnológicas, Biomedicas y Medioambientales, Callao, Peru
- Department of Internal Medicine, Division of Infectious Diseases, University of Cincinnati, Cincinnati, USA
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88
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Nuermberger EL, Chaisson RE. Restocking the tuberculosis drug arsenal. Nat Med 2024; 30:642-643. [PMID: 38459183 DOI: 10.1038/s41591-024-02840-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/10/2024]
Affiliation(s)
- Eric L Nuermberger
- Center for Tuberculosis Research, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Richard E Chaisson
- Center for Tuberculosis Research, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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89
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Nimmo C, Ortiz AT, Tan CCS, Pang J, Acman M, Millard J, Padayatchi N, Grant AD, O'Donnell M, Pym A, Brynildsrud OB, Eldholm V, Grandjean L, Didelot X, Balloux F, van Dorp L. Detection of a historic reservoir of bedaquiline/clofazimine resistance-associated variants in Mycobacterium tuberculosis. Genome Med 2024; 16:34. [PMID: 38374151 PMCID: PMC10877763 DOI: 10.1186/s13073-024-01289-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 01/19/2024] [Indexed: 02/21/2024] Open
Abstract
BACKGROUND Drug resistance in tuberculosis (TB) poses a major ongoing challenge to public health. The recent inclusion of bedaquiline into TB drug regimens has improved treatment outcomes, but this advance is threatened by the emergence of strains of Mycobacterium tuberculosis (Mtb) resistant to bedaquiline. Clinical bedaquiline resistance is most frequently conferred by off-target resistance-associated variants (RAVs) in the mmpR5 gene (Rv0678), the regulator of an efflux pump, which can also confer cross-resistance to clofazimine, another TB drug. METHODS We compiled a dataset of 3682 Mtb genomes, including 180 carrying variants in mmpR5, and its immediate background (i.e. mmpR5 promoter and adjacent mmpL5 gene), that have been associated to borderline (henceforth intermediate) or confirmed resistance to bedaquiline. We characterised the occurrence of all nonsynonymous mutations in mmpR5 in this dataset and estimated, using time-resolved phylogenetic methods, the age of their emergence. RESULTS We identified eight cases where RAVs were present in the genomes of strains collected prior to the use of bedaquiline in TB treatment regimes. Phylogenetic reconstruction points to multiple emergence events and circulation of RAVs in mmpR5, some estimated to predate the introduction of bedaquiline. However, epistatic interactions can complicate bedaquiline drug-susceptibility prediction from genetic sequence data. Indeed, in one clade, Ile67fs (a RAV when considered in isolation) was estimated to have emerged prior to the antibiotic era, together with a resistance reverting mmpL5 mutation. CONCLUSIONS The presence of a pre-existing reservoir of Mtb strains carrying bedaquiline RAVs prior to its clinical use augments the need for rapid drug susceptibility testing and individualised regimen selection to safeguard the use of bedaquiline in TB care and control.
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Affiliation(s)
- Camus Nimmo
- UCL Genetics Institute, University College London, Darwin Building, Gower Street, London, UK.
- Division of Infection and Immunity, University College London, London, UK.
- Africa Health Research Institute, Durban, South Africa.
| | - Arturo Torres Ortiz
- UCL Genetics Institute, University College London, Darwin Building, Gower Street, London, UK
- Department of Medicine, Imperial College, London, UK
| | - Cedric C S Tan
- UCL Genetics Institute, University College London, Darwin Building, Gower Street, London, UK
| | - Juanita Pang
- UCL Genetics Institute, University College London, Darwin Building, Gower Street, London, UK
- Division of Infection and Immunity, University College London, London, UK
| | - Mislav Acman
- UCL Genetics Institute, University College London, Darwin Building, Gower Street, London, UK
| | - James Millard
- Africa Health Research Institute, Durban, South Africa
- Wellcome Trust Liverpool Glasgow Centre for Global Health Research, Liverpool, UK
- Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
| | - Nesri Padayatchi
- CAPRISA MRC-HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - Alison D Grant
- Africa Health Research Institute, Durban, South Africa
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - Max O'Donnell
- CAPRISA MRC-HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
- Department of Medicine & Epidemiology, Columbia University Irving Medical Center, New York, NY, USA
| | - Alex Pym
- Africa Health Research Institute, Durban, South Africa
| | - Ola B Brynildsrud
- Division of Infectious Diseases and Environmental Health, Norwegian Institute of Public Health, Oslo, Norway
| | - Vegard Eldholm
- Division of Infectious Diseases and Environmental Health, Norwegian Institute of Public Health, Oslo, Norway
| | - Louis Grandjean
- Division of Infection and Immunity, University College London, London, UK
- Laboratorio de Investigacion y Enfermedades Infecciosas, Universidad Peruana Cayetano Heredia, Lima, Peru
- Department of Infection, Immunity and Inflammation, Institute of Child Health, University College London, London, UK
| | - Xavier Didelot
- School of Life Sciences and Department of Statistics, University of Warwick, Coventry, UK
| | - François Balloux
- UCL Genetics Institute, University College London, Darwin Building, Gower Street, London, UK.
| | - Lucy van Dorp
- UCL Genetics Institute, University College London, Darwin Building, Gower Street, London, UK.
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Fu L, Wang W, Xiong J, Zhang P, Li H, Zhang X, Liang H, Yang Q, Wang Z, Chen X, Deng G, Cai Y, Tang S. Evaluation of Sulfasalazine as an Adjunctive Therapy in Treating Pulmonary Pre-XDR-TB: Efficacy, Safety, and Treatment Implication. Infect Drug Resist 2024; 17:595-604. [PMID: 38390619 PMCID: PMC10882277 DOI: 10.2147/idr.s443897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 02/12/2024] [Indexed: 02/24/2024] Open
Abstract
Background The rising prevalence and limited efficacy of treatments for pre-extensively drug-resistant tuberculosis (pre-XDR-TB) underscore an immediate need for innovative therapeutic options. A combination of host-directed therapy (HDT) and anti-TB treatment presents a viable alternative for pre-XDR-TB management. Sulfasalazine (SASP), by targeting the amino acid transport system xc (xCT), potentially reduces the intracellular Mycobacterium tuberculosis load and mitigates lung pathology, positioning it as a promising TB HDT agent. This study aims to assess the efficacy of SASP as a supplementary therapy for pre-XDR-TB. Methods A pilot study examined the safety and effectiveness of two 9-month short-course, all-oral regimens for pre-XDR-TB treatment: Bdq-regimen (consisting of Bdq, linezolid, cycloserine, clofazimine, and pyrazinamide) and SASP-regimen (comprising SASP, linezolid, cycloserine, clofazimine, and pyrazinamide). The primary endpoint was the incidence of unfavorable outcomes 12 months post-treatment. Results Of the 44 participants enrolled, 43 were assessable 12 months post-treatment. Culture conversion rates stood at 73.2% by Month 2 and escalated to 95.1% by Month 6. Overall, 88.4% (38/43) of the participants exhibited favorable outcomes, 85.2% (19/23) for the Bdq-regimen and 93.8% (14/15) for the SASP-regimen. The SASP-regimen group recorded no deaths or treatment failures. Conclusion Both 9-month short-course, all-oral regimens manifested commendable primary efficacy in treating pre-XDR-TB patients. The SASP-regimen emerged as effective, safe, well-tolerated, and cost-effective.
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Affiliation(s)
- Liang Fu
- Beijing Chest Hospital, Capital Medical University, Beijing Tuberculosis and Thoracic Tumour Research Institute, Beijing, People's Republic of China
- Shenzhen Third People's Hospital, National Clinical Research Center for Infectious Disease (Shenzhen), Shenzhen Clinical Research Center for Tuberculosis, Southern University of Science and Technology, Shenzhen, Guangdong, People's Republic of China
| | - Wenfei Wang
- Shenzhen Third People's Hospital, National Clinical Research Center for Infectious Disease (Shenzhen), Shenzhen Clinical Research Center for Tuberculosis, Southern University of Science and Technology, Shenzhen, Guangdong, People's Republic of China
- Department of Pathogen Biology, Guangdong Key Laboratory of Regional Immunity and Diseases, Shenzhen University School of Medicine, Shenzhen, Guangdong, People's Republic of China
| | - Juan Xiong
- Health Science Center, Shenzhen University, Shenzhen, Guangdong, People's Republic of China
| | - Peize Zhang
- Shenzhen Third People's Hospital, National Clinical Research Center for Infectious Disease (Shenzhen), Shenzhen Clinical Research Center for Tuberculosis, Southern University of Science and Technology, Shenzhen, Guangdong, People's Republic of China
| | - Hui Li
- Shenzhen Third People's Hospital, National Clinical Research Center for Infectious Disease (Shenzhen), Shenzhen Clinical Research Center for Tuberculosis, Southern University of Science and Technology, Shenzhen, Guangdong, People's Republic of China
| | - Xilin Zhang
- Tuberculosis Prevention and Control Department, the Fourth People's Hospital of Foshan, Foshan, Guangdong, People's Republic of China
| | - Hancheng Liang
- Division Two of Tuberculosis Diseases Department, the Sixth People's Hospital of Dongguan, Dongguan, Guangdong, People's Republic of China
| | - Qianting Yang
- Shenzhen Third People's Hospital, National Clinical Research Center for Infectious Disease (Shenzhen), Shenzhen Clinical Research Center for Tuberculosis, Southern University of Science and Technology, Shenzhen, Guangdong, People's Republic of China
| | - Zhaoqin Wang
- Shenzhen Third People's Hospital, National Clinical Research Center for Infectious Disease (Shenzhen), Shenzhen Clinical Research Center for Tuberculosis, Southern University of Science and Technology, Shenzhen, Guangdong, People's Republic of China
| | - Xinchun Chen
- Department of Pathogen Biology, Guangdong Key Laboratory of Regional Immunity and Diseases, Shenzhen University School of Medicine, Shenzhen, Guangdong, People's Republic of China
| | - Guofang Deng
- Shenzhen Third People's Hospital, National Clinical Research Center for Infectious Disease (Shenzhen), Shenzhen Clinical Research Center for Tuberculosis, Southern University of Science and Technology, Shenzhen, Guangdong, People's Republic of China
| | - Yi Cai
- Department of Pathogen Biology, Guangdong Key Laboratory of Regional Immunity and Diseases, Shenzhen University School of Medicine, Shenzhen, Guangdong, People's Republic of China
| | - Shenjie Tang
- Beijing Chest Hospital, Capital Medical University, Beijing Tuberculosis and Thoracic Tumour Research Institute, Beijing, People's Republic of China
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Zou F, Cui Z, Lou S, Ou Y, Zhu C, Shu C, Chen J, Zhao R, Wu Z, Wang L, Chen Z, Chen H, Lan Y. Adverse drug events associated with linezolid administration: a real-world pharmacovigilance study from 2004 to 2023 using the FAERS database. Front Pharmacol 2024; 15:1338902. [PMID: 38434706 PMCID: PMC10904462 DOI: 10.3389/fphar.2024.1338902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 01/31/2024] [Indexed: 03/05/2024] Open
Abstract
Introduction: Linezolid is an oxazolidinone antibiotic that is active against drug-resistant Gram-positive bacteria and multidrug-resistant Mycobacterium tuberculosis. Real-world studies on the safety of linezolid in large populations are lacking. This study aimed to determine the adverse events associated with linezolid in real-world settings by analyzing data from the US Food and Drug Administration (FDA) Adverse Event Reporting System (FAERS). Methods: We retrospectively extracted reports on adverse drug events (ADEs) from the FAERS database from the first quarter of 2004 to that of 2023. By using disproportionality analysis including reporting odds ratio (ROR), proportional reporting ratio (PRR), Bayesian Confidence Propagation Neural Network (BCPNN), along with the multi-item gamma Poisson shrinker (MGPS), we evaluated whether there was a significant association between linezolid and ADE. The time to onset of ADE was further analyzed in the general population and within each age, weight, reporting population, and weight subgroups. Results: A total of 11,176 reports of linezolid as the "primary suspected" drug and 263 significant adverse events of linezolid were identified, including some common adverse events such as thrombocytopenia (n = 1,139, ROR 21.98), anaemia (n = 704, ROR 7.39), and unexpected signals that were not listed on the drug label such as rhabdomyolysis (n = 90, ROR 4.33), and electrocardiogram QT prolonged (n = 73, ROR 4.07). Linezolid-induced adverse reactions involved 27 System Organ Class (SOC). Gender differences existed in ADE signals related to linezolid. The median onset time of all ADEs was 6 days, and most ADEs (n = 3,778) occurred within the first month of linezolid use but some may continue to occur even after a year of treatment (n = 46). Conclusion: This study reports the time to onset of adverse effects in detail at the levels of SOC and specific preferred term (PT). The results of our study provide valuable insights for optimizing the use of linezolid and reducing potential side effects, expected to facilitate the safe use of linezolid in clinical settings.
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Affiliation(s)
- Fan Zou
- Department of Tuberculosis, Affiliated Hospital of Zunyi Medical University, Zunyi, Guizhou, China
| | - Zhiwei Cui
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Siyu Lou
- Department of Tuberculosis, Affiliated Hospital of Zunyi Medical University, Zunyi, Guizhou, China
| | - Yingyong Ou
- Department of Tuberculosis, Affiliated Hospital of Zunyi Medical University, Zunyi, Guizhou, China
| | - Chengyu Zhu
- Department of Tuberculosis, Affiliated Hospital of Zunyi Medical University, Zunyi, Guizhou, China
| | - Chengjie Shu
- Department of Tuberculosis, Affiliated Hospital of Zunyi Medical University, Zunyi, Guizhou, China
| | - Junyou Chen
- Department of Tuberculosis, Affiliated Hospital of Zunyi Medical University, Zunyi, Guizhou, China
| | - Ruizhen Zhao
- Department of Tuberculosis, Affiliated Hospital of Zunyi Medical University, Zunyi, Guizhou, China
| | - Zhu Wu
- Department of Respiratory and Critical Care Medicine, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Li Wang
- Department of Respiratory and Critical Care Medicine, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Zhenyong Chen
- Department of Tuberculosis, Affiliated Hospital of Zunyi Medical University, Zunyi, Guizhou, China
| | - Huayu Chen
- Department of Respiratory and Critical Care Medicine, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Yuanbo Lan
- Department of Tuberculosis, Affiliated Hospital of Zunyi Medical University, Zunyi, Guizhou, China
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Ur Rehman O, Fatima E, Ali A, Akram U, Nashwan A, Yunus F. Efficacy and safety of bedaquiline containing regimens in patients of drug-resistant tuberculosis: An updated systematic review and meta-analysis. J Clin Tuberc Other Mycobact Dis 2024; 34:100405. [PMID: 38152568 PMCID: PMC10750101 DOI: 10.1016/j.jctube.2023.100405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2023] Open
Abstract
Background Tuberculosis is an infectious disease caused by Mycobacterium tuberculosis and leads to serious complications if left untreated. Some strains of Mycobacterium tuberculosis are multi-drug resistant and require treatment with newer drugs. Bedaquiline based treatment regimens have been used in patients who are diagnosed with drug resistant tuberculosis. The aim of this study is to assess the efficacy and safety profile of bedaquiline-based treatment regimens using a systematic review of existing literature and meta-analysis. Methods In this study, an electronic search was carried out on PubMed, ScienceDirect, and Cochrane library to find relevant literature from March 2021 onwards. Random-effects model was used to assess pooled treatment success rate and 95 % CIs. p-value of <0.05 was suggestive of publication bias. The review is registered with PROSPERO: CRD42023432748. Results A total of 543 articles were retrieved by database searching, out of which 12 new studies met the inclusion criteria. The total number of articles included in the review was 41 including 36 observational studies (having a total of 9,934 patients) and 5 experimental studies (having a total of 468 patients). The pooled treatment success rate was 76.9 % (95 % CI, 72.9-80.4) in the observational studies and 81.7 % (95 % CI, 67.2-90.7) in the experimental studies. Further subgroup analysis was done on the basis of treatment regimens containing bedaquiline only and treatment regimens containing bedaquiline and delamanid. The pooled treatment success rate in the studies consisting of patients who were treated with regimens containing bedaquiline only was 78.4 % (95 % CI, 74.2-82.1) and 73.6 % (95 % CI, 64.6-81.0) in studies consisting of patients who were treated with regimens containing bedaquiline and delamanid. There was no evidence of publication bias. Conclusions In patients of drug resistant tuberculosis having highly resistant strains of Mycobacterium tuberculosis undergoing treatment with bedaquiline-based regimen demonstrate high rates of culture conversion and treatment success. Moreover, the safety profile of bedaquiline-based regimens is well-established in all studies.
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Affiliation(s)
- Obaid Ur Rehman
- Department of Medicine, Services Institute of Medical Sciences, Lahore, Pakistan
| | - Eeshal Fatima
- Department of Medicine, Services Institute of Medical Sciences, Lahore, Pakistan
| | - Abraish Ali
- Department of Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Umar Akram
- Department of Medicine, Allama Iqbal Medical College, Lahore, Pakistan
| | | | - Faryal Yunus
- Department of Pathology, Services Institute of Medical Sciences, Lahore, Pakistan
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Nyang'wa BT, Berry C, Kazounis E, Motta I, Parpieva N, Tigay Z, Moodliar R, Dodd M, Solodovnikova V, Liverko I, Rajaram S, Rassool M, McHugh T, Spigelman M, Moore DA, Ritmeijer K, du Cros P, Fielding K. Short oral regimens for pulmonary rifampicin-resistant tuberculosis (TB-PRACTECAL): an open-label, randomised, controlled, phase 2B-3, multi-arm, multicentre, non-inferiority trial. THE LANCET. RESPIRATORY MEDICINE 2024; 12:117-128. [PMID: 37980911 DOI: 10.1016/s2213-2600(23)00389-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 10/12/2023] [Accepted: 10/19/2023] [Indexed: 11/21/2023]
Abstract
BACKGROUND Around 500 000 people worldwide develop rifampicin-resistant tuberculosis each year. The proportion of successful treatment outcomes remains low and new treatments are needed. Following an interim analysis, we report the final safety and efficacy outcomes of the TB-PRACTECAL trial, evaluating the safety and efficacy of oral regimens for the treatment of rifampicin-resistant tuberculosis. METHODS This open-label, randomised, controlled, multi-arm, multicentre, non-inferiority trial was conducted at seven hospital and community sites in Uzbekistan, Belarus, and South Africa, and enrolled participants aged 15 years and older with pulmonary rifampicin-resistant tuberculosis. Participants were randomly assigned, in a 1:1:1:1 ratio using variable block randomisation and stratified by trial site, to receive 36-80 week standard care; 24-week oral bedaquiline, pretomanid, and linezolid (BPaL); BPaL plus clofazimine (BPaLC); or BPaL plus moxifloxacin (BPaLM) in stage one of the trial, and in a 1:1 ratio to receive standard care or BPaLM in stage two of the trial, the results of which are described here. Laboratory staff and trial sponsors were masked to group assignment and outcomes were assessed by unmasked investigators. The primary outcome was the percentage of participants with a composite unfavourable outcome (treatment failure, death, treatment discontinuation, disease recurrence, or loss to follow-up) at 72 weeks after randomisation in the modified intention-to-treat population (all participants with rifampicin-resistant disease who received at least one dose of study medication) and the per-protocol population (a subset of the modified intention-to-treat population excluding participants who did not complete a protocol-adherent course of treatment (other than because of treatment failure or death) and those who discontinued treatment early because they violated at least one of the inclusion or exclusion criteria). Safety was measured in the safety population. The non-inferiority margin was 12%. This trial is registered with ClinicalTrials.gov, NCT02589782, and is complete. FINDINGS Between Jan 16, 2017, and March 18, 2021, 680 patients were screened for eligibility, of whom 552 were enrolled and randomly assigned (152 to the standard care group, 151 to the BPaLM group, 126 to the BPaLC group, and 123 to the BPaL group). The standard care and BPaLM groups proceeded to stage two and are reported here, post-hoc analyses of the BPaLC and BPaL groups are also reported. 151 participants in the BPaLM group and 151 in the standard care group were included in the safety population, with 138 in the BPaLM group and 137 in the standard care group in the modified intention-to-treat population. In the modified intention-to-treat population, unfavourable outcomes were reported in 16 (12%) of 137 participants for whom outcome was assessable in the BPaLM group and 56 (41%) of 137 participants in the standard care group (risk difference -29·2 percentage points [96·6% CI -39·8 to -18·6]; non-inferiority and superiority p<0·0001). 34 (23%) of 151 participants receiving BPaLM had adverse events of grade 3 or higher or serious adverse events, compared with 72 (48%) of 151 participants receiving standard care (risk difference -25·2 percentage points [96·6% CI -36·4 to -13·9]). Five deaths were reported in the standard care group by week 72, of which one (COVID-19 pneumonia) was unrelated to treatment and four (acute pancreatitis, suicide, sudden death, and sudden cardiac death) were judged to be treatment-related. INTERPRETATION The 24-week, all-oral BPaLM regimen is safe and efficacious for the treatment of pulmonary rifampicin-resistant tuberculosis, and was added to the WHO guidance for treatment of this condition in 2022. These findings will be key to BPaLM becoming the preferred regimen for adolescents and adults with pulmonary rifampicin-resistant tuberculosis. FUNDING Médecins Sans Frontières.
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Affiliation(s)
- Bern-Thomas Nyang'wa
- Public Health Department OCA, Médecins Sans Frontières, Amsterdam, Netherlands; London School of Hygiene & Tropical Medicine, London, UK; Institute for Global Health, University College London, London, UK.
| | - Catherine Berry
- Public Health Department OCA, Médecins Sans Frontières, London, UK
| | - Emil Kazounis
- Public Health Department OCA, Médecins Sans Frontières, London, UK
| | - Ilaria Motta
- Public Health Department OCA, Médecins Sans Frontières, London, UK
| | - Nargiza Parpieva
- Republican Specialised Scientific Practical Medical Centre of Phthisiology and Pulmonology, Tashkent, Uzbekistan
| | - Zinaida Tigay
- Republican Phthisiological Hospital #2, Nukus, Uzbekistan
| | | | - Matthew Dodd
- London School of Hygiene & Tropical Medicine, London, UK
| | - Varvara Solodovnikova
- Republican Scientific and Practical Centre for Pulmonology and Tuberculosis, Minsk, Belarus
| | - Irina Liverko
- Republican Specialised Scientific Practical Medical Centre of Phthisiology and Pulmonology, Tashkent, Uzbekistan
| | | | | | - Timothy McHugh
- Centre for Clinical Microbiology, University College London, London, UK
| | | | - David A Moore
- London School of Hygiene & Tropical Medicine, London, UK
| | - Koert Ritmeijer
- Public Health Department OCA, Médecins Sans Frontières, Amsterdam, Netherlands
| | - Philipp du Cros
- Burnet Institute, Melbourne, VIC, Australia; Monash Infectious Diseases, Monash Health, Melbourne, VIC, Australia
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94
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Mehta K, Guo T, van der Graaf PH, van Hasselt JGC. Model-based dose optimization framework for bedaquiline, pretomanid and linezolid for the treatment of drug-resistant tuberculosis. Br J Clin Pharmacol 2024; 90:463-474. [PMID: 37817504 DOI: 10.1111/bcp.15925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 09/29/2023] [Accepted: 10/04/2023] [Indexed: 10/12/2023] Open
Abstract
AIMS Bedaquiline, pretomanid and linezolid (BPaL) combination treatment against Mycobacterium tuberculosis is promising, yet safety and adherence concerns exist that motivate exploration of alternative dosing regimens. We developed a mechanistic modelling framework to compare the efficacy of the current and alternative BPaL treatment strategies. METHODS Pharmacodynamic models for each drug in the BPaL combination treatment were developed using in vitro time-kill data. These models were combined with pharmacokinetic models, incorporating body weight, lesion volume, site-of-action distribution, bacterial susceptibility and pharmacodynamic interactions to assemble the framework. The model was qualified by comparing the simulations against the observed clinical data. Simulations were performed evaluating bedaquiline and linezolid approved (bedaquiline 400 mg once daily [QD] for 14 days followed by 200 mg three times a week, linezolid 1200 mg QD) and alternative dosing regimens (bedaquiline 200 mg QD, linezolid 600 mg QD). RESULTS The framework adequately described the observed antibacterial activity data in patients following monotherapy for each drug and approved BPaL dosing. The simulations suggested a minor difference in median time to colony forming unit (CFU)-clearance state with the bedaquiline alternative compared to the approved dosing and the linezolid alternative compared to the approved dosing. Median time to non-replicating-clearance state was predicted to be 15 days from the CFU-clearance state. CONCLUSIONS The model-based simulations suggested that comparable efficacy can be achieved using alternative bedaquiline and linezolid dosing, which may improve safety and adherence in drug-resistant tuberculosis patients. The framework can be utilized to evaluate treatment optimization approaches, including dosing regimen and duration of treatment predictions to eradicate both replicating- and non-replicating bacteria from lung and lesions.
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Affiliation(s)
- Krina Mehta
- Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands
| | - Tingjie Guo
- Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands
| | - Piet H van der Graaf
- Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands
- Certara, Canterbury, UK
| | - J G Coen van Hasselt
- Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands
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95
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Sangsayunh P, Sanchat T, Chuchottaworn C, Cheewakul K, Rattanawai S. The use of BPaL containing regimen in the MDR/PreXDR TB treatments in Thailand. J Clin Tuberc Other Mycobact Dis 2024; 34:100408. [PMID: 38225943 PMCID: PMC10788258 DOI: 10.1016/j.jctube.2023.100408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2024] Open
Abstract
The primary objective of this study was to evaluate the real-world effectiveness, side effects and challenges associated with the implementing of the groundbreaking BPaL-containing regimen in Thailand. Another aim was to investigate the characteristics and severity of the disease, the presence of abnormal extensive lesions in chest X-Rays and the influence of cavitation on sputum conversion. MATERIAL AND METHOD The case series study included patients at TB clinic of Central chest institute of Thailand between August 2021-April 2023. All 28 Patients fullfilled the diagnostic criterial for MDR-TB by molecular tests and/or sputum culture. Sputum molecular test, utilizing GeneXpert MRB/XDR or Genotype MTBDRsl assay, was conducted. The 8 Pre-XDR patients who exhibited quinolone resistance and the 2 MDR-TB patients who encountered side effected from quinolone drugs were treated with BPaL regimen, while the remainder received BPaLM regimens. RESULTS Among the 28 patients, 23 (82.1 %) successfully completed the treatment with favorable outcomes. However, one patient from the BpaL regimen died due to severe destroy lung lesion, and four patients from the BpalM regimen discontinued treatment. The investigation into the correlation between extension lesion, cavitation lesions, and culture conversion unveiled that the group with extension lesions and cavitation ≥4 cm had a diminished probability of achieving sputum culture conversion within 8 weeks in comparison to the group without attributes. The associated risk ratio was 0.56 (95 % CI, 0.14-2.27), p = 0.14. Although the study report minimal side effects, 6 patients (22.2 %) experienced peripheral neuropathy and a notable adverse reaction identified was optic neuritis, affecting 2 cases (7.1 %). SUMMARY The administration of the BPaL-containing regimen resulted in rapid sputum conversion within 8 weeks and had minimal side effects.
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96
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Prasad K, Borre ED, Dillard LK, Ayer A, Der C, Bainbridge KE, McMahon CM, Tucci DL, Wilson BS, Schmidler GDS, Saunders J. Priorities for hearing loss prevention and estimates of global cause-specific burdens of hearing loss: a systematic rapid review. Lancet Glob Health 2024; 12:e217-e225. [PMID: 38245112 DOI: 10.1016/s2214-109x(23)00514-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 10/16/2023] [Accepted: 10/26/2023] [Indexed: 01/22/2024]
Abstract
BACKGROUND Hearing loss affects approximately 1·6 billion individuals worldwide. Many cases are preventable. We aimed to estimate the annual number of new hearing loss cases that could be attributed to meningitis, otitis media, congenital rubella syndrome, cytomegalovirus, and ototoxic medications, specifically aminoglycosides, platinum-based chemotherapeutics, and antimalarials. METHODS We used a targeted and a rapid systematic literature review to calculate yearly global incidences of each cause of hearing loss. We estimated the prevalence of hearing loss for each presumed cause. For each cause, we calculated the global number of yearly hearing loss cases associated with the exposure by multiplying the estimated exposed population by the prevalence of hearing loss associated with the exposure, accounting for mortality when warranted. FINDINGS An estimated 257·3 million people per year are exposed to these preventable causes of hearing loss, leading to an estimated 33·8 million new cases of hearing loss worldwide per year. Most hearing loss cases were among those with exposure to ototoxic medications (19·6 million [range 12·6 million-27·9 million] from short-course aminoglycoside therapy and 12·3 million from antimalarials). We estimated that 818 000 cases of hearing loss were caused by otitis media, 346 000 by meningitis, 114 000 by cytomegalovirus, and 59 000 by congenital rubella syndrome. INTERPRETATION The global burden of preventable hearing loss is large. Hearing loss that is attributable to disease sequelae or ototoxic medications contributes substantially to the global burden of hearing loss. Prevention of these conditions should be a global health priority. FUNDING The US National Institute on Deafness and Other Communication Disorders and the US National Institute on Aging.
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Affiliation(s)
- Kavita Prasad
- Tufts University School of Medicine, Boston, MA, USA
| | - Ethan D Borre
- Department of Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Lauren K Dillard
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Austin Ayer
- University of California San Diego, San Diego, CA, USA
| | - Carolina Der
- Facultad de Medicina Universidad del Desarrollo, Clínica Alemana de Santiago, Santiago, Chile
| | - Kathleen E Bainbridge
- National Institute on Deafness and Other Communication Disorders, National Institutes of Health, Bethesda, MD, USA
| | | | - Debara L Tucci
- National Institute on Deafness and Other Communication Disorders, National Institutes of Health, Bethesda, MD, USA
| | - Blake S Wilson
- Duke Global Health Institute, Duke University, Durham, NC, USA; Department of Electrical & Computer Engineering, Department of Biomedical Engineering, Pratt School of Engineering, Duke University, Durham, NC, USA; Department of Surgery, Geisel School of Medicine, Dartmouth University, Lebanon, NH, USA
| | - Gillian D Sanders Schmidler
- Department of Head and Neck Surgery and Communication Sciences, Duke University School of Medicine, Durham, NC, USA; Duke-Margolis Center for Health Policy, Durham, NC, USA
| | - James Saunders
- Duke-Margolis Center for Health Policy, Durham, NC, USA.
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97
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Bark CM, Boom WH, Furin JJ. More Tailored Approaches to Tuberculosis Treatment and Prevention. Annu Rev Med 2024; 75:177-188. [PMID: 37983385 DOI: 10.1146/annurev-med-100622-024848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2023]
Abstract
Recent advances in the treatment of tuberculosis (TB) have led to improvements unprecedented in our lifetime. Decades of research in developing new drugs, especially for multidrug-resistant TB, have created not only multiple new antituberculous agents but also a new approach to development and treatment, with a focus on maximizing the benefit to the individual patient. Prevention of TB disease has also been improved and recognized as a critical component of global TB control. While the momentum is positive, it will take continued investment at all levels, especially training of new dedicated TB researchers and advocates around the world, to maintain this progress.
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Affiliation(s)
- Charles M Bark
- Division of Infectious Diseases, MetroHealth Medical Center, Cleveland, Ohio, USA;
| | - W Henry Boom
- Division of Infectious Diseases and HIV Medicine, Case Western Reserve University and University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Jennifer J Furin
- Division of Infectious Diseases and HIV Medicine, Case Western Reserve University and University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
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Zeng C, Hernán MA, Trevisi L, Sauer S, Mitnick CD, Hewison C, Bastard M, Khan P, Seung KJ, Rich ML, Law S, Kikvidze M, Kirakosyan O, Miankou A, Thit P, Mamsa S, Janmohamed A, Melikyan N, Ahmed S, Vargas D, Binegdie AB, Temirova K, Oyewusi L, Philippe K, Vilbrun SC, Khan U, Huerga H, Franke MF. Effectiveness of a bedaquiline, linezolid, clofazimine "core" for multidrug-resistant tuberculosis. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.01.18.24301453. [PMID: 38293100 PMCID: PMC10827266 DOI: 10.1101/2024.01.18.24301453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2024]
Abstract
Rationale Treatment outcomes may be compromised among patients with multidrug- or rifampicin-resistant tuberculosis with additional fluoroquinolone resistance. Evidence is needed to inform optimal treatment for these patients. Objectives We compared the effectiveness of longer individualized regimens comprised of bedaquiline for 5 to 8 months, linezolid, and clofazimine to those reinforced with at least 1 third-tier drug and/or longer duration of bedaquiline. Methods We emulated a target trial to compare the effectiveness of initiating and remaining on the core regimen to one of five regimens reinforced with (1) bedaquiline for ≥9 months, (2) bedaquiline for ≥9 months and delamanid, (3) imipenem, (4) a second-line injectable, or (5) delamanid and imipenem. We included patients in whom a fluoroquinolone was unlikely to be effective based on drug susceptibility testing and/or prior exposure. Our analysis consisted of cloning, censoring, and inverse-probability weighting to estimate the probability of successful treatment. Measurements and Main Results Adjusted probabilities of successful treatment were high across regimens, ranging from 0.75 (95%CI:0.61, 0.89) to 0.84 (95%CI:0.76, 0.91). We found no substantial evidence that any of the reinforced regimens improved effectiveness of the core regimen, with ratios of treatment success ranging from 1.01 for regimens reinforced with bedaquiline ≥9 months (95%CI:0.79, 1.28) and bedaquiline ≥9 months plus delamanid (95%CI:0.81, 1.31) to 1.11 for regimens reinforced by a second-line injectable (95%CI:0.92, 1.39) and delamanid and imipenem (95%CI:0.90, 1.41). Conclusions High treatment success underscores the effectiveness of regimens comprised of bedaquiline, linezolid, and clofazimine, highlighting the need for expanded access to these drugs.
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Campbell JR, Brode SK, Barry P, Bastos ML, Bonnet M, Guglielmetti L, Kempker R, Klimuk D, Laniado Laborín R, Milanov V, Singla R, Skrahina A, Trajman A, van der Werf TS, Viiklepp P, Menzies D. Association of indicators of extensive disease and rifampin-resistant tuberculosis treatment outcomes: an individual participant data meta-analysis. Thorax 2024; 79:169-178. [PMID: 38135489 DOI: 10.1136/thorax-2023-220249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 10/29/2023] [Indexed: 12/24/2023]
Abstract
BACKGROUND Indicators of extensive disease-acid fast bacilli (AFB) smear positivity and lung cavitation-have been inconsistently associated with clinical rifampin-resistant/multidrug-resistant tuberculosis (RR/MDR-TB) outcomes. We evaluated the association of these indicators with end-of-treatment outcomes. METHODS We did an individual participant data meta-analysis of people treated for RR/MDR-TB with longer regimens with documented AFB smear and chest radiography findings. We compared people AFB smear-negative without cavities to people: (1) smear-negative with lung cavities; (2) smear-positive without lung cavities and (3) AFB smear-positive with lung cavities. Using multivariable logistic regression accounting for demographic, treatment and clinical factors, we calculated adjusted ORs (aOR) for any unfavourable outcome (death, lost to follow-up, failure/recurrence), and mortality and treatment failure/recurrence alone. RESULTS We included 5596 participants; included participants significantly differed from excluded participants. Overall, 774 (13.8%) were AFB smear-negative without cavities, 647 (11.6%) only had cavities, 1424 (25.4%) were AFB smear-positive alone and 2751 (49.2%) were AFB smear-positive with cavities. The median age was 37 years (IQR: 28-47), 3580 (64%) were male and 686 (12.5%) had HIV. Compared with participants AFB smear-negative without cavities, aOR (95% CI) for any unfavourable outcome was 1.0 (0.8 to 1.4) for participants smear-negative with lung cavities, 1.2 (0.9 to 1.5) if smear-positive without cavities and 1.6 (1.3 to 2.0) if AFB smear-positive with lung cavities. Odds were only significantly increased for mortality (1.5, 95% CI 1.1 to 2.1) and failure/recurrence (2.2, 95% CI 1.5 to 3.3) among participants AFB smear-positive with lung cavities. CONCLUSION Only the combination of AFB smear-positivity and lung cavitation was associated with unfavourable outcomes, suggesting they may benefit from stronger regimens.
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Affiliation(s)
- Jonathon R Campbell
- Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
- Respiratory Epidemiology and Clinical Research Unit, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
- Montreal Chest Institute & McGill International TB Centre, McGill University, Montreal, Quebec, Canada
| | - Sarah K Brode
- West Park Healthcare Centre, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Pennan Barry
- Tuberculosis Control Branch, California Department of Public Health, Richmond, California, USA
| | - Mayara Lisboa Bastos
- Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
| | | | | | - Russell Kempker
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Dzmitry Klimuk
- Republican Scientific and Practical Centre for Pulmonology and Tuberculosis, Minsk, Belarus
| | | | - Vladimir Milanov
- Occupational Diseases, Medical University-Sofia, Sofia, Bulgaria
| | - Rupak Singla
- Tuberculosis and Respiratory Diseases, National Institute of Tuberculosis and Respiratory Diseases, New Delhi, India
| | - Alena Skrahina
- Republican Scientific and Practical Centre for Pulmonology and Tuberculosis, Minsk, Belarus
| | - Anete Trajman
- Montreal Chest Institute & McGill International TB Centre, McGill University, Montreal, Quebec, Canada
- Department of Internal Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Tjip S van der Werf
- Departments of Internal Medicine, Infectious Diseases, Pulmonary Diseases, and Tuberculosis, UMC Groningen, Groningen, The Netherlands
| | - Piret Viiklepp
- Department of Registries, National Institute for Health Development, Tallinn, Estonia
| | - Dick Menzies
- Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
- Respiratory Epidemiology and Clinical Research Unit, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
- Montreal Chest Institute & McGill International TB Centre, McGill University, Montreal, Quebec, Canada
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100
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Gupta A, Juneja S, Babawale V, Rustam Majidovich N, Ndjeka N, Thi Mai Nguyen P, Nargiza Nusratovna P, Robert Omanito D, Tiara Pakasi T, Terleeva Y, Toktogonova A, Waheed Y, Myint Z, Yanlin Z, Sahu S. Global adoption of 6-month drug-resistant TB regimens: Projected uptake by 2026. PLoS One 2024; 19:e0296448. [PMID: 38180980 PMCID: PMC10769048 DOI: 10.1371/journal.pone.0296448] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 12/13/2023] [Indexed: 01/07/2024] Open
Abstract
BACKGROUND The WHO has issued a call to action urging countries to accelerate the rollout of new WHO-recommended shorter all-oral treatment regimens for drug-resistant TB (DR-TB), which remains a public-health crisis. The all-oral, 6-month BPaL/M regimen comprises 3-4 drugs: pretomanid used in combination with bedaquiline and linezolid, with or without moxifloxacin. This regimen has been recommended by the WHO for use in DR-TB patients instead of ≥9-month (up to 24-month) regimens. This study aims to project this regimen's use, along with its components bedaquiline, pretomanid and linezolid, and other treatments for DR-TB globally through 2026. It is intended to guide global health stakeholders in planning and budgeting for DR-TB interventions. Projected usage could help estimate cost of the individual components of DR-TB regimens over time. METHODS Semi-structured interviews were conducted with national TB programme participants in key countries to gather intelligence on established plans and targets for use of various DR-TB treatment regimens from 2023 to 2026. These data informed development of projections for the global use of regimens and drugs. RESULTS Consistent global growth in the use of shorter regimens in DR-TB treatment was shown: BPaLM reaching 126,792 patients, BPaL reaching 43,716 patients, and the 9-11-month all-oral bedaquiline-based regimen reaching 13,119 patients by 2026. By 2026, the longer all-oral regimen is projected to be used by 19,262 patients, and individualised treatment regimens by 15,344 patients. CONCLUSION The study shows BPaL/M will be used in majority of DR-TB patients by 2024, reaching 78% by 2026. However, national efforts to scale-up, case-finding, monitoring, drug-susceptibility testing, and implementation of new treatments will be essential for ensuring they are accessible to all eligible patients in the coming years and goals for ending TB are met. There is an urgent need to engage communities in capacity building and demand generation.
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Affiliation(s)
- Aastha Gupta
- TB Alliance, New York, NY, United States of America
| | | | - Victor Babawale
- National Tuberculosis and Leprosy Control Programme, Abuja, Nigeria
| | | | | | | | | | - David Robert Omanito
- Disease Prevention and Control Bureau, Philippine Department of Health, Manila, Philippines
| | | | | | | | - Yasir Waheed
- National TB Control Programme, Islamabad, Pakistan
| | - Zaw Myint
- National TB Programme, Naypyidaw, Myanmar
| | - Zhao Yanlin
- National Center for TB Control and Prevention, National Tuberculosis Reference Laboratory of China, Chinese Center for Disease Control and Prevention, Beijing, China
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