51
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Castro RAD, Borrell S, Gagneux S. The within-host evolution of antimicrobial resistance in Mycobacterium tuberculosis. FEMS Microbiol Rev 2021; 45:fuaa071. [PMID: 33320947 PMCID: PMC8371278 DOI: 10.1093/femsre/fuaa071] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 12/11/2020] [Indexed: 12/12/2022] Open
Abstract
Tuberculosis (TB) has been responsible for the greatest number of human deaths due to an infectious disease in general, and due to antimicrobial resistance (AMR) in particular. The etiological agents of human TB are a closely-related group of human-adapted bacteria that belong to the Mycobacterium tuberculosis complex (MTBC). Understanding how MTBC populations evolve within-host may allow for improved TB treatment and control strategies. In this review, we highlight recent works that have shed light on how AMR evolves in MTBC populations within individual patients. We discuss the role of heteroresistance in AMR evolution, and review the bacterial, patient and environmental factors that likely modulate the magnitude of heteroresistance within-host. We further highlight recent works on the dynamics of MTBC genetic diversity within-host, and discuss how spatial substructures in patients' lungs, spatiotemporal heterogeneity in antimicrobial concentrations and phenotypic drug tolerance likely modulates the dynamics of MTBC genetic diversity in patients during treatment. We note the general characteristics that are shared between how the MTBC and other bacterial pathogens evolve in humans, and highlight the characteristics unique to the MTBC.
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Affiliation(s)
- Rhastin A D Castro
- Swiss Tropical and Public Health Institute, Socinstrasse 57, 4051 Basel, Basel, Switzerland
- University of Basel, Petersplatz 1, 4001 Basel, Basel, Switzerland
| | - Sonia Borrell
- Swiss Tropical and Public Health Institute, Socinstrasse 57, 4051 Basel, Basel, Switzerland
- University of Basel, Petersplatz 1, 4001 Basel, Basel, Switzerland
| | - Sebastien Gagneux
- Swiss Tropical and Public Health Institute, Socinstrasse 57, 4051 Basel, Basel, Switzerland
- University of Basel, Petersplatz 1, 4001 Basel, Basel, Switzerland
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52
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The effect of isoniazid intake on ethionamide pharmacokinetics and target attainment in multidrug-resistant tuberculosis patients. Antimicrob Agents Chemother 2021; 65:e0027821. [PMID: 34310215 DOI: 10.1128/aac.00278-21] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Ethionamide is recommended as part of regimens to treat multidrug-resistant and rifampicin-resistant tuberculosis. The study was conducted to (i) describe the distribution of ethionamide minimum inhibitory concentrations (MICs), (ii) describe the pharmacokinetics of ethionamide, and (iii) determine the probability of attaining target AUC0-24/MIC values associated with suppression of resistant subpopulation and microbial kill. Participants received 15-20 mg/kg of ethionamide daily (in 500 or 750 mg doses), as part of a multidrug regimen. Pretreatment MICs of ethionamide for M. tuberculosis sputum isolates were determined using Sensititre MYCOTB MIC plates. Plasma concentrations of ethionamide (measured pre-dose and at 2, 4, 6, 8 and 10 hours post-dose) were available for 84 patients. A one-compartment disposition model including a liver compartment capturing hepatic extraction, best described ethionamide pharmacokinetics. Clearance and volume were allometrically scaled using fat-free mass. Isoniazid co-administration reduced ethionamide clearance by 31% resulting in a 44% increase in AUC0-24. The median (range) MIC (n=111) was 2.5 mg/L (<0.3 to >40 mg/L). Simulations showed increased daily doses of ethionamide (1 250 mg, 1 500 mg, and 1 750 mg for patients weighing ≤45 kg, 46-70 kg, and >70 kg, respectively) resulted in the probability of attaining a fAUC0-24/MIC ratio ≥ 42 in more than 90% of patients, only at the lowest MIC of 0.3 mg/L. The WHO recommended doses of ethionamide do not achieve target concentrations even for the lowest MIC measured in the cohort.
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53
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Mondoni M, Saderi L, Sotgiu G. Novel treatments in multidrug-resistant tuberculosis. Curr Opin Pharmacol 2021; 59:103-115. [PMID: 34186381 DOI: 10.1016/j.coph.2021.05.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 05/17/2021] [Accepted: 05/25/2021] [Indexed: 02/07/2023]
Abstract
The management of multidrug-resistant tuberculosis (TB) is associated with low treatment success, high mortality and failure rates. New drugs and novel short-therapeutic regimens have only recently helped overcome these obstacles. We carried out a narrative literature review aimed at summarizing the scientific evidence on the recent therapeutic advances in the field of drug-resistant TB. Experimental and observational studies on novel (i.e. bedaquiline, delamanid, pretomanid) drugs and novel regimens and the main pharmacological characteristics of the newest compounds are described. We also highlight the main scientific evidence on therapeutic strategies complementary to standard chemotherapy (i.e. new approaches to drug delivery, host-directed therapy, surgery, new collapse therapy, rehabilitation, and palliative care).
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Affiliation(s)
- Michele Mondoni
- Respiratory Unit, ASST Santi Paolo e Carlo, San Paolo Hospital, Department of Health Sciences, Università degli Studi di Milano, Milan, Italy
| | - Laura Saderi
- Clinical Epidemiology and Medical Statistics Unit, Dept of Medical, Surgical and Experimental Medicine, University of Sassari, Sassari, Italy
| | - Giovanni Sotgiu
- Clinical Epidemiology and Medical Statistics Unit, Dept of Medical, Surgical and Experimental Medicine, University of Sassari, Sassari, Italy.
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54
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Srivastava S, Deshpande D, Magombedze G, van Zyl J, Cirrincione K, Martin K, Bendet P, Berg A, Hanna D, Romero K, Hermann D, Gumbo T. Duration of pretomanid/moxifloxacin/pyrazinamide therapy compared with standard therapy based on time-to-extinction mathematics. J Antimicrob Chemother 2021; 75:392-399. [PMID: 31713607 PMCID: PMC6966096 DOI: 10.1093/jac/dkz460] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Revised: 09/29/2019] [Accepted: 10/08/2019] [Indexed: 01/13/2023] Open
Abstract
Objectives Animal models have suggested that the combination of pretomanid with pyrazinamide and moxifloxacin (PaMZ) may shorten TB therapy duration to 3–4 months. Here, we tested that in the hollow-fibre system model of TB (HFS-TB). Methods A series of HFS-TB experiments were performed to compare the kill rates of the PaMZ regimen with the standard three-drug combination therapy. HFS-TB experiments were performed with bacilli in log-phase growth treated for 28 days, intracellular bacilli treated daily for 28 days and semi-dormant Mycobacterium tuberculosis treated with daily therapy for 56 days for sterilizing effect. Next, time-to-extinction equations were employed, followed by morphism transformation and Latin hypercube sampling, to determine the proportion of patients who achieved a time to extinction of 3, 4 or 6 months with each regimen. Results Using linear regression, the HFS-TB sterilizing effect rates of the PaMZ regimen versus the standard-therapy regimen during the 56 days were 0.18 (95% credible interval=0.13–0.23) versus 0.15 (95% credible interval=0.08–0.21) log10 cfu/mL/day, compared with 0.16 (95% credible interval=0.13–0.18) versus 0.11 (95% credible interval=0.09–0.13) log10 cfu/mL/day in the Phase II clinical trial, respectively. Using time-to-extinction and Latin hypercube sampling modelling, the expected percentages of patients in which the PaMZ regimen would achieve sterilization were 40.37% (95% credible interval=39.1–41.34) and 72.30% (95% credible interval=71.41–73.17) at 3 and 4 months duration of therapy, respectively, versus 93.67% (95% credible interval=93.18–94.13) at 6 months for standard therapy. Conclusions The kill rates of the PaMZ regimen were predicted to be insufficient to achieve cure in less than 6 months in most patients.
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Affiliation(s)
- Shashikant Srivastava
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Devyani Deshpande
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Gesham Magombedze
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Johanna van Zyl
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Kayle Cirrincione
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, TX, USA
| | | | | | - Alexander Berg
- Critical Path to TB Drug Regimens, Critical Path Institute, Tucson, AZ, USA
| | - Debra Hanna
- Critical Path to TB Drug Regimens, Critical Path Institute, Tucson, AZ, USA.,Bill & Melinda Gates Foundation, Seattle, WA, USA
| | - Klaus Romero
- Critical Path to TB Drug Regimens, Critical Path Institute, Tucson, AZ, USA
| | - Dave Hermann
- Bill & Melinda Gates Foundation, Seattle, WA, USA
| | - Tawanda Gumbo
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, TX, USA.,Praedicare Laboratories, Dallas, TX, USA.,Lung Infection and Immunity Unit, Division of Pulmonology and UCT Lung Institute, Department of Medicine, University of Cape Town, Cape Town, South Africa
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55
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Cushman J, Freeman E, McCallister S, Schumann A, Hutchison KW, Molloy SD. Increased whiB7 expression and antibiotic resistance in Mycobacterium chelonae carrying two prophages. BMC Microbiol 2021; 21:176. [PMID: 34107872 PMCID: PMC8191103 DOI: 10.1186/s12866-021-02224-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Accepted: 05/05/2021] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND The global rise in the incidence of non-tuberculosis mycobacterial infections is of increasing concern due their high levels of intrinsic antibiotic resistance. Although integrated viral genomes, called prophage, are linked to increased antibiotic resistance in some bacterial species, we know little of their role in mycobacterial drug resistance. RESULTS We present here for the first time, evidence of increased antibiotic resistance and expression of intrinsic antibiotic resistance genes in a strain of Mycobacterium chelonae carrying prophage. Strains carrying the prophage McProf demonstrated increased resistance to amikacin. Resistance in these strains was further enhanced by exposure to sub-inhibitory concentrations of the antibiotic, acivicin, or by the presence of a second prophage, BPs. Increased expression of the virulence gene, whiB7, was observed in strains carrying both prophages, BPs and McProf, relative to strains carrying a single prophage or no prophages. CONCLUSIONS This study provides evidence that prophage alter expression of important mycobacterial intrinsic antibiotic resistance genes and additionally offers insight into the role prophage may play in mycobacterial adaptation to stress.
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Affiliation(s)
- Jaycee Cushman
- Department of Molecular and Biomedical Sciences, University of Maine, Orono, ME, United States
| | - Emma Freeman
- Department of Molecular and Biomedical Sciences, University of Maine, Orono, ME, United States
- The Honors College, University of Maine, Orono, ME, United States
| | - Sarah McCallister
- Department of Molecular and Biomedical Sciences, University of Maine, Orono, ME, United States
| | - Anna Schumann
- Department of Molecular and Biomedical Sciences, University of Maine, Orono, ME, United States
| | - Keith W Hutchison
- Department of Molecular and Biomedical Sciences, University of Maine, Orono, ME, United States
- The Honors College, University of Maine, Orono, ME, United States
| | - Sally D Molloy
- Department of Molecular and Biomedical Sciences, University of Maine, Orono, ME, United States.
- The Honors College, University of Maine, Orono, ME, United States.
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56
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Moreno-Molina M, Shubladze N, Khurtsilava I, Avaliani Z, Bablishvili N, Torres-Puente M, Villamayor L, Gabrielian A, Rosenthal A, Vilaplana C, Gagneux S, Kempker RR, Vashakidze S, Comas I. Genomic analyses of Mycobacterium tuberculosis from human lung resections reveal a high frequency of polyclonal infections. Nat Commun 2021; 12:2716. [PMID: 33976135 PMCID: PMC8113332 DOI: 10.1038/s41467-021-22705-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 03/22/2021] [Indexed: 01/15/2023] Open
Abstract
Polyclonal infections occur when at least two unrelated strains of the same pathogen are detected in an individual. This has been linked to worse clinical outcomes in tuberculosis, as undetected strains with different antibiotic resistance profiles can lead to treatment failure. Here, we examine the amount of polyclonal infections in sputum and surgical resections from patients with tuberculosis in the country of Georgia. For this purpose, we sequence and analyse the genomes of Mycobacterium tuberculosis isolated from the samples, acquired through an observational clinical study (NCT02715271). Access to the lung enhanced the detection of multiple strains (40% of surgery cases) as opposed to just using a sputum sample (0-5% in the general population). We show that polyclonal infections often involve genetically distant strains and can be associated with reversion of the patient's drug susceptibility profile over time. In addition, we find different patterns of genetic diversity within lesions and across patients, including mutational signatures known to be associated with oxidative damage; this suggests that reactive oxygen species may be acting as a selective pressure in the granuloma environment. Our results support the idea that the magnitude of polyclonal infections in high-burden tuberculosis settings is underestimated when only testing sputum samples.
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MESH Headings
- Antitubercular Agents/therapeutic use
- Biopsy
- Clone Cells
- Cohort Studies
- Drug Resistance, Multiple, Bacterial/genetics
- Genetic Variation
- Genome, Bacterial
- Georgia (Republic)
- Granuloma/drug therapy
- Granuloma/microbiology
- Granuloma/pathology
- Granuloma/surgery
- Humans
- Lung/microbiology
- Lung/pathology
- Lung/surgery
- Mycobacterium tuberculosis/classification
- Mycobacterium tuberculosis/drug effects
- Mycobacterium tuberculosis/genetics
- Mycobacterium tuberculosis/pathogenicity
- Reactive Oxygen Species/metabolism
- Sputum/microbiology
- Tuberculosis, Multidrug-Resistant/drug therapy
- Tuberculosis, Multidrug-Resistant/microbiology
- Tuberculosis, Multidrug-Resistant/pathology
- Tuberculosis, Multidrug-Resistant/surgery
- Tuberculosis, Pulmonary/drug therapy
- Tuberculosis, Pulmonary/microbiology
- Tuberculosis, Pulmonary/pathology
- Tuberculosis, Pulmonary/surgery
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Affiliation(s)
| | - Natalia Shubladze
- National Center for Tuberculosis and Lung Diseases of Georgia, Tbilisi, Georgia
| | - Iza Khurtsilava
- National Center for Tuberculosis and Lung Diseases of Georgia, Tbilisi, Georgia
| | - Zaza Avaliani
- National Center for Tuberculosis and Lung Diseases of Georgia, Tbilisi, Georgia
| | - Nino Bablishvili
- National Center for Tuberculosis and Lung Diseases of Georgia, Tbilisi, Georgia
| | | | | | - Andrei Gabrielian
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, U.S. Department of Health and Human Services, Maryland, USA
| | - Alex Rosenthal
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, U.S. Department of Health and Human Services, Maryland, USA
| | - Cristina Vilaplana
- Fundació Institut Germans Trias i Pujol (IGTP), Barcelona, Spain
- Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
- CIBER of Respiratory Diseases, Madrid, Spain
| | - Sebastien Gagneux
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Russell R Kempker
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, USA
| | - Sergo Vashakidze
- National Center for Tuberculosis and Lung Diseases of Georgia, Tbilisi, Georgia
| | - Iñaki Comas
- Instituto de Biomedicina de Valencia IBV-CSIC, Valencia, Spain.
- CIBER in Epidemiology and Public Health, Madrid, Spain.
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57
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Peloquin CA, Davies GR. The Treatment of Tuberculosis. Clin Pharmacol Ther 2021; 110:1455-1466. [PMID: 33837535 DOI: 10.1002/cpt.2261] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 03/24/2021] [Indexed: 12/18/2022]
Abstract
Tuberculosis (TB) remains a leading cause of infectious death worldwide, and poverty is a major driver. Clinically, TB presents as "latent" TB and active TB disease, and the treatment for each is different. TB drugs can display "early bactericidal activity (EBA)" and / or "sterilizing activity" (clearing persisters). Isoniazid is excellent at the former, and rifampin is excellent at the latter. Pyrazinamide and ethambutol complete the first-line regimen for drug-susceptible TB, each playing a specific role. Drug-resistant TB is an increasing concern, being met, in part, with repurposed drugs (including moxifloxacin, levofloxacin, linezolid, clofazimine, and beta-lactams) and new drugs (including bedaquiline, pretomanid, and delamanid). One challenge is to select drugs without overlapping adverse drug reaction profiles. QTc interval prolongation is one such concern, but to date, it has been manageable. Drug penetration into organism sanctuaries, such as the central nervous system, bone, and pulmonary TB cavities remain important challenges. The pharmacodynamics of most TB drugs can be described by the area under the curve (AUC) divided by the minimal inhibitory concentration (MIC). The hollow fiber infection model (HFIM) and various animal models (especially mouse and macaque) allow for sophisticated pharmacokinetic/pharmacodynamic experiments. These experiments may hasten the selection of the most potent, shortest possible regimens to treat even extremely drug resistant TB. These findings can be translated to humans by optimizing drug exposure in each patient, using therapeutic drug monitoring and dose individualization.
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Affiliation(s)
- Charles A Peloquin
- College of Pharmacy and Emerging Pathogens Institute, University of Florida, Gainesville, Florida, USA
| | - Geraint R Davies
- Institute of Infection and Global Health, University of Liverpool, Liverpool, UK.,Institute of Translational Medicine, University of Liverpool, Liverpool, UK
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58
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Srivastava S, Gumbo T. Therapeutic drug monitoring and fluoroquinolones for multidrug-resistant tuberculosis. Eur Respir J 2021; 57:57/4/2004454. [PMID: 33795358 DOI: 10.1183/13993003.04454-2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 12/16/2020] [Indexed: 11/05/2022]
Affiliation(s)
- Shashikant Srivastava
- Dept of Pulmonary Immunology, University of Texas Health Science Center at Tyler, Tyler, TX, USA .,Dept of Immunology, UT Southwestern Medical Center, Dallas, TX, USA
| | - Tawanda Gumbo
- Quantitative Preclinical and Clinical Sciences Dept, Praedicare Inc., Dallas, TX, USA
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59
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Court R, Centner CM, Chirehwa M, Wiesner L, Denti P, de Vries N, Harding J, Gumbo T, Maartens G, McIlleron H. Neuropsychiatric toxicity and cycloserine concentrations during treatment for multidrug-resistant tuberculosis. Int J Infect Dis 2021; 105:688-694. [PMID: 33684562 PMCID: PMC8126338 DOI: 10.1016/j.ijid.2021.03.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 02/19/2021] [Accepted: 03/02/2021] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Cycloserine, or its structural analogue terizidone, has been associated with neuropsychiatric toxicity (psychosis, depression, and neuropathy). Prospective clinical data on the incidence of and risk factors for neuropsychiatric toxicity in TB patients treated with cycloserine are limited. METHODS A prospective evaluation of neuropsychiatric toxicity was performed using validated screening tools in patients with multidrug-resistant tuberculosis treated with terizidone. Cox proportional hazard modelling was performed to explore the effects of clinical variables and measures of cycloserine pharmacokinetics in plasma. RESULTS A total 144 participants were recruited: 86 were male and 58 were female; their median age was 35.7 years and 91 (63%) were HIV-infected. Fifty-five (38%) participants developed at least one neuropsychiatric event (30 cases per 100 person-months): 50 (35%) neuropathy, 14 (10%) depression, and 11 (8%) psychosis. Neuropathy was independently associated with cycloserine clearance ((adjusted hazard ratio 0.34 (aHR), P = 0.03)) and high-dose pyridoxine (200 mg vs 150 mg daily, aHR: 2.79, P = 0.01). CONCLUSIONS A high incidence of early neuropsychiatric toxicity was observed in this cohort of patients treated with terizidone. Cycloserine clearance and higher doses of pyridoxine are associated with incident or worsening peripheral neuropathy.
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Affiliation(s)
- Richard Court
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa.
| | - Chad M Centner
- Division of Medical Microbiology, University of Cape Town, Cape Town, South Africa.
| | - Maxwell Chirehwa
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa.
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa.
| | - Paolo Denti
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa.
| | | | | | - Tawanda Gumbo
- Quantitative Preclinical and Clinical Sciences Department, Praedicare, Dallas, TX, USA.
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa; Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa.
| | - Helen McIlleron
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa; Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa.
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60
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Ordonez AA, Tucker EW, Anderson CJ, Carter CL, Ganatra S, Kaushal D, Kramnik I, Lin PL, Madigan CA, Mendez S, Rao J, Savic RM, Tobin DM, Walzl G, Wilkinson RJ, Lacourciere KA, Via LE, Jain SK. Visualizing the dynamics of tuberculosis pathology using molecular imaging. J Clin Invest 2021; 131:145107. [PMID: 33645551 PMCID: PMC7919721 DOI: 10.1172/jci145107] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Nearly 140 years after Robert Koch discovered Mycobacterium tuberculosis, tuberculosis (TB) remains a global threat and a deadly human pathogen. M. tuberculosis is notable for complex host-pathogen interactions that lead to poorly understood disease states ranging from latent infection to active disease. Additionally, multiple pathologies with a distinct local milieu (bacterial burden, antibiotic exposure, and host response) can coexist simultaneously within the same subject and change independently over time. Current tools cannot optimally measure these distinct pathologies or the spatiotemporal changes. Next-generation molecular imaging affords unparalleled opportunities to visualize infection by providing holistic, 3D spatial characterization and noninvasive, temporal monitoring within the same subject. This rapidly evolving technology could powerfully augment TB research by advancing fundamental knowledge and accelerating the development of novel diagnostics, biomarkers, and therapeutics.
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Affiliation(s)
- Alvaro A. Ordonez
- Center for Infection and Inflammation Imaging Research
- Center for Tuberculosis Research
- Department of Pediatrics, and
| | - Elizabeth W. Tucker
- Center for Infection and Inflammation Imaging Research
- Center for Tuberculosis Research
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - Claire L. Carter
- Hackensack Meridian Health Center for Discovery and Innovation, Nutley, New Jersey, USA
| | - Shashank Ganatra
- Southwest National Primate Research Center, Texas Biomedical Research Institute, San Antonio, Texas, USA
| | - Deepak Kaushal
- Southwest National Primate Research Center, Texas Biomedical Research Institute, San Antonio, Texas, USA
| | - Igor Kramnik
- Pulmonary Center, Department of Medicine, Boston University School of Medicine, Boston, Massachusets, USA
- National Emerging Infectious Diseases Laboratories, Boston University, Boston, Massachusetts, USA
| | - Philana L. Lin
- Children’s Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Cressida A. Madigan
- Department of Biological Sciences, UCSD, San Diego, La Jolla, California, USA
| | - Susana Mendez
- National Institute of Allergy and Infectious Diseases (NIAID), NIH, Rockville, Maryland, USA
| | - Jianghong Rao
- Molecular Imaging Program at Stanford, Department of Radiology and Chemistry, Stanford University, Stanford, California, USA
| | - Rada M. Savic
- Department of Bioengineering and Therapeutic Sciences, School of Pharmacy and Medicine, UCSF, San Francisco, California, USA
| | - David M. Tobin
- Department of Molecular Genetics and Microbiology, Duke University, Durham, North Carolina, USA
| | - Gerhard Walzl
- SAMRC Centre for Tuberculosis Research, DST/NRF Centre of Excellence for Biomedical Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Department of Biomedical Sciences, Stellenbosch University, Cape Town, South Africa
| | - Robert J. Wilkinson
- Department of Infectious Diseases, Imperial College London, London, United Kingdom
- Wellcome Centre for Infectious Diseases Research in Africa and Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- The Francis Crick Institute, London, United Kingdom
| | - Karen A. Lacourciere
- National Institute of Allergy and Infectious Diseases (NIAID), NIH, Rockville, Maryland, USA
| | - Laura E. Via
- Tuberculosis Research Section, Laboratory of Clinical Immunology and Microbiology, and Tuberculosis Imaging Program, Division of Intramural Research, NIAID, NIH, Bethesda, Maryland, USA
| | - Sanjay K. Jain
- Center for Infection and Inflammation Imaging Research
- Center for Tuberculosis Research
- Department of Pediatrics, and
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61
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Gumbo T, Sherman CM, Deshpande D, Alffenaar JW, Srivastava S. Mycobacterium tuberculosis sterilizing activity of faropenem, pyrazinamide and linezolid combination and failure to shorten the therapy duration. Int J Infect Dis 2021; 104:680-684. [PMID: 33556616 PMCID: PMC8168785 DOI: 10.1016/j.ijid.2021.01.062] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 01/20/2021] [Accepted: 01/23/2021] [Indexed: 01/26/2023] Open
Abstract
Background: Faropenem (F), an orally bioavailable β-lactam, kills Mycobacterium tuberculosis (Mtb) without the help of a β-lactamase inhibitor. This study explored the sterilizing effect of adding F once or twice daily to a linezolid (L) plus pyrazinamide (Z) backbone regimen. Methods: In vitro studies were performed using the hollow fiber model of tuberculosis (HFS-TB) to compare the kill rates of: 1) ZL two-drug combination; 2) F administered once daily plus ZL (F1ZL); 3) F administered twice-daily plus once daily ZL (F2ZL); 4) F2ZL with high-dose Z (F2ZhiL); 5) standard therapy of isoniazid, rifampin and Z; and 6) non-treated controls. The study was performed over 56 days with three HFS-TB replicates for each regimen. Results: Mtb in the non-treated HFS-TB grew at a rate of 0.018 ± 0.007 log10 CFU/mL/day. The exponential kill rates for standard therapy were 6.6–13.2-fold higher than ZL dual therapy. The F1ZL and F2ZL regimens ranked third. The pre-existing isoniazid-resistant sub-population in the inoculum (1.34 ± 0.57 log10 CFU/mL) grew to 4.21 ± 0.58 log10 CFU/mL in 56 days in non-treated HFS-TB. However, no isoniazid-resistant sub-population was recorded in any of the FZL combination regimens. Conclusion: Due to the slow kill rate compared to standard therapy, FZL regimens are unlikely to shorten therapy duration. Efficacy of these regimens against drug-resistant tuberculosis needs to be determined.
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Affiliation(s)
- Tawanda Gumbo
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, TX, USA; Praedicare Laboratories and Quantitative Preclinical & Clinical Sciences Department, Praedicare Inc., Dallas, TX, USA; Department of Medicine, University of Cape Town, Observatory, South Africa
| | - Carleton M Sherman
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, TX, USA; Praedicare Laboratories and Quantitative Preclinical & Clinical Sciences Department, Praedicare Inc., Dallas, TX, USA
| | - Devyani Deshpande
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Jan-Willem Alffenaar
- The University of Sydney, Faculty of Medicine and Health, School of Pharmacy, Sydney, Australia; Westmead Hospital, Sydney, Australia; Marie Bashir Institute of Infectious Diseases, The University of Sydney, Sydney, Australia
| | - Shashikant Srivastava
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, TX, USA; Department of Immunology, UT Southwestern Medical Center, Dallas, TX, USA; Department of Pulmonary Immunology, University of Texas Health Science Centre, Tyler, TX, USA.
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Srivastava S, Chapagain M, van Zyl J, Deshpande D, Gumbo T. Potency of vancomycin against Mycobacterium tuberculosis in the hollow fiber system model. J Glob Antimicrob Resist 2021; 24:403-410. [PMID: 33508482 DOI: 10.1016/j.jgar.2021.01.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 12/11/2020] [Accepted: 01/05/2021] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES To determine whether an inhaled vancomycin formulation resulting in high intrapulmonary 24-h area under the concentration-time curve (AUC0-24) could be optimised for tuberculosis treatment. We also explored vancomycin synergy and antagonism with d-cycloserine and benzylpenicillin. METHODS We determined MICs of two Mycobacterium tuberculosis (Mtb) laboratory strains (H37Ra and H37Rv) and two drug-susceptible and nine multidrug resistant clinical strains. Second, in the hollow fiber system model of TB [HFS-TB] using Mtb H37Ra strain, we recapitulated vancomycin intrapulmonary pharmacokinetics of eight doses administered twice daily over 28 days, mimicking a 6-h half-life. Using the HFS-TB, vancomycin was tested in combination with d-cycloserine and benzylpenicillin to determine synergy or antagonism between drugs targeting the same pathway. RESULTS Vancomycin MICs were 12 and 48 mg/L in drug-susceptible clinical isolates but >96 mg/L in all MDR isolates.In the HFS-TB, vancomycin killed 3.9 ± 0.6 log10 CFU/mL Mtb. The EC50 was calculated as AUC0-24/MIC of 184.6 ± 106.5. Compared with day 0, 1.0 and 2.0 log10 CFU/mL kill was achieved by AUC0-24/MIC of 168 and 685, respectively. Acquired vancomycin resistance developed to all vancomycin doses tested in the HFS-TB. In the HFS-TB, vancomycin was antagonistic to benzylpenicillin, which works downstream to glycopeptides in peptidoglycan synthesis, but synergistic with d-cycloserine, which inhibits upstream d-Ala-d-Ala ligase and alanine racemase. CONCLUSION Our proof-of-concept studies show that vancomycin optimal exposure target for Mtb kill could be achieved via inhalational drug delivery. Addition of drugs synergistic with vancomycin, e.g. d-cycloserine, may lower the vancomycin concentrations required to kill Mtb.
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Affiliation(s)
- Shashikant Srivastava
- Department of Pulmonary Immunology, University of Texas Health Science Center at Tyler, Tyler, TX, USA; Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Moti Chapagain
- Department of Pulmonary Immunology, University of Texas Health Science Center at Tyler, Tyler, TX, USA; Quantitative Preclinical and Clinical Sciences Department, Praedicare Inc., Dallas, TX, USA
| | - Johanna van Zyl
- Department of Pulmonary Immunology, University of Texas Health Science Center at Tyler, Tyler, TX, USA
| | - Devyani Deshpande
- Department of Pulmonary Immunology, University of Texas Health Science Center at Tyler, Tyler, TX, USA
| | - Tawanda Gumbo
- Department of Pulmonary Immunology, University of Texas Health Science Center at Tyler, Tyler, TX, USA; Quantitative Preclinical and Clinical Sciences Department, Praedicare Inc., Dallas, TX, USA; Lung Infection and Immunity Unit, Division of Pulmonology and UCT Lung Institute, Department of Medicine, University of Cape Town, Cape Town, South Africa.
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Bose P, Harit AK, Das R, Sau S, Iyer AK, Kashaw SK. Tuberculosis: current scenario, drug targets, and future prospects. Med Chem Res 2021. [DOI: 10.1007/s00044-020-02691-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Alffenaar JWC, Gumbo T, Dooley KE, Peloquin CA, Mcilleron H, Zagorski A, Cirillo DM, Heysell SK, Silva DR, Migliori GB. Integrating Pharmacokinetics and Pharmacodynamics in Operational Research to End Tuberculosis. Clin Infect Dis 2021; 70:1774-1780. [PMID: 31560376 PMCID: PMC7146003 DOI: 10.1093/cid/ciz942] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 09/20/2019] [Indexed: 12/11/2022] Open
Abstract
Tuberculosis (TB) elimination requires innovative approaches. The new Global Tuberculosis Network (GTN) aims to conduct research on key unmet therapeutic and diagnostic needs in the field of TB elimination using multidisciplinary, multisectorial approaches. The TB Pharmacology section within the new GTN aims to detect and study the current knowledge gaps, test potential solutions using human pharmacokinetics informed through preclinical infection systems, and return those findings to the bedside. Moreover, this approach would allow prospective identification and validation of optimal shorter therapeutic durations with new regimens. Optimized treatment using available and repurposed drugs may have an increased impact when prioritizing a person-centered approach and acknowledge the importance of age, gender, comorbidities, and both social and programmatic environments. In this viewpoint article, we present an in-depth discussion on how TB pharmacology and the related strategies will contribute to TB elimination.
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Affiliation(s)
- Jan-Willem C Alffenaar
- University of Sydney, Faculty of Medicine and Health, School of Pharmacy, Sydney, Australia.,Westmead Hospital, Sydney, Australia
| | - Tawanda Gumbo
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, Texas, USA
| | - Kelly E Dooley
- Division of Clinical Pharmacology, Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Charles A Peloquin
- Infectious Disease Pharmacokinetics Laboratory, University of Florida College of Pharmacy, Gainesville, Florida, USA
| | - Helen Mcilleron
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Andre Zagorski
- Management Sciences for Health, Arlington, Virginia, USA
| | - Daniela M Cirillo
- Emerging Bacterial Pathogens Unit, Division of Immunology, Transplantation and Infectious Diseases, Istituto Di Ricovero e Cura a Carattere Scientifico (IRCCS) San Raffaele Scientific Institute, Milan, Italy
| | - Scott K Heysell
- University of Virginia, Division of Infectious Diseases and International Health, Charlottesville, Virginia, USA
| | - Denise Rossato Silva
- Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Giovanni Battista Migliori
- Servizio di Epidemiologia Clinica delle Malattie Respiratorie, Istituti Clinici Scientifici Maugeri IRCCS, Tradate, Italy
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Pavlatovská B, Machálková M, Brisudová P, Pruška A, Štěpka K, Michálek J, Nečasová T, Beneš P, Šmarda J, Preisler J, Kozubek M, Navrátilová J. Lactic Acidosis Interferes With Toxicity of Perifosine to Colorectal Cancer Spheroids: Multimodal Imaging Analysis. Front Oncol 2020; 10:581365. [PMID: 33344237 PMCID: PMC7746961 DOI: 10.3389/fonc.2020.581365] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 10/20/2020] [Indexed: 11/13/2022] Open
Abstract
Colorectal cancer (CRC) is a disease with constantly increasing incidence and high mortality. The treatment efficacy could be curtailed by drug resistance resulting from poor drug penetration into tumor tissue and the tumor-specific microenvironment, such as hypoxia and acidosis. Furthermore, CRC tumors can be exposed to different pH depending on the position in the intestinal tract. CRC tumors often share upregulation of the Akt signaling pathway. In this study, we investigated the role of external pH in control of cytotoxicity of perifosine, the Akt signaling pathway inhibitor, to CRC cells using 2D and 3D tumor models. In 3D settings, we employed an innovative strategy for simultaneous detection of spatial drug distribution and biological markers of proliferation/apoptosis using a combination of mass spectrometry imaging and immunohistochemistry. In 3D conditions, low and heterogeneous penetration of perifosine into the inner parts of the spheroids was observed. The depth of penetration depended on the treatment duration but not on the external pH. However, pH alteration in the tumor microenvironment affected the distribution of proliferation- and apoptosis-specific markers in the perifosine-treated spheroid. Accurate co-registration of perifosine distribution and biological response in the same spheroid section revealed dynamic changes in apoptotic and proliferative markers occurring not only in the perifosine-exposed cells, but also in the perifosine-free regions. Cytotoxicity of perifosine to both 2D and 3D cultures decreased in an acidic environment below pH 6.7. External pH affects cytotoxicity of the other Akt inhibitor, MK-2206, in a similar way. Our innovative approach for accurate determination of drug efficiency in 3D tumor tissue revealed that cytotoxicity of Akt inhibitors to CRC cells is strongly dependent on pH of the tumor microenvironment. Therefore, the effect of pH should be considered during the design and pre-clinical/clinical testing of the Akt-targeted cancer therapy.
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Affiliation(s)
- Barbora Pavlatovská
- Department of Experimental Biology, Faculty of Science, Masaryk University, Brno, Czechia
| | - Markéta Machálková
- Department of Chemistry, Faculty of Science, Masaryk University, Brno, Czechia
| | - Petra Brisudová
- Department of Experimental Biology, Faculty of Science, Masaryk University, Brno, Czechia
| | - Adam Pruška
- Department of Chemistry and Applied Biosciences, ETH Zurich, Zurich, Switzerland
| | - Karel Štěpka
- Centre for Biomedical Image Analysis, Faculty of Informatics, Masaryk University, Brno, Czechia
| | - Jan Michálek
- Centre for Biomedical Image Analysis, Faculty of Informatics, Masaryk University, Brno, Czechia
| | - Tereza Nečasová
- Centre for Biomedical Image Analysis, Faculty of Informatics, Masaryk University, Brno, Czechia
| | - Petr Beneš
- Department of Experimental Biology, Faculty of Science, Masaryk University, Brno, Czechia.,Center for Biological and Cellular Engineering, International Clinical Research Center, St. Anne's University Hospital, Brno, Czechia
| | - Jan Šmarda
- Department of Experimental Biology, Faculty of Science, Masaryk University, Brno, Czechia
| | - Jan Preisler
- Department of Chemistry, Faculty of Science, Masaryk University, Brno, Czechia
| | - Michal Kozubek
- Centre for Biomedical Image Analysis, Faculty of Informatics, Masaryk University, Brno, Czechia
| | - Jarmila Navrátilová
- Department of Experimental Biology, Faculty of Science, Masaryk University, Brno, Czechia.,Center for Biological and Cellular Engineering, International Clinical Research Center, St. Anne's University Hospital, Brno, Czechia
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Cumulative Fraction of Response for Once- and Twice-Daily Delamanid in Patients with Pulmonary Multidrug-Resistant Tuberculosis. Antimicrob Agents Chemother 2020; 65:AAC.01207-20. [PMID: 33106263 PMCID: PMC7927872 DOI: 10.1128/aac.01207-20] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 10/13/2020] [Indexed: 01/03/2023] Open
Abstract
Pharmacokinetic (PK) and pharmacodynamic (PD) analyses were conducted to determine the cumulative fraction of response (CFR) for 100 mg twice-daily (BID) and 200 mg once-daily (QD) delamanid in patients with multidrug-resistant tuberculosis (MDR-TB), using a pharmacodynamic target (PDT) that achieves 80% of maximum efficacy. First, in the mouse model of chronic TB, the PK/PD index for delamanid efficacy was determined to be area under the drug concentration-time curve over 24 h divided by MIC (AUC0–24/MIC), with a PDT of 252. Pharmacokinetic (PK) and pharmacodynamic (PD) analyses were conducted to determine the cumulative fraction of response (CFR) for 100 mg twice-daily (BID) and 200 mg once-daily (QD) delamanid in patients with multidrug-resistant tuberculosis (MDR-TB), using a pharmacodynamic target (PDT) that achieves 80% of maximum efficacy. First, in the mouse model of chronic TB, the PK/PD index for delamanid efficacy was determined to be area under the drug concentration-time curve over 24 h divided by MIC (AUC0–24/MIC), with a PDT of 252. Second, in the hollow-fiber system model of tuberculosis, plasma-equivalent PDTs were identified as an AUC0–24/MIC of 195 in log-phase bacteria and 201 in pH 5.8 cultures. Third, delamanid plasma AUC0–24/MIC and sputum bacterial decline data from two early bactericidal activity trials identified a clinical PDT of AUC0–24/MIC of 171. Finally, the CFRs for the currently approved 100-mg BID dose were determined to be above 95% in two MDR-TB clinical trials. The CFR for the 200-mg QD dose, evaluated in a trial in which delamanid was administered as 100 mg BID for 8 weeks plus 200 mg QD for 18 weeks, was 89.3% based on the mouse PDT and >90% on the other PDTs. QTcF (QTc interval corrected for heart rate by Fridericia’s formula) prolongation was approximately 50% lower for the 200 mg QD dose than the 100 mg BID dose. In conclusion, while CFRs of 100 mg BID and 200 mg QD delamanid were close to or above 90% in patients with MDR-TB, more-convenient once-daily dosing of delamanid is feasible and likely to have less effect on QTcF prolongation.
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An Q, Song W, Liu J, Tao N, Liu Y, Zhang Q, Xu T, Li S, Liu S, Li Y, Yu C, Li H. Primary Drug-Resistance Pattern and Trend in Elderly Tuberculosis Patients in Shandong, China, from 2004 to 2019. Infect Drug Resist 2020; 13:4133-4145. [PMID: 33223840 PMCID: PMC7671465 DOI: 10.2147/idr.s277203] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Accepted: 10/09/2020] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND With an aging population, China is facing a huge burden of elderly patients with drug resistant tuberculosis (DR-TB), which has become a significant obstacle for the global TB control. There is still little study on DR-TB in the elderly in China so far. Thus, more research on the epidemiological characteristics and trend of primary DR-TB among the elderly will be necessary. METHODS A retrospective study was conducted in Shandong, China from 2004 to 2019. We collected 12,661 primary TB cases, of which 4368 elderly (≥60 years) primary TB cases were involved. Clinical characteristics including age, sex, cavity, smoking, drinking, comorbidity and drug susceptibility data were collected from 36 TB prevention and control institutions of Shandong Province. Sputum samples were collected by each surveillance site, and examined in the TB Reference Laboratory of SPCH. Descriptive statistical analysis, chi-square and linear regression were used for analyzing. RESULTS Among 4368 elderly patients with primary TB, the DR-TB and multi-resistant tuberculosis (MDR-TB) accounted for 17.19% and 2.29%, respectively. During 2004-2019, the proportions of MDR-TB, polydrug resistant tuberculosis (PDR-TB), rifampin (RFP)-resistance increased by 160.00%, 18.18%, 231.82%, respectively and the rate of DR-TB among elderly patients with primary cavitary TB increased by 255%. Among the elderly with primary DR-TB during 2004-2019, the proportion of male (from 85.19 to 89.06), cavity (from 7.41 to 46.88), RFP-resistance (from 3.70 to 21.88), and streptomycin (SM)-resistance (from 37.04 to 62.5) increased significantly (P<0.05). And the proportion of female (from 14.81 to 10.94), non-cavity (from 92.59 to 32.81), INH-resistance (from 66.67 to 57.81) decreased significantly (P<0.05). CONCLUSION Among the elderly, the proportions of MDR-TB, PDR-TB, RFP-resistance and cavitary DR-TB increased significantly. The pattern of DR-TB changed from female, non-cavity and INH-resistant groups to male, cavity, RFP or SM-resistant groups. For a better control on the elderly DR-TB in the future, we should pay more attention to male, smoking, drinking, chronic obstructive pulmonary disease (COPD) and diabetes subgroups and take targeted measures to control these subgroups.
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Affiliation(s)
- Qiqi An
- Department of Respiratory Medicine, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong250012, People’s Republic of China
| | - Wanmei Song
- Department of Respiratory Medicine, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong250012, People’s Republic of China
| | - Jinyue Liu
- Intensive Care Unit, Shandong Provincial Third Hospital, Jinan, Shandong100191, People’s Republic of China
| | - Ningning Tao
- Peking Union Medical College, Beijing100005, People’s Republic of China
| | - Yao Liu
- Department of Respiratory Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong250021, People’s Republic of China
| | - Qianyun Zhang
- Department of Respiratory Medicine, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong250012, People’s Republic of China
| | - Tingting Xu
- Department of Respiratory Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong250021, People’s Republic of China
| | - Shijin Li
- Department of Respiratory Medicine, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong250012, People’s Republic of China
| | - Siqi Liu
- Department of Respiratory Medicine, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong250012, People’s Republic of China
| | - Yifan Li
- Department of Respiratory Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong250021, People’s Republic of China
| | - Chunbao Yu
- Department of Respiratory Medicine, Shandong Provincial Chest Hospital, Jinan, Shandong250013, People’s Republic of China
| | - Huaichen Li
- Department of Respiratory Medicine, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong250012, People’s Republic of China
- Department of Respiratory Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong250021, People’s Republic of China
- Shandong University of Traditional Chinese Medicine, Jinan, Shandong250355, People’s Republic of China
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Morales-Arce AY, Sabin SJ, Stone AC, Jensen JD. The population genomics of within-host Mycobacterium tuberculosis. Heredity (Edinb) 2020; 126:1-9. [PMID: 33060846 DOI: 10.1038/s41437-020-00377-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 10/02/2020] [Accepted: 10/03/2020] [Indexed: 11/09/2022] Open
Abstract
Recent progress in genomic sequencing from patient samples has allowed for the first detailed insight into the within-host genetic diversity of Mycobacterium tuberculosis (M.TB), revealing remarkably low levels of variation. While this has often been attributed to low mutation rates, other factors have been described, including resistance evolution (i.e., selective sweeps), widespread purifying and background selection, and, more recently, progeny skew. Here we review recent findings pertaining to the processes governing the evolutionary dynamics of M.TB, discuss their implications for improving our understanding of this important human pathogen, and make recommendations for future work. Significantly, this emerging evolutionary framework involving the joint estimation of demographic, selective, and reproductive processes is forming a new paradigm for the study of within-host pathogen evolution that will be widely applicable across organisms.
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Affiliation(s)
- Ana Y Morales-Arce
- Center for Evolution and Medicine, Arizona State University, Tempe, AZ, USA.
| | - Susanna J Sabin
- Center for Evolution and Medicine, Arizona State University, Tempe, AZ, USA
| | - Anne C Stone
- Center for Evolution and Medicine, Arizona State University, Tempe, AZ, USA.,School of Human Evolution and Social Change, Arizona State University, Tempe, AZ, USA
| | - Jeffrey D Jensen
- Center for Evolution and Medicine, Arizona State University, Tempe, AZ, USA. .,School of Life Sciences, Arizona State University, Tempe, AZ, USA.
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Dousa KM, Kurz SG, Bark CM, Bonomo RA, Furin JJ. Drug-Resistant Tuberculosis: A Glance at Progress and Global Challenges. Infect Dis Clin North Am 2020; 34:863-886. [PMID: 33011048 DOI: 10.1016/j.idc.2020.06.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Multidrug-resistant Mycobacterium tuberculosis remains a major public health threat; its management poses a significant economic burden. Treatment requires a programmatic approach with access to laboratory services, second-line medications, and adequate clinical resources. In recent years, we have seen rapid developments in diagnostic techniques with whole genome sequencing-based drug susceptibility prediction now in reach, an array of new drugs that transform treatment regimens to purely oral formulations, and a steady stream of multinational trials that inform us about most efficient combinations. Our hope is that the current momentum keeps the ambitious goal to end tuberculosis in 2030 in reach.
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Affiliation(s)
- Khalid M Dousa
- Division of Infectious Diseases & HIV Medicine, University Hospitals Cleveland Medical Center, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, OH 44106, USA
| | - Sebastian G Kurz
- Mount Sinai National Jewish Health Respiratory Institute, 10 East 102nd Street, New York City, NY 10029, USA
| | - Charles M Bark
- Division of Infectious Diseases, MetroHealth Medical Center, 2500 MetroHealth Drive, Cleveland, OH 44109, USA
| | - Robert A Bonomo
- Department of Medicine, Case Western Reserve University School of Medicine, 10900 Euclid Avenue, Cleveland, OH 44106, USA; Department of Pharmacology, Case Western Reserve University School of Medicine, 10900 Euclid Avenue, Cleveland, OH 44106, USA; Department of Molecular Biology and Microbiology, Case Western Reserve University School of Medicine, 10900 Euclid Avenue, Cleveland, OH 44106, USA; Department of Biochemistry, Case Western Reserve University School of Medicine, 10900 Euclid Avenue, Cleveland, OH 44106, USA; Department of Proteomics and Bioinformatics, Case Western Reserve University School of Medicine, 10900 Euclid Avenue, Cleveland, OH 44106, USA; Medical Service and GRECC, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, OH, USA; CWRU-Cleveland VAMC Center for Antimicrobial Resistance and Epidemiology (Case VA CARES), Cleveland, OH, USA
| | - Jennifer J Furin
- Division of Infectious Diseases & HIV Medicine, University Hospitals Cleveland Medical Center, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, OH 44106, USA; Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Avenue, Boston, MA 02115, USA.
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Shaw LP, Doyle RM, Kavaliunaite E, Spencer H, Balloux F, Dixon G, Harris KA. Children With Cystic Fibrosis Are Infected With Multiple Subpopulations of Mycobacterium abscessus With Different Antimicrobial Resistance Profiles. Clin Infect Dis 2020; 69:1678-1686. [PMID: 30689761 PMCID: PMC6821159 DOI: 10.1093/cid/ciz069] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Accepted: 01/21/2019] [Indexed: 12/12/2022] Open
Abstract
Background Children with cystic fibrosis (CF) can develop life-threatening infections of Mycobacterium abscessus. These present a significant clinical challenge, particularly when the strains involved are resistant to antibiotics. Recent evidence of within-patient subclones of M. abscessus in adults with CF suggests the possibility that within-patient diversity may be relevant for the treatment of pediatric CF patients. Methods We performed whole-genome sequencing (WGS) on 32 isolates of M. abscessus that were taken from multiple body sites of 2 patients with CF who were undergoing treatment at Great Ormond Street Hospital, United Kingdom, in 2015. Results We found evidence of extensive diversity within patients over time. A clustering analysis of single nucleotide variants revealed that each patient harbored multiple subpopulations, which were differentially abundant between sputum, lung samples, chest wounds, and pleural fluid. The sputum isolates did not reflect the overall within-patient diversity and did not allow for the detection of subclones with mutations previously associated with macrolide resistance (rrl 2058/2059). Some variants were present at intermediate frequencies before the lung transplants. The time of the transplants coincided with extensive variation, suggesting that this event is particularly disruptive for the microbial community, but the transplants did not clear the M. abscessus infections and both patients died as a result of these infections. Conclusions Isolates of M. abscessus from sputum do not always reflect the entire diversity present within the patient, which can include subclones with differing antimicrobial resistance profiles. An awareness of this phenotypic variability, with the sampling of multiple body sites in conjunction with WGS, may be necessary to ensure the best treatment for this vulnerable patient group.
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Affiliation(s)
- Liam P Shaw
- UCL Genetics Institute, University College London, London.,Nuffield Department of Medicine, John Radcliffe Hospital, Oxford
| | - Ronan M Doyle
- Department of Microbiology, Virology and Infection Control.,National Institute for Health Research Biomedical Research Centre
| | - Ema Kavaliunaite
- Paediatric Respiratory Medicine and Lung Transplantation, Great Ormond Street Hospital National Health Services Foundation Trust, London, United Kingdom
| | - Helen Spencer
- Paediatric Respiratory Medicine and Lung Transplantation, Great Ormond Street Hospital National Health Services Foundation Trust, London, United Kingdom
| | | | - Garth Dixon
- Department of Microbiology, Virology and Infection Control.,National Institute for Health Research Biomedical Research Centre
| | - Kathryn A Harris
- Department of Microbiology, Virology and Infection Control.,National Institute for Health Research Biomedical Research Centre
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Theron G, Limberis J, Venter R, Smith L, Pietersen E, Esmail A, Calligaro G, Te Riele J, de Kock M, van Helden P, Gumbo T, Clark TG, Fennelly K, Warren R, Dheda K. Bacterial and host determinants of cough aerosol culture positivity in patients with drug-resistant versus drug-susceptible tuberculosis. Nat Med 2020; 26:1435-1443. [PMID: 32601338 PMCID: PMC8353872 DOI: 10.1038/s41591-020-0940-2] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 05/13/2020] [Indexed: 12/27/2022]
Abstract
A burgeoning epidemic of drug-resistant tuberculosis (TB) threatens to derail global control efforts. Although the mechanisms remain poorly clarified, drug-resistant strains are widely believed to be less infectious than drug-susceptible strains. Consequently, we hypothesized that lower proportions of patients with drug-resistant TB would have culturable Mycobacterium tuberculosis from respirable, cough-generated aerosols compared to patients with drug-susceptible TB, and that multiple factors, including mycobacterial genomic variation, would predict culturable cough aerosol production. We enumerated the colony forming units in aerosols (≤10 µm) from 452 patients with TB (227 with drug resistance), compared clinical characteristics, and performed mycobacterial whole-genome sequencing, dormancy phenotyping and drug-susceptibility analyses on M. tuberculosis from sputum. After considering treatment duration, we found that almost half of the patients with drug-resistant TB were cough aerosol culture-positive. Surprisingly, neither mycobacterial genomic variants, lineage, nor dormancy status predicted cough aerosol culture positivity. However, mycobacterial sputum bacillary load and clinical characteristics, including a lower symptom score and stronger cough, were strongly predictive, thereby supporting targeted transmission-limiting interventions. Effective treatment largely abrogated cough aerosol culture positivity; however, this was not always rapid. These data question current paradigms, inform public health strategies and suggest the need to redirect TB transmission-associated research efforts toward host-pathogen interactions.
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Affiliation(s)
- Grant Theron
- 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
- DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research and South African Medical Research Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Jason Limberis
- 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
| | - Rouxjeane Venter
- DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research and South African Medical Research Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Liezel Smith
- 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
- DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research and South African Medical Research Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Elize Pietersen
- 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
| | - Aliasgar Esmail
- 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
| | - Greg Calligaro
- 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
| | | | - Marianna de Kock
- DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research and South African Medical Research Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Paul van Helden
- DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research and South African Medical Research Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Tawanda Gumbo
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor University Medical Center, Dallas, TX, USA
| | - Taane G Clark
- Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
- Faculty of Epidemiology and Public Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Kevin Fennelly
- Pulmonary Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Robin Warren
- DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research and South African Medical Research Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - 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, London School of Hygiene & Tropical Medicine, London, UK.
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Mehta K, Ravimohan S, Pasipanodya JG, Srivastava S, Modongo C, Zetola NM, Weissman D, Ivaturi V, Gumbo T, Bisson GP, Vinnard C. Optimizing ethambutol dosing among HIV/tuberculosis co-infected patients: a population pharmacokinetic modelling and simulation study. J Antimicrob Chemother 2020; 74:2994-3002. [PMID: 31273386 DOI: 10.1093/jac/dkz265] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 05/22/2019] [Accepted: 05/27/2019] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Reduced ethambutol serum concentrations are commonly observed among TB patients co-infected with HIV and may lead to treatment failure. OBJECTIVES To perform a population pharmacokinetic study of ethambutol in HIV/TB patients, and to evaluate an intensified ethambutol weight-based dosing strategy to support pharmacokinetic target attainment. METHODS We conducted a prospective study of ethambutol pharmacokinetics among HIV/TB patients administered first-line TB treatment in Botswana, with study visits before and after initiation of ART. Clinical and disease status markers, including HIV-associated systemic immune activation and gut dysfunction biomarkers, were evaluated as covariates of ethambutol pharmacokinetic parameters in non-linear mixed effects analysis. Monte Carlo simulations were performed to compare pharmacokinetic target attainment under standard and intensified weight-based ethambutol dosing strategies. RESULTS We studied 40 HIV/TB patients prior to initiation of ART, of whom 24 returned for a second visit a median of 33 days following ART initiation. Ethambutol serum concentrations were best explained by a two-compartment model with first-order elimination, with a significant improvement in oral bioavailability following ART initiation. In Monte Carlo simulations, a supplementary ethambutol dose of 400 mg daily led to >2-fold improvements in pharmacokinetic target attainment probabilities in lung tissue, both before and after ART initiation. CONCLUSIONS Low serum ethambutol concentrations were commonly observed among HIV/TB patients in Botswana, and the oral bioavailability of ethambutol increased following ART initiation. Supplementary ethambutol dosing among HIV/TB patients may provide a strategy to optimize anti-TB treatment regimens in this high-risk population.
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Affiliation(s)
- Krina Mehta
- Center for Translational Medicine, University of Maryland, Baltimore, MD, USA
| | | | - Jotam G Pasipanodya
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Shashikant Srivastava
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, TX, USA
| | | | | | - Drew Weissman
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Vijay Ivaturi
- Center for Translational Medicine, University of Maryland, Baltimore, MD, USA
| | - Tawanda Gumbo
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Gregory P Bisson
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Christopher Vinnard
- Public Health Research Institute, New Jersey Medical School, Newark, NJ, USA
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73
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Ernest JP, Strydom N, Wang Q, Zhang N, Nuermberger E, Dartois V, Savic RM. Development of New Tuberculosis Drugs: Translation to Regimen Composition for Drug-Sensitive and Multidrug-Resistant Tuberculosis. Annu Rev Pharmacol Toxicol 2020; 61:495-516. [PMID: 32806997 DOI: 10.1146/annurev-pharmtox-030920-011143] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Tuberculosis (TB) kills more people than any other infectious disease. Challenges for developing better treatments include the complex pathology due to within-host immune dynamics, interpatient variability in disease severity and drug pharmacokinetics-pharmacodynamics (PK-PD), and the growing emergence of resistance. Model-informed drug development using quantitative and translational pharmacology has become increasingly recognized as a method capable of drug prioritization and regimen optimization to efficiently progress compounds through TB drug development phases. In this review, we examine translational models and tools, including plasma PK scaling, site-of-disease lesion PK, host-immune and bacteria interplay, combination PK-PD models of multidrug regimens, resistance formation, and integration of data across nonclinical and clinical phases.We propose a workflow that integrates these tools with computational platforms to identify drug combinations that have the potential to accelerate sterilization, reduce relapse rates, and limit the emergence of resistance.
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Affiliation(s)
- Jacqueline P Ernest
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, California 94158, USA;
| | - Natasha Strydom
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, California 94158, USA;
| | - Qianwen Wang
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, California 94158, USA;
| | - Nan Zhang
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, California 94158, USA;
| | - Eric Nuermberger
- Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, Maryland 21231, USA
| | - Véronique Dartois
- Center for Discovery and Innovation, Hackensack Meridian School of Medicine at Seton Hall University, Nutley, New Jersey 07110, USA
| | - Rada M Savic
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, California 94158, USA;
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74
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Sibandze DB, Magazi BT, Malinga LA, Maningi NE, Shey BA, Pasipanodya JG, Mbelle NN. Machine learning reveals that Mycobacterium tuberculosis genotypes and anatomic disease site impacts drug resistance and disease transmission among patients with proven extra-pulmonary tuberculosis. BMC Infect Dis 2020; 20:556. [PMID: 32736602 PMCID: PMC7393820 DOI: 10.1186/s12879-020-05256-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 07/14/2020] [Indexed: 11/10/2022] Open
Abstract
Background There is a general dearth of information on extrapulmonary tuberculosis (EPTB). Here, we investigated Mycobacterium tuberculosis (Mtb) drug resistance and transmission patterns in EPTB patients treated in the Tshwane metropolitan area, in South Africa. Methods Consecutive Mtb culture-positive non-pulmonary samples from unique EPTB patients underwent mycobacterial genotyping and were assigned to phylogenetic lineages and transmission clusters based on spoligotypes. MTBDRplus assay was used to search mutations for isoniazid and rifampin resistance. Machine learning algorithms were used to identify clinically meaningful patterns in data. We computed odds ratio (OR), attributable risk (AR) and corresponding 95% confidence intervals (CI). Results Of the 70 isolates examined, the largest cluster comprised 25 (36%) Mtb strains that belonged to the East Asian lineage. East Asian lineage was significantly more likely to occur within chains of transmission when compared to the Euro-American and East-African Indian lineages: OR = 10.11 (95% CI: 1.56–116). Lymphadenitis, meningitis and cutaneous TB, were significantly more likely to be associated with drug resistance: OR = 12.69 (95% CI: 1.82–141.60) and AR = 0.25 (95% CI: 0.06–0.43) when compared with other EPTB sites, which suggests that poor rifampin penetration might be a contributing factor. Conclusions The majority of Mtb strains circulating in the Tshwane metropolis belongs to East Asian, Euro-American and East-African Indian lineages. Each of these are likely to be clustered, suggesting on-going EPTB transmission. Since 25% of the drug resistance was attributable to sanctuary EPTB sites notorious for poor rifampin penetration, we hypothesize that poor anti-tuberculosis drug dosing might have a role in the development of resistance.
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Affiliation(s)
- Doctor B Sibandze
- Department of Medical Microbiology, Faculty of Health Sciences, University of Pretoria, Private Bag X323, Arcadia, Pretoria, 0007, South Africa.,National Tuberculosis Control Program, Ministry of Health, Manzini, Kingdom of Eswatini
| | - Beki T Magazi
- Department of Medical Microbiology, Faculty of Health Sciences, University of Pretoria, Private Bag X323, Arcadia, Pretoria, 0007, South Africa.,Tshwane Division, National Health Laboratory Services, Pretoria, South Africa
| | - Lesibana A Malinga
- Department of Medical Microbiology, Faculty of Health Sciences, University of Pretoria, Private Bag X323, Arcadia, Pretoria, 0007, South Africa.,Tuberculosis Platform, South African Medical Research Council, Pretoria, South Africa
| | - Nontuthuko E Maningi
- Department of Medical Microbiology, Faculty of Health Sciences, University of Pretoria, Private Bag X323, Arcadia, Pretoria, 0007, South Africa
| | - Bong-Akee Shey
- Department of Medical Microbiology, Faculty of Health Sciences, University of Pretoria, Private Bag X323, Arcadia, Pretoria, 0007, South Africa
| | - Jotam G Pasipanodya
- Center For Infectious Diseases Research and Experimental Therapeutics, Texas Tech University Health Sciences Center, 5920 Forest Park Road, Dallas, TX, 75235, USA. .,Praedicare Laboratories, 14830 Venture Drive, Dallas, TX, 75234, USA.
| | - Nontombi N Mbelle
- Department of Medical Microbiology, Faculty of Health Sciences, University of Pretoria, Private Bag X323, Arcadia, Pretoria, 0007, South Africa.,Tshwane Division, National Health Laboratory Services, Pretoria, South Africa
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75
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Deshpande D, Magombedze G, Srivastava S, Bendet P, Lee PS, Cirrincione KN, Martin KR, Dheda K, Gumbo T. Once-a-week tigecycline for the treatment of drug-resistant TB. J Antimicrob Chemother 2020; 74:1607-1617. [PMID: 30820554 DOI: 10.1093/jac/dkz061] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 01/17/2019] [Accepted: 01/22/2019] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND MDR-TB and XDR-TB have poor outcomes. OBJECTIVES To examine the efficacy of tigecycline monotherapy in the hollow fibre system model of TB. METHODS We performed pharmacokinetic/pharmacodynamic studies using tigecycline human-like concentration-time profiles in the hollow fibre system model of TB in five separate experiments using Mycobacterium tuberculosis in log-phase growth or as semi-dormant or intracellular bacilli, as monotherapy. We also compared efficacy with the isoniazid/rifampicin/pyrazinamide combination (standard therapy). We then applied extinction mathematics, morphisms and Latin hypercube sampling to identify duration of therapy with tigecycline monotherapy. RESULTS The median tigecycline MIC for 30 M. tuberculosis clinical and laboratory isolates (67% MDR/XDR) was 2 mg/L. Tigecycline monotherapy was highly effective in killing M. tuberculosis in log-phase-growth and semi-dormant and intracellular M. tuberculosis. Once-a-week dosing had the same efficacy as daily therapy for the same cumulative dose; thus, tigecycline efficacy was linked to the AUC0-24/MIC ratio. Tigecycline replacement by daily minocycline after 4 weeks of therapy was effective in sterilizing bacilli. The AUC0-24/MIC ratio associated with optimal kill was 42.3. Tigecycline monotherapy had a maximum sterilizing effect (day 0 minus day 28) of 3.06 ± 0.20 log10 cfu/mL (r2 = 0.92) compared with 3.92 ± 0.45 log10 cfu/mL (r2 = 0.80) with optimized standard therapy. In our modelling, at a tigecycline monotherapy duration of 12 months, the proportion of patients with XDR-TB who reached bacterial population extinction was 64.51%. CONCLUSIONS Tigecycline could cure patients with XDR-TB or MDR-TB who have failed recommended therapy. Once-a-week tigecycline could also replace second-line injectables in MDR-TB regimens.
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Affiliation(s)
- Devyani Deshpande
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Gesham Magombedze
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Shashikant Srivastava
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Paula Bendet
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Pooi S Lee
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Kayle N Cirrincione
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Katherine R Martin
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Keertan Dheda
- Lung Infection and Immunity Unit, Department of Medicine, Division of Pulmonology and UCT Lung Institute, Department of Medicine, University of Cape Town, Observatory, South Africa
| | - Tawanda Gumbo
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, TX, USA.,Lung Infection and Immunity Unit, Department of Medicine, Division of Pulmonology and UCT Lung Institute, Department of Medicine, University of Cape Town, Observatory, South Africa
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76
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Dheda K, Gumbo T, Maartens G, Dooley KE, Murray M, Furin J, Nardell EA, Warren RM. The Lancet Respiratory Medicine Commission: 2019 update: epidemiology, pathogenesis, transmission, diagnosis, and management of multidrug-resistant and incurable tuberculosis. THE LANCET RESPIRATORY MEDICINE 2020; 7:820-826. [PMID: 31486393 DOI: 10.1016/s2213-2600(19)30263-2] [Citation(s) in RCA: 78] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 07/24/2019] [Accepted: 07/25/2019] [Indexed: 01/23/2023]
Abstract
The Lancet Respiratory Medicine Commission on drug-resistant tuberculosis was published in 2017, which comprehensively reviewed and provided recommendations on various aspects of the disease. Several key new developments regarding drug-resistant tuberculosis are outlined in this Commission Update. The WHO guidelines on treating drug-resistant tuberculosis were updated in 2019 with a reclassification of second line anti-tuberculosis drugs. An injection-free MDR tuberculosis treatment regimen is now recommended. Over the past 3 years, advances in treatment include the recognition of the safety and mortality benefit of bedaquiline, the finding that the 9-11 month injectable-based 'Bangladesh' regimen was non-inferior to longer regimens, and promising interim results of a novel 6 month 3-drug regimen (bedaquiline, pretomanid, and linezolid). Studies of explanted lungs from patients with drug-resistant tuberculosis have shown substantial drug-specific gradients across pulmonary cavities, suggesting that alternative dosing and drug delivery strategies are needed to reduce functional monotherapy at the site of disease. Several controversies are discussed including the optimal route of drug administration, optimal number of drugs constituting a regimen, selection of individual drugs for a regimen, duration of the regimen, and minimal desirable standards of antibiotic stewardship. Newer rapid nucleic acid amplification test platforms, including point-of-care systems that facilitate active case-finding, are discussed. The rapid diagnosis of resistance to other drugs, (notably fluoroquinolones), and detection of resistance by targeted or whole genome sequencing will probably change the diagnostic landscape in the near future.
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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 Medical Research Council/University of Cape Town Centre for the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa; Faculty of Infectious and Tropical Diseases, Department of Infection Biology, London School of Hygiene and Tropical Medicine, London, UK.
| | - Tawanda Gumbo
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Kelly E Dooley
- Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Megan Murray
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - Jennifer Furin
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA; T H Chan School of Public Health, Harvard Medical School, Boston, MA, USA
| | - Edward A Nardell
- T H Chan School of Public Health, Harvard Medical School, Boston, MA, USA
| | - Robin M Warren
- South African Medical Research Council Centre for Tuberculosis Research/Department of Science and Technology/ National Research Foundation Centre of Excellence for Biomedical Tuberculosis Research, Division of Molecular Biology and Human Genetics, Stellenbosch University, Tygerberg, South Africa
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77
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Urbanowski ME, Ordonez AA, Ruiz-Bedoya CA, Jain SK, Bishai WR. Cavitary tuberculosis: the gateway of disease transmission. THE LANCET. INFECTIOUS DISEASES 2020; 20:e117-e128. [PMID: 32482293 PMCID: PMC7357333 DOI: 10.1016/s1473-3099(20)30148-1] [Citation(s) in RCA: 68] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 02/24/2020] [Accepted: 02/25/2020] [Indexed: 12/11/2022]
Abstract
Tuberculosis continues to be a major threat to global health. Cavitation is a dangerous consequence of pulmonary tuberculosis associated with poor outcomes, treatment relapse, higher transmission rates, and development of drug resistance. However, in the antibiotic era, cavities are often identified as the most extreme outcome of treatment failure and are one of the least-studied aspects of tuberculosis. We review the epidemiology, clinical features, and concurrent standards of care for individuals with cavitary tuberculosis. We also discuss developments in the understanding of tuberculosis cavities as dynamic physical and biochemical structures that interface the host response with a unique mycobacterial niche to drive tuberculosis-associated morbidity and transmission. Advances in preclinical models and non-invasive imaging can provide valuable insights into the drivers of cavitation. These insights will guide the development of specific pharmacological interventions to prevent cavitation and improve lung function for individuals with tuberculosis.
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Affiliation(s)
- Michael E. Urbanowski
- Center for Tuberculosis Research, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Center for Infection and Inflammation Imaging Research, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Alvaro A. Ordonez
- Center for Tuberculosis Research, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Center for Infection and Inflammation Imaging Research, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Camilo A. Ruiz-Bedoya
- Center for Tuberculosis Research, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Center for Infection and Inflammation Imaging Research, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sanjay K. Jain
- Center for Tuberculosis Research, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Center for Infection and Inflammation Imaging Research, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - William R. Bishai
- Center for Tuberculosis Research, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Center for Infection and Inflammation Imaging Research, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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78
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Griffith DE. Mycobacterium abscessus and Antibiotic Resistance: Same As It Ever Was. Clin Infect Dis 2020; 69:1687-1689. [PMID: 30689764 DOI: 10.1093/cid/ciz071] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Accepted: 01/24/2019] [Indexed: 11/13/2022] Open
Affiliation(s)
- David E Griffith
- Pulmonary Infectious Disease Section, University of Texas Health Science Center, Tyler
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79
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Nimmo C, Brien K, Millard J, Grant AD, Padayatchi N, Pym AS, O'Donnell M, Goldstein R, Breuer J, Balloux F. Dynamics of within-host Mycobacterium tuberculosis diversity and heteroresistance during treatment. EBioMedicine 2020; 55:102747. [PMID: 32361247 PMCID: PMC7195533 DOI: 10.1016/j.ebiom.2020.102747] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 03/02/2020] [Accepted: 03/19/2020] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Studying within-host genetic diversity of Mycobacterium tuberculosis (Mtb) in patients during treatment may identify adaptations to antibiotic and immune pressure. Understanding the significance of genetic heteroresistance, and more specifically heterozygous resistance-associated variants (RAVs), is clinically important given increasing use of rapid molecular tests and whole genome sequencing (WGS). METHODS We analyse data from six studies in KwaZulu-Natal, South Africa. Most patients (>75%) had baseline rifampicin resistance. Sputum was collected for culture at baseline and at between two and nine intervals until month six. Positive cultures underwent WGS. Mixed infections and reinfections were excluded from analysis. FINDINGS Baseline Mtb overall genetic diversity (at treatment initiation or major change to regimen) was associated with cavitary disease, not taking antiretroviral therapy if HIV infected, infection with lineage 2 strains and absence of second-line drug resistance on univariate analyses. Baseline genetic diversity was not associated with six-month outcome. Genetic diversity increased from baseline to weeks one and two before returning to previous levels. Baseline genetic heteroresistance was most common for bedaquiline (6/10 [60%] of isolates with RAVs) and fluoroquinolones (9/62 [13%]). Most patients with heterozygous RAVs on WGS with sequential isolates available demonstrated RAV persistence or fixation (17/20, 85%). New RAVs emerged in 9/286 (3%) patients during treatment. We could detect low-frequency RAVs preceding emergent resistance in only one case, although validation of deep sequencing to detect rare variants is required. INTERPRETATION In this study of single-strain Mtb infections, baseline within-host bacterial genetic diversity did not predict outcome but may reveal adaptations to host and drug pressures. Predicting emergent resistance from low-frequency RAVs requires further work to separate transient from consequential mutations. FUNDING Wellcome Trust, NIH/NIAID.
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MESH Headings
- Adult
- Antitubercular Agents/therapeutic use
- Cohort Studies
- Diarylquinolines/therapeutic use
- Drug Resistance, Multiple, Bacterial/genetics
- Female
- Fluoroquinolones/therapeutic use
- Gene Expression Regulation, Bacterial
- Genes, Bacterial
- Genetic Variation
- Host-Pathogen Interactions/genetics
- Humans
- Male
- Metabolic Networks and Pathways/genetics
- Microbial Sensitivity Tests
- Middle Aged
- Mycobacterium tuberculosis/drug effects
- Mycobacterium tuberculosis/genetics
- Mycobacterium tuberculosis/metabolism
- Rifampin/therapeutic use
- South Africa
- Sputum/microbiology
- Tuberculosis, Multidrug-Resistant/drug therapy
- Tuberculosis, Multidrug-Resistant/microbiology
- Tuberculosis, Multidrug-Resistant/pathology
- Tuberculosis, Pulmonary/drug therapy
- Tuberculosis, Pulmonary/microbiology
- Tuberculosis, Pulmonary/pathology
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Affiliation(s)
- Camus Nimmo
- Division of Infection and Immunity, University College London, London, UK; UCL Genetics Institute, University College London, London, UK; Africa Health Research Institute, Durban, South Africa.
| | - Kayleen Brien
- Africa Health Research Institute, Durban, South Africa
| | - 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
| | - Alison D Grant
- Africa Health Research Institute, Durban, South Africa; London School of Hygiene & Tropical Medicine, London, UK
| | - Nesri Padayatchi
- CAPRISA MRC-HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | | | - Max O'Donnell
- CAPRISA MRC-HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa; Department of Medicine & Epidemiology, Columbia University Medical Center, New York, NY, USA
| | - Richard Goldstein
- Division of Infection and Immunity, University College London, London, UK
| | - Judith Breuer
- Division of Infection and Immunity, University College London, London, UK
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80
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Van Der Werf TS, Barogui YT, Converse PJ, Phillips RO, Stienstra Y. Pharmacologic management of Mycobacterium ulcerans infection. Expert Rev Clin Pharmacol 2020; 13:391-401. [PMID: 32310683 DOI: 10.1080/17512433.2020.1752663] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Pharmacological treatment of Buruli ulcer (Mycobacterium ulcerans infection; BU) is highly effective, as shown in two randomized trials in Africa. AREAS COVERED We review BU drug treatment - in vitro, in vivo and clinical trials (PubMed: '(Buruli OR (Mycobacterium AND ulcerans)) AND (treatment OR therapy).' We also highlight the pathogenesis of M. ulcerans infection that is dominated by mycolactone, a secreted exotoxin, that causes skin and soft tissue necrosis, and impaired immune response and tissue repair. Healing is slow, due to the delayed wash-out of mycolactone. An array of repurposed tuberculosis and leprosy drugs appears effective in vitro and in animal models. In clinical trials and observational studies, only rifamycins (notably, rifampicin), macrolides (notably, clarithromycin), aminoglycosides (notably, streptomycin) and fluoroquinolones (notably, moxifloxacin, and ciprofloxacin) have been tested. EXPERT OPINION A combination of rifampicin and clarithromycin is highly effective but lesions still take a long time to heal. Novel drugs like telacebec have the potential to reduce treatment duration but this drug may remain unaffordable in low-resourced settings. Research should address ulcer treatment in general; essays to measure mycolactone over time hold promise to use as a readout for studies to compare drug treatment schedules for larger lesions of Buruli ulcer.
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Affiliation(s)
- Tjip S Van Der Werf
- Departments of Internal Medicine/Infectious Diseases, University Medical Centre Groningen, University of Groningen , Groningen, Netherlands.,Pulmonary Diseases & Tuberculosis, University Medical Centre Groningen, University of Groningen , Groningen, Netherlands
| | - Yves T Barogui
- Ministère De La Sante ́, Programme National Lutte Contre La Lèpre Et l'Ulcère De Buruli , Cotonou, Benin
| | - Paul J Converse
- Department of Medicine, Johns Hopkins University Center for Tuberculosis Research , Baltimore, Maryland, USA
| | - Richard O Phillips
- Kumasi, Ghana And Kwame Nkrumah University of Science and Technology, Komfo Anokye Teaching Hospital , Kumasi, Ghana
| | - Ymkje Stienstra
- Departments of Internal Medicine/Infectious Diseases, University Medical Centre Groningen, University of Groningen , Groningen, Netherlands
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Abstract
The control of tuberculosis (TB) is hampered by the emergence of multidrug-resistant (MDR) Mycobacterium tuberculosis (Mtb) strains, defined as resistant to at least isoniazid and rifampin, the two bactericidal drugs essential for the treatment of the disease. Due to the worldwide estimate of almost half a million incident cases of MDR/rifampin-resistant TB, it is important to continuously update the knowledge on the mechanisms involved in the development of this phenomenon. Clinical, biological and microbiological reasons account for the generation of resistance, including: (i) nonadherence of patients to their therapy, and/or errors of physicians in therapy management, (ii) complexity and poor vascularization of granulomatous lesions, which obstruct drug distribution to some sites, resulting in resistance development, (iii) intrinsic drug resistance of tubercle bacilli, (iv) formation of non-replicating, drug-tolerant bacilli inside the granulomas, (v) development of mutations in Mtb genes, which are the most important molecular mechanisms of resistance. This review provides a comprehensive overview of these issues, and releases up-dated information on the therapeutic strategies recently endorsed and recommended by the World Health Organization to facilitate the clinical and microbiological management of drug-resistant TB at the global level, with attention also to the most recent diagnostic methods.
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82
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Niederman MS, Nair GB, Matt U, Herold S, Pennington K, Crothers K, Cummings M, Schluger NW. Update in Lung Infections and Tuberculosis 2018. Am J Respir Crit Care Med 2020; 200:414-422. [PMID: 31042415 DOI: 10.1164/rccm.201903-0606up] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Michael S Niederman
- 1Division of Pulmonary and Critical Care Medicine, Weill Cornell Medical College, New York Presbyterian/Weill Cornell Medical Center, New York, New York
| | - Girish Balachandran Nair
- 2Division of Pulmonary and Critical Care Medicine, Beaumont Health, William Beaumont School of Medicine, Oakland University, Royal Oak, Michigan
| | - Ulrich Matt
- 3Department of Internal Medicine II, Universities of Giessen and Marburg Lung Center, member of the German Center for Lung Research, Justus Liebig University, Giessen, Germany
| | - Susanne Herold
- 3Department of Internal Medicine II, Universities of Giessen and Marburg Lung Center, member of the German Center for Lung Research, Justus Liebig University, Giessen, Germany
| | - Kelly Pennington
- 4Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Kristina Crothers
- 5Pulmonary, Critical Care and Sleep Medicine, VA Puget Sound Health Care System, Seattle, Washington.,6University of Washington, Seattle, Washington; and
| | | | - Neil W Schluger
- 7Columbia University Irving Medical Center, New York, New York
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83
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Ordonez AA, Wang H, Magombedze G, Ruiz-Bedoya CA, Srivastava S, Chen A, Tucker EW, Urbanowski ME, Pieterse L, Fabian Cardozo E, Lodge MA, Shah MR, Holt DP, Mathews WB, Dannals RF, Gobburu JVS, Peloquin CA, Rowe SP, Gumbo T, Ivaturi VD, Jain SK. Dynamic imaging in patients with tuberculosis reveals heterogeneous drug exposures in pulmonary lesions. Nat Med 2020; 26:529-534. [PMID: 32066976 DOI: 10.1038/s41591-020-0770-2] [Citation(s) in RCA: 77] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 01/15/2020] [Indexed: 11/09/2022]
Abstract
Tuberculosis (TB) is the leading cause of death from a single infectious agent, requiring at least 6 months of multidrug treatment to achieve cure1. However, the lack of reliable data on antimicrobial pharmacokinetics (PK) at infection sites hinders efforts to optimize antimicrobial dosing and shorten TB treatments2. In this study, we applied a new tool to perform unbiased, noninvasive and multicompartment measurements of antimicrobial concentration-time profiles in humans3. Newly identified patients with rifampin-susceptible pulmonary TB were enrolled in a first-in-human study4 using dynamic [11C]rifampin (administered as a microdose) positron emission tomography (PET) and computed tomography (CT). [11C]rifampin PET-CT was safe and demonstrated spatially compartmentalized rifampin exposures in pathologically distinct TB lesions within the same patients, with low cavity wall rifampin exposures. Repeat PET-CT measurements demonstrated independent temporal evolution of rifampin exposure trajectories in different lesions within the same patients. Similar findings were recapitulated by PET-CT in experimentally infected rabbits with cavitary TB and confirmed using postmortem mass spectrometry. Integrated modeling of the PET-captured concentration-time profiles in hollow-fiber bacterial kill curve experiments provided estimates on the rifampin dosing required to achieve cure in 4 months. These data, capturing the spatial and temporal heterogeneity of intralesional drug PK, have major implications for antimicrobial drug development.
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Affiliation(s)
- Alvaro A Ordonez
- Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Hechuan Wang
- Center for Translational Medicine, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Gesham Magombedze
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor University Medical Center and Texas Tech University Health Sciences Center, Dallas, TX, USA
| | - Camilo A Ruiz-Bedoya
- Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Shashikant Srivastava
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor University Medical Center and Texas Tech University Health Sciences Center, Dallas, TX, USA
| | - Allen Chen
- Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Elizabeth W Tucker
- Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Michael E Urbanowski
- Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Lisa Pieterse
- Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - E Fabian Cardozo
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Martin A Lodge
- Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Maunank R Shah
- Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Daniel P Holt
- Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - William B Mathews
- Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Robert F Dannals
- Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jogarao V S Gobburu
- Center for Translational Medicine, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Charles A Peloquin
- Infectious Disease Pharmacokinetics Laboratory, Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Gainesville, FL, USA
| | - Steven P Rowe
- Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Tawanda Gumbo
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor University Medical Center and Texas Tech University Health Sciences Center, Dallas, TX, USA
| | - Vijay D Ivaturi
- Center for Translational Medicine, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Sanjay K Jain
- Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA. .,Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA. .,Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA. .,Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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84
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Braunstein M, Hickey AJ, Ekins S. Why Wait? The Case for Treating Tuberculosis with Inhaled Drugs. Pharm Res 2019; 36:166. [PMID: 31650321 PMCID: PMC7607971 DOI: 10.1007/s11095-019-2704-6] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 09/13/2019] [Indexed: 11/27/2022]
Abstract
The discovery of drugs to treat tuberculosis (TB) was a major medical milestone in the twentieth century. However, from the outset, drug resistance was observed. Currently, of the 10 million people that exhibit TB symptoms each year, 450,000 have multidrug or extensively drug resistant (MDR or XDR) TB. While greater understanding of the host and pathogen (Mycobacterium tuberculosis, Mtb) coupled with scientific ingenuity will lead to new drugs and vaccines, in the meantime 4000 people die daily from TB. Thus, efforts to improve existing TB drugs should also be prioritized. Improved efficacy and decreased dose and associated toxicity of existing drugs would translate to greater compliance, life expectancy and quality of life of Mtb infected individuals. One potential strategy to improve existing drugs is to deliver them by inhalation as aerosols to the lung, the primary site of Mtb infection. Inhaled drugs are used for other pulmonary diseases, but they have yet to be utilized for TB. Inhaled therapies for TB represent an untapped opportunity that the pharmaceutical, clinical and regulatory communities should consider.
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Affiliation(s)
- Miriam Braunstein
- Department of Microbiology and Immunology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Anthony J Hickey
- RTI International, Research Triangle Park, North Carolina, USA
- UNC Catalyst for Rare Diseases, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Sean Ekins
- UNC Catalyst for Rare Diseases, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.
- Collaborations Pharmaceuticals, Inc., 840 Main Campus Drive, Lab 3510, Raleigh, North Carolina, USA.
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85
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Safi H, Gopal P, Lingaraju S, Ma S, Levine C, Dartois V, Yee M, Li L, Blanc L, Ho Liang HP, Husain S, Hoque M, Soteropoulos P, Rustad T, Sherman DR, Dick T, Alland D. Phase variation in Mycobacterium tuberculosis glpK produces transiently heritable drug tolerance. Proc Natl Acad Sci U S A 2019; 116:19665-19674. [PMID: 31488707 PMCID: PMC6765255 DOI: 10.1073/pnas.1907631116] [Citation(s) in RCA: 81] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
The length and complexity of tuberculosis (TB) therapy, as well as the propensity of Mycobacterium tuberculosis to develop drug resistance, are major barriers to global TB control efforts. M. tuberculosis is known to have the ability to enter into a drug-tolerant state, which may explain many of these impediments to TB treatment. We have identified a mechanism of genetically encoded but rapidly reversible drug tolerance in M. tuberculosis caused by transient frameshift mutations in a homopolymeric tract (HT) of 7 cytosines (7C) in the glpK gene. Inactivating frameshift mutations associated with the 7C HT in glpK produce small colonies that exhibit heritable multidrug increases in minimal inhibitory concentrations and decreases in drug-dependent killing; however, reversion back to a fully drug-susceptible large-colony phenotype occurs rapidly through the introduction of additional insertions or deletions in the same glpK HT region. These reversible frameshift mutations in the 7C HT of M. tuberculosis glpK occur in clinical isolates, accumulate in M. tuberculosis-infected mice with further accumulation during drug treatment, and exhibit a reversible transcriptional profile including induction of dosR and sigH and repression of kstR regulons, similar to that observed in other in vitro models of M. tuberculosis tolerance. These results suggest that GlpK phase variation may contribute to drug tolerance, treatment failure, and relapse in human TB. Drugs effective against phase-variant M. tuberculosis may hasten TB treatment and improve cure rates.
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Affiliation(s)
- Hassan Safi
- Center for Emerging Pathogens, New Jersey Medical School, Rutgers University, Newark, NJ 07103;
- Department of Medicine, New Jersey Medical School, Rutgers University, Newark, NJ 07103
| | - Pooja Gopal
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, 117597 Singapore, Republic of Singapore
| | - Subramanya Lingaraju
- Center for Emerging Pathogens, New Jersey Medical School, Rutgers University, Newark, NJ 07103
- Department of Medicine, New Jersey Medical School, Rutgers University, Newark, NJ 07103
| | - Shuyi Ma
- Center for Infectious Disease, Seattle Children's Hospital, Seattle, WA 98105
| | - Carly Levine
- Center for Emerging Pathogens, New Jersey Medical School, Rutgers University, Newark, NJ 07103
- Department of Medicine, New Jersey Medical School, Rutgers University, Newark, NJ 07103
| | - Veronique Dartois
- The Public Health Research Institute, New Jersey Medical School, Rutgers University, Newark, NJ 07103
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, NJ 07110
| | - Michelle Yee
- Department of Microbiology and Immunology, Yong Loo Lin School of Medicine, National University of Singapore, 117597 Singapore, Republic of Singapore
| | - Liping Li
- The Public Health Research Institute, New Jersey Medical School, Rutgers University, Newark, NJ 07103
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, NJ 07110
| | - Landry Blanc
- The Public Health Research Institute, New Jersey Medical School, Rutgers University, Newark, NJ 07103
| | - Hsin-Pin Ho Liang
- The Public Health Research Institute, New Jersey Medical School, Rutgers University, Newark, NJ 07103
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, NJ 07110
| | - Seema Husain
- Genomics Center, New Jersey Medical School, Rutgers University, Newark, NJ 07103
| | - Mainul Hoque
- Genomics Center, New Jersey Medical School, Rutgers University, Newark, NJ 07103
| | | | - Tige Rustad
- Center for Infectious Disease, Seattle Children's Hospital, Seattle, WA 98105
| | - David R Sherman
- Center for Infectious Disease, Seattle Children's Hospital, Seattle, WA 98105
| | - Thomas Dick
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, NJ 07110
| | - David Alland
- Center for Emerging Pathogens, New Jersey Medical School, Rutgers University, Newark, NJ 07103;
- Department of Medicine, New Jersey Medical School, Rutgers University, Newark, NJ 07103
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86
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Lange C, Dheda K, Chesov D, Mandalakas AM, Udwadia Z, Horsburgh CR. Management of drug-resistant tuberculosis. Lancet 2019; 394:953-966. [PMID: 31526739 DOI: 10.1016/s0140-6736(19)31882-3] [Citation(s) in RCA: 116] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 07/08/2019] [Accepted: 07/18/2019] [Indexed: 12/11/2022]
Abstract
Drug-resistant tuberculosis is a major public health concern in many countries. Over the past decade, the number of patients infected with Mycobacterium tuberculosis resistant to the most effective drugs against tuberculosis (ie, rifampicin and isoniazid), which is called multidrug-resistant tuberculosis, has continued to increase. Globally, 4·6% of patients with tuberculosis have multidrug-resistant tuberculosis, but in some areas, like Kazakhstan, Kyrgyzstan, Moldova, and Ukraine, this proportion exceeds 25%. Treatment for patients with multidrug-resistant tuberculosis is prolonged (ie, 9-24 months) and patients with multidrug-resistant tuberculosis have less favourable outcomes than those treated for drug-susceptible tuberculosis. Individualised multidrug-resistant tuberculosis treatment with novel (eg, bedaquiline) and repurposed (eg, linezolid, clofazimine, or meropenem) drugs and guided by genotypic and phenotypic drug susceptibility testing can improve treatment outcomes. Some clinical trials are evaluating 6-month regimens to simplify management and improve outcomes of patients with multidrug-resistant tuberculosis. Here we review optimal diagnostic and treatment strategies for patients with drug-resistant tuberculosis and their contacts.
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Affiliation(s)
- Christoph Lange
- Clinical Infectious Diseases, Research Center Borstel, Borstel, Germany; Respiratory Medicine and International Health, University of Lübeck, Lübeck, Germany; German Center for Infection Research Clinical Tuberculosis Unit, Borstel, Germany; Department of Medicine, Karolinska Institute, Stockholm, Sweden.
| | - Keertan Dheda
- Department of Medicine, Division of Pulmonology, Centre for Lung Infection and Immunity, Lung Institute, and Centre for the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa; South African Medical Research Council, Cape Town, South Africa; Faculty of Infectious and Tropical Diseases, Department of Immunology and Infection, London School of Hygiene & Tropical Medicine, London, UK
| | - Dumitru Chesov
- Clinical Infectious Diseases, Research Center Borstel, Borstel, Germany; Department of Pneumology and Alergollogy, Nicoale Testemitanu State University of Medicine and Pharmacy, Chisinau, Moldova
| | - Anna Maria Mandalakas
- The Global Tuberculosis Programme, Texas Children's Hospital, and Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Zarir Udwadia
- Hinduja Hospital and Research Center, Veer Savarkar Marg, Mumbai, India
| | - C Robert Horsburgh
- Department of Medicine, School of Medicine, and Department of Epidemiology, Department of Biostatistics, and Department of Global Health, School of Public Health, Boston University, Boston, MA, USA
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87
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Direct transmission of within-host Mycobacterium tuberculosis diversity to secondary cases can lead to variable between-host heterogeneity without de novo mutation: A genomic investigation. EBioMedicine 2019; 47:293-300. [PMID: 31420303 PMCID: PMC6796532 DOI: 10.1016/j.ebiom.2019.08.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 08/02/2019] [Accepted: 08/04/2019] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Whole genome sequencing (WGS) has enabled the development of new approaches to track Mycobacterium tuberculosis (Mtb) transmission between tuberculosis (TB) cases but its utility may be challenged by the discovery that Mtb diversifies within hosts. Nevertheless, there is limited data on the presence and degree of within-host evolution. METHODS We profiled a well-documented Mtb transmission cluster with three pulmonary TB cases to investigate within-host evolution and describe its impact on recent transmission estimates. We used deep sequencing to track minority allele frequencies (<50·0% abundance) during transmission and standard treatment. FINDINGS Pre-treatment (n = 3) and serial samples collected over 2 months of antibiotic treatment (n = 16) from all three cases were analysed. Consistent with the epidemiological data, zero fixed SNP separated all genomes. However, we identified six subclones between the three cases with an allele frequency ranging from 35·0% to 100·0% across sampling intervals. Five subclones were identified within the index case pre-treatment and shared with one secondary case, while only the dominant clone was observed in the other secondary case. By tracking the frequency of these heterogeneous alleles over the two-month therapy, we observed distinct signatures of drift and negative selection, but limited evidence for de novo mutations, even under drug pressure. INTERPRETATION We document within-host Mtb diversity in an index case, which led to transmission of minority alleles to a secondary case. Incorporating data on heterogeneous alleles may refine our understanding of Mtb transmission dynamics. However, more evidence is needed on the role of transmission bottleneck on observed heterogeneity between cases.
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88
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Dheda K, Lenders L, Srivastava S, Magombedze G, Wainwright H, Raj P, Bush SJ, Pollara G, Steyn R, Davids M, Pooran A, Pennel T, Linegar A, McNerney R, Moodley L, Pasipanodya JG, Turner CT, Noursadeghi M, Warren RM, Wakeland E, Gumbo T. Spatial Network Mapping of Pulmonary Multidrug-Resistant Tuberculosis Cavities Using RNA Sequencing. Am J Respir Crit Care Med 2019; 200:370-380. [PMID: 30694692 PMCID: PMC6680310 DOI: 10.1164/rccm.201807-1361oc] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 01/24/2019] [Indexed: 01/09/2023] Open
Abstract
Rationale: There is poor understanding about protective immunity and the pathogenesis of cavitation in patients with tuberculosis.Objectives: To map pathophysiological pathways at anatomically distinct positions within the human tuberculosis cavity.Methods: Biopsies were obtained from eight predetermined locations within lung cavities of patients with multidrug-resistant tuberculosis undergoing therapeutic surgical resection (n = 14) and healthy lung tissue from control subjects without tuberculosis (n = 10). RNA sequencing, immunohistochemistry, and bacterial load determination were performed at each cavity position. Differentially expressed genes were normalized to control subjects without tuberculosis, and ontologically mapped to identify a spatially compartmentalized pathophysiological map of the cavity. In silico perturbation using a novel distance-dependent dynamical sink model was used to investigate interactions between immune networks and bacterial burden, and to integrate these identified pathways.Measurements and Main Results: The median (range) lung cavity volume on positron emission tomography/computed tomography scans was 50 cm3 (15-389 cm3). RNA sequence reads (31% splice variants) mapped to 19,049 annotated human genes. Multiple proinflammatory pathways were upregulated in the cavity wall, whereas a downregulation "sink" in the central caseum-fluid interface characterized 53% of pathways including neuroendocrine signaling, calcium signaling, triggering receptor expressed on myeloid cells-1, reactive oxygen and nitrogen species production, retinoic acid-mediated apoptosis, and RIG-I-like receptor signaling. The mathematical model demonstrated that neuroendocrine, protein kinase C-θ, and triggering receptor expressed on myeloid cells-1 pathways, and macrophage and neutrophil numbers, had the highest correlation with bacterial burden (r > 0.6), whereas T-helper effector systems did not.Conclusions: These data provide novel insights into host immunity to Mycobacterium tuberculosis-related cavitation. The pathways defined may serve as useful targets for the design of host-directed therapies, and transmission prevention interventions.
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Affiliation(s)
- Keertan Dheda
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and UCT Lung Institute and 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, United Kingdom
| | - Laura Lenders
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and UCT Lung Institute and South African MRC/UCT Centre for the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa
| | - Shashikant Srivastava
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, Texas
- Department of Immunology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Gesham Magombedze
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, Texas
| | | | - Prithvi Raj
- Department of Immunology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Stephen J. Bush
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, Texas
| | - Gabriele Pollara
- Division of Infection and Immunity, University College London, London, United Kingdom; and
| | | | - Malika Davids
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and UCT Lung Institute and South African MRC/UCT Centre for the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa
| | - Anil Pooran
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and UCT Lung Institute and South African MRC/UCT Centre for the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa
| | - Timothy Pennel
- Chris Barnard Division of Cardiothoracic Surgery, Department of Surgery, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Anthony Linegar
- Chris Barnard Division of Cardiothoracic Surgery, Department of Surgery, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Ruth McNerney
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and UCT Lung Institute and South African MRC/UCT Centre for the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa
| | - Loven Moodley
- Chris Barnard Division of Cardiothoracic Surgery, Department of Surgery, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Jotam G. Pasipanodya
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, Texas
| | - Carolin T. Turner
- Division of Infection and Immunity, University College London, London, United Kingdom; and
| | - Mahdad Noursadeghi
- Division of Infection and Immunity, University College London, London, United Kingdom; and
| | - Robin M. Warren
- South African Medical Research Council Centre for Tuberculosis Research/Department of Science and Technology/National Research Foundation Centre of Excellence for Biomedical Tuberculosis Research, Division of Molecular Biology and Human Genetics, Stellenbosch University, Cape Town, South Africa
| | - Edward Wakeland
- Department of Immunology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Tawanda Gumbo
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and UCT Lung Institute and South African MRC/UCT Centre for the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, Texas
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89
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Cohen KA, Manson AL, Desjardins CA, Abeel T, Earl AM. Deciphering drug resistance in Mycobacterium tuberculosis using whole-genome sequencing: progress, promise, and challenges. Genome Med 2019; 11:45. [PMID: 31345251 PMCID: PMC6657377 DOI: 10.1186/s13073-019-0660-8] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Tuberculosis (TB) is a global infectious threat that is intensified by an increasing incidence of highly drug-resistant disease. Whole-genome sequencing (WGS) studies of Mycobacterium tuberculosis, the causative agent of TB, have greatly increased our understanding of this pathogen. Since the first M. tuberculosis genome was published in 1998, WGS has provided a more complete account of the genomic features that cause resistance in populations of M. tuberculosis, has helped to fill gaps in our knowledge of how both classical and new antitubercular drugs work, and has identified specific mutations that allow M. tuberculosis to escape the effects of these drugs. WGS studies have also revealed how resistance evolves both within an individual patient and within patient populations, including the important roles of de novo acquisition of resistance and clonal spread. These findings have informed decisions about which drug-resistance mutations should be included on extended diagnostic panels. From its origins as a basic science technique, WGS of M. tuberculosis is becoming part of the modern clinical microbiology laboratory, promising rapid and improved detection of drug resistance, and detailed and real-time epidemiology of TB outbreaks. We review the successes and highlight the challenges that remain in applying WGS to improve the control of drug-resistant TB through monitoring its evolution and spread, and to inform more rapid and effective diagnostic and therapeutic strategies.
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Affiliation(s)
- Keira A Cohen
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MA, 21205, USA.
| | - Abigail L Manson
- Broad Institute of Harvard and Massachusetts Institute of Technology, 415 Main Street, Cambridge, MA, 02142, USA
| | - Christopher A Desjardins
- Broad Institute of Harvard and Massachusetts Institute of Technology, 415 Main Street, Cambridge, MA, 02142, USA
| | - Thomas Abeel
- Broad Institute of Harvard and Massachusetts Institute of Technology, 415 Main Street, Cambridge, MA, 02142, USA
- Delft Bioinformatics Lab, Delft University of Technology, 2628, XE, Delft, The Netherlands
| | - Ashlee M Earl
- Broad Institute of Harvard and Massachusetts Institute of Technology, 415 Main Street, Cambridge, MA, 02142, USA.
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90
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Dheda K. Improving outcomes in patients with non-tuberculous mycobacterial disease: is there light at the end of the tunnel? Eur Respir J 2019; 54:54/1/1901149. [DOI: 10.1183/13993003.01149-2019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 06/21/2019] [Indexed: 11/05/2022]
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91
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Advancing the development of new tuberculosis treatment regimens: The essential role of translational and clinical pharmacology and microbiology. PLoS Med 2019; 16:e1002842. [PMID: 31276490 PMCID: PMC6611566 DOI: 10.1371/journal.pmed.1002842] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
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92
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Chirehwa MT, Velásquez GE, Gumbo T, McIlleron H. Quantitative assessment of the activity of antituberculosis drugs and regimens. Expert Rev Anti Infect Ther 2019; 17:449-457. [PMID: 31144539 PMCID: PMC6581212 DOI: 10.1080/14787210.2019.1621747] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 05/17/2019] [Indexed: 10/26/2022]
Abstract
Introduction: Identification of optimal drug doses and drug combinations is crucial for optimized treatment of tuberculosis. Areas covered: An unprecedented level of research activity involving multiple approaches is seeking to improve tuberculosis treatment. This report is a review of the quantitative methods currently used on clinical data sets to identify drug exposure targets and optimal drug combinations for tuberculosis treatment. A high-level summary of the methods, including the strengths and weaknesses of each method and potential methodological improvements is presented. Methods incorporating data generated from multiple sources such as in vitro and clinical studies, and their potential to provide better estimates of pharmacokinetic/pharmacodynamic (PK/PD) targets, are discussed. PK/PD relationships identified are compared between different studies and data analysis methods. Expert opinion: The relationships between drug exposures and tuberculosis treatment outcomes are complex and require analytical methods capable of handling the multidimensional nature of the relationships. The choice of a method is guided by its complexity, interpretability of results, and type of data available.
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Affiliation(s)
- Maxwell T. Chirehwa
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, South Africa
| | - Gustavo E. Velásquez
- Division of Infectious Diseases, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - Tawanda Gumbo
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, Texas, USA
| | - Helen McIlleron
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, South Africa
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93
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Abstract
Tuberculosis remains the leading cause of death from an infectious disease among adults worldwide, with more than 10 million people becoming newly sick from tuberculosis each year. Advances in diagnosis, including the use of rapid molecular testing and whole-genome sequencing in both sputum and non-sputum samples, could change this situation. Although little has changed in the treatment of drug-susceptible tuberculosis, data on increased efficacy with new and repurposed drugs have led WHO to recommend all-oral therapy for drug-resistant tuberculosis for the first time ever in 2018. Studies have shown that shorter latent tuberculosis prevention regimens containing rifampicin or rifapentine are as effective as longer, isoniazid-based regimens, and there is a promising vaccine candidate to prevent the progression of infection to the disease. But new tools alone are not sufficient. Advances must be made in providing high-quality, people-centred care for tuberculosis. Renewed political will, coupled with improved access to quality care, could relegate the morbidity, mortality, and stigma long associated with tuberculosis, to the past.
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Affiliation(s)
- Jennifer Furin
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA.
| | - Helen Cox
- Division of Medical Microbiology and the Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Madhukar Pai
- McGill International Tuberculosis Centre, McGill University, Montreal, QC, Canada; Manipal McGill Centre for Infectious Diseases, Manipal Academy of Higher Education, Manipal, India
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94
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Deciphering Within-Host Microevolution of Mycobacterium tuberculosis through Whole-Genome Sequencing: the Phenotypic Impact and Way Forward. Microbiol Mol Biol Rev 2019; 83:83/2/e00062-18. [PMID: 30918049 DOI: 10.1128/mmbr.00062-18] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
The Mycobacterium tuberculosis genome is more heterogenous and less genetically stable within the host than previously thought. Currently, only limited data exist on the within-host microevolution, diversity, and genetic stability of M. tuberculosis As a direct consequence, our ability to infer M. tuberculosis transmission chains and to understand the full complexity of drug resistance profiles in individual patients is limited. Furthermore, apart from the acquisition of certain drug resistance-conferring mutations, our knowledge on the function of genetic variants that emerge within a host and their phenotypic impact remains scarce. We performed a systematic literature review of whole-genome sequencing studies of serial and parallel isolates to summarize the knowledge on genetic diversity and within-host microevolution of M. tuberculosis We identified genomic loci of within-host emerged variants found across multiple studies and determined their functional relevance. We discuss important remaining knowledge gaps and finally make suggestions on the way forward.
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95
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Rohlwink UK, Walker NF, Ordonez AA, Li YJ, Tucker EW, Elkington PT, Wilkinson RJ, Wilkinson KA. Matrix Metalloproteinases in Pulmonary and Central Nervous System Tuberculosis-A Review. Int J Mol Sci 2019; 20:ijms20061350. [PMID: 30889803 PMCID: PMC6471445 DOI: 10.3390/ijms20061350] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 02/27/2019] [Accepted: 03/03/2019] [Indexed: 01/06/2023] Open
Abstract
Tuberculosis (TB) remains the single biggest infectious cause of death globally, claiming almost two million lives and causing disease in over 10 million individuals annually. Matrix metalloproteinases (MMPs) are a family of proteolytic enzymes with various physiological roles implicated as key factors contributing to the spread of TB. They are involved in the breakdown of lung extracellular matrix and the consequent release of Mycobacterium tuberculosis bacilli into the airways. Evidence demonstrates that MMPs also play a role in central nervous system (CNS) tuberculosis, as they contribute to the breakdown of the blood brain barrier and are associated with poor outcome in adults with tuberculous meningitis (TBM). However, in pediatric TBM, data indicate that MMPs may play a role in both pathology and recovery of the developing brain. MMPs also have a significant role in HIV-TB-associated immune reconstitution inflammatory syndrome in the lungs and the brain, and their modulation offers potential novel therapeutic avenues. This is a review of recent research on MMPs in pulmonary and CNS TB in adults and children and in the context of co-infection with HIV. We summarize different methods of MMP investigation and discuss the translational implications of MMP inhibition to reduce immunopathology.
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Affiliation(s)
- Ursula K Rohlwink
- Neuroscience Institute, University of Cape Town, Faculty of Health Sciences, Anzio Road, Observatory 7925, South Africa.
| | - Naomi F Walker
- TB Centre and Department of Clinical Research, London School of Hygiene and Tropical Medicine, Keppel St, London WC1E 7HT, UK.
| | - Alvaro A Ordonez
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.
- Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.
| | - Yifan J Li
- Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory 7925, South Africa.
| | - Elizabeth W Tucker
- Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.
- Division of Pediatric Critical Care, Johns Hopkins All Children's Hospital, St. Petersburg, FL 33701, USA.
| | - Paul T Elkington
- NIHR Biomedical Research Centre, School of Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, SO16 6YD, UK.
| | - Robert J Wilkinson
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town 7925, South Africa.
- The Francis Crick Institute, 1 Midland Road, London NW1 1AT, UK.
- Department of Medicine, Imperial College London, London W2 1PG, UK.
| | - Katalin A Wilkinson
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town 7925, South Africa.
- The Francis Crick Institute, 1 Midland Road, London NW1 1AT, UK.
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96
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Shenje J, Gumbo T, Wiesner L, Ntsekhe M, Mayosi B, Ross I. Detectable prednisolone is delayed in pericardial fluid, compared with plasma of patients with tuberculous pericarditis: A pilot study. IJC HEART & VASCULATURE 2019; 22:105-110. [PMID: 30963091 PMCID: PMC6437290 DOI: 10.1016/j.ijcha.2018.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 12/17/2018] [Indexed: 11/29/2022]
Abstract
Background In patients with tuberculous pericarditis [TBP] adjunctive prednisolone reduces the incidence of constrictive pericarditis. It is unknown whether prednisolone permeates adequately into pericardial fluid. Drug measurements in pericardial fluid require invasive procedures, and thus less invasive methods are needed to perform full pharmacokinetic characterization of prednisolone in large numbers of patients. We sought to evaluate the relationship between prednisolone concentrations in pericardial fluid, plasma, and saliva. Methods Plasma, pericardial fluid, and saliva samples were collected at 7 time points from TBP patients randomized to 120 mg prednisolone or placebo. Compartmental pharmacokinetic parameters, peak concentration [Cmax], and 0-24 h area under the concentration-time curve [AUC0-24] were identified in plasma, saliva and pericardial fluid. Results There were five patients each in the prednisolone and placebo groups. Prednisolone concentrations were best described using a one compartment model. The absorption half-life into plasma was 1 h, while that into pericardial fluid was 9.4 h, which led to a median time-to-maximum concentration in plasma of 2.0 h versus 5.0 h in pericardial fluid [p = 0.048]. The concentration-time profiles in pericardial fluid versus plasma exhibited system hysteresis. The pericardial fluid-to-plasma Cmax peak concentration ratio was 0.28 (p = 0.032), while the AUC0-24 ratio was 0.793. The concentration-time profiles in saliva had a similar shape to those in plasma, but the saliva-to-plasma Cmax was 0.59 [p = 0.032]. Conclusion The prednisolone AUC0-24 achieved in pericardial fluid approximates that in plasma, but the Cmax is low due to delayed absorption. Saliva can be used as surrogate sampling site for pericardial fluid prednisolone.
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Affiliation(s)
- Justin Shenje
- Department of Medicine, University of Cape Town, South Africa
| | - Tawanda Gumbo
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Dallas, TX, USA
| | - Lubbe Wiesner
- Department of Medicine, University of Cape Town, South Africa
| | - Mpiko Ntsekhe
- Department of Medicine, University of Cape Town, South Africa
| | - Bongani Mayosi
- Department of Medicine, University of Cape Town, South Africa
| | - Ian Ross
- Department of Medicine, University of Cape Town, South Africa
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97
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Magombedze G, Marino S. Mathematical and computational approaches in understanding the immunobiology of granulomatous diseases. ACTA ACUST UNITED AC 2018. [DOI: 10.1016/j.coisb.2018.07.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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98
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Gumbo T, Alffenaar JWC. Pharmacokinetic/Pharmacodynamic Background and Methods and Scientific Evidence Base for Dosing of Second-line Tuberculosis Drugs. Clin Infect Dis 2018; 67:S267-S273. [PMID: 30496455 PMCID: PMC6260166 DOI: 10.1093/cid/ciy608] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
A World Health Organization workshop systematically examined the evidence base for dosing second-line tuberculosis drugs, identifying knowledge gaps. To fill these in, pharmacokinetics/pharmacodynamics, Monte Carlo experiments, and artificial intelligence algorithms were used in hollow-fiber model studies and clinical data analyses.
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Affiliation(s)
- Tawanda Gumbo
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, Texas
| | - Jan-Willem C Alffenaar
- University of Groningen, University Medical Center Groningen, Department of Clinical Pharmacy and Pharmacology, The Netherlands
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99
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Deshpande D, Alffenaar JWC, Köser CU, Dheda K, Chapagain ML, Simbar N, Schön T, Sturkenboom MGG, McIlleron H, Lee PS, Koeuth T, Mpagama SG, Banu S, Foongladda S, Ogarkov O, Pholwat S, Houpt ER, Heysell SK, Gumbo T. d-Cycloserine Pharmacokinetics/Pharmacodynamics, Susceptibility, and Dosing Implications in Multidrug-resistant Tuberculosis: A Faustian Deal. Clin Infect Dis 2018; 67:S308-S316. [PMID: 30496460 PMCID: PMC6260153 DOI: 10.1093/cid/ciy624] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background d-cycloserine is used to treat multidrug-resistant tuberculosis. Its efficacy, contribution in combination therapy, and best clinical dose are unclear, also data on the d-cycloserine minimum inhibitory concentration (MIC) distributions is scant. Methods We performed a systematic search to identify pharmacokinetic and pharmacodynamic studies performed with d-cycloserine. We then performed a combined exposure-effect and dose fractionation study of d-cycloserine in the hollow fiber system model of tuberculosis (HFS-TB). In parallel, we identified d-cycloserine MICs in 415 clinical Mycobacterium tuberculosis (Mtb) isolates from patients. We utilized these results, including intracavitary concentrations, to identify the clinical dose that would be able to achieve or exceed target exposures in 10000 patients using Monte Carlo experiments (MCEs). Results There were no published d-cycloserine pharmacokinetics/pharmacodynamics studies identified. Therefore, we performed new HFS-TB experiments. Cyloserine killed 6.3 log10 colony-forming units (CFU)/mL extracellular bacilli over 28 days. Efficacy was driven by the percentage of time concentration persisted above MIC (%TMIC), with 1.0 log10 CFU/mL kill achieved by %TMIC = 30% (target exposure). The tentative epidemiological cutoff value with the Sensititre MYCOTB assay was 64 mg/L. In MCEs, 750 mg twice daily achieved target exposure in lung cavities of 92% of patients whereas 500 mg twice daily achieved target exposure in 85% of patients with meningitis. The proposed MCE-derived clinical susceptibility breakpoint at the proposed doses was 64 mg/L. Conclusions Cycloserine is cidal against Mtb. The susceptibility breakpoint is 64 mg/L. However, the doses likely to achieve the cidality in patients are high, and could be neurotoxic.
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Affiliation(s)
- Devyani Deshpande
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, Texas
| | - Jan-Willem C Alffenaar
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, The Netherlands
| | - Claudio U Köser
- Department of Genetics, University of Cambridge, United Kingdom
| | - Keertan Dheda
- Lung Immunity Unit, Division of Pulmonology, Department of Medicine, University of Cape Town, Observatory, South Africa
| | - Moti L Chapagain
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, Texas
| | - Noviana Simbar
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, The Netherlands
| | - Thomas Schön
- Department of Infectious Diseases and Clinical Microbiology, Kalmar County Hospital
- Department of Clinical and Experimental Medicine, Division of Medical Microbiology, Linköping University, Sweden
| | - Marieke G G Sturkenboom
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, The Netherlands
| | - Helen McIlleron
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Observatory, South Africa
| | - Pooi S Lee
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, Texas
| | - Thearith Koeuth
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, Texas
| | | | - Sayera Banu
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka
| | | | - Oleg Ogarkov
- Scientific Centre of the Family Health and Human Reproduction Problems, Irkutsk, Russian Federation
| | - Suporn Pholwat
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville
| | - Eric R Houpt
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville
| | - Scott K Heysell
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville
| | - Tawanda Gumbo
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, Texas
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100
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Magombedze G, Pasipanodya JG, Srivastava S, Deshpande D, Visser ME, Chigutsa E, McIlleron H, Gumbo T. Transformation Morphisms and Time-to-Extinction Analysis That Map Therapy Duration From Preclinical Models to Patients With Tuberculosis: Translating From Apples to Oranges. Clin Infect Dis 2018; 67:S349-S358. [PMID: 30496464 PMCID: PMC6260172 DOI: 10.1093/cid/ciy623] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Background A major challenge in medicine is translation of preclinical model findings to humans, especially therapy duration. One major example is recent shorter-duration therapy regimen failures in tuberculosis. Methods We used set theory mapping to develop a computational/modeling framework to map the time it takes to extinguish the Mycobacterium tuberculosis population on chemotherapy from multiple hollow fiber system model of tuberculosis (HFS-TB) experiments to that observed in patients. The predictive accuracy of the derived translation transformations was then tested using data from 108 HFS-TB Rapid Evaluation of Moxifloxacin in Tuberculosis (REMoxTB) units, including 756 colony-forming units (CFU)/mL. Derived transformations, and Latin hypercube sampling-guided simulations were used to predict cure and relapse after 4 and 6 months of therapy. Outcomes were compared to observations, in 1932 patients in the REMoxTB clinical trial. Results HFS-TB serial bacillary burden and serial sputum data in the derivation dataset formed a structure-preserving map. Bactericidal effect was mapped with a single step transformation, while the sterilizing effect was mapped with a 3-step transformation function. Using the HFS-TB REMoxTB data, we accurately predicted the proportion of patients cured in the 4-month REMoxTB clinical trial. Model-predicted vs clinical trial observations were (i) the ethambutol arm (77.0% [95% confidence interval {CI}, 74.4%-79.6%] vs 77.7% [95% CI, 74.3%-80.9%]) and (ii) the isoniazid arm (76.4% [95% CI, 73.9%-79.0%] vs 79.5% [95% CI, 76.1%-82.5%]). Conclusions We developed a method to translate duration of therapy outcomes from preclinical models to tuberculosis patients.
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Affiliation(s)
- Gesham Magombedze
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Dallas, Texas
| | - Jotam G Pasipanodya
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Dallas, Texas
| | - Shashikant Srivastava
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Dallas, Texas
| | - Devyani Deshpande
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Dallas, Texas
| | - Marianne E Visser
- Division of Pharmacology, Department of Medicine, University of Cape Town, Observatory, South Africa
| | - Emmanuel Chigutsa
- Division of Pharmacology, Department of Medicine, University of Cape Town, Observatory, South Africa
| | - Helen McIlleron
- Division of Pharmacology, Department of Medicine, University of Cape Town, Observatory, South Africa
| | - Tawanda Gumbo
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Dallas, Texas
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