201
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Naidoo A, Naidoo K, McIlleron H, Essack S, Padayatchi N. A Review of Moxifloxacin for the Treatment of Drug-Susceptible Tuberculosis. J Clin Pharmacol 2017; 57:1369-1386. [PMID: 28741299 DOI: 10.1002/jcph.968] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2017] [Accepted: 05/21/2017] [Indexed: 11/08/2022]
Abstract
Moxifloxacin, an 8-methoxy quinolone, is an important drug in the treatment of multidrug-resistant tuberculosis and is being investigated in novel drug regimens with pretomanid, bedaquiline, and pyrazinamide, or rifapentine, for the treatment of drug-susceptible tuberculosis. Early results of these studies are promising. Although current evidence does not support the use of moxifloxacin in treatment-shortening regimens for drug-susceptible tuberculosis, it may be recommended in patients unable to tolerate standard first-line drug regimens or for isoniazid monoresistance. Evidence suggests that the standard 400-mg dose of moxifloxacin used in the treatment of tuberculosis may be suboptimal in some patients, leading to worse tuberculosis treatment outcomes and emergence of drug resistance. Furthermore, a drug interaction with the rifamycins results in up to 31% reduced plasma concentrations of moxifloxacin when these are combined for treatment of drug-susceptible tuberculosis, although the clinical relevance of this interaction is unclear. Moxifloxacin exhibits extensive interindividual pharmacokinetic variability. Higher doses of moxifloxacin may be needed to achieve drug exposures required for improved clinical outcomes. Further study is, however, needed to determine the safety of proposed higher doses and clinically validated targets for drug exposure to moxifloxacin associated with improved tuberculosis treatment outcomes. We discuss in this review the evidence for the use of moxifloxacin in drug-susceptible tuberculosis and explore the role of moxifloxacin pharmacokinetics, pharmacodynamics, and drug interactions with rifamycins, on tuberculosis treatment outcomes when used in first-line tuberculosis drug regimens.
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Affiliation(s)
- Anushka Naidoo
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa
| | - Kogieleum Naidoo
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa.,MRC-CAPRISA HIV-TB Pathogenesis and Treatment Research Unit, Doris Duke Medical Research Institute, University of KwaZulu-Natal, Durban, South Africa
| | - Helen McIlleron
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Sabiha Essack
- Antimicrobial Research Unit, School of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Nesri Padayatchi
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa.,MRC-CAPRISA HIV-TB Pathogenesis and Treatment Research Unit, Doris Duke Medical Research Institute, University of KwaZulu-Natal, Durban, South Africa
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202
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The importance of clinical pharmacokinetic-pharmacodynamic studies in unraveling the determinants of early and late tuberculosis outcomes. ACTA ACUST UNITED AC 2017; 2:195-212. [PMID: 30283633 PMCID: PMC6161803 DOI: 10.4155/ipk-2017-0004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Accepted: 05/16/2017] [Indexed: 12/17/2022]
Abstract
Tuberculosis remains a major infectious cause of morbidity and mortality worldwide. Current antibiotic regimens, constructed prior to the development of modern pharmacokinetic-pharmacodynamic (PK–PD) tools, are based on incomplete understanding of exposure–response relationships in drug susceptible and multidrug resistant tuberculosis. Preclinical and population PK data suggest that clinical PK–PD studies may enable therapeutic drug monitoring for some agents and revised dosing for others. Future clinical PK–PD challenges include: incorporation of PK methods to assay free concentrations for all active metabolites; selection of appropriate early outcome measures which reflect therapeutic response; elucidation of genetic contributors to interindividual PK variability; conduct of targeted studies on special populations (including children); and measurement of PK–PD parameters at the site of disease.
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203
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Moxifloxacin is an effective and safe candidate agent for tuberculosis treatment: a meta-analysis. Int J Infect Dis 2017; 60:35-41. [DOI: 10.1016/j.ijid.2017.05.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
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204
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Gao M, Gao J, Du J, Liu Y, Zhang Y, Ma L, Mi F, Li L, Tang S. Efficacy of ultra-short course chemotherapy for new smear positive drug susceptible pulmonary tuberculosis: study protocol of a multicenter randomized controlled clinical trial. BMC Infect Dis 2017. [PMID: 28629333 PMCID: PMC5474865 DOI: 10.1186/s12879-017-2505-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background Shortening the standard 6-month treatment for drug-susceptible pulmonary tuberculosis (DS-PTB) would be a major improvement for TB case management and disease control. Methods We are conducting a randomized, open-label, controlled, non-inferiority trial involving patients with smear-positive, newly diagnosed DS-PTB cases nationwide to assess the efficacy and safety of two 4.5- month regimens in comparison to the standard 6-month WHO recommended regimen. The regimen used in one experiment group is a 4.5-month fluoroquinolone-containing regimen, which consists of full course of levofloxacin, isoniazid (H), rifampin (R), parazinamid (Z) and ethambutol (E). Regimen used in the second experiment group includes 4.5-month full course of H, R, Z, E with levofloxacin removed. Patients in the control group, receive H, R, Z and E for 2 months, followed by 4 months of H and R. The primary endpoint is treatment failure or relapse within 24 month after treatment completion. Discussion Results from this trial along with other studies will contribute to the science of constructing a shorter, effective and safe regiment for TB patients. Trial registration The protocol has been registered on ClinicalTrials.gov on 2 September,2016 with identifier NCT02901288.
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Affiliation(s)
- Mengqiu Gao
- Beijing Chest Hospital, Capital Medical University, Tuberculosis and Thoracic Tumor Research Institute, Beijing101149, Beijing, China
| | - Jingtao Gao
- Beijing Chest Hospital, Capital Medical University, Tuberculosis and Thoracic Tumor Research Institute, Beijing101149, Beijing, China
| | - Jian Du
- Beijing Chest Hospital, Capital Medical University, Tuberculosis and Thoracic Tumor Research Institute, Beijing101149, Beijing, China
| | - Yuhong Liu
- Beijing Chest Hospital, Capital Medical University, Tuberculosis and Thoracic Tumor Research Institute, Beijing101149, Beijing, China
| | - Yao Zhang
- Family Health International 360 (FHI360), Beijing, 100020, China
| | - Liping Ma
- Beijing Chest Hospital, Capital Medical University, Tuberculosis and Thoracic Tumor Research Institute, Beijing101149, Beijing, China
| | - Fengling Mi
- Beijing Chest Hospital, Capital Medical University, Tuberculosis and Thoracic Tumor Research Institute, Beijing101149, Beijing, China
| | - Liang Li
- Beijing Chest Hospital, Capital Medical University, Tuberculosis and Thoracic Tumor Research Institute, Beijing101149, Beijing, China.
| | - Shenjie Tang
- Beijing Chest Hospital, Capital Medical University, Tuberculosis and Thoracic Tumor Research Institute, Beijing101149, Beijing, China.
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205
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Monedero I, Bhavaraju R, Mendoza-Ticona A, Sánchez-Montalvá A. The paradigm shift to end tuberculosis. Are we ready to assume the changes? Expert Rev Respir Med 2017; 11:565-579. [PMID: 28562103 DOI: 10.1080/17476348.2017.1335599] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Tuberculosis (TB) is the number one infectious disease killer and exemplifies the most neglected of them. Drug-susceptible TB presents with high mortality especially in atypical forms, disproportionally affecting immunosuppressed and vulnerable populations. The drug-resistant TB (DR-TB) epidemic, a world crisis, is sustained and increased through person-to-person transmission in households and the community. TB diagnostics and treatment in recent years are highly evolving fields. New rapid molecular tests are changing the perspectives in diagnosis and resistance screening. Also, new drugs and shorter regimens for DR-TB are appearing. For the first time in recent history, a large number of randomized control trials are incoming. Areas covered: This article reviews most TB advances including new diagnostic tests, drugs, and regimens and outlines upcoming drug trials while disclosing the potential gaps the in development of patient-centered systems and current organizational challenges leading to a delay in the uptake of these innovations. Expert commentary: Innovations are occurring, but not many are implemented on a wide scale in developing countries. TB health systems and staff are not getting updated in parallel. More efforts and funds are needed not only to implement current novelties but also to research for future solutions to eliminate TB.
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Affiliation(s)
- Ignacio Monedero
- a TB-HIV Department. International Union against Tuberculosis and Lung Disease (The Union) , Paris , France
| | - Rajita Bhavaraju
- b Global Tuberculosis Institute, Rutgers, The State University of New Jersey , Newark , NJ , USA
| | - Alberto Mendoza-Ticona
- a TB-HIV Department. International Union against Tuberculosis and Lung Disease (The Union) , Paris , France.,c Clinical Research Department , Asociación Civil IMPACTA , Lima , Peru
| | - Adrián Sánchez-Montalvá
- d Infectious diseases department, Tropical Medicine Unit, PROCIS (International Health Program of the Catalan Health Institute) , Vall d'Hebron University Hospital,Universistat Autònoma de Barcelona , Barcelona , Spain
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206
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Bartelink IH, Zhang N, Keizer RJ, Strydom N, Converse PJ, Dooley KE, Nuermberger EL, Savic RM. New Paradigm for Translational Modeling to Predict Long-term Tuberculosis Treatment Response. Clin Transl Sci 2017; 10:366-379. [PMID: 28561946 PMCID: PMC5593171 DOI: 10.1111/cts.12472] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 04/10/2017] [Indexed: 02/06/2023] Open
Abstract
Disappointing results of recent tuberculosis chemotherapy trials suggest that knowledge gained from preclinical investigations was not utilized to maximal effect. A mouse‐to‐human translational pharmacokinetics (PKs) – pharmacodynamics (PDs) model built on a rich mouse database may improve clinical trial outcome predictions. The model included Mycobacterium tuberculosis growth function in mice, adaptive immune response effect on bacterial growth, relationships among moxifloxacin, rifapentine, and rifampin concentrations accelerating bacterial death, clinical PK data, species‐specific protein binding, drug‐drug interactions, and patient‐specific pathology. Simulations of recent trials testing 4‐month regimens predicted 65% (95% confidence interval [CI], 55–74) relapse‐free patients vs. 80% observed in the REMox‐TB trial, and 79% (95% CI, 72–87) vs. 82% observed in the Rifaquin trial. Simulation of 6‐month regimens predicted 97% (95% CI, 93–99) vs. 92% and 95% observed in 2RHZE/4RH control arms, and 100% predicted and observed in the 35 mg/kg rifampin arm of PanACEA MAMS. These results suggest that the model can inform regimen optimization and predict outcomes of ongoing trials.
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Affiliation(s)
- I H Bartelink
- Department of Bioengineering and Therapeutic Sciences, University of California San Francisco, California, USA.,Department of Medicine, University of California, San Francisco, California, USA
| | - N Zhang
- Department of Bioengineering and Therapeutic Sciences, University of California San Francisco, California, USA.,Center for Tuberculosis Research, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - R J Keizer
- Department of Bioengineering and Therapeutic Sciences, University of California San Francisco, California, USA.,InsightRX, a company developing dose optimization software for hospitals
| | - N Strydom
- Department of Bioengineering and Therapeutic Sciences, University of California San Francisco, California, USA
| | - P J Converse
- Center for Tuberculosis Research, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - K E Dooley
- Center for Tuberculosis Research, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - E L Nuermberger
- Center for Tuberculosis Research, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - R M Savic
- Department of Bioengineering and Therapeutic Sciences, University of California San Francisco, California, USA
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207
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Use of whole-genome sequencing to distinguish relapse from reinfection in a completed tuberculosis clinical trial. BMC Med 2017; 15:71. [PMID: 28351427 PMCID: PMC5371199 DOI: 10.1186/s12916-017-0834-4] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 03/09/2017] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND RIFAQUIN was a tuberculosis chemotherapy trial in southern Africa including regimens with high-dose rifapentine with moxifloxacin. Here, the application of whole-genome sequencing (WGS) is evaluated within RIFAQUIN for identifying new infections in treated patients as either relapses or reinfections. WGS is further compared with mycobacterial interspersed repetitive units-variable number tandem repeats (MIRU-VNTR) typing. This is the first report of WGS being used to evaluate new infections in a completed clinical trial for which all treatment and epidemiological data are available for analysis. METHODS DNA from 36 paired samples of Mycobacterium tuberculosis cultured from patients before and after treatment was typed using 24-loci MIRU-VNTR, in silico spoligotyping and WGS. Following WGS, the sequences were mapped against the reference strain H37Rv, the single-nucleotide polymorphism (SNP) differences between pairs were identified, and a phylogenetic reconstruction was performed. RESULTS WGS indicated that 32 of the paired samples had a very low number of SNP differences (0-5; likely relapses). One pair had an intermediate number of SNP differences, and was likely the result of a mixed infection with a pre-treatment minor genotype that was highly related to the post-treatment genotype; this was reclassified as a relapse, in contrast to the MIRU-VNTR result. The remaining three pairs had very high SNP differences (>750; likely reinfections). CONCLUSIONS WGS and MIRU-VNTR both similarly differentiated relapses and reinfections, but WGS provided significant extra information. The low proportion of reinfections seen suggests that in standard chemotherapy trials with up to 24 months of follow-up, typing the strains brings little benefit to an analysis of the trial outcome in terms of differentiating relapse and reinfection. However, there is a benefit to using WGS as compared to MIRU-VNTR in terms of the additional genotype information obtained, in particular for defining the presence of mixed infections and the potential to identify known and novel drug-resistance markers.
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208
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Sharing the spotlight in Durban: A report from IAS TB2016 at AIDS2016. J Clin Tuberc Other Mycobact Dis 2017; 7:34-39. [PMID: 31723699 PMCID: PMC6850242 DOI: 10.1016/j.jctube.2017.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Revised: 03/06/2017] [Accepted: 03/07/2017] [Indexed: 11/03/2022] Open
Abstract
Tuberculosis (TB) is now recognized as the number one cause of death worldwide due to a single infectious pathogen and is the cause of death in one-third of people living with HIV worldwide. An inaugural pre-conference focused on TB (TB2016) was held at the International AIDS Society Conference AIDS2016. This report focuses on key messages from the TB2016 conference that are important for the medical, public health, activist, and scientific communities.
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209
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Manson AL, Cohen KA, Abeel T, Desjardins CA, Armstrong DT, Barry CE, Brand J, Chapman SB, Cho SN, Gabrielian A, Gomez J, Jodals AM, Joloba M, Jureen P, Lee JS, Malinga L, Maiga M, Nordenberg D, Noroc E, Romancenco E, Salazar A, Ssengooba W, Velayati AA, Winglee K, Zalutskaya A, Via LE, Cassell GH, Dorman SE, Ellner J, Farnia P, Galagan JE, Rosenthal A, Crudu V, Homorodean D, Hsueh PR, Narayanan S, Pym AS, Skrahina A, Swaminathan S, Van der Walt M, Alland D, Bishai WR, Cohen T, Hoffner S, Birren BW, Earl AM. Genomic analysis of globally diverse Mycobacterium tuberculosis strains provides insights into the emergence and spread of multidrug resistance. Nat Genet 2017; 49:395-402. [PMID: 28092681 PMCID: PMC5402762 DOI: 10.1038/ng.3767] [Citation(s) in RCA: 174] [Impact Index Per Article: 24.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 12/14/2016] [Indexed: 11/09/2022]
Abstract
Multidrug-resistant tuberculosis (MDR-TB), caused by drug-resistant strains of Mycobacterium tuberculosis, is an increasingly serious problem worldwide. Here we examined a data set of whole-genome sequences from 5,310 M. tuberculosis isolates from five continents. Despite the great diversity of these isolates with respect to geographical point of isolation, genetic background and drug resistance, the patterns for the emergence of drug resistance were conserved globally. We have identified harbinger mutations that often precede multidrug resistance. In particular, the katG mutation encoding p.Ser315Thr, which confers resistance to isoniazid, overwhelmingly arose before mutations that conferred rifampicin resistance across all of the lineages, geographical regions and time periods. Therefore, molecular diagnostics that include markers for rifampicin resistance alone will be insufficient to identify pre-MDR strains. Incorporating knowledge of polymorphisms that occur before the emergence of multidrug resistance, particularly katG p.Ser315Thr, into molecular diagnostics should enable targeted treatment of patients with pre-MDR-TB to prevent further development of MDR-TB.
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Affiliation(s)
- Abigail L. Manson
- Broad Institute of M.I.T. and Harvard, 415 Main Street, Cambridge, MA, 02142, USA
| | - Keira A. Cohen
- Broad Institute of M.I.T. and Harvard, 415 Main Street, Cambridge, MA, 02142, USA
- KwaZulu-Natal Research Institute for TB and HIV (K-RITH), Durban, South Africa
- Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Thomas Abeel
- Broad Institute of M.I.T. and Harvard, 415 Main Street, Cambridge, MA, 02142, USA
- Delft Bioinformatics Lab, Delft University of Technology, Delft, The Netherlands
| | | | | | - Clifton E. Barry
- National Institute of Allergy and Infectious Disease, National Institute of Health, USA
| | - Jeannette Brand
- Medical Research Council, TB Platform, Pretoria, South Africa
- TBResist Global Genome Consortium
| | - Sinéad B. Chapman
- Broad Institute of M.I.T. and Harvard, 415 Main Street, Cambridge, MA, 02142, USA
| | - Sang-Nae Cho
- International Tuberculosis Research Center, Changwon and Department of Microbiology, Yonsei University College of Medicine, Seoul, South Korea
| | - Andrei Gabrielian
- Office of Cyber Infrastructure and Computational Biology, National Institute of Health, USA
| | - James Gomez
- Broad Institute of M.I.T. and Harvard, 415 Main Street, Cambridge, MA, 02142, USA
| | | | - Moses Joloba
- Makerere University, Department of Medical Microbiology, Mycobacteriology Laboratory, Kampala, Uganda
| | - Pontus Jureen
- The Public Health Agency of Sweden, Sweden
- TBResist Global Genome Consortium
| | - Jong Seok Lee
- International Tuberculosis Research Center, Changwon and Department of Microbiology, Yonsei University College of Medicine, Seoul, South Korea
| | - Lesibana Malinga
- Medical Research Council, TB Platform, Pretoria, South Africa
- TBResist Global Genome Consortium
| | - Mamoudou Maiga
- University of Sciences, Techniques and Technologies of Bamako (USTTB), Bamako, Mali
| | - Dale Nordenberg
- Novasano Health and Science
- TBResist Global Genome Consortium
| | - Ecaterina Noroc
- Microbiology & Morphology Laboratory Phthisiopneumology Institute, Chisinau, Moldova
| | - Elena Romancenco
- Microbiology & Morphology Laboratory Phthisiopneumology Institute, Chisinau, Moldova
| | - Alex Salazar
- Broad Institute of M.I.T. and Harvard, 415 Main Street, Cambridge, MA, 02142, USA
- Delft Bioinformatics Lab, Delft University of Technology, Delft, The Netherlands
| | - Willy Ssengooba
- Makerere University, Department of Medical Microbiology, Mycobacteriology Laboratory, Kampala, Uganda
| | - A. A. Velayati
- Mycobacteriology Research Centre, National Research Institute of Tuberculosis and Lung Disease (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
- TBResist Global Genome Consortium
| | | | - Aksana Zalutskaya
- Republican Research and Practical Centre for Pulmonology and Tuberculosis, Belarus
| | - Laura E. Via
- National Institute of Allergy and Infectious Disease, National Institute of Health, USA
| | - Gail H. Cassell
- Department of Global Health and Social Medicine, Harvard Medical School, Division of Global Health Equity, Brigham and Women’s Hospital, Boston, MA
- TBResist Global Genome Consortium
| | | | | | - Parissa Farnia
- Mycobacteriology Research Centre, National Research Institute of Tuberculosis and Lung Disease (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
- TBResist Global Genome Consortium
| | - James E. Galagan
- Broad Institute of M.I.T. and Harvard, 415 Main Street, Cambridge, MA, 02142, USA
- Boston University, Boston, MA, USA
| | - Alex Rosenthal
- Office of Cyber Infrastructure and Computational Biology, National Institute of Health, USA
| | - Valeriu Crudu
- Microbiology & Morphology Laboratory Phthisiopneumology Institute, Chisinau, Moldova
| | - Daniela Homorodean
- Clinical Hospital of Pneumology Leon Daniello Cluj Napoca, Romania
- TBResist Global Genome Consortium
| | - Po-Ren Hsueh
- National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | | | - Alexander S. Pym
- KwaZulu-Natal Research Institute for TB and HIV (K-RITH), Durban, South Africa
| | - Alena Skrahina
- Republican Research and Practical Centre for Pulmonology and Tuberculosis, Belarus
- TBResist Global Genome Consortium
| | | | - Martie Van der Walt
- Medical Research Council, TB Platform, Pretoria, South Africa
- TBResist Global Genome Consortium
| | - David Alland
- Rutgers-New Jersey Medical School, New Jersey, USA
| | - William R. Bishai
- KwaZulu-Natal Research Institute for TB and HIV (K-RITH), Durban, South Africa
- Johns Hopkins University, Baltimore, MD, USA
| | - Ted Cohen
- Harvard T. H. Chan School of Public Health, Boston, MA, USA
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, USA
| | - Sven Hoffner
- The Public Health Agency of Sweden, Sweden
- TBResist Global Genome Consortium
| | - Bruce W. Birren
- Broad Institute of M.I.T. and Harvard, 415 Main Street, Cambridge, MA, 02142, USA
| | - Ashlee M. Earl
- Broad Institute of M.I.T. and Harvard, 415 Main Street, Cambridge, MA, 02142, USA
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Muliaditan M, Davies GR, Simonsson US, Gillespie SH, Della Pasqua O. The implications of model-informed drug discovery and development for tuberculosis. Drug Discov Today 2017; 22:481-486. [DOI: 10.1016/j.drudis.2016.09.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2016] [Revised: 08/05/2016] [Accepted: 09/06/2016] [Indexed: 12/31/2022]
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211
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Hanna D, Romero K, Schito M. Advancing tuberculosis drug regimen development through innovative quantitative translational pharmacology methods and approaches. Int J Infect Dis 2017; 56:208-211. [DOI: 10.1016/j.ijid.2016.10.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Accepted: 10/11/2016] [Indexed: 12/21/2022] Open
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212
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Tiberi S, Buchanan R, Caminero JA, Centis R, Arbex MA, Salazar M, Potter J, Migliori GB. The challenge of the new tuberculosis drugs. Presse Med 2017; 46:e41-e51. [PMID: 28256383 DOI: 10.1016/j.lpm.2017.01.016] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2016] [Accepted: 01/05/2017] [Indexed: 12/01/2022] Open
Abstract
Tuberculosis (TB) continues to cause more deaths worldwide than any other single infectious disease. Even though tuberculosis appears to be decreasing in incidence globally for some time, the proportion of drug resistance is increasing, contributing to greater complexity, morbidity and mortality as well as cost. Since the advent of rifampicin in the 1960s, and the implementation of standard quadruple anti-tuberculosis regimen in the late 1970s, no new drugs have been changed the first line regimen. This regimen is effective however it is pill burden, and duration has not received investment and innovation. Drug-resistant regimens are long and frequently poorly tolerated due to significant toxicity. This review is an update on what is new in the treatment of drug-susceptible and drug-resistant tuberculosis, new TB drugs currently being used and studied in clinical trials are also mentioned. Fortunately, there have been many significant advances in this field in recent years. The horizon is changing with the new WHO shorter multidrug-resistant tuberculosis regimens and with the increasing availability of new or repurposed drugs like bedaquiline, delamanid, clofazimine and linezolid. These drugs pose new challenges relating to their rational use to prevent selection of resistant strains of Mycobacterium tuberculosis even before a new regimen has been studied. The availability of these new drugs is offering hope and new possibilities for saving patients who had few or no treatment options. Their use and combination into effective regimens need to be studied; trials are in progress. It is hoped that soon we will be able to treat sensitive and drug-resistant cases with a universal regimen, this would revolutionise treatment and take us another step closer towards elimination.
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Affiliation(s)
- Simon Tiberi
- Barts Health NHS Trust, Royal London Hospital, Division of Infection, 80 Newark Street, E1 2ES London, United Kingdom
| | - Ruaridh Buchanan
- Barts Health NHS Trust, Royal London Hospital, Division of Infection, 80 Newark Street, E1 2ES London, United Kingdom
| | - José A Caminero
- University Hospital of Gran Canaria "Dr Negrin", Pneumology Department, Barranco de la Ballena, s/n, 35010 Las Palmas de Gran Canaria, Las Palmas, Spain; International Union against Tuberculosis and Lung Disease, Paris, France
| | - Rosella Centis
- Maugeri Care and Research Institute, IRCCS, World Health Organization Collaborating Centre for Tuberculosis and Lung Diseases, Tradate, Italy
| | - Marcos Abdo Arbex
- University Center of Araraquara Hospital Nestor Goulart Reis, São Paulo State Secretary of Health, São Paulo, Brazil
| | - Miguel Salazar
- Tuberculosis Clinic, National Institute of Respiratory Diseases of Mexico (INER), Mexico City, Mexico
| | - Jessica Potter
- Barts Health NHS Trust, Royal London Hospital, Department of Respiratory Medicine, 80, Newark Street, E1 2ES London, United Kingdom; Blizard Institute, Barts and the London School of Medicine and Dentistry, Centre for Primary Care and Public Health, E1 2AB London, United Kingdom
| | - Giovanni Battista Migliori
- Maugeri Care and Research Institute, IRCCS, World Health Organization Collaborating Centre for Tuberculosis and Lung Diseases, Tradate, Italy.
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213
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Lee JY, Kim DK, Lee JK, Yoon HI, Jeong I, Heo E, Park YS, Lee JH, Park SS, Lee SM, Lee CH, Lee J, Choi SM, Park JS, Joh JS, Cho YJ, Lee YJ, Kim SJ, Hwang YR, Kim H, Ki J, Choi H, Han J, Ahn H, Hahn S, Yim JJ. Substitution of ethambutol with linezolid during the intensive phase of treatment of pulmonary tuberculosis: study protocol for a prospective, multicenter, randomized, open-label, phase II trial. Trials 2017; 18:68. [PMID: 28193240 PMCID: PMC5307889 DOI: 10.1186/s13063-017-1811-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2016] [Accepted: 01/23/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Linezolid, an oxazolidinone, substantially improves treatment outcomes of multidrug-resistant tuberculosis and extensively drug-resistant tuberculosis. We started a trial to test whether the use of linezolid instead of ethambutol could increase the rate of sputum culture conversion as of 8 weeks of treatment in patients with drug-susceptible tuberculosis. METHODS/DESIGN This is a phase II, multicenter, randomized study with three arms. We are enrolling patients with pulmonary tuberculosis without rifampicin resistance screened by the Xpert MTB/RIF® assay. The standard treatment arm uses isoniazid (6 months), rifampicin (6 months), pyrazinamide (2 months), and ethambutol (2 months). Experimental arm 1 uses linezolid (600 mg/day) for 4 weeks instead of ethambutol. Experimental arm 2 uses linezolid (600 mg/day) for 2 weeks instead of ethambutol. The primary outcome is the sputum culture conversion rate on liquid media after 2 months of treatment. Secondary outcomes include the sputum culture conversion rate on solid media after 2 months of treatment, time to sputum culture conversion on liquid and solid media, cure rate, and treatment success rate. The frequencies of total adverse events (AEs) and serious AEs will be described and documented. Based on an α = 0.05 level of significance, a power of 85%, a 15% difference in the culture conversion rate after 2 months between the control arm and experimental arm 1 (75% vs. 90%), a 10% default (loss to follow-up) rate, and a 10% culture failure, the required number per arm was calculated to be 143 (429 in total). DISCUSSION This trial will reveal the effectiveness and safety of 2 or 4 weeks of use of linezolid instead of ethambutol for patients with drug-susceptible pulmonary tuberculosis. If a new regimen including linezolid shows a higher culture conversion rate by week 8, and is safe, it could be tested as a 4-month antituberculosis treatment regimen in the future. TRIAL REGISTRATION ClincalTrials.gov, NCT01994460 . Registered on 13 November 2013.
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Affiliation(s)
- Ji Yeon Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, National Medical Center, Seoul, Republic of Korea
| | - Deog Kyeom Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul, Republic of Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jung-Kyu Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul, Republic of Korea
| | - Ho Il Yoon
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ina Jeong
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, National Medical Center, Seoul, Republic of Korea
| | - Eunyoung Heo
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul, Republic of Korea
| | - Young Sik Park
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jae Ho Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Sung Soo Park
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul, Republic of Korea
| | - Sang-Min Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Chang-Hoon Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jinwoo Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Sun Mi Choi
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jong Sun Park
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Joon-Sung Joh
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, National Medical Center, Seoul, Republic of Korea
| | - Young-Jae Cho
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Yeon Joo Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Se Joong Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Young Ran Hwang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul, Republic of Korea
| | - Hyeonjeong Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jongeun Ki
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, National Medical Center, Seoul, Republic of Korea
| | - Hyungsook Choi
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Jiyeon Han
- Medical Research Collaborating Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Heejung Ahn
- Medical Research Collaborating Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Seokyung Hahn
- Medical Research Collaborating Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jae-Joon Yim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea. .,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea.
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214
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Ndounga Diakou LA, Ntoumi F, Ravaud P, Boutron I. Published randomized trials performed in Sub-Saharan Africa focus on high-burden diseases but are frequently funded and led by high-income countries. J Clin Epidemiol 2017; 82:29-36.e6. [DOI: 10.1016/j.jclinepi.2016.10.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Revised: 10/10/2016] [Accepted: 10/26/2016] [Indexed: 01/05/2023]
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215
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New tuberculosis drug leads from naturally occurring compounds. Int J Infect Dis 2017; 56:212-220. [PMID: 28062229 DOI: 10.1016/j.ijid.2016.12.024] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Revised: 12/21/2016] [Accepted: 12/22/2016] [Indexed: 12/21/2022] Open
Abstract
Tuberculosis (TB) continues to be a significant cause of mortality and morbidity worldwide. An estimated 2 billion individuals are infected with Mycobacterium tuberculosis and annually there are approximately 10 million new cases of clinical TB and 1.5 million deaths. Currently available drugs and vaccines have had no significant impact on TB control. In addition, the emergence of drug resistant TB is considered a public health crisis, with some strains now resistant to all available drugs. Unfortunately, the growing burden of antibiotic resistance is coupled with decreased effort in the development of new antibiotics. Natural sources are attractive starting points in the search for anti-tubercular drugs because they are extremely rich in chemical diversity and have privileged antimicrobial activity. This review will discuss recent advances in the development of TB drug leads from natural products, with a particular focus on anti-mycobacterial compounds in late-stage preclinical and clinical development.
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216
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Kendall EA, Shrestha S, Cohen T, Nuermberger E, Dooley KE, Gonzalez-Angulo L, Churchyard GJ, Nahid P, Rich ML, Bansbach C, Forissier T, Lienhardt C, Dowdy DW. Priority-Setting for Novel Drug Regimens to Treat Tuberculosis: An Epidemiologic Model. PLoS Med 2017; 14:e1002202. [PMID: 28045934 PMCID: PMC5207633 DOI: 10.1371/journal.pmed.1002202] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Accepted: 11/16/2016] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Novel drug regimens are needed for tuberculosis (TB) treatment. New regimens aim to improve on characteristics such as duration, efficacy, and safety profile, but no single regimen is likely to be ideal in all respects. By linking these regimen characteristics to a novel regimen's ability to reduce TB incidence and mortality, we sought to prioritize regimen characteristics from a population-level perspective. METHODS AND FINDINGS We developed a dynamic transmission model of multi-strain TB epidemics in hypothetical populations reflective of the epidemiological situations in India (primary analysis), South Africa, the Philippines, and Brazil. We modeled the introduction of various novel rifampicin-susceptible (RS) or rifampicin-resistant (RR) TB regimens that differed on six characteristics, identified in consultation with a team of global experts: (1) efficacy, (2) duration, (3) ease of adherence, (4) medical contraindications, (5) barrier to resistance, and (6) baseline prevalence of resistance to the novel regimen. We compared scale-up of these regimens to a baseline reflective of continued standard of care. For our primary analysis situated in India, our model generated baseline TB incidence and mortality of 157 (95% uncertainty range [UR]: 113-187) and 16 (95% UR: 9-23) per 100,000 per year at the time of novel regimen introduction and RR TB incidence and mortality of 6 (95% UR: 4-10) and 0.6 (95% UR: 0.3-1.1) per 100,000 per year. An optimal RS TB regimen was projected to reduce 10-y TB incidence and mortality in the India-like scenario by 12% (95% UR: 6%-20%) and 11% (95% UR: 6%-20%), respectively, compared to current-care projections. An optimal RR TB regimen reduced RR TB incidence by an estimated 32% (95% UR: 18%-46%) and RR TB mortality by 30% (95% UR: 18%-44%). Efficacy was the greatest determinant of impact; compared to a novel regimen meeting all minimal targets only, increasing RS TB treatment efficacy from 94% to 99% reduced TB mortality by 6% (95% UR: 1%-13%, half the impact of a fully optimized regimen), and increasing the efficacy against RR TB from 76% to 94% lowered RR TB mortality by 13% (95% UR: 6%-23%). Reducing treatment duration or improving ease of adherence had smaller but still substantial impact: shortening RS TB treatment duration from 6 to 2 mo lowered TB mortality by 3% (95% UR: 1%-6%), and shortening RR TB treatment from 20 to 6 mo reduced RR TB mortality by 8% (95% UR: 4%-13%), while reducing nonadherence to the corresponding regimens by 50% reduced TB and RR TB mortality by 2% (95% UR: 1%-4%) and 6% (95% UR: 3%-10%), respectively. Limitations include sparse data on key model parameters and necessary simplifications to model structure and outcomes. CONCLUSIONS In designing clinical trials of novel TB regimens, investigators should consider that even small changes in treatment efficacy may have considerable impact on TB-related incidence and mortality. Other regimen improvements may still have important benefits for resource allocation and outcomes such as patient quality of life.
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Affiliation(s)
- Emily A. Kendall
- Johns Hopkins University School of Medicine, Division of Infectious Diseases, Baltimore, Maryland, United States of America
- * E-mail:
| | - Sourya Shrestha
- Johns Hopkins Bloomberg School of Public Health, Department of Epidemiology, Baltimore, Maryland, United States of America
| | - Ted Cohen
- Yale School of Public Health, Department of Epidemiology of Microbial Diseases, New Haven, Connecticut, United States of America
| | - Eric Nuermberger
- Johns Hopkins University School of Medicine, Division of Infectious Diseases, Baltimore, Maryland, United States of America
| | - Kelly E. Dooley
- Johns Hopkins University School of Medicine, Division of Infectious Diseases, Baltimore, Maryland, United States of America
- Johns Hopkins University School of Medicine, Division of Clinical Pharmacology, Baltimore, Maryland, United States of America
| | | | | | - Payam Nahid
- University of California San Francisco, Division of Pulmonary and Critical Care Medicine, San Francisco, California, United States of America
| | - Michael L. Rich
- Partners In Health, Boston, Massachusetts, United States of America
- Brigham and Women's Hospital, Division of Global Health Equity, Boston, Massachusetts, United States of America
| | - Cathy Bansbach
- Bill and Melinda Gates Foundation, Seattle, Washington, United States of America
| | - Thomas Forissier
- Bill and Melinda Gates Foundation, Seattle, Washington, United States of America
| | | | - David W. Dowdy
- Johns Hopkins Bloomberg School of Public Health, Department of Epidemiology, Baltimore, Maryland, United States of America
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217
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Geadas C, Stoszek SK, Sherman D, Andrade BB, Srinivasan S, Hamilton CD, Ellner J. Advances in basic and translational tuberculosis research. Tuberculosis (Edinb) 2017; 102:55-67. [DOI: 10.1016/j.tube.2016.11.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Revised: 11/13/2016] [Accepted: 11/25/2016] [Indexed: 12/16/2022]
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218
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Finding the right dose of rifampicin, and the right dose of optimism. THE LANCET. INFECTIOUS DISEASES 2017; 17:2-3. [DOI: 10.1016/s1473-3099(16)30315-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Accepted: 08/08/2016] [Indexed: 11/18/2022]
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219
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Choice between Levofloxacin and Moxifloxacin and Multidrug-Resistant Tuberculosis Treatment Outcomes. Ann Am Thorac Soc 2016; 13:364-70. [PMID: 26871879 DOI: 10.1513/annalsats.201510-690bc] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
RATIONALE We previously showed that the choice of levofloxacin or moxifloxacin for the treatment of patients with fluoroquinolone-sensitive multidrug-resistant tuberculosis (MDR-TB) did not affect sputum culture conversion at 3 months of treatment. OBJECTIVES To compare final treatment outcomes between patients with MDR-TB randomized to levofloxacin or moxifloxacin. METHODS A total of 151 participants with MDR-TB who were included for the final analysis in our previous trial were followed through the end of treatment. Treatment outcomes were compared between 77 patients in the levofloxacin group and 74 in the moxifloxacin group, based on the 2008 World Health Organization definitions as well as 2013 revised definitions of treatment outcomes. In addition, the time to culture conversion was compared between the two groups. MEASUREMENTS AND MAIN RESULTS Treatment outcomes were not different between the two groups, based on 2008 World Health Organization definitions as well as 2013 definitions. With 2008 definitions, cure was achieved in 54 patients (70.1%) in the levofloxacin group and 54 (73.0%) in the moxifloxacin group (P = 0.72). Treatment success rates, including cure and treatment completed, were not different between the two groups (87.0 vs. 81.1%, P = 0.38). With 2013 definitions, cure rates (83.1 vs. 78.4%, P = 0.54) and treatment success rates (84.4 vs. 79.7%, P = 0.53) were also similar between the levofloxacin and moxifloxacin groups. Time to culture conversion was also not different between the two groups (27.0 vs. 45.0 d, P = 0.11 on liquid media; 17.0 vs. 42.0 d, P = 0.14 on solid media). Patients in the levofloxacin group had more adverse events than those in the moxifloxacin group (79.2 vs. 63.5%, P = 0.03), especially musculoskeletal ones (37.7 vs. 14.9%, P = 0.001). CONCLUSIONS The choice of levofloxacin or moxifloxacin made no difference to the final treatment outcome among patients with fluoroquinolone-sensitive MDR-TB. Clinical trial registered with www.clinicalrials.gov (NCT01055145).
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220
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Abstract
Tuberculosis (TB) remains a global threat with more than 9 million new infections. Treatment remains difficult and there has been no change in the duration of the standard regimen since the early 1980s. Moreover, many patients are unable to tolerate this treatment and discontinue therapy, increasing the risk of resistance. There is a growing tide of multidrug resistance and few effective antibiotics to tackle the problem. Since the turn of the millennium there has been a surge in interest in developing new therapies for TB and a number of new drugs have been developed. In this review the repurposing of moxifloxacin, an 8-methoxy-fluoroquinolone, for TB treatment is discussed. The evidence that underpins the development of this agent is reviewed. The results of the recently completed phase III trials are summarised and the reasons for the unexpected outcome are explored. Finally, the design of new trials that incorporate moxifloxacin, and that address both susceptible disease and multidrug resistance, is described.
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221
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Seddon JA, Schaaf HS. Drug-resistant tuberculosis and advances in the treatment of childhood tuberculosis. Pneumonia (Nathan) 2016; 8:20. [PMID: 28702299 PMCID: PMC5471710 DOI: 10.1186/s41479-016-0019-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Accepted: 11/03/2016] [Indexed: 11/18/2022] Open
Abstract
Over the last 10 years, interest in pediatric tuberculosis (TB) has increased dramatically, together with increased funding and research. We have a better understanding of the burden of childhood TB as well as a better idea of how to diagnose it. Our appreciation of pathophysiology is improved and with it investigators are beginning to consider pediatric TB as a heterogeneous entity, with different types and severity of disease being treated in different ways. There have been advances in how to treat both TB infection and TB disease caused by both drug-susceptible as well as drug-resistant organisms. Two completely novel drugs, bedaquiline and delamanid, have been developed, in addition to the use of older drugs that have been re-purposed. New regimens are being evaluated that have the potential to shorten treatment. Many of these drugs and regimens have first been investigated in adults with children an afterthought, but increasingly children are being considered at the outset and, in some instances studies are only conducted in children where pediatric-specific issues exist.
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Affiliation(s)
- James A Seddon
- Centre for International Child Health, Department of Paediatrics, Imperial College London, London, UK
| | - H Simon Schaaf
- Department of Paediatrics and Child Health, Desmond Tutu TB Centre, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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222
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Zhang D, Gomez JE, Chien JY, Haseley N, Desjardins CA, Earl AM, Hsueh PR, Hung DT. Genomic Analysis of the Evolution of Fluoroquinolone Resistance in Mycobacterium tuberculosis Prior to Tuberculosis Diagnosis. Antimicrob Agents Chemother 2016; 60:6600-6608. [PMID: 27572408 PMCID: PMC5075065 DOI: 10.1128/aac.00664-16] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Accepted: 08/07/2016] [Indexed: 02/01/2023] Open
Abstract
Fluoroquinolones (FQs) are effective second-line drugs for treating antibiotic-resistant tuberculosis (TB) and are being considered for use as first-line agents. Because FQs are used to treat a range of infections, in a setting of undiagnosed TB, there is potential to select for drug-resistant Mycobacterium tuberculosis mutants during FQ-based treatment of other infections, including pneumonia. Here we present a detailed characterization of ofloxacin-resistant M. tuberculosis samples isolated directly from patients in Taiwan, which demonstrates that selection for FQ resistance can occur within patients who have not received FQs for the treatment of TB. Several of these samples showed no mutations in gyrA or gyrB based on PCR-based molecular assays, but genome-wide next-generation sequencing (NGS) revealed minority populations of gyrA and/or gyrB mutants. In other samples with PCR-detectable gyrA mutations, NGS revealed subpopulations containing alternative resistance-associated genotypes. Isolation of individual clones from these apparently heterogeneous samples confirmed the presence of the minority drug-resistant variants suggested by the NGS data. Further NGS of these purified clones established evolutionary links between FQ-sensitive and -resistant clones derived from the same patient, suggesting de novo emergence of FQ-resistant TB. Importantly, most of these samples were isolated from patients without a history of FQ treatment for TB. Thus, selective pressure applied by FQ monotherapy in the setting of undiagnosed TB infection appears to be able to drive the full or partial emergence of FQ-resistant M. tuberculosis, which has the potential to confound diagnostic tests for antibiotic susceptibility and limit the effectiveness of FQs in TB treatment.
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Affiliation(s)
- Danfeng Zhang
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
- School of Biological Science and Biotechnology, Minnan Normal University, Zhangzhou, China
| | - James E Gomez
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
| | - Jung-Yien Chien
- Graduate Institute of Clinical Medicine, National Taiwan University Medical College, Taipei, Taiwan
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University Medical College, Taipei, Taiwan
| | - Nathan Haseley
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
| | | | - Ashlee M Earl
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
| | - Po-Ren Hsueh
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University Medical College, Taipei, Taiwan
- Department of Laboratory Medicine, National Taiwan University Hospital, National Taiwan University Medical College, Taipei, Taiwan
| | - Deborah T Hung
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
- Department of Molecular Biology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Center for Computational and Integrative Biology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Microbiology and Immunobiology, Harvard Medical School, Boston, Massachusetts, USA
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223
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Abstract
Tuberculosis (TB) is an airborne infectious disease caused by organisms of the Mycobacterium tuberculosis complex. Although primarily a pulmonary pathogen, M. tuberculosis can cause disease in almost any part of the body. Infection with M. tuberculosis can evolve from containment in the host, in which the bacteria are isolated within granulomas (latent TB infection), to a contagious state, in which the patient will show symptoms that can include cough, fever, night sweats and weight loss. Only active pulmonary TB is contagious. In many low-income and middle-income countries, TB continues to be a major cause of morbidity and mortality, and drug-resistant TB is a major concern in many settings. Although several new TB diagnostics have been developed, including rapid molecular tests, there is a need for simpler point-of-care tests. Treatment usually requires a prolonged course of multiple antimicrobials, stimulating efforts to develop shorter drug regimens. Although the Bacillus Calmette-Guérin (BCG) vaccine is used worldwide, mainly to prevent life-threatening TB in infants and young children, it has been ineffective in controlling the global TB epidemic. Thus, efforts are underway to develop newer vaccines with improved efficacy. New tools as well as improved programme implementation and financing are necessary to end the global TB epidemic by 2035.
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224
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Abstract
Tuberculosis (TB) has been a leading cause of death for more than a century. While effective therapies exist, treatment is long and cumbersome. TB control is complicated by the overlapping problems created by global inadequacy of public health infrastructures, the interaction of the TB and human immunodeficiency virus (HIV) epidemics, and the emergence of drug-resistant TB. After a long period of neglect, there is now significant progress in the development of novel treatment regimens for TB. Focusing on treatment for active disease, we review pathways to TB regimen development and the new and repurposed anti-TB agents in clinical development.
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Affiliation(s)
- Anthony T Podany
- College of Pharmacy, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Susan Swindells
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
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225
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Nahid P, Dorman SE, Alipanah N, Barry PM, Brozek JL, Cattamanchi A, Chaisson LH, Chaisson RE, Daley CL, Grzemska M, Higashi JM, Ho CS, Hopewell PC, Keshavjee SA, Lienhardt C, Menzies R, Merrifield C, Narita M, O'Brien R, Peloquin CA, Raftery A, Saukkonen J, Schaaf HS, Sotgiu G, Starke JR, Migliori GB, Vernon A. Official American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America Clinical Practice Guidelines: Treatment of Drug-Susceptible Tuberculosis. Clin Infect Dis 2016; 63:e147-e195. [PMID: 27516382 PMCID: PMC6590850 DOI: 10.1093/cid/ciw376] [Citation(s) in RCA: 680] [Impact Index Per Article: 85.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2016] [Accepted: 06/06/2016] [Indexed: 02/06/2023] Open
Abstract
The American Thoracic Society, Centers for Disease Control and Prevention, and Infectious Diseases Society of America jointly sponsored the development of this guideline for the treatment of drug-susceptible tuberculosis, which is also endorsed by the European Respiratory Society and the US National Tuberculosis Controllers Association. Representatives from the American Academy of Pediatrics, the Canadian Thoracic Society, the International Union Against Tuberculosis and Lung Disease, and the World Health Organization also participated in the development of the guideline. This guideline provides recommendations on the clinical and public health management of tuberculosis in children and adults in settings in which mycobacterial cultures, molecular and phenotypic drug susceptibility tests, and radiographic studies, among other diagnostic tools, are available on a routine basis. For all recommendations, literature reviews were performed, followed by discussion by an expert committee according to the Grading of Recommendations, Assessment, Development and Evaluation methodology. Given the public health implications of prompt diagnosis and effective management of tuberculosis, empiric multidrug treatment is initiated in almost all situations in which active tuberculosis is suspected. Additional characteristics such as presence of comorbidities, severity of disease, and response to treatment influence management decisions. Specific recommendations on the use of case management strategies (including directly observed therapy), regimen and dosing selection in adults and children (daily vs intermittent), treatment of tuberculosis in the presence of HIV infection (duration of tuberculosis treatment and timing of initiation of antiretroviral therapy), as well as treatment of extrapulmonary disease (central nervous system, pericardial among other sites) are provided. The development of more potent and better-tolerated drug regimens, optimization of drug exposure for the component drugs, optimal management of tuberculosis in special populations, identification of accurate biomarkers of treatment effect, and the assessment of new strategies for implementing regimens in the field remain key priority areas for research. See the full-text online version of the document for detailed discussion of the management of tuberculosis and recommendations for practice.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Julie M. Higashi
- Tuberculosis Control Section, San Francisco Department
of Public Health, California
| | - Christine S. Ho
- Division of Tuberculosis Elimination, National Center
for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and
Prevention, Atlanta, Georgia
| | | | | | | | | | | | - Masahiro Narita
- Tuberculosis Control Program, Seattle and King County Public Health, and
University of Washington, Seattle
| | - Rick O'Brien
- Ethics Advisory Group, International Union Against TB
and Lung Disease, Paris,
France
| | | | | | | | - H. Simon Schaaf
- Department of Paediatrics and Child Health, Stellenbosch University, Cape
Town, South Africa
| | | | | | - Giovanni Battista Migliori
- WHO Collaborating Centre for TB and Lung Diseases, Fondazione S. Maugeri Care and
Research Institute, Tradate, Italy
| | - Andrew Vernon
- Division of Tuberculosis Elimination, National Center
for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and
Prevention, Atlanta, Georgia
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226
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Gopalan N, Chandrasekaran P, Swaminathan S, Tripathy S. Current trends and intricacies in the management of HIV-associated pulmonary tuberculosis. AIDS Res Ther 2016; 13:34. [PMID: 27708678 PMCID: PMC5037900 DOI: 10.1186/s12981-016-0118-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Accepted: 09/16/2016] [Indexed: 01/08/2023] Open
Abstract
Human immunodeficiency virus (HIV) epidemic has undoubtedly increased the incidence of tuberculosis (TB) globally, posing a formidable global health challenge affecting 1.2 million cases. Pulmonary TB assumes utmost significance in the programmatic perspective as it is readily transmissible as well as easily diagnosable. HIV complicates every aspect of pulmonary tuberculosis from diagnosis to treatment, demanding a different approach to effectively tackle both the diseases. In order to control these converging epidemics, it is important to diagnose early, initiate appropriate therapy for both infections, prevent transmission and administer preventive therapy. Liquid culture methods and nucleic acid amplification tests for TB confirmation have replaced conventional solid media, enabling quicker and simultaneous detection of mycobacterium and its drug sensitivity profile Unique problems posed by the syndemic include Acquired rifampicin resistance, drug-drug interactions, malabsorption of drugs and immune reconstitution inflammatory syndrome or paradoxical reaction that complicate dual and concomitant therapy. While the antiretroviral therapy armamentarium is constantly reinforced by discovery of newer and safer drugs every year, only a few drugs for anti tuberculosis treatment have successfully emerged. These include bedaquiline, delamanid and pretomanid which have entered phase III B trials and are also available through conditional access national programmes. The current guidelines by WHO to start Antiretroviral therapy irrespective of CD4+ cell count based on benefits cited by recent trials could go a long way in preventing various complications caused by the deadly duo. This review provides a consolidated gist of the advancements, concepts and updates that have emerged in the management of HIV-associated pulmonary TB for maximizing efficacy, offering latest solutions for tackling drug-drug interactions and remedial measures for immune reconstitution inflammatory syndrome.
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Affiliation(s)
- Narendran Gopalan
- Division of HIV, National Institute for Research in Tuberculosis (Formerly Tuberculosis Research Centre), No. 1, Mayor Sathyamoorthy Road, Chetpet, Chennai, 600 031 India
| | - Padmapriyadarsini Chandrasekaran
- Division of HIV, National Institute for Research in Tuberculosis (Formerly Tuberculosis Research Centre), No. 1, Mayor Sathyamoorthy Road, Chetpet, Chennai, 600 031 India
| | - Soumya Swaminathan
- Division of HIV, National Institute for Research in Tuberculosis (Formerly Tuberculosis Research Centre), No. 1, Mayor Sathyamoorthy Road, Chetpet, Chennai, 600 031 India
| | - Srikanth Tripathy
- Division of HIV, National Institute for Research in Tuberculosis (Formerly Tuberculosis Research Centre), No. 1, Mayor Sathyamoorthy Road, Chetpet, Chennai, 600 031 India
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227
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Cellamare M, Ventz S, Baudin E, Mitnick CD, Trippa L. A Bayesian response-adaptive trial in tuberculosis: The endTB trial. Clin Trials 2016; 14:17-28. [PMID: 27559021 DOI: 10.1177/1740774516665090] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
PURPOSE To evaluate the use of Bayesian adaptive randomization for clinical trials of new treatments for multidrug-resistant tuberculosis. METHODS We built a response-adaptive randomization procedure, adapting on two preliminary outcomes for tuberculosis patients in a trial with five experimental regimens and a control arm. The primary study outcome is treatment success after 73 weeks from randomization; preliminary responses are culture conversion at 8 weeks and treatment success at 39 weeks. We compared the adaptive randomization design with balanced randomization using hypothetical scenarios. RESULTS When we compare the statistical power under adaptive randomization and non-adaptive designs, under several hypothetical scenarios we observe that adaptive randomization requires fewer patients than non-adaptive designs. Moreover, adaptive randomization consistently allocates more participants to effective arm(s). We also show that these advantages are limited to scenarios consistent with the assumptions used to develop the adaptive randomization algorithm. CONCLUSION Given the objective of evaluating several new therapeutic regimens in a timely fashion, Bayesian response-adaptive designs are attractive for tuberculosis trials. This approach tends to increase allocation to the effective regimens.
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Affiliation(s)
- Matteo Cellamare
- 1 Department of Biostatistics, Dana-Farber Cancer Institute and Harvard T.H. Chan School of Public Health, Boston, MA, USA.,2 Department of Statistical Sciences, Sapienza University of Rome, Rome, Italy
| | - Steffen Ventz
- 1 Department of Biostatistics, Dana-Farber Cancer Institute and Harvard T.H. Chan School of Public Health, Boston, MA, USA.,3 Department of Computer Science and Statistics, The University of Rhode Island, Kingston, RI, USA
| | | | - Carole D Mitnick
- 5 Harvard Medical School, Department of Global Health and Social Medicine, Boston, MA, USA.,6 Partners In Health, Boston, MA, USA
| | - Lorenzo Trippa
- 1 Department of Biostatistics, Dana-Farber Cancer Institute and Harvard T.H. Chan School of Public Health, Boston, MA, USA
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Abstract
The treatment of drug-sensitive tuberculosis consists of 2 months of isoniazid, rifampin, pyrazinamide and ethambutol, followed by 4 months of isoniazid and rifampin. These drugs are well tolerated and cure rate are above 95 %. In contrast the treatment of drug-resistent tuberculosis is difficult, mostly due to side effects of the drugs used under these circumstances. Therefore, any treatment of drug-resistant tuberculosis has to be done by experts.
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Affiliation(s)
- T Schaberg
- Zentrum für Pneumologie, Agaplesion Diakonieklinikum Rotenburg, Elise-Averdieck-Str. 17, 27356, Rotenburg, Deutschland.
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229
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Salzer HJF, Wassilew N, Köhler N, Olaru ID, Günther G, Herzmann C, Kalsdorf B, Sanchez-Carballo P, Terhalle E, Rolling T, Lange C, Heyckendorf J. Personalized Medicine for Chronic Respiratory Infectious Diseases: Tuberculosis, Nontuberculous Mycobacterial Pulmonary Diseases, and Chronic Pulmonary Aspergillosis. Respiration 2016; 92:199-214. [PMID: 27595540 DOI: 10.1159/000449037] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Chronic respiratory infectious diseases are causing high rates of morbidity and mortality worldwide. Tuberculosis, a major cause of chronic pulmonary infection, is currently responsible for approximately 1.5 million deaths per year. Although important advances in the fight against tuberculosis have been made, the progress towards eradication of this disease is being challenged by the dramatic increase in multidrug-resistant bacilli. Nontuberculous mycobacteria causing pulmonary disease and chronic pulmonary aspergillosis are emerging infectious diseases. In contrast to other infectious diseases, chronic respiratory infections share the trait of having highly variable treatment outcomes despite longstanding antimicrobial therapy. Recent scientific progress indicates that medicine is presently at a transition stage from programmatic to personalized management. We explain current state-of-the-art management concepts of chronic pulmonary infectious diseases as well as the underlying methods for therapeutic decisions and their implications for personalized medicine. Furthermore, we describe promising biomarkers and techniques with the potential to serve future individual treatment concepts in this field of difficult-to-treat patients. These include candidate markers to improve individual risk assessment for disease development, the design of tailor-made drug therapy regimens, and individualized biomarker-guided therapy duration to achieve relapse-free cure. In addition, the use of therapeutic drug monitoring to reach optimal drug dosing with the smallest rate of adverse events as well as candidate agents for future host-directed therapies are described. Taken together, personalized medicine will provide opportunities to substantially improve the management and treatment outcome of difficult-to-treat patients with chronic respiratory infections.
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Affiliation(s)
- Helmut J F Salzer
- Division of Clinical Infectious Diseases, Research Center Borstel, Borstel, Germany
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Persisting positron emission tomography lesion activity and Mycobacterium tuberculosis mRNA after tuberculosis cure. Nat Med 2016; 22:1094-1100. [PMID: 27595324 PMCID: PMC5053881 DOI: 10.1038/nm.4177] [Citation(s) in RCA: 198] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Accepted: 07/29/2016] [Indexed: 01/07/2023]
Abstract
The absence of a gold standard to determine when antibiotics have induced sterilizing cure confounds the development of new approaches to treat pulmonary tuberculosis (PTB). We detected PET-CT imaging response patterns consistent with active disease along with the presence of Mycobacterium tuberculosis mRNA in sputum and bronchoalveolar lavage samples in a substantial proportion of adult, HIV-negative PTB patients after standard 6-month treatment plus one year follow-up, including patients with a durable cure and others who later developed recurrent disease. The presence of MTB mRNA in the context of non-resolving and intensifying lesions on PET-CT might indicate ongoing transcription, suggesting that even apparently curative PTB treatment may not eradicate all organisms in most patients. This suggests an important complementary role for the immune response in maintaining a disease-free state. Sterilizing drugs or host-directed therapies and better treatment response markers are likely needed for the successful development of improved and shortened PTB treatment strategies.
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232
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Milstein M, Lecca L, Peloquin C, Mitchison D, Seung K, Pagano M, Coleman D, Osso E, Coit J, Vargas Vasquez DE, Sanchez Garavito E, Calderon R, Contreras C, Davies G, Mitnick CD. Evaluation of high-dose rifampin in patients with new, smear-positive tuberculosis (HIRIF): study protocol for a randomized controlled trial. BMC Infect Dis 2016; 16:453. [PMID: 27567500 PMCID: PMC5002098 DOI: 10.1186/s12879-016-1790-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Accepted: 08/18/2016] [Indexed: 11/10/2022] Open
Abstract
Background Evidence has existed for decades that higher doses of rifampin may be more effective, but potentially more toxic, than standard doses used in tuberculosis treatment. Whether increased doses of rifampin could safely shorten treatment remains an open question. Methods/Design The HIRIF study is a phase II randomized trial comparing rifampin doses of 20 and 15 mg/kg/day to the standard 10 mg/kg/day for the first 2 months of tuberculosis treatment. All participants receive standard doses of companion drugs and a standard continuation-phase treatment (4 months, 2 drugs). They are followed for 6 months post treatment. Study participants are adults with newly diagnosed, previously untreated, smear positive (≥2+) pulmonary tuberculosis. The primary outcome is rifampin area under the plasma concentration-time curve (AUC0–24) after at least 14 days of study treatment/minimum inhibitory concentration. 180 randomized participants affords 90 % statistical power to detect a difference of at least 14 mcg/mL*hr between the 20 mg/kg group and the 10 mg/kg group, assuming a loss to follow-up of up to 17 %. Discussion Extant evidence suggests the potential for increased doses of rifampin to shorten tuberculosis treatment duration. Early studies that explored this potential using intermittent, higher dosing were derailed by toxicity. Given the continued large, global burden of tuberculosis with nearly 10 million new cases annually, shortened regimens with existing drugs would offer an important advantage to patients and health systems. Trial registration This trial was registered with clinicaltrials.gov (registration number: NCT01408914) on 2 August 2011.
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Affiliation(s)
| | - Leonid Lecca
- Partners In Health, Boston, MA, 02215, USA.,Socios En Salud, Sucursal-Peru, Lima, Peru
| | | | | | - Kwonjune Seung
- Partners In Health, Boston, MA, 02215, USA.,Brigham and Women's Hospital, Boston, MA, USA
| | | | | | - Elna Osso
- Harvard Medical School, Boston, MA, 02118, USA
| | - Julia Coit
- Harvard Medical School, Boston, MA, 02118, USA
| | | | | | - Roger Calderon
- Partners In Health, Boston, MA, 02215, USA.,Socios En Salud, Sucursal-Peru, Lima, Peru
| | - Carmen Contreras
- Partners In Health, Boston, MA, 02215, USA.,Socios En Salud, Sucursal-Peru, Lima, Peru
| | | | - Carole D Mitnick
- Harvard Medical School, Boston, MA, 02118, USA. .,Partners In Health, Boston, MA, 02215, USA.
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233
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Tuberculosis--advances in development of new drugs, treatment regimens, host-directed therapies, and biomarkers. THE LANCET. INFECTIOUS DISEASES 2016; 16:e34-46. [PMID: 27036358 DOI: 10.1016/s1473-3099(16)00070-0] [Citation(s) in RCA: 197] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Revised: 01/27/2016] [Accepted: 01/29/2016] [Indexed: 12/24/2022]
Abstract
Tuberculosis is the leading infectious cause of death worldwide, with 9·6 million cases and 1·5 million deaths reported in 2014. WHO estimates 480,000 cases of these were multidrug resistant (MDR). Less than half of patients who entered into treatment for MDR tuberculosis successfully completed that treatment, mainly due to high mortality and loss to follow-up. These in turn illustrate weaknesses in current treatment regimens and national tuberculosis programmes, coupled with operational treatment challenges. In this Review we provide an update on recent developments in the tuberculosis drug-development pipeline (including new and repurposed antimicrobials and host-directed drugs) as they are applied to new regimens to shorten and improve outcomes of tuberculosis treatment. Several new or repurposed antimicrobial drugs are in advanced trial stages for MDR tuberculosis, and two new antimicrobial drug candidates are in early-stage trials. Several trials to reduce the duration of therapy in MDR and drug-susceptible tuberculosis are ongoing. A wide range of candidate host-directed therapies are being developed to accelerate eradication of infection, prevent new drug resistance, and prevent permanent lung injury. As these drugs have been approved for other clinical indications, they are now ready for repurposing for tuberculosis in phase 2 clinical trials. We assess risks associated with evaluation of new treatment regimens, and highlight opportunities to advance tuberculosis research generally through regulatory innovation in MDR tuberculosis. Progress in tuberculosis-specific biomarkers (including culture conversion, PET and CT imaging, and gene expression profiles) can support this innovation. Several global initiatives now provide unique opportunities to tackle the tuberculosis epidemic through collaborative partnerships between high-income countries and middle-income and low-income countries for clinical trials training and research, allowing funders to coordinate several national and regional programmes for greatest overall effect.
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Abstract
INTRODUCTION The goal of this article is to review the use of rifapentine in the treatment of latent tuberculosis infection (LTBI). Controlling LTBI is an important part of the global strategy to end the spread of tuberculosis. Rifapentine's potent sterilizing effect against Mycobacterium tuberculosis combined with its long half-life make it an attractive LTBI treatment option. Areas covered: A systematic literature search of Pubmed using the terms 'rifapentine' and 'tuberculosis' was performed. Articles identified were cross-referenced for other relevant publications. The mechanisms of action and resistance, pharmacokinetic and pharmacodynamics, potential drug interactions and side effects are discussed. Expert commentary: Rifapentine in combination with isoniazid for twelve weeks is the best available option for treating latent TB in the majority of patients in the United States due to its favorable safety profile and the increased likelihood of completing therapy. Currently, rifapentine is not registered or available in other countries.
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Affiliation(s)
- Eric F Egelund
- a Department of Pharmacotherapy and Translational Research, College of Pharmacy , University of Florida , Gainesville , FL , USA.,b Infectious Disease Pharmacokinetics Laboratory , University of Florida , Gainesville , FL , USA
| | - Charles A Peloquin
- a Department of Pharmacotherapy and Translational Research, College of Pharmacy , University of Florida , Gainesville , FL , USA.,b Infectious Disease Pharmacokinetics Laboratory , University of Florida , Gainesville , FL , USA.,c Emerging Pathogens Institute , University of Florida , Gainesville , FL , USA
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235
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Abstract
Although it is curable, tuberculosis remains one of the most frequent causes of pleural effusions on a global scale, especially in developing countries. Tuberculous pleural effusion (TPE) is one of the most common forms of extrapulmonary tuberculosis. TPE usually presents as an acute illness with fever, cough and pleuritic chest pain. The pleural fluid is an exudate that usually has predominantly lymphocytes. The gold standard for the diagnosis of TPE remains the detection of Mycobacterium tuberculosis in pleural fluid, or pleural biopsy specimens, either by microscopy and/or culture, or the histological demonstration of caseating granulomas in the pleura along with acid fast bacilli, Although adenosine deaminase and interferon-γ in pleural fluid have been documented to be useful tests for the diagnosis of TPE. It can be accepted that in areas with high tuberculosis prevalence, the easiest way to establish the diagnosis of TPE in a patient with a lymphocytic pleural effusion is to generally demonstrate a adenosine deaminase level above 40 U/L. The recommended treatment for TPE is a regimen with isoniazid, rifampin, and pyrazinamide for two months followed by four months of two drugs, isoniazid and rifampin.
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Affiliation(s)
- Kan Zhai
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China
| | - Yong Lu
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China
| | - Huan-Zhong Shi
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China
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Lee HW, Lee JK, Kim E, Yim JJ, Lee CH. The Effectiveness and Safety of Fluoroquinolone-Containing Regimen as a First-Line Treatment for Drug-Sensitive Pulmonary Tuberculosis: A Systematic Review and Meta-Analysis. PLoS One 2016; 11:e0159827. [PMID: 27455053 PMCID: PMC4959712 DOI: 10.1371/journal.pone.0159827] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Accepted: 07/09/2016] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Fluoroquinolone is recommended as a pivotal antituberculous agent for treating multi-drug-resistant pulmonary tuberculosis. However, its effectiveness as first-line treatment remains controversial. The present study was conducted to validate the fluoroquinolone-containing regimen for drug-sensitive pulmonary tuberculosis. METHODS We searched MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials until June 5, 2015. Randomized controlled trials (RCTs) that compared antituberculous regimens containing fluoroquinolone with the standard regimen were included. RESULTS Eleven RCTs that included 6,334 patients were selected. Fluoroquinolone-containing regimens had a higher rate of sputum culture conversion at 2 months of treatment (M-H fixed odds ratio [OR], 1.36; 95% confidence interval [CI], 1.20-1.54). However, the outcomes were less favorable (M-H fixed OR, 0.69; 95% CI, 0.59-0.82) and the associated total adverse events were more frequent (M-H fixed OR, 1.84; 95% CI, 1.46-2.31) in the fluoroquinolone-containing regimen group, without a significant heterogeneity according to treatment duration. Treatment with the fluoroquinolone-containing regimen for 4 months showed a higher relapse rate. CONCLUSIONS Despite a higher culture conversion rate at 2 months of treatment, the fluoroquinolone-containing regimen had limitations, including less favorable outcomes and more adverse events, as the first-line therapy for drug-sensitive pulmonary tuberculosis.
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Affiliation(s)
- Hyun Woo Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, 03080, Republic of Korea
| | - Jung Kyu Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, 07061, Republic of Korea
| | - Eunyoung Kim
- Department of Statistics, Kyungpook National University, Daegu, 41566, Republic of Korea
| | - Jae-Joon Yim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, 03080, Republic of Korea
| | - Chang-Hoon Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, 03080, Republic of Korea
- * E-mail:
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Dodd LE, Lantos JD, Pinheiro J. University of Pennsylvania 8th annual conference on statistical issues in clinical trials: Pragmatic clinical trials (morning panel). Clin Trials 2016; 13:493-503. [PMID: 27430711 DOI: 10.1177/1740774516657547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Schito M, Migliori GB, Fletcher HA, McNerney R, Centis R, D'Ambrosio L, Bates M, Kibiki G, Kapata N, Corrah T, Bomanji J, Vilaplana C, Johnson D, Mwaba P, Maeurer M, Zumla A. Perspectives on Advances in Tuberculosis Diagnostics, Drugs, and Vaccines. Clin Infect Dis 2016; 61Suppl 3:S102-18. [PMID: 26409271 DOI: 10.1093/cid/civ609] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Despite concerted efforts over the past 2 decades at developing new diagnostics, drugs, and vaccines with expanding pipelines, tuberculosis remains a global emergency. Several novel diagnostic technologies show promise of better point-of-care rapid tests for tuberculosis including nucleic acid-based amplification tests, imaging, and breath analysis of volatile organic compounds. Advances in new and repurposed drugs for use in multidrug-resistant (MDR) or extensively drug-resistant (XDR) tuberculosis have focused on development of several new drug regimens and their evaluation in clinical trials and now influence World Health Organization guidelines. Since the failure of the MVA85A vaccine 2 years ago, there have been no new tuberculosis vaccine candidates entering clinical testing. The current status quo of the lengthy treatment duration and poor treatment outcomes associated with MDR/XDR tuberculosis and with comorbidity of tuberculosis with human immunodeficiency virus and noncommunicable diseases is unacceptable. New innovations and political and funder commitment for early rapid diagnosis, shortening duration of therapy, improving treatment outcomes, and prevention are urgently required.
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Affiliation(s)
- Marco Schito
- Critical Path to TB Drug Regimens, Critical Path Institute, Tucson, Arizona
| | - Giovanni Battista Migliori
- World Health Organization Collaborating Centre for Tuberculosis and Lung Diseases, Fondazione S. Maugeri, Care and Research Institute, Tradate, Italy
| | - Helen A Fletcher
- Department of Immunology and Infection, London School of Hygiene and Tropical Medicine
| | | | - Rosella Centis
- World Health Organization Collaborating Centre for Tuberculosis and Lung Diseases, Fondazione S. Maugeri, Care and Research Institute, Tradate, Italy
| | - Lia D'Ambrosio
- World Health Organization Collaborating Centre for Tuberculosis and Lung Diseases, Fondazione S. Maugeri, Care and Research Institute, Tradate, Italy
| | - Matthew Bates
- University of Zambia-University College London Medical School Research and Training Project, University Teaching Hospital, Lusaka, Zambia
| | - Gibson Kibiki
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania
| | - Nathan Kapata
- University of Zambia-University College London Medical School Research and Training Project, University Teaching Hospital, Lusaka, Zambia
| | - Tumena Corrah
- Department of Infectious Diseases and Tropical Medicine, Northwick Park Hospital
| | - Jamshed Bomanji
- Department of Nuclear Imaging, University College London Hospitals NHS Foundation Trust, United Kingdom
| | - Cris Vilaplana
- Unitat de Tuberculosi Experimental, Fundació Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol, Ctra. de Can Ruti, Camí de les Escoles, Barcelona, Spain
| | - Daniel Johnson
- Division of AIDS, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | - Peter Mwaba
- University of Zambia-University College London Medical School Research and Training Project, University Teaching Hospital, Lusaka, Zambia
| | - Markus Maeurer
- Therapeutic Immunology, Departments of Laboratory Medicine and Microbiology, Tumour and Cell Biology, Karolinska Institute, Stockholm, Sweden
| | - Alimuddin Zumla
- Division of Infection and Immunity, University College London and National Institute for Health Research Biomedical Research Centre, UCL Hospitals NHS Foundation Trust, United Kingdom
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Schito M, Maeurer M, Kim P, Hanna D, Zumla A. Translating the Tuberculosis Research Agenda: Much Accomplished, but Much More to Be Done. Clin Infect Dis 2016; 61Suppl 3:S95-101. [PMID: 26409286 DOI: 10.1093/cid/civ608] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Despite the availability of effective diagnostics and curative treatment regimens for tuberculosis, millions of people die each year of this disease. The steady global increase in the number of tuberculosis cases caused by multidrug-resistant and extensively drug-resistant strains of Mycobacterium tuberculosis are of major concern, especially in light of the thin tuberculosis drug pipeline. New tuberculosis drugs are undergoing clinical evaluation, and renewed hope comes from fresh approaches to improve treatment outcomes using a range of adjunct host-directed cellular and repurposed drug therapies. Current efforts in developing second-generation and new rapid point-of-care diagnostic assays take advantage of recent genetic and molecular advances. Slow progress in the development of prophylactic and therapeutic vaccines requires increased funding for basic as well as translational research. Although major challenges remain, these can be overcome by cementing our resolve, raising advocacy, bolstering global funder investments, and leveraging more effective collaborations through equitable public-private partnerships.
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Affiliation(s)
- Marco Schito
- Critical Path to TB Drug Regimens, Critical Path Institute, Tucson, Arizona
| | - Markus Maeurer
- Therapeutic Immunology Division, Department of Laboratory Medicine, Karolinska Institutet Center for Allogeneic Stem Cell Transplantation, Karolinska University Hospital, Stockholm, Sweden
| | - Peter Kim
- Division of AIDS, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | - Debra Hanna
- Critical Path to TB Drug Regimens, Critical Path Institute, Tucson, Arizona
| | - Alimuddin Zumla
- Division of Infection and Immunity Center for Clinical Microbiology, University College London Biomedical Research Centre at University College Hospitals NHS Trust, London, United Kingdom
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Wallis RS, Peppard T. Early Biomarkers and Regulatory Innovation in Multidrug-Resistant Tuberculosis. Clin Infect Dis 2016; 61Suppl 3:S160-3. [PMID: 26409278 DOI: 10.1093/cid/civ612] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Biomarkers play an essential role in accelerating drug development. Sputum culture conversion using solid medium is the best-characterized tuberculosis biomarker, having been examined at the patient and trial levels in studies with thousands of subjects, and having recently been validated using data from 3 unsuccessful phase 3 trials. We presently are poised at the threshold of regulatory innovation for antibacterials to treat drug-resistant infections, in which Special Medical Use authorization restricted to patients with limited options could be based on the results of small clinical trials. Patients worldwide would be well served by licensing of new regimens for multidrug-resistant tuberculosis based on biomarker evidence commensurate with the urgency of the current global crisis.
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Seddon JA, McKenna L, Shah T, Kampmann B. Recent Developments and Future Opportunities in the Treatment of Tuberculosis in Children. Clin Infect Dis 2016; 61Suppl 3:S188-99. [PMID: 26409282 DOI: 10.1093/cid/civ582] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Tuberculosis in children accounts for a significant proportion of the overall burden of disease, and yet for many years research into pediatric treatment has been neglected. Recently, there have been major developments in our understanding of pediatric tuberculosis, and a large number of studies are under way or planned. New drugs and regimens are being evaluated, and older drugs are being repurposed. Shorter regimens with potentially fewer side effects are being assessed for the treatment and prevention of both drug-susceptible and drug-resistant tuberculosis. It may be possible to tailor treatment so that children with less severe disease are given shorter regimens, and weekly dosing is under investigation for preventive therapy and for the continuation phase of treatment. The interaction with human immunodeficiency virus and the management of tuberculosis meningitis are also likely to be better understood. Exciting times lie ahead for pediatric tuberculosis, but much work remains to be done.
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Affiliation(s)
- James A Seddon
- Academic Department of Paediatrics, Imperial College London Department of Paediatric Infectious Diseases, Imperial College London NHS Healthcare Trust, United Kingdom
| | | | - Tejshri Shah
- Department of Paediatric Infectious Diseases, Imperial College London NHS Healthcare Trust, United Kingdom
| | - Beate Kampmann
- Academic Department of Paediatrics, Imperial College London Department of Paediatric Infectious Diseases, Imperial College London NHS Healthcare Trust, United Kingdom Vaccines & Immunity Theme, MRC Unit, The Gambia, Fajara
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Zignol M, Dean AS, Alikhanova N, Andres S, Cabibbe AM, Cirillo DM, Dadu A, Dreyer A, Driesen M, Gilpin C, Hasan R, Hasan Z, Hoffner S, Husain A, Hussain A, Ismail N, Kamal M, Mansjö M, Mvusi L, Niemann S, Omar SV, Qadeer E, Rigouts L, Ruesch-Gerdes S, Schito M, Seyfaddinova M, Skrahina A, Tahseen S, Wells WA, Mukadi YD, Kimerling M, Floyd K, Weyer K, Raviglione MC. Population-based resistance of Mycobacterium tuberculosis isolates to pyrazinamide and fluoroquinolones: results from a multicountry surveillance project. THE LANCET. INFECTIOUS DISEASES 2016; 16:1185-1192. [PMID: 27397590 PMCID: PMC5030278 DOI: 10.1016/s1473-3099(16)30190-6] [Citation(s) in RCA: 120] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Revised: 05/31/2016] [Accepted: 06/10/2016] [Indexed: 02/06/2023]
Abstract
Background Pyrazinamide and fluoroquinolones are essential antituberculosis drugs in new rifampicin-sparing regimens. However, little information about the extent of resistance to these drugs at the population level is available. Methods In a molecular epidemiology analysis, we used population-based surveys from Azerbaijan, Bangladesh, Belarus, Pakistan, and South Africa to investigate resistance to pyrazinamide and fluoroquinolones among patients with tuberculosis. Resistance to pyrazinamide was assessed by gene sequencing with the detection of resistance-conferring mutations in the pncA gene, and susceptibility testing to fluoroquinolones was conducted using the MGIT system. Findings Pyrazinamide resistance was assessed in 4972 patients. Levels of resistance varied substantially in the surveyed settings (3·0–42·1%). In all settings, pyrazinamide resistance was significantly associated with rifampicin resistance. Among 5015 patients who underwent susceptibility testing to fluoroquinolones, proportions of resistance ranged from 1·0–16·6% for ofloxacin, to 0·5–12·4% for levofloxacin, and 0·9–14·6% for moxifloxacin when tested at 0·5 μg/mL. High levels of ofloxacin resistance were detected in Pakistan. Resistance to moxifloxacin and gatifloxacin when tested at 2 μg/mL was low in all countries. Interpretation Although pyrazinamide resistance was significantly associated with rifampicin resistance, this drug may still be effective in 19–63% of patients with rifampicin-resistant tuberculosis. Even though the high level of resistance to ofloxacin found in Pakistan is worrisome because it might be the expression of extensive and unregulated use of fluoroquinolones in some parts of Asia, the negligible levels of resistance to fourth-generation fluoroquinolones documented in all survey sites is an encouraging finding. Rational use of this class of antibiotics should therefore be ensured to preserve its effectiveness. Funding Bill & Melinda Gates Foundation, United States Agency for International Development, Global Alliance for Tuberculosis Drug Development.
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Affiliation(s)
- Matteo Zignol
- Global Tuberculosis Programme, World Health Organization, Geneva, Switzerland.
| | - Anna S Dean
- Global Tuberculosis Programme, World Health Organization, Geneva, Switzerland
| | | | - Sönke Andres
- National and Supranational Reference Laboratory for Mycobacterium, Borstel, Germany
| | | | | | - Andrei Dadu
- Regional Office for Europe, World Health Organization, Copenhagen, Denmark
| | - Andries Dreyer
- National Institute for Communicable Diseases, Sandringham, South Africa
| | - Michèle Driesen
- Mycobacteriology Unit, Institute of Tropical Medicine, Antwerp, Belgium
| | - Christopher Gilpin
- Global Tuberculosis Programme, World Health Organization, Geneva, Switzerland
| | - Rumina Hasan
- Department of Pathology and Laboratory Medicine, Aga Khan University, Karachi, Pakistan
| | - Zahra Hasan
- Department of Pathology and Laboratory Medicine, Aga Khan University, Karachi, Pakistan
| | - Sven Hoffner
- Department of Microbiology, Public Health Agency of Sweden, Solna, Sweden; Department of Microbiology, Tumor and Cell Biology, Karolinska Institute, Stockholm, Sweden
| | - Ashaque Husain
- National Tuberculosis Control Programme, Dhaka, Bangladesh
| | - Alamdar Hussain
- National Tuberculosis Reference Laboratory, National Tuberculosis Control Programme, Islamabad, Pakistan
| | - Nazir Ismail
- National Institute for Communicable Diseases, Sandringham, South Africa; University of Pretoria, Pretoria, South Africa
| | - Mostofa Kamal
- National Institute of Diseases of the Chest and Hospital, Dhaka, Bangladesh
| | - Mikael Mansjö
- Department of Microbiology, Public Health Agency of Sweden, Solna, Sweden
| | - Lindiwe Mvusi
- Tuberculosis Control and Management, National Department of Health, Pretoria, South Africa
| | - Stefan Niemann
- National and Supranational Reference Laboratory for Mycobacterium, Borstel, Germany
| | - Shaheed V Omar
- National Institute for Communicable Diseases, Sandringham, South Africa
| | - Ejaz Qadeer
- National Tuberculosis Control Programme, Ministry of National Health Services, Regulation and Coordination, Islamabad, Pakistan
| | - Leen Rigouts
- Mycobacteriology Unit, Institute of Tropical Medicine, Antwerp, Belgium; Biomedical Sciences, Antwerp University, Antwerp, Belgium
| | - Sabine Ruesch-Gerdes
- National and Supranational Reference Laboratory for Mycobacterium, Borstel, Germany
| | | | | | - Alena Skrahina
- Republican Research and Practical Centre for Pulmonology and Tuberculosis, Minsk, Belarus
| | - Sabira Tahseen
- National Tuberculosis Reference Laboratory, National Tuberculosis Control Programme, Islamabad, Pakistan
| | - William A Wells
- Bureau for Global Health, US Agency for International Development, Washington, DC, USA
| | - Ya Diul Mukadi
- Bureau for Global Health, US Agency for International Development, Washington, DC, USA
| | | | - Katherine Floyd
- Global Tuberculosis Programme, World Health Organization, Geneva, Switzerland
| | - Karin Weyer
- Global Tuberculosis Programme, World Health Organization, Geneva, Switzerland
| | - Mario C Raviglione
- Global Tuberculosis Programme, World Health Organization, Geneva, Switzerland
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243
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Flisikowska T, Kind A, Schnieke A. Pigs as models of human cancers. Theriogenology 2016; 86:433-7. [DOI: 10.1016/j.theriogenology.2016.04.058] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Accepted: 03/14/2016] [Indexed: 10/21/2022]
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244
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Polverino E, Bothamley GH, Goletti D, Heyckendorf J, Sotgiu G, Aliberti S. The best of respiratory infections from the 2015 European Respiratory Society International Congress. ERJ Open Res 2016; 2:00049-2016. [PMID: 27730203 PMCID: PMC5034596 DOI: 10.1183/23120541.00049-2016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Accepted: 05/27/2016] [Indexed: 12/01/2022] Open
Abstract
The breadth and quality of scientific presentations on clinical and translational research into respiratory infections at the 2015 European Respiratory Society (ERS) International Congress in Amsterdam, the Netherlands, establishes this area as one of the leadings fields in pulmonology. The host-pathogen relationship in chronic obstructive pulmonary disease, and the impact of comorbidities and chronic treatment on clinical outcomes in patients with pneumonia were studied. Various communications were dedicated to bronchiectasis and, in particular, to different prognostic and clinical aspects of this disease, including chronic infection with Pseudomonas and inhaled antibiotic therapy. Recent data from the World Health Organization showed that Europe has the highest number of multidrug-resistant tuberculosis cases and the poorest countries have the least access to suitable treatments. Latent tuberculosis and different screening programmes were also discussed with particular attention to risk factors such as HIV infection and diabetes. Several biomarkers were proposed to distinguish between active tuberculosis and latent infection. Major treatment trials were discussed (REMOX, RIFQUIN and STREAM). The possibility of once-weekly treatment in the continuation phase (RIAQUIN) was especially exciting. The continuing rise of Mycobacterium abscessus as a significant pathogen was noted. This article reviews some of the best contributions from the Respiratory Infections Assembly to the 2015 ERS International Congress.
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Affiliation(s)
- Eva Polverino
- Fundació Clinic, Hospital Clinic of Barcelona – Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Ciber de Enfermedades Respiratorias, Barcelona, Spain
- These authors contributed equally
| | - Graham H. Bothamley
- Dept of Respiratory Medicine, Homerton University Hospital, London, UK
- These authors contributed equally
| | - Delia Goletti
- Translational Research Unit, Dept of Epidemiology and Preclinical Research, National Institute for Infectious Diseases, Rome, Italy
| | - Jan Heyckendorf
- Division of Clinical Infectious Diseases, German Center for Infection Research, Research Center, Borstel, Germany
| | - Giovanni Sotgiu
- Clinical Epidemiology and Medical Statistics Unit, Dept of Biomedical Sciences, University of Sassari, Medical Education and Professional Development Unit, Sassari, Italy
| | - Stefano Aliberti
- Dept of Pathophysiology and Transplantation, University of Milan, Cardio-Thoracic Unit and Cystic Fibrosis Adult Center, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
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245
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Dooley KE, Phillips PPJ, Nahid P, Hoelscher M. Challenges in the clinical assessment of novel tuberculosis drugs. Adv Drug Deliv Rev 2016; 102:116-22. [PMID: 26827911 DOI: 10.1016/j.addr.2016.01.014] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Revised: 12/29/2015] [Accepted: 01/21/2016] [Indexed: 11/18/2022]
Abstract
To tackle the global TB epidemic effectively, novel treatment strategies are critically needed to shorten the duration of TB therapy and treat drug-resistant TB. Drug development for TB, stymied for decades, has enjoyed a renaissance over the past several years. However, the development of new TB regimens is hindered by the limitations in our understanding and use of preclinical models; the paucity of accurate, early surrogate markers of cure, and challenges in untangling the individual contributions of drugs to multidrug regimens in a complex, multi-compartment disease. Lack of profit motive, advocacy, and imagination has contributed mightily to the dearth of drugs we have on the shelf to treat this ancient disease. Areas that will speed the development of new regimens for TB include novel murine and in vitro pharmacodynamics models, clinical endpoints that are not culture-based, innovative clinical trial designs, and an infusion of much-needed funding.
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Affiliation(s)
- Kelly E Dooley
- Divisions of Clinical Pharmacology & Infectious Diseases, Center for Tuberculosis Research, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Osler 527, Baltimore, MD, 2187, USA.
| | - Patrick P J Phillips
- MRC Clinical Trials Unit at UCL, Aviation House, 125 Kingsway, London WC1B 6NH, UK.
| | - Payam Nahid
- Division of Pulmonary and Critical Care Medicine, University of California, San Francisco, at San Francisco General Hospital, 1001 Potrero Ave., 5K1, San Francisco, CA, USA.
| | - Michael Hoelscher
- Division of Infectious Diseases and Tropical Medicine, Medical Centre of the University of Munich (LMU), Leopoldstrasse 5, 80802 Munich, Germany; German Centre for Infection Research (DZIF), Leopoldstrasse 5, 80802 Munich, Germany; German Centre for Infection Research, Leopoldstrasse 5, 80802 Munich, Germany.
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246
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Abstract
Rifamycins inhibit RNA polymerase of most bacterial genera. Rifampicin remains part of combination therapy for treating tuberculosis (TB), and for treating Gram-positive prosthetic joint and valve infections, in which biofilms are prominent. Rifabutin has use for AIDS patients in treating mycobacterial infections TB and Mycobacterium avium complex (MAC), having fewer drug-drug interactions that interfere with AIDS medications. Rifabutin is occasionally used in combination to eradicate Helicobacter pylori (peptic ulcer disease). Rifapentine has yet to fulfill its potential in reducing time of treatment for TB. Rifaximin is a monotherapeutic agent to treat gastrointestinal (GI) disorders, such as hepatic encephalopathy, irritable bowel syndrome, and travelers' diarrhea. Rifaximin is confined to the GI tract because it is not systemically absorbed on oral dosing, achieving high local concentrations, and showing anti-inflammatory properties in addition to its antibacterial activity. Resistance issues are unavoidable with all the rifamycins when the bioburden is high, because of mutations that modify RNA polymerase.
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247
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Goletti D, Petruccioli E, Joosten SA, Ottenhoff THM. Tuberculosis Biomarkers: From Diagnosis to Protection. Infect Dis Rep 2016; 8:6568. [PMID: 27403267 PMCID: PMC4927936 DOI: 10.4081/idr.2016.6568] [Citation(s) in RCA: 118] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Accepted: 04/29/2016] [Indexed: 12/25/2022] Open
Abstract
New approaches to control tuberculosis (TB) worldwide are needed. In particular, new tools for diagnosis and new biomarkers are required to evaluate both pathogen and host key elements of the response to infection. Non-sputum based diagnostic tests, biomarkers predictive of adequate responsiveness to treatment, and biomarkers of risk of developing active TB disease are major goals. Here, we review the current state of the field. Although reports on new candidate biomarkers are numerous, validation and independent confirmation are rare. Efforts are needed to reduce the gap between the exploratory up-stream identification of candidate biomarkers, and the validation of biomarkers against clear clinical endpoints in different populations. This will need a major commitment from both scientists and funding bodies.
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Affiliation(s)
- Delia Goletti
- Translational Research Unit, Department of Epidemiology and Preclinical Research, National Institute for Infectious Diseases, L. Spallanzani , Rome, Italy
| | - Elisa Petruccioli
- Translational Research Unit, Department of Epidemiology and Preclinical Research, National Institute for Infectious Diseases, L. Spallanzani , Rome, Italy
| | - Simone A Joosten
- Department of Infectious Diseases, Leiden University Medical Centre , The Netherlands
| | - Tom H M Ottenhoff
- Department of Infectious Diseases, Leiden University Medical Centre , The Netherlands
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248
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Gualano G, Capone S, Matteelli A, Palmieri F. New Antituberculosis Drugs: From Clinical Trial to Programmatic Use. Infect Dis Rep 2016; 8:6569. [PMID: 27403268 PMCID: PMC4927937 DOI: 10.4081/idr.2016.6569] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Accepted: 04/29/2016] [Indexed: 01/05/2023] Open
Abstract
Treatment of multidrug-resistant tuberculosis (MDR-TB) cases is challenging because it relies on second-line drugs that are less potent and more toxic than those used in the clinical management of drug-susceptible TB. Moreover, treatment outcomes for MDR-TB are generally poor compared to drug sensitive disease, highlighting the need for of new drugs. For the first time in more than 50 years, two new anti-TB drugs were approved and released. Bedaquiline is a first-in-class diarylquinoline compound that showed durable culture conversion at 24 weeks in phase IIb trials. Delamanid is the first drug of the nitroimidazole class to enter clinical practice. Similarly to bedaquiline results of phase IIb studies showed increased sputum-culture conversion at 2 months and better final treatment outcomes in patients with MDR-TB. Among repurposed drugs linezolid and carbapenems may represent a valuable drug to treat cases of MDR and extensively drug-resistant TB. The recommended regimen for MDR-TB is the combination of at least four drugs to which M. tuberculosis is likely to be susceptible for the duration of 20 months. Drugs are chosen with a stepwise selection process through five groups on the basis of efficacy, safety, and cost. Clinical phase III trials on new regimen are ongoing that could prove transformative against MDR-TB, by being shorter (six months), simpler (an all-oral regimen) and safer than current standard therapy. It is fundamental that the adoption of the new drugs is done responsibly to avoid inappropriate use. Concentration of in-patient MDR-TB treatment in specialized centers could be considered in countries with low numbers of cases in order to provide appropriate clinical case management and to prevent emergence of drug resistance.
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Affiliation(s)
- Gina Gualano
- Respiratory Infectious Diseases Unit, National Institute for Infectious Diseases L. Spallanzani , Rome
| | - Susanna Capone
- Department of Infectious and Tropical Diseases, WHO Collaborating Centre for TB/HIV and TB Elimination, University of Brescia , Italy
| | - Alberto Matteelli
- Department of Infectious and Tropical Diseases, WHO Collaborating Centre for TB/HIV and TB Elimination, University of Brescia , Italy
| | - Fabrizio Palmieri
- Respiratory Infectious Diseases Unit, National Institute for Infectious Diseases L. Spallanzani , Rome
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249
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Stagg HR, Harris RJ, Hatherell HA, Obach D, Zhao H, Tsuchiya N, Kranzer K, Nikolayevskyy V, Kim J, Lipman MC, Abubakar I. What are the most efficacious treatment regimens for isoniazid-resistant tuberculosis? A systematic review and network meta-analysis. Thorax 2016; 71:940-9. [PMID: 27298314 PMCID: PMC5036252 DOI: 10.1136/thoraxjnl-2015-208262] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2015] [Accepted: 04/30/2016] [Indexed: 12/02/2022]
Abstract
Introduction Consensus on the best treatment regimens for patients with isoniazid-resistant TB is limited; global treatment guidelines differ. We undertook a systematic review and meta-analysis using mixed-treatment comparisons methodology to provide an up-to-date summary of randomised controlled trials (RCTs) and relative regimen efficacy. Methods Ovid MEDLINE, the Web of Science and EMBASE were mined using search terms for TB, drug therapy and RCTs. Extracted data were inputted into fixed-effects and random-effects models. ORs for all possible network comparisons and hierarchical rankings for different regimens were obtained. Results 12 604 records were retrieved and 118 remained postextraction, representing 59 studies—27 standalone and 32 with multiple papers. In comparison to a baseline category that included the WHO-recommended regimen for countries with high levels of isoniazid resistance (rifampicin-containing regimens using fewer than three effective drugs at 4 months, in which rifampicin was protected by another effective drug at 6 months, and rifampicin was taken for 6 months), extending the duration of rifampicin and increasing the number of effective drugs at 4 months lowered the odds of unfavourable outcomes (treatment failure or the lack of microbiological cure; relapse post-treatment; death due to TB) in a fixed-effects model (OR 0.31 (95% credible interval 0.12–0.81)). In a random-effects model all estimates crossed the null. Conclusions Our systematic review and network meta-analysis highlight a regimen category that may be more efficacious than the WHO population level recommendation, and identify knowledge gaps where data are sparse. Systematic review registration number PROSPERO CRD42014015025.
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Affiliation(s)
- H R Stagg
- Research Department of Infection and Population Health, University College London, London, UK
| | - R J Harris
- Statistics, Modelling and Economics Department, Public Health England, London, UK
| | - H-A Hatherell
- Research Department of Infection and Population Health, University College London, London, UK UCL CoMPLEX, Faculty of Mathematics and Physical Sciences, University College London, London, UK
| | - D Obach
- Research Department of Infection and Population Health, University College London, London, UK
| | - H Zhao
- Respiratory Diseases Department, National Infections Service, Public Health England, London, UK
| | - N Tsuchiya
- Department of Preventive Medicine and Epidemiology, Tohoku Medical Megabank Organization, Tohoku University, Sendai, Japan
| | - K Kranzer
- National and Supranational Mycobacterium Reference Laboratory, Research Centre Borstel, Borstel, Germany
| | - V Nikolayevskyy
- National Mycobacterium Reference Laboratory, Public Health England, London, UK Department of Medicine, Imperial College London, London, UK
| | - J Kim
- Research Department of Infection and Population Health, University College London, London, UK Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, College of Medicine, Incheon St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
| | - M C Lipman
- UCL Respiratory, Division of Medicine, University College London, London, UK Royal Free London National Health Service Foundation Trust, London, UK
| | - I Abubakar
- Research Department of Infection and Population Health, University College London, London, UK MRC Clinical Trials Unit, University College London, London, UK
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250
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Lienhardt C, Kraigsley AM, Sizemore CF. Driving the Way to Tuberculosis Elimination: The Essential Role of Fundamental Research. Clin Infect Dis 2016; 63:370-5. [PMID: 27270671 DOI: 10.1093/cid/ciw250] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Accepted: 04/14/2016] [Indexed: 01/13/2023] Open
Abstract
Tuberculosis has impacted human health for millennia. The World Health Organization estimated that, in 2014, 9.6 million people developed tuberculosis and 1.5 million people died from the disease. In May 2014, the World Health Assembly endorsed the new "End TB Strategy" that presents a pathway to tuberculosis elimination. The strategy outlines 3 areas of emphasis, one of which is intensified research and innovation. In this article we highlight the essential role for fundamental tuberculosis research in the future of tuberculosis diagnostics, treatment, and prevention. To maximize the impact of fundamental research, we must foster collaboration among all stakeholders engaged in tuberculosis research and control to facilitate open dialogue to assure that critical gaps in outcome-oriented science are identified and addressed. We present here a framework for future discussions among scientists, physicians, research and development specialists, and public health managers for the reinforcement of national and international strategies toward tuberculosis elimination.
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Affiliation(s)
- Christian Lienhardt
- Global Tuberculosis Programme, World Health Organization, Geneva, Switzerland
| | - Alison M Kraigsley
- American Association for the Advancement of Science, Washington D.C. National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | - Christine F Sizemore
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
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