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Huang YW, Yu MC, Lin CB, Lee JJ, Lin CJ, Chien ST, Lee CH, Chiang CY. Mitigating treatment failure of pulmonary pre-extensively drug-resistant tuberculosis: The role of new and repurposed drugs. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2024; 57:617-628. [PMID: 38705821 DOI: 10.1016/j.jmii.2024.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Revised: 04/17/2024] [Accepted: 04/18/2024] [Indexed: 05/07/2024]
Abstract
BACKGROUND Pre-extensively drug-resistant tuberculosis (pre-XDR-TB), defined as multidrug-resistant TB (MDR-TB) with additional resistance to any fluoroquinolone (FQ) is difficult to treat. We assessed whether the use of new or repurposed drugs (bedaquiline, delamanid, linezolid, carbapenem, clofazimine, pretomanid) mitigated treatment failure of pre-XDR-TB. METHODS MDR-TB patients managed in the Taiwan MDR-TB consortium between July 2009-December 2019 were eligible. Treatment outcomes at 30 months were assessed. Logistic regression models were constructed to investigate factors associated with treatment outcomes. RESULTS 109 patients with FQ-resistant MDR-TB and 218 patients with FQ-susceptible MDR-TB were included. 60 (55.1%) patients with FQ-resistant MDR-TB and 63 (28.9%) patients with FQ-susceptible MDR-TB have been treated with new or repurposed drugs (p < 0.01). Of the 218 patients with FQ-susceptible MDR-TB, 187 (85.8%) had treatment success, 30 (13.8%) died, no treatment failure, and 1 (0.5%) was loss-to-follow-up; of the 109 patients with FQ-resistant MDR-TB, 78 (71.6%) had treatment success, 21 (19.3%) died, 9 (8.3%) had treatment failure, and 1 (0.9%) was loss-to-follow-up (p < 0.01). The use of new or repurposed drugs was not associated with treatment outcomes among patients with FQ-susceptible MDR-TB. No patients with FQ-resistant MDR-TB treated with ≥2 new or repurposed drugs within 6 months of treatment initiation had treatment failure (p = 0.03). Patients with FQ-resistant MDR-TB treated with 1 new or repurposed drugs was more likely to have treatment failure as compared with patients not treated with new or repurposed drugs (adjOR 7.06, 95% CI 1.72-29.06). CONCLUSIONS Proper use of new or repurposed anti-TB drugs can mitigate treatment failure in FQ-resistant MDR-TB.
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Affiliation(s)
- Yi-Wen Huang
- Chang-Hua Hospital, Ministry of Health and Welfare, Chang-Hua, Taiwan; Institute of Medicine, Chang Shan Medical University, Taichung, Taiwan
| | - Ming-Chih Yu
- Division of Pulmonary Medicine, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan; School of Respiratory Therapy, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chih-Bin Lin
- Division of Chest Medicine, Department of Internal Medicine, Tzu Chi General Hospital, Tzu Chi University, Hualien, Taiwan; School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Jen-Jyh Lee
- Division of Chest Medicine, Department of Internal Medicine, Tzu Chi General Hospital, Tzu Chi University, Hualien, Taiwan
| | - Chou-Jui Lin
- Tao-Yuan General Hospital, Ministry of Health and Welfare, Tao-Yuan, Taiwan
| | - Shun-Tien Chien
- Chest Hospital, Ministry of Health and Welfare, Tainan, Taiwan
| | - Chih-Hsin Lee
- Division of Pulmonary Medicine, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan; Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chen-Yuan Chiang
- Division of Pulmonary Medicine, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan; Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; International Union Against Tuberculosis and Lung Disease, Paris, France.
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Chen Q, Huang T, Zou L, Tang X, Shi Z, Wang X, Wu H, Sun J, Lu X, Liang L, Jiang L, Liu D, Tang S, Wu G, He W. Clinical outcomes of multidrug-resistant tracheobronchial tuberculosis receiving anti-tuberculosis regimens containing bedaquiline or delamanid. Sci Rep 2024; 14:17347. [PMID: 39069547 PMCID: PMC11284204 DOI: 10.1038/s41598-024-68550-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 07/24/2024] [Indexed: 07/30/2024] Open
Abstract
The treatment of multidrug-resistant tracheobronchial tuberculosis poses challenges, and research investigating the efficacy of bedaquiline or delamanid as treatment for this condition is limited. This retrospective cohort study was conducted from 2017 to 2021. The study extracted data of patients with multidrug-resistant tracheobronchial tuberculosis from medical records and followed up on prognoses. Participants were divided into three groups: the bedaquiline, delamanid, and control group. Clinical outcomes and the risk factors associated with early culture conversion were analyzed. This study included 101 patients, with 32, 25, and 44 patients in the bedaquiline, delamanid, and control groups respectively. The differences in the treatment success rates among the three groups did not show statistical significance. Both the bedaquiline and delamanid groups had significantly higher culture conversion rates compared to the control after 2 or 6 months of treatment, with significantly shorter median times to culture conversion (bedaquiline group: 2 weeks, delamanid group: 2 weeks, control group: 12 weeks, P < 0.001). Treatment with bedaquiline or delamanid were identified as independent predictors of culture conversion at 2 months (bedaquiline group: aOR = 13.417, 95% CI 4.067-44.260, delamanid group: aOR = 9.333, 95% CI 2.498-34.878) or 6 months (bedaquiline group: aOR = 13.333, 95% CI 3.379-52.610, delamanid group: aOR = 5.000, 95% CI 1.357-18.426) of treatment through multivariable logistic regression analyses. The delamanid group showed better improvement in lumen stenosis compared to bedaquiline. Regimens containing bedaquiline or delamanid may accelerate the culture conversion during the early treatment phase in multidrug-resistant tracheobronchial tuberculosis, and delamanid appears to have the potential to effectively improve airway stenosis.
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Affiliation(s)
- Qing Chen
- Department of Tuberculosis, Public Health Clinical Center of Chengdu, Jingjusi 18 Street, Jingjiang District, Chengdu, Sichuan, China
| | - Tao Huang
- Department of Tuberculosis, Public Health Clinical Center of Chengdu, Jingjusi 18 Street, Jingjiang District, Chengdu, Sichuan, China
| | - Liping Zou
- Department of Tuberculosis, Public Health Clinical Center of Chengdu, Jingjusi 18 Street, Jingjiang District, Chengdu, Sichuan, China
| | - Xianzhen Tang
- Department of Tuberculosis, Public Health Clinical Center of Chengdu, Jingjusi 18 Street, Jingjiang District, Chengdu, Sichuan, China
| | - Zhengyu Shi
- Department of Tuberculosis, Public Health Clinical Center of Chengdu, Jingjusi 18 Street, Jingjiang District, Chengdu, Sichuan, China
| | - Xinwei Wang
- Department of Imaging, Public Health Clinical Center of Chengdu, Chengdu, Sichuan, China
| | - Huaige Wu
- Department of Tuberculosis, Public Health Clinical Center of Chengdu, Jingjusi 18 Street, Jingjiang District, Chengdu, Sichuan, China
| | - Jiying Sun
- Department of Tuberculosis, Public Health Clinical Center of Chengdu, Jingjusi 18 Street, Jingjiang District, Chengdu, Sichuan, China
| | - Xiaoli Lu
- Department of Tuberculosis, Public Health Clinical Center of Chengdu, Jingjusi 18 Street, Jingjiang District, Chengdu, Sichuan, China
| | - Li Liang
- Department of Tuberculosis, Public Health Clinical Center of Chengdu, Jingjusi 18 Street, Jingjiang District, Chengdu, Sichuan, China
| | - Liangshuang Jiang
- Department of Thoracic Surgery, Public Health Clinical Center of Chengdu, Chengdu, Sichuan, China
| | - Dafeng Liu
- Department of Internal Medicine, Public Health Clinical Center of Chengdu, Chengdu, Sichuan, China
| | - Shenjie Tang
- Beijing Tuberculosis and Thoracic Tumor Research Institute, Beijing Chest Hospital, Capital Medical University, Beijing, 101149, China.
| | - Guihui Wu
- Department of Tuberculosis, Public Health Clinical Center of Chengdu, Jingjusi 18 Street, Jingjiang District, Chengdu, Sichuan, China.
| | - Wei He
- Department of Tuberculosis, Public Health Clinical Center of Chengdu, Jingjusi 18 Street, Jingjiang District, Chengdu, Sichuan, China.
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Metcalfe JZ, Economou T, Naufal F, Kucukosmanoglu M, Kleiman R, Phillips PPJ, Conradie F. Validation of a Handheld 6-Lead Device for QT Interval Monitoring in Resource-Limited Settings. JAMA Netw Open 2024; 7:e2415576. [PMID: 38848063 PMCID: PMC11161846 DOI: 10.1001/jamanetworkopen.2024.15576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 04/08/2024] [Indexed: 06/10/2024] Open
Abstract
Importance Rifampin-resistant tuberculosis treatment regimens require electrocardiographic (ECG) monitoring due to the use of multiple QTc-prolonging agents. Formal 12-lead ECG devices represent a significant burden in resource-constrained clinics worldwide and a potential barrier to treatment scale-up in some settings. Objective To evaluate the diagnostic accuracy of a handheld 6-lead ECG device within resource-constrained clinics. Design, Setting, and Participants This diagnostic study was performed within a multicenter, pragmatic (broad eligibility criteria with no exclusions for randomized participants), phase 3 rifampin-resistant tuberculosis treatment trial (BEAT Tuberculosis [Building Evidence for Advancing New Treatment for Tuberculosis]) in South Africa. A total of 192 consecutive trial participants were assessed, and 191 were recruited for this substudy between January 21, 2021, and March 27, 2023. A low proportion (3 of 432 [0.7%]) of all screened trial participants were excluded due to a QTc interval greater than 450 milliseconds. Triplicate reference standard 12-lead ECG results were human calibrated with readers blinded to 6-lead ECG results. Main Outcomes and Measures Diagnostic accuracy, repeatability, and feasibility of a 6-lead ECG device. Results A total of 191 participants (median age, 36 years [IQR, 28-45 years]; 81 female participants [42.4%]; 91 participants [47.6%] living with HIV) with a median of 4 clinic visits (IQR, 3-4 visits) contributed 2070 and 2015 12-lead and 6-lead ECG assessments, respectively. Across 170 participants attending 489 total clinic visits where valid triplicate QTc measurements were available for both devices, the mean 12-lead QTc measurement was 418 milliseconds (range, 321-519 milliseconds), and the mean 6-lead QTc measurement was 422 milliseconds (range, 288-574 milliseconds; proportion of variation explained, R2 = 0.4; P < .001). At a QTc interval threshold of 500 milliseconds, the 6-lead ECG device had a negative predictive value of 99.8% (95% CI, 98.8%-99.9%) and a positive predictive value of 16.7% (95% CI, 0.4%-64.1%). The normal expected range of within-individual variability of the 6-lead ECG device was high (±50.2 milliseconds [coefficient of variation, 6.0%]) relative to the 12-lead ECG device (±22.0 milliseconds [coefficient of variation, 2.7%]). The mean (SD) increase in the 12-lead QTc measurement during treatment was 10.1 (25.8) milliseconds, with 0.8% of clinic visits (4 of 489) having a QTc interval of 500 milliseconds or more. Conclusions and Relevance This study suggests that simplified, handheld 6-lead ECG devices are effective triage tests that could reduce the need to perform 12-lead ECG monitoring in resource-constrained settings.
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Affiliation(s)
- John Z. Metcalfe
- Division of Pulmonary and Critical Care Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco
| | - Tamsin Economou
- Department of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Fahd Naufal
- Division of Pulmonary and Critical Care Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco
| | | | | | - Patrick P. J. Phillips
- Division of Pulmonary and Critical Care Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco
| | - Francesca Conradie
- Department of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
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Schönfeld N, Barkane L, Davoliene I, Danilovits M, Miliauskas S, Ader F, Kon OM, Lange C, Duvignaud A, Heiss-Neumann M, Hittel N, Lazarević N, Knebel I, Martin A, Eschenbach B, van Heumen E, George V. Real-life use of delamanid: results from the European post-authorisation safety study. IJTLD OPEN 2024; 1:274-278. [PMID: 39021446 PMCID: PMC11249655 DOI: 10.5588/ijtldopen.24.0113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 05/23/2024] [Indexed: 07/20/2024]
Abstract
BACKGROUND A post-authorisation safety study (PASS) on delamanid (DLM) was conducted as part of a post-approval commitment to the European Medicines Agency. The aim of this study was to evaluate the use of DLM in a real-life setting, its safety, and treatment outcomes in patients with multidrug-resistant TB (MDR-TB). METHODS This was a prospective, multicentric, non-interventional study conducted in the European Union. MDR-TB Regimen selection and patient monitoring were conducted in accordance with existing medical practices. Data on the use of DLM, related adverse events, and treatment outcomes were collected for up to 30 months after the first DLM dose. Descriptive summary statistics were used for continuous and categorical variables. RESULTS Out of 86 patients, one had extrapulmonary TB. Two-thirds of the patients were treated with DLM for more than 24 weeks. The most frequent adverse drug reaction to DLM was QT interval prolongation. Resistance to DLM was detected in one patient during treatment. The treatment success rate was 77%. CONCLUSION No new safety concerns were revealed, including in patients treated with DLM for more than 24 weeks. QT interval prolongations were well managed and did not lead to any clinically significant cardiac effects. The treatment outcomes were in line with the WHO target for Europe.
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Affiliation(s)
- N Schönfeld
- Helios Klinikum Emil von Behring, Berlin, Germany
| | - L Barkane
- Riga East University Hospital, Riga, Latvia
| | - I Davoliene
- Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania
| | | | - S Miliauskas
- Department of Pulmonology, Lithuania University of Health Sciences, Kaunas, Lithuania
| | - F Ader
- Hospices Civils de Lyon, Département des Maladies Infectieuses et Tropicales, Lyon, France
| | - O M Kon
- Imperial College Healthcare NHS Trust, St Mary's Hospital, London, UK
| | - C Lange
- Research Center Borstel, Leibniz Lung Center, Borstel, Germany
- Tuberculosis Unit, German Center for Infection Research (DZIF), Hamburg-Lübeck-Borstel Riems, Borstel, Germany
- Respiratory Medicine & International Health, University Lübeck, Lübeck, Germany
- Baylor College of Medicine and Texas Children´s Hospital, Global TB Program, Houston, TX, USA
| | - A Duvignaud
- Department of Infectious Diseases and Tropical Medicine, Centre Hospitalier Universitaire de Bordeaux-Groupe Hospitalier Pellegrin, Bordeaux, France
| | | | - N Hittel
- Otsuka Novel Products, Munich, Germany
| | | | - I Knebel
- Otsuka Novel Products, Munich, Germany
| | - A Martin
- Otsuka Novel Products, Munich, Germany
| | | | | | - V George
- Otsuka Pharmaceutical Development and Commercialization, Princeton, NJ, USA
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5
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Martínez-Campreciós J, Espinosa-Pereiro J, Sánchez-Montalvá A. Update on the treatment of tuberculosis. Med Clin (Barc) 2024:S0025-7753(24)00213-6. [PMID: 38705792 DOI: 10.1016/j.medcli.2024.02.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 02/27/2024] [Accepted: 02/29/2024] [Indexed: 05/07/2024]
Abstract
Tuberculosis (TB) affects more than 10 million people each year. We have contested this burden with a paradoxically slow development of treatments, as compared to other infectious diseases. This review aims to update health care professionals on the last developments for the management of TB. The combination of drugs established more than 40years ago is still adequate to cure most people affected by TB. However, with the generalisation of regimens based on rifampicin and isoniazid for (only) 6months, resistance emerged. Resistant cases needed long treatments based on injectable drugs. Now, after an exciting decade of research, we can treat resistant TB with oral regimens based on bedaquiline, nitroimidazoles, and linezolid for (only) 6months, and we may soon break the 6-month barrier for treatment duration. However, these improvements are not enough to end TB without an engagement of people affected and their communities to achieve adherence to treatment, transmission control, and improve socioeconomic determinants of health.
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Affiliation(s)
- Joan Martínez-Campreciós
- Servicio de Enfermedades Infecciosas, Hospital Universitario Vall d'Hebron, Departamento de Medicina, Universitat Autónoma de Barcelona. Programa de Salud Internacional del Instituto Catalán de la Salud (PROSICS), Barcelona, España; Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, España
| | - Juan Espinosa-Pereiro
- Servicio de Enfermedades Infecciosas, Hospital Universitario Vall d'Hebron, Departamento de Medicina, Universitat Autónoma de Barcelona. Programa de Salud Internacional del Instituto Catalán de la Salud (PROSICS), Barcelona, España; Grupo de Estudio de Infecciones por Micobacterias (GEIM), Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica (SEIMC), Madrid, España.
| | - Adrián Sánchez-Montalvá
- Servicio de Enfermedades Infecciosas, Hospital Universitario Vall d'Hebron, Departamento de Medicina, Universitat Autónoma de Barcelona. Programa de Salud Internacional del Instituto Catalán de la Salud (PROSICS), Barcelona, España; Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, España; Grupo de Estudio de Infecciones por Micobacterias (GEIM), Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica (SEIMC), Madrid, España
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Mongia H, Mamnoon F, Silsarma A, Mahajan R, Dalal A, Galindo MA, Iyer A, Singh P, Mansoor H, Das M, Morales M, Spencer H, Isaakidis P. Concomitant bedaquiline and delamanid therapy in patients with drug-resistant extra-pulmonary tuberculosis in Mumbai, India. J Clin Tuberc Other Mycobact Dis 2024; 35:100433. [PMID: 38617837 PMCID: PMC11015490 DOI: 10.1016/j.jctube.2024.100433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2024] Open
Abstract
Background World Health Organization suggests concurrent bedaquiline-delamanid (BDQ-DLM) as part of individualised regimens for eligible patients with pulmonary drug-resistant tuberculosis (DR-TB); however, data for patients with drug-resistant extrapulmonary tuberculosis (EPTB) is extremely limited. This study documents the treatment outcomes and adverse events associated with concurrent BDQ-DLM-based regimens in patients with drug-resistant EPTB at a Médecins Sans Frontières clinic in Mumbai, India. Methods Retrospective cohort study based on routinely collected programmatic data. Individualised regimens were based on drug-susceptibility testing and previous drug exposure. Drug-resistant EPTB patients initiated on regimens containing concurrent BDQ and DLM from April 2016 to October 2019 were included. Patients who completed treatment were followed up at 12 months. Results Of 17 patients, median age was 23 years (IQR = 21-30 years) and 12/17 (71 %) were female. Pre-extensively drug-resistant tuberculosis and extensively drug-resistant TB was reported in 13/17 (76.4 %) and 2/17 (11.7 %) patients respectively. Microbiological reports were unavailable for two patients with central nervous system TB. Lymph node TB was the commonest form of EPTB in 9/17 (53 %) of patients. Median duration of treatment was 18.9 months. At least one grade three or four severe adverse event (SAE) was reported by 13/17 (76.4 %) patients. Thirteen (76.4 %) patients had favourable outcomes. None of the patients relapsed or died in the one-year period of post-treatment follow-up. Conclusion Concurrent BDQ-DLM-based regimens in drug-resistant EPTB were effective and associated with manageable adverse events.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Hannah Spencer
- Southern Africa Medical Unit, Médecins Sans Frontières, Cape Town, South Africa
| | - Petros Isaakidis
- Southern Africa Medical Unit, Médecins Sans Frontières, Cape Town, South Africa
- Clinical and Molecular Epidemiology Unit, Department of Hygiene and Epidemiology, University of Ioannina School of Medicine, Ioannina, Greece
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Mikiashvili L, Kempker RR, Chakhaia TS, Bablishvili N, Avaliani Z, Lomtadze N, Schechter MC, Kipiani M. Impact of Prior Tuberculosis Treatment With New/Companion Drugs on Clinical Outcomes in Patients Receiving Concomitant Bedaquiline and Delamanid for Multidrug- and Rifampicin-Resistant Tuberculosis. Clin Infect Dis 2024; 78:1043-1052. [PMID: 37962987 PMCID: PMC11006115 DOI: 10.1093/cid/ciad694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Revised: 10/27/2023] [Accepted: 11/10/2023] [Indexed: 11/16/2023] Open
Abstract
BACKGROUND There are scarce data on the clinical outcomes of persons retreated with new/companion anti-tuberculosis (TB) drugs for multidrug- and rifampicin-resistant tuberculosis (MDR/RR-TB). We sought to evaluate the efficacy and safety of bedaquiline and delamanid containing regimens among patients with and without prior exposure to the new/companion drugs (bedaquiline, delamanid, linezolid, clofazimine, and fluoroquinolones). METHODS We conducted a retrospective cohort study among patients with pulmonary MDR/RR-TB in Georgia who received bedaquiline and delamanid combination as a part of a salvage regimen from November 2017 to December 2020 in a programmatic setting. RESULTS Among 106 persons with a median age of 39.5 years, 44 (41.5%) were previously treated with new/companion TB drugs. Patients with prior exposure to new/companion drugs had higher rates of baseline resistance compared to those without exposure to new/companion TB drugs (bedaquiline 15.2% vs 1.8%, linezolid 22.2% vs 16.7%). Sputum culture conversion rates among patients exposed and not exposed to new/companion drugs were 65.9% vs 98.0%, respectively (P < .001). Among patients with and without prior new/companion TB drug use, favorable outcome rates were 41.0% and 82.3%, respectively (P < .001). Treatment adherence in 32 (30.2%) patients was ≤80%. Five of 21 patients (23.8%) who had a baseline and repeat susceptibility test had acquired bedaquiline resistance. QTC/F prolongation (>500 ms) was rare (2.8%). CONCLUSIONS Prior exposure to new/companion TB drugs was associated with poor clinical outcomes and acquired drug resistance. Tailoring the TB regimen to each patient's drug susceptibility test results and burden of disease and enhancing adherence support may improve outcomes.
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Affiliation(s)
- L Mikiashvili
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - R R Kempker
- Department of Medicine, Division of Infectious Disease, Emory University School of Medicine, Atlanta, Georgia, USA
| | - T S Chakhaia
- School of Public Health, Georgia State University, Atlanta, Georgia, USA
| | - N Bablishvili
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Z Avaliani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - N Lomtadze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
- Department of Medicine, David Tvildiani Medical University, Tbilisi, Georgia
- Department of Medicine, The University of Georgia, Tbilisi, Georgia
| | - M C Schechter
- Department of Medicine, Division of Infectious Disease, Emory University School of Medicine, Atlanta, Georgia, USA
| | - M Kipiani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
- Department of Medicine, David Tvildiani Medical University, Tbilisi, Georgia
- Department of Medicine, The University of Georgia, Tbilisi, Georgia
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8
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Negi A, Perveen S, Gupta R, Singh PP, Sharma R. Unraveling Dilemmas and Lacunae in the Escalating Drug Resistance of Mycobacterium tuberculosis to Bedaquiline, Delamanid, and Pretomanid. J Med Chem 2024; 67:2264-2286. [PMID: 38351709 DOI: 10.1021/acs.jmedchem.3c01892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2024]
Abstract
Delamanid, bedaquiline, and pretomanid have been recently added in the anti-tuberculosis (anti-TB) treatment regimens and have emerged as potential solutions for combating drug-resistant TB. These drugs have proven to be effective in treating drug-resistant TB when used in combination. However, concerns have been raised about the eventual loss of these drugs due to evolving resistance mechanisms and certain adverse effects such as prolonged QT period, gastrointestinal problems, hepatotoxicity, and renal disorders. This Perspective emphasizes the properties of these first-in-class drugs, including their mechanism of action, pharmacokinetics/pharmacodynamics profiles, clinical studies, adverse events, and underlying resistance mechanisms. A brief coverage of efforts toward the generation of best-in-class leads in each class is also provided. The ongoing clinical trials of new combinations of these drugs are discussed, thus providing a better insight into the use of these drugs while designing an effective treatment regimen for resistant TB cases.
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Affiliation(s)
- Anjali Negi
- Infectious Diseases Division, CSIR - Indian Institute of Integrative Medicine, Jammu-180001, India
- Academy of Scientific and Innovative Research (AcSIR), Ghaziabad-201002, India
| | - Summaya Perveen
- Infectious Diseases Division, CSIR - Indian Institute of Integrative Medicine, Jammu-180001, India
- Academy of Scientific and Innovative Research (AcSIR), Ghaziabad-201002, India
| | - Ria Gupta
- Natural Products and Medicinal Chemistry, CSIR - Indian Institute of Integrative Medicine, Jammu-180001, India
- Academy of Scientific and Innovative Research (AcSIR), Ghaziabad-201002, India
| | - Parvinder Pal Singh
- Natural Products and Medicinal Chemistry, CSIR - Indian Institute of Integrative Medicine, Jammu-180001, India
- Academy of Scientific and Innovative Research (AcSIR), Ghaziabad-201002, India
| | - Rashmi Sharma
- Infectious Diseases Division, CSIR - Indian Institute of Integrative Medicine, Jammu-180001, India
- Academy of Scientific and Innovative Research (AcSIR), Ghaziabad-201002, India
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9
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Ur Rehman O, Fatima E, Ali A, Akram U, Nashwan A, Yunus F. Efficacy and safety of bedaquiline containing regimens in patients of drug-resistant tuberculosis: An updated systematic review and meta-analysis. J Clin Tuberc Other Mycobact Dis 2024; 34:100405. [PMID: 38152568 PMCID: PMC10750101 DOI: 10.1016/j.jctube.2023.100405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2023] Open
Abstract
Background Tuberculosis is an infectious disease caused by Mycobacterium tuberculosis and leads to serious complications if left untreated. Some strains of Mycobacterium tuberculosis are multi-drug resistant and require treatment with newer drugs. Bedaquiline based treatment regimens have been used in patients who are diagnosed with drug resistant tuberculosis. The aim of this study is to assess the efficacy and safety profile of bedaquiline-based treatment regimens using a systematic review of existing literature and meta-analysis. Methods In this study, an electronic search was carried out on PubMed, ScienceDirect, and Cochrane library to find relevant literature from March 2021 onwards. Random-effects model was used to assess pooled treatment success rate and 95 % CIs. p-value of <0.05 was suggestive of publication bias. The review is registered with PROSPERO: CRD42023432748. Results A total of 543 articles were retrieved by database searching, out of which 12 new studies met the inclusion criteria. The total number of articles included in the review was 41 including 36 observational studies (having a total of 9,934 patients) and 5 experimental studies (having a total of 468 patients). The pooled treatment success rate was 76.9 % (95 % CI, 72.9-80.4) in the observational studies and 81.7 % (95 % CI, 67.2-90.7) in the experimental studies. Further subgroup analysis was done on the basis of treatment regimens containing bedaquiline only and treatment regimens containing bedaquiline and delamanid. The pooled treatment success rate in the studies consisting of patients who were treated with regimens containing bedaquiline only was 78.4 % (95 % CI, 74.2-82.1) and 73.6 % (95 % CI, 64.6-81.0) in studies consisting of patients who were treated with regimens containing bedaquiline and delamanid. There was no evidence of publication bias. Conclusions In patients of drug resistant tuberculosis having highly resistant strains of Mycobacterium tuberculosis undergoing treatment with bedaquiline-based regimen demonstrate high rates of culture conversion and treatment success. Moreover, the safety profile of bedaquiline-based regimens is well-established in all studies.
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Affiliation(s)
- Obaid Ur Rehman
- Department of Medicine, Services Institute of Medical Sciences, Lahore, Pakistan
| | - Eeshal Fatima
- Department of Medicine, Services Institute of Medical Sciences, Lahore, Pakistan
| | - Abraish Ali
- Department of Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Umar Akram
- Department of Medicine, Allama Iqbal Medical College, Lahore, Pakistan
| | | | - Faryal Yunus
- Department of Pathology, Services Institute of Medical Sciences, Lahore, Pakistan
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10
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Rodriguez CA, Lodi S, Horsburgh CR, Mitnick CD, Bastard M, Huerga H, Khan U, Rich M, Seung KJ, Atwood S, Manzur-ul-Alam M, Melikyan N, Mpinda S, Myint Z, Naidoo Y, Petrosyan O, Salahuddin N, Sarfaraz S, Vilbrun SC, Yae K, Achar J, Ahmed S, Algozhina E, Beauchamp J, de Guadelupe Perea Moreno S, Gulanbaeva M, Gergedava M, Indah Sari CY, Hewison C, Khan P, Franke MF. Comparative effectiveness of adding delamanid to a multidrug-resistant tuberculosis regimen comprised of three drugs likely to be effective. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0000818. [PMID: 37115740 PMCID: PMC10146539 DOI: 10.1371/journal.pgph.0000818] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 04/04/2023] [Indexed: 04/29/2023]
Abstract
Clarity about the role of delamanid in longer regimens for multidrug-resistant TB is needed after discordant Phase IIb and Phase III randomized controlled trial results. The Phase IIb trial found that the addition of delamanid to a background regimen hastened culture conversion; the results of the Phase III trial were equivocal. We evaluated the effect of adding delamanid for 24 weeks to three-drug MDR/RR-TB regimens on two- and six-month culture conversion in the endTB observational study. We used pooled logistic regression to estimate the observational analogue of the intention-to-treat effect (aITT) adjusting for baseline confounders and to estimate the observational analogue of the per-protocol effect (aPP) using inverse probability of censoring weighting to control for time-varying confounding. At treatment initiation, 362 patients received three likely effective drugs (delamanid-free) or three likely effective drugs plus delamanid (delamanid-containing). Over 80% of patients received two to three Group A drugs (bedaquiline, linezolid, moxifloxacin/levofloxacin) in their regimen. We found no evidence the addition of delamanid to a three-drug regimen increased two-month (aITT relative risk: 0.90 (95% CI: 0.73-1.11), aPP relative risk: 0.89 (95% CI: 0.66-1.21)) or six-month culture conversion (aITT relative risk: 0.94 (95% CI: 0.84, 1.02), aPP relative risk: 0.93 (95% CI: 0.83, 1.04)). In regimens containing combinations of three likely effective, highly active anti-TB drugs the addition of delamanid had no discernible effect on culture conversion at two or six months. As the standard of care for MDR/RR-TB treatment becomes more potent, it may become increasingly difficult to detect the benefit of adding a single agent to standard of care MDR/RR-TB regimens. Novel approaches like those implemented may help account for background regimens and establish effectiveness of new chemical entities.
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Affiliation(s)
- Carly A. Rodriguez
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, United States of America
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Sara Lodi
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - C. Robert Horsburgh
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, United States of America
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, United States of America
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
- Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, United States of America
| | - Carole D. Mitnick
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
- Partners In Health, Boston, Massachusetts, United States of America
- Division of Global Health Equity, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
| | | | | | - Uzma Khan
- Interactive Research and Development Global, Singapore, Singapore
| | - Michael Rich
- Partners In Health, Boston, Massachusetts, United States of America
- Division of Global Health Equity, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
| | - Kwonjune J. Seung
- Partners In Health, Boston, Massachusetts, United States of America
- Division of Global Health Equity, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
| | - Sidney Atwood
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
| | | | | | | | - Zaw Myint
- National Tuberculosis Program, Ministry of Health, Yangon, Myanmar
| | - Yugandran Naidoo
- Interactive Research and Development, Johannesburg, South Africa
| | | | | | | | | | | | - Jay Achar
- Médecins Sans Frontières, United Kingdom
| | - Saman Ahmed
- Interactive Research and Development, Karachi, Pakistan
| | | | | | | | | | | | | | | | - Palwasha Khan
- Interactive Research and Development Global, Singapore, Singapore
| | - Molly F. Franke
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
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11
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Mpagama SG, Mvungi HC, Mbelele PM, Semvua HH, Liyoyo AA, de Guex KP, Sloan D, Kibiki GS, Boeree M, Phillips PPJ, Heysell SK. Protocol for a feasibility randomized controlled trial to evaluate the efficacy, safety and tolerability of N-acetylcysteine in reducing adverse drug reactions among adults treated for multidrug-resistant tuberculosis in Tanzania. Pilot Feasibility Stud 2023; 9:55. [PMID: 37005695 PMCID: PMC10066962 DOI: 10.1186/s40814-023-01281-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 03/10/2023] [Indexed: 04/04/2023] Open
Abstract
BACKGROUND Adverse drug reactions (ADRs) frequently occur in patients using second-line anti-tuberculosis medicine for treatment of multidrug resistant tuberculosis (MDR-TB). ADRs contribute to treatment interruptions which can compromise treatment response and risk acquired drug resistance to critical newer drugs such as bedaquiline, while severe ADRs carry considerable morbidity and mortality. N-acetylcysteine (NAC) has shown promise in reducing ADRs for medications related to TB in case series or randomized controlled trials in other medical conditions, yet evidence is lacking in MDR-TB patients. TB endemic settings have limited capacity to conduct clinical trials. We designed a proof-of-concept clinical trial primarily to explore the preliminary evidence on the protective effect of NAC among people treated for MDR-TB with second-line anti-TB medications. METHODS This is a proof-of-concept randomized open label clinical trial with 3 treatment arms including a control arm, an interventional arm of NAC 900 mg daily, and an interventional arm of NAC 900 mg twice-daily administered during the intensive phase of MDR-TB treatment. Patients initiating MDR-TB treatment will be enrolled at Kibong'oto National Center of Excellence for MDR-TB in the Kilimanjaro region of Tanzania. The minimum anticipated sample size is 66; with 22 participants in each arm. ADR monitoring will be performed at baseline and daily follow-up over 24 weeks including blood and urine specimen collection for hepatic and renal function and electrolyte abnormalities, and electrocardiogram. Sputum will be collected at baseline and monthly thereafter and cultured for mycobacteria as well as assayed for other molecular targets of Mycobacterium tuberculosis. Adverse drug events will be analysed over time using mixed effect models. Mean differences between arms in change of the ADRs from baseline (with 95% confidence intervals) will be derived from the fitted model. DISCUSSION Given that NAC promotes synthesis of glutathione, an intracellular antioxidant that combats the impact of oxidative stress, it may protect against medication induced oxidative damage in organs such as liver, pancreas, kidney, and cells of the immune system. This randomized controlled trial will determine if NAC leads to fewer ADRs, and if this protection is dose dependent. Fewer ADRs among patients treated with MDR-TB may significantly improve treatment outcomes for multidrug regimens that necessitate prolonged treatment durations. Conduct of this trial will set the needed infrastructure for clinical trials. TRIAL REGISTRATION PACTR202007736854169 Registered 03 July 2020.
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Affiliation(s)
- Stellah G Mpagama
- Kibong'oto Infectious Diseases Hospital-Sanya Juu Siha/Kilimanjaro Clinical Research Institute, Mae Street, Lomakaa Road, Siha Kilimanjaro, Tanzania.
- Kilimanjaro Christian Medical University College, Moshi, Kilimanjaro, Tanzania.
| | - Happiness C Mvungi
- Kibong'oto Infectious Diseases Hospital-Sanya Juu Siha/Kilimanjaro Clinical Research Institute, Mae Street, Lomakaa Road, Siha Kilimanjaro, Tanzania
- Kilimanjaro Christian Medical University College, Moshi, Kilimanjaro, Tanzania
| | - Peter M Mbelele
- Kibong'oto Infectious Diseases Hospital-Sanya Juu Siha/Kilimanjaro Clinical Research Institute, Mae Street, Lomakaa Road, Siha Kilimanjaro, Tanzania
- Nelson Mandela African Institute of Science and Technology, Arusha, Tanzania
| | - Hadija H Semvua
- Kilimanjaro Christian Medical University College, Moshi, Kilimanjaro, Tanzania
| | - Alphonce A Liyoyo
- Kibong'oto Infectious Diseases Hospital-Sanya Juu Siha/Kilimanjaro Clinical Research Institute, Mae Street, Lomakaa Road, Siha Kilimanjaro, Tanzania
| | - Kristen Petros de Guex
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, USA
| | | | | | - Martin Boeree
- Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Patrick P J Phillips
- UCSF Center for Tuberculosis, University of California San Francisco, San Francisco, USA
| | - Scott K Heysell
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, USA
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12
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Alzain AA, Makki AA, Ibraheem W. Insights into the Inhibition of Mycolic Acid Synthesis by Cytosporone E Derivatives for Tuberculosis Treatment Via an In Silico Multi-target Approach. CHEMISTRY AFRICA 2023. [DOI: 10.1007/s42250-023-00605-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
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13
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Putra ON, Yulistiani Y, Soedarsono S, Subay S. Favorable outcome of individual regimens containing bedaquiline and delamanid in drug-resistant tuberculosis: A systematic review. Int J Mycobacteriol 2023; 12:1-9. [PMID: 36926755 DOI: 10.4103/ijmy.ijmy_217_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023] Open
Abstract
Background Drug-resistant tuberculosis (DR-TB) is a public health concern that is difficult to treat, requiring long and complex treatment with highly effective drugs. Bedaquiline and/or delamanid have already shown promising outcomes in patients with DR-TB, increasing the rate of culture conversion and lowering TB-related mortality. Methods We comprehensively searched and evaluated the effectiveness of individual regimens containing bedaquiline and delamanid on culture conversion and treatment success. We assessed for quality either observational or experimental studies. Results We identified 14 studies that met the inclusion criteria using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses flowchart with 12 observational and 2 experimental studies. Of 1691 DR-TB patients enrolled in the included studies, 1407 of them concomitantly received regimens containing bedaquiline and delamanid. Overall multidrug resistant (MDR), preextensively drug resistant (XDR), and XDR-TB were seen in 21.4%, 44.1%, and 34.5%, respectively. Of 14 studies, 8 of them reported favorable outcomes including sputum culture conversion and cure rate at the end of treatment, meanwhile 6 studies only reported sputum culture conversion. Sputum culture conversion at the end of the 6th month was 63.6%-94.7% for observational studies, and 87.6%-95.0% for experimental studies. The favorable outcome at the end of treatment was 67.5%-91.4%. With high pre-XDR and XDR cases among DR-TB patients with limited treatment options, regimens containing bedaquiline and delamanid provide successful treatment. Conclusion In DR-TB patients receiving regimens containing bedaquiline and delamanid, favorable outcomes were high including sputum conversion and cure rate.
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Affiliation(s)
- Oki Nugraha Putra
- Doctoral Program of Pharmacy, Faculty of Pharmacy, Airlangga University; Study Program of Pharmacy, Faculty of Medicine, Hang Tuah University, Surabaya, Indonesia
| | - Yulistiani Yulistiani
- Doctoral Program of Pharmacy, Faculty of Pharmacy, Airlangga University, Surabaya, Indonesia
| | - Soedarsono Soedarsono
- Study Program of Pharmacy, Faculty of Medicine, Hang Tuah University; Department of Pulmonology and Respiratory Medicine, Dr. Soetomo Hospital, Surabaya, Indonesia
| | - Susi Subay
- Department of Pulmonology and Respiratory Medicine, Dr. Soetomo Hospital, Surabaya, Indonesia
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14
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Dookie N, Ngema SL, Perumal R, Naicker N, Padayatchi N, Naidoo K. The Changing Paradigm of Drug-Resistant Tuberculosis Treatment: Successes, Pitfalls, and Future Perspectives. Clin Microbiol Rev 2022; 35:e0018019. [PMID: 36200885 PMCID: PMC9769521 DOI: 10.1128/cmr.00180-19] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Drug-resistant tuberculosis (DR-TB) remains a global crisis due to the increasing incidence of drug-resistant forms of the disease, gaps in detection and prevention, models of care, and limited treatment options. The DR-TB treatment landscape has evolved over the last 10 years. Recent developments include the remarkable activity demonstrated by the newly approved anti-TB drugs bedaquiline and pretomanid against Mycobacterium tuberculosis. Hence, treatment of DR-TB has drastically evolved with the introduction of the short-course regimen for multidrug-resistant TB (MDR-TB), transitioning to injection-free regimens and the approval of the 6-month short regimens for rifampin-resistant TB and MDR-TB. Moreover, numerous clinical trials are under way with the aim to reduce pill burden and shorten the DR-TB treatment duration. While there have been apparent successes in the field, some challenges remain. These include the ongoing inclusion of high-dose isoniazid in DR-TB regimens despite a lack of evidence for its efficacy and the inclusion of ethambutol and pyrazinamide in the standard short regimen despite known high levels of background resistance to both drugs. Furthermore, antimicrobial heteroresistance, extensive cavitary disease and intracavitary gradients, the emergence of bedaquiline resistance, and the lack of biomarkers to monitor DR-TB treatment response remain serious challenges to the sustained successes. In this review, we outline the impact of the new drugs and regimens on patient treatment outcomes, explore evidence underpinning current practices on regimen selection and duration, reflect on the disappointments and pitfalls in the field, and highlight key areas that require continued efforts toward improving treatment approaches and rapid biomarkers for monitoring treatment response.
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Affiliation(s)
- Navisha Dookie
- Centre for the AIDS Programme of Research in South Africa, University of KwaZulu-Natal, Durban, South Africa
| | - Senamile L. Ngema
- Centre for the AIDS Programme of Research in South Africa, University of KwaZulu-Natal, Durban, South Africa
| | - Rubeshan Perumal
- Centre for the AIDS Programme of Research in South Africa, University of KwaZulu-Natal, Durban, South Africa
- South African Medical Research Council–CAPRISA HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - Nikita Naicker
- Centre for the AIDS Programme of Research in South Africa, University of KwaZulu-Natal, Durban, South Africa
- South African Medical Research Council–CAPRISA HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - Nesri Padayatchi
- Centre for the AIDS Programme of Research in South Africa, University of KwaZulu-Natal, Durban, South Africa
- South African Medical Research Council–CAPRISA HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - Kogieleum Naidoo
- Centre for the AIDS Programme of Research in South Africa, University of KwaZulu-Natal, Durban, South Africa
- South African Medical Research Council–CAPRISA HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
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15
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Nasiri MJ, Zangiabadian M, Arabpour E, Amini S, Khalili F, Centis R, D'Ambrosio L, Denholm JT, Schaaf HS, van den Boom M, Kurhasani X, Dalcolmo MP, Al-Abri S, Chakaya J, Alffenaar JW, Akkerman O, Silva DR, Muňoz-Torrico M, Seaworth B, Pontali E, Saderi L, Tiberi S, Zumla A, Migliori GB, Sotgiu G. Delamanid-containing regimens and multidrug-resistant tuberculosis: A systematic review and meta-analysis. Int J Infect Dis 2022; 124 Suppl 1:S90-S103. [PMID: 35245659 PMCID: PMC9731904 DOI: 10.1016/j.ijid.2022.02.043] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 02/20/2022] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Multidrug-resistant tuberculosis (MDR-TB) is a life-threatening condition needing long poly-chemotherapy regimens. As no systematic reviews/meta-analysis is available to comprehensively evaluate the role of delamanid (DLM), we evaluated its effectiveness and safety. METHODS We reviewed the relevant scientific literature published up to January 20, 2022. The pooled success treatment rate with 95% confidence intervals (CI) was assessed using a random-effect model. We assessed studies for quality and bias, and considered P<0.05 to be statistically significant. RESULTS After reviewing 626 records, we identified 25 studies that met the inclusion criteria, 22 observational and 3 experimental, with 1276 and 411 patients, respectively. In observational studies the overall pooled treatment success rate of DLM-containing regimens was 80.9% (95% CI 72.6-87.2) with no evidence of publication bias (Begg's test; P >0.05). The overall pooled treatment success rate in DLM and bedaquiline-containing regimens was 75.2% (95% CI 68.1-81.1) with no evidence of publication bias (Begg's test; P >0.05). In experimental studies the pooled treatment success rate of DLM-containing regimens was 72.5 (95% CI 44.2-89.8, P <0.001, I2: 95.1%) with no evidence of publication bias (Begg's test; P >0.05). CONCLUSIONS In MDR-TB patients receiving DLM, culture conversion and treatment success rates were high despite extensive resistance with limited adverse events.
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Affiliation(s)
- Mohammad Javad Nasiri
- Department of Microbiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Moein Zangiabadian
- Department of Microbiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Erfan Arabpour
- Department of Microbiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Sirus Amini
- Department of Microbiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Farima Khalili
- Department of Microbiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Rosella Centis
- Servizio di Epidemiologia Clinica delle Malattie Respiratorie, Istituti Clinici Scientifici Maugeri IRCCS, Tradate, Italy
| | | | - Justin T. Denholm
- Victorian Tuberculosis Program, Melbourne Health, Victoria, Australia,Department of Infectious Diseases, University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Parkville, Victoria, Australia
| | - H. Simon Schaaf
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Martin van den Boom
- World Health Organization Regional Office for the Eastern Mediterranean Region, Cairo, Egypt
| | | | | | - Seif Al-Abri
- Directorate General for Disease Surveillance and Control, Ministry of Health, Muscat, Oman
| | - Jeremiah Chakaya
- Department of Medicine, dermatology and therapeutics, Kenyatta University, Nairobi, Kenya,Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Jan-Willem Alffenaar
- Sydney Institute of Infectious Diseases, University of Sydney, Sydney, NSW, Australia,School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia,Westmead Hospital, Sydney, NSW, Australia
| | - Onno Akkerman
- University of Groningen, University Medical Center Groningen, Department of Pulmonary Diseases and Tuberculosis, Groningen, the Netherlands,University of Groningen, University Medical Center Groningen, Tuberculosis center Beatrixoord, Haren, the Netherlands
| | - Denise Rossato Silva
- Faculdade de Medicina, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Marcela Muňoz-Torrico
- Tuberculosis clinic, Instituto Nacional de Enfermedades Respiratorias Ismael Cosio Villegas, Mexico City, Mexico
| | - Barbara Seaworth
- Department of Medicine University of Texas Health Science Center, Tyler, Texas
| | - Emanuele Pontali
- Department of Infectious Diseases, Galliera Hospital, Genoa, Italy
| | - Laura Saderi
- Unità di Epidemiologia Clinica e Statistica Medica, Dipartimento di Scienze Mediche Chirurgiche e Sperimentali, Università degli Studi di Sassari, Sassari, Italia
| | - Simon Tiberi
- Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Alimuddin Zumla
- Division of Infection and Immunity, Centre for Clinical Microbiology, University College London, London, United Kingdom,National Institute for Health Research Biomedical Research Centre, UCL Hospitals NHS Foundation Trust, London, United Kingdom
| | - Giovanni Battista Migliori
- Servizio di Epidemiologia Clinica delle Malattie Respiratorie, Istituti Clinici Scientifici Maugeri IRCCS, Tradate, Italy,Address for correspondence: Giovanni Battista Migliori, Servizio di Epidemiologia Clinica delle Malattie Respiratorie, Istituti Clinici Scientifici Maugeri IRCCS, Via Roncaccio 16, Tradate, Varese, 21049, Italy.
| | - Giovanni Sotgiu
- Unità di Epidemiologia Clinica e Statistica Medica, Dipartimento di Scienze Mediche Chirurgiche e Sperimentali, Università degli Studi di Sassari, Sassari, Italia
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16
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Putra ON, Yulistiani Y, Soedarsono S. Scoping review: QT interval prolongation in regimen containing bedaquiline and delamanid in patients with drug-resistant tuberculosis. Int J Mycobacteriol 2022; 11:349-355. [PMID: 36510917 DOI: 10.4103/ijmy.ijmy_178_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background A regimen containing bedaquiline-delamanid is recommended in management of drug-resistant tuberculosis (DR TB) to increase a success rate. However, this regimen was rare in a clinical setting due to a potential risk of QT prolongation. Several studies have reported the incidence of QT prolongation after administration of this regimen, but the results are inconsistent due to different sample size, study design, and covariate. The aim of this review is to summarize and analyze the published articles related to QT prolongation of bedaquiline and delamanid in PubMed and ScienceDirect databases using a scoping review. Methods This scoping review was conducted under PRISMA for scoping review. The outcomes of this review were incidence of QT prolongation and death. We found 8 articles to be included in this review. Results The incidence of QT prolongation was higher for DR TB patients who received a regimen containing bedaquiline and delamanid. However, this review found no clinical symptoms, such as cardiac arrhythmias, torsade de pointes, or even death. DR TB patients, especially the elderly, were at risk for QT prolongation. Special consideration in patients with HIV and low level of potassium should be closely monitored for QT interval. Conclusion The regular measurement of electrocardiography was highly recommended to evaluate QT interval. Generally, the use of individualized regimen containing bedaquiline and delamanid is relatively safe in DR TB patients.
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Affiliation(s)
- Oki Nugraha Putra
- Doctoral Program of Pharmacy, Faculty of Pharmacy, Airlangga University; Study Program of Pharmacy, Faculty of Medicine, Hang Tuah University, Surabaya, Indonesia
| | | | - Soedarsono Soedarsono
- Faculty of Medicine, Hang Tuah University; Department of Pulmonology and Respiratory Medicine, Dr. Soetomo Hospital, Surabaya, Indonesia
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17
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Tanneau L, Karlsson MO, Rosenkranz SL, Cramer YS, Shenje J, Upton CM, Morganroth J, Diacon AH, Maartens G, Dooley KE, Svensson EM. Assessing Prolongation of the Corrected QT Interval with Bedaquiline and Delamanid Coadministration to Predict the Cardiac Safety of Simplified Dosing Regimens. Clin Pharmacol Ther 2022; 112:873-881. [PMID: 35687528 PMCID: PMC9474693 DOI: 10.1002/cpt.2685] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 05/30/2022] [Indexed: 11/29/2022]
Abstract
Delamanid and bedaquiline are two drugs approved to treat drug-resistant tuberculosis, and each have been associated with corrected QT interval (QTc) prolongation. We aimed to investigate the relationships between the drugs' plasma concentrations and the prolongation of observed QT interval corrected using Fridericia's formula (QTcF) and to evaluate their combined effects on QTcF, using a model-based population approach. Furthermore, we predicted the safety profiles of once daily regimens. Data were obtained from a trial where participants were randomized 1:1:1 to receive delamanid, bedaquiline, or delamanid + bedaquiline. The effect on QTcF of delamanid and/or its metabolite (DM-6705) and the pharmacodynamic interactions under coadministration were explored based on a published model between bedaquiline's metabolite (M2) and QTcF. The metabolites of each drug were found to be responsible for the drug-related QTcF prolongation. The final drug-effect model included a competitive interaction between M2 and DM-6705 acting on the same cardiac receptor and thereby reducing each other's apparent potency, by 28% (95% confidence interval (CI), 22-40%) for M2 and 33% (95% CI, 24-54%) for DM-6705. The generated combined effect was not greater but close to "additivity" in the analyzed concentration range. Predictions with the final model suggested a similar QT prolonging potential with simplified, once-daily dosing regimens compared with the approved regimens, with a maximum median change from baseline QTcF increase of 20 milliseconds in both regimens. The concentrations-QTcF relationship of the combination of bedaquiline and delamanid was best described by a competitive binding model involving the two main metabolites. Model predictions demonstrated that QTcF prolongation with simplified once daily regimens would be comparable to currently used dosing regimens.
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Affiliation(s)
| | | | | | | | - Justin Shenje
- South African Tuberculosis Vaccine Initiative, University of Cape TownCape TownSouth Africa
| | | | | | | | - Gary Maartens
- Division of Clinical Pharmacology, Department of MedicineUniversity of Cape TownCape TownSouth Africa
| | - Kelly E. Dooley
- Center for Tuberculosis ResearchJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Elin M. Svensson
- Department of PharmacyUppsala UniversityUppsalaSweden
- Department of Pharmacy, Radboud Institute for Health SciencesRadboud University Medical CenterNijmegenThe Netherlands
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Zhang W, Lun S, Wang SS, Cai YP, Yang F, Tang J, Bishai WR, Yu LF. Structure-Based Optimization of Coumestan Derivatives as Polyketide Synthase 13-Thioesterase(Pks13-TE) Inhibitors with Improved hERG Profiles for Mycobacterium tuberculosis Treatment. J Med Chem 2022; 65:13240-13252. [PMID: 36174223 DOI: 10.1021/acs.jmedchem.2c01064] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Pks13 was identified as a key enzyme involved in the final step of mycolic acid biosynthesis. We previously identified antitubercular coumestans that targeted Pks13-TE, and these compounds exhibited high potency both in vitro and in vivo. However, lead compound 8 presented potential safety concerns because it inhibits the hERG potassium channel in electrophysiology patch-clamp assays (IC50 = 0.52 μM). By comparing the Pks13-TE-compound 8 complex and the ligand-binding pocket of the hERG ion channel, fluoro-substituted and oxazine-containing coumestans were designed and synthesized. Fluoro-substituted compound 23 and oxazine-containing coumestan 32 showed excellent antitubercular activity against both drug-susceptible and drug-resistant Mtb strains (MIC = 0.0039-0.0078 μg/mL) and exhibited limited hERG inhibition (IC50 ≥ 25 μM). Moreover, 32 exhibited improved metabolic stability relative to parent compound 8 while showing favorable bioavailability in mouse models via serum inhibition titration assays.
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Affiliation(s)
- Wei Zhang
- Shanghai Engineering Research Center of Molecular Therapeutics and New Drug Development, School of Chemistry and Molecular Engineering, East China Normal University, 3663 North Zhongshan Road, Shanghai 200062, China
| | - Shichun Lun
- Center for Tuberculosis Research, Department of Medicine, Division of Infectious Disease, Johns Hopkins School of Medicine, Baltimore, Maryland 21231-1044, United States
| | - Shuang-Shuang Wang
- Shanghai Engineering Research Center of Molecular Therapeutics and New Drug Development, School of Chemistry and Molecular Engineering, East China Normal University, 3663 North Zhongshan Road, Shanghai 200062, China
| | - Yan-Peng Cai
- Shanghai Engineering Research Center of Molecular Therapeutics and New Drug Development, School of Chemistry and Molecular Engineering, East China Normal University, 3663 North Zhongshan Road, Shanghai 200062, China
| | - Fan Yang
- Shanghai Engineering Research Center of Molecular Therapeutics and New Drug Development, School of Chemistry and Molecular Engineering, East China Normal University, 3663 North Zhongshan Road, Shanghai 200062, China
| | - Jie Tang
- Shanghai Key Laboratory of Green Chemistry and Chemical Process, School of Chemistry and Molecular Engineering, East China Normal University, 3663 North Zhongshan Road, Shanghai 200062, China
| | - William R Bishai
- Center for Tuberculosis Research, Department of Medicine, Division of Infectious Disease, Johns Hopkins School of Medicine, Baltimore, Maryland 21231-1044, United States
| | - Li-Fang Yu
- Shanghai Engineering Research Center of Molecular Therapeutics and New Drug Development, School of Chemistry and Molecular Engineering, East China Normal University, 3663 North Zhongshan Road, Shanghai 200062, China
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Padmapriyadarsini C, Vohra V, Bhatnagar A, Solanki R, Sridhar R, Anande L, Muthuvijaylakshmi M, Rana MB, Jeyadeepa B, Taneja G, Balaji S, Shah P, Saravanan N, Chavan V, Kumar H, Ponnuraja C, Livchits V, Bahl M, Alavadi U, Sachdeva KS, Swaminathan S. Bedaquiline, Delamanid, Linezolid and Clofazimine for Treatment of Pre-extensively Drug-Resistant Tuberculosis. Clin Infect Dis 2022; 76:ciac528. [PMID: 35767251 PMCID: PMC9907500 DOI: 10.1093/cid/ciac528] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Revised: 06/18/2022] [Accepted: 06/24/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Treatment success rates for multidrug-resistant tuberculosis (MDR-TB) remain low globally. Availability of newer drugs has given scope to develop regimens that can be patient-friendly, less toxic, with improved outcomes. We proposed to determine the effectiveness of an entirely oral, short-course regimen with Bedaquiline and Delamanid in treating MDR-TB with additional resistance to fluoroquinolones (MDR-TBFQ+) or second-line injectable (MDR-TBSLI+). METHODS We prospectively determined the effectiveness and safety of combining two new drugs with two repurposed drugs - Bedaquiline, Delamanid, Linezolid, and Clofazimine for 24-36 weeks in adults with pulmonary MDR-TBFQ+ or/and MDR-TBSLI+. The primary outcome was a favorable response at end of treatment, defined as two consecutive negative cultures taken four weeks apart. The unfavorable outcomes included bacteriologic or clinical failure during treatment period. RESULTS Of the 165 participants enrolled, 158 had MDR-TBFQ+. At the end of treatment, after excluding 12 patients due to baseline drug susceptibility and culture negatives, 139 of 153 patients (91%) had a favorable outcome. Fourteen patients (9%) had unfavorable outcomes: four deaths, seven treatment changes, two bacteriological failures, and one withdrawal. During treatment, 85 patients (52%) developed myelosuppression, 69 (42%) reported peripheral neuropathy, and none had QTc(F) prolongation >500msec. At 48 weeks of follow-up, 131 patients showed sustained treatment success with the resolution of adverse events in the majority. CONCLUSION After 24-36 weeks of treatment, this regimen resulted in a satisfactory favorable outcome in pulmonary MDR-TB patients with additional drug resistance. Cardiotoxicity was minimal, and myelosuppression, while common, was detected early and treated successfully.
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Affiliation(s)
| | - Vikram Vohra
- National Institute for Tuberculosis and Respiratory Diseases, New Delhi, India
| | - Anuj Bhatnagar
- Rajan Babu Institute of Pulmonary Medicine and Tuberculosis, Delhi, India
| | | | | | | | | | - Meera Bhatia Rana
- National Institute for Tuberculosis and Respiratory Diseases, New Delhi, India
| | | | - Gaurav Taneja
- Rajan Babu Institute of Pulmonary Medicine and Tuberculosis, Delhi, India
| | - S Balaji
- ICMR–National Institute for Research in Tuberculosis, Chennai, India
| | - Prashant Shah
- B. J. Medical College and Hospital, Ahmedabad, India
| | - N Saravanan
- ICMR–National Institute for Research in Tuberculosis, Chennai, India
| | | | - Hemanth Kumar
- ICMR–National Institute for Research in Tuberculosis, Chennai, India
| | | | | | - Monica Bahl
- Clinical Development Service Agency, New Delhi, India
| | - Umesh Alavadi
- US Agency for International Development, Washington D.C., USA
| | - K S Sachdeva
- Central TB Division, Ministry of Health and Family Welfare, New Delhi, India
| | - Soumya Swaminathan
- Indian Council of Medical Research, New Delhi, India
- World Health Organization, Geneva, Switzerland
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20
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Hatami H, Sotgiu G, Bostanghadiri N, Abadi SSD, Mesgarpour B, Goudarzi H, Migliori GB, Nasiri MJ. Bedaquiline-containing regimens and multidrug-resistant tuberculosis: a systematic review and meta-analysis. J Bras Pneumol 2022; 48:e20210384. [PMID: 35649043 PMCID: PMC8836629 DOI: 10.36416/1806-3756/e20210384] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 10/30/2021] [Indexed: 12/01/2022] Open
Abstract
Objective: Multidrug-resistant tuberculosis (MDR-TB) is a life-threatening infectious disease. Treatment requires multiple antimicrobial agents used for extended periods of time. The present study sought to evaluate the treatment success rate of bedaquiline-based regimens in MDR-TB patients. Methods: This was a systematic review and meta-analysis of studies published up to March 15, 2021. The pooled treatment success rates and 95% CIs were assessed with the fixed-effect model or the random-effects model. Values of p < 0.05 were considered significant for publication bias. Results: A total of 2,679 articles were retrieved by database searching. Of those, 29 met the inclusion criteria. Of those, 25 were observational studies (including a total of 3,536 patients) and 4 were experimental studies (including a total of 440 patients). The pooled treatment success rate was 74.7% (95% CI, 69.8-79.0) in the observational studies and 86.1% (95% CI, 76.8-92.1; p = 0.00; I2 = 75%) in the experimental studies. There was no evidence of publication bias (p > 0.05). Conclusions: In patients with MDR-TB receiving bedaquiline, culture conversion and treatment success rates are high even in cases of extensive resistance.
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Affiliation(s)
- Hossein Hatami
- . Department of Public Health, School of Public Health and Safety; Environmental and Occupational Hazards Control Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Giovanni Sotgiu
- . Unità di Epidemiologia Clinica e Statistica Medica, Dipartimento di Scienze Mediche Chirurgiche e Sperimentali, Università degli Studi di Sassari, Sassari, Italia
| | - Narjess Bostanghadiri
- . Department of Microbiology, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Sahel Shafiee Dolat Abadi
- . Department of Microbiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Bita Mesgarpour
- . Department of Public and International Affairs, National Institute for Medical Research Development - NIMAD - Tehran, Iran
| | - Hossein Goudarzi
- . Department of Microbiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Mohammad Javad Nasiri
- . Department of Microbiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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21
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Effectiveness of the Novel Anti-TB Bedaquiline against Drug-Resistant TB in Africa: A Systematic Review of the Literature. Pathogens 2022; 11:pathogens11060636. [PMID: 35745490 PMCID: PMC9229213 DOI: 10.3390/pathogens11060636] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 05/28/2022] [Accepted: 05/30/2022] [Indexed: 11/23/2022] Open
Abstract
Background: In 2018, an estimated 10.0 million people contracted tuberculosis (TB), and 1.5 million died from it, including 1.25 million HIV-negative persons and 251,000 HIV-associated TB fatalities. Drug-resistant tuberculosis (DR-TB) is an important contributor to global TB mortality. Multi-drug-resistant TB (MDR-TB) is defined as TB resistant to at least isoniazid (INH) and rifampin (RMP), which are recommended by the WHO as essential drugs for treatment. Objective: To investigate the effectiveness of bedaquiline addition to the treatment of drug-resistant TB infections on the African continent. Methodology: The search engine databases Medline, PubMed, Google Scholar, and Embase were used to obtain published data pertaining to DR-TB between 2012 and 2021 in Africa. Included studies had to document clinical characteristics at treatment initiation and outcomes at the end of treatment (i.e., success, failure, recurrence, loss to follow-up, and death). The included studies were used to conduct a meta-analysis. All data analysis and visualization were performed using the R programming environment. The log risk ratios and sample variances were calculated for DR-TB patients treated with BBQ monotherapy vs. BDQ and other drug therapy. To quantify heterogeneity among the included studies, random effect sizes were calculated. Results: A total of 16 studies in Africa from Mozambique (N = 1 study), Eswatini (N = 1 study), Democratic Republic of the Congo (N = 1 study), South Africa (N = 12 studies), and a multicenter study undertaken across Africa (N = 1 study) were included. In total, 22,368 individuals participated in the research studies. Among the patients, (55.2%; 12,350/22,368) were male while 9723/22,368 (44%) were female. Overall, (9%; 2033/22,368) of patients received BDQ monotherapy, while (88%; 19,630/22,368) patients received bedaquiline combined with other antibiotics. In total, (42%; 9465/22,368) of the patients were successfully treated. About (39%; 8653/22,368) of participants finished their therapy, meanwhile (5%; 1166/22,368) did not finish their therapy, while people (0.4%; 99/22,368) were lost to follow up. A total of (42%; 9265/22,368) patients died. Conclusion: Very few studies on bedaquiline usage in DR-TB in Africa have been published to date. Bedaquiline has been shown to enhance DR-TB results in clinical studies and programmatic settings. Hence, the World Health Organization (WHO) has recommended that it be included in DR-TB regimens. However, in the current study limited improvement to DR-TB treatment results were observed using BDQ on the continent. Better in-country monitoring and reporting, as well as multi-country collaborative cohort studies of DR-TB, can expand the knowledge of bedaquiline usage and clinical impact, as well as the risks and benefits throughout the continent.
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22
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Pooranagangadevi N, Padmapriyadarsini C. Treatment of Tuberculosis and the Drug Interactions Associated With HIV-TB Co-Infection Treatment. FRONTIERS IN TROPICAL DISEASES 2022. [DOI: 10.3389/fitd.2022.834013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Tuberculosis (TB) is a communicable disease that is a major source of illness, one of the ten causes of mortality worldwide, and the largest cause of death from a single infectious agent Mycobacterium tuberculosis. HIV infection and TB are a fatal combination, with each speeding up the progression of the other. Barriers to integrated treatment as well as safety concerns on the co-management of HIV- TB co-infection do exist. Many HIV TB co-infected people require concomitant anti-retroviral therapy (ART) and anti-TB medication, which increases survival but also introduces certain management issues, such as drug interactions, combined drug toxicities, and TB immune reconstitution inflammatory syndrome which has been reviewed here. In spite of considerable pharmacokinetic interactions between antiretrovirals and antitubercular drugs, when the pharmacological characteristics of drugs are known and appropriate combination regimens, dosing, and timing of initiation are used, adequate clinical response of both infections can be achieved with an acceptable safety profile. To avoid undesirable drug interactions and side effects in patients, anti TB treatment and ART must be closely monitored. To reduce TB-related mortality among HIV-TB co-infected patients, ART and ATT (Anti Tuberculosis Treatment) outcomes must improve. Clinical practise should prioritise strategies to promote adherence, such as reducing treatment duration, monitoring and treating adverse events, and improving treatment success rates, to reduce the mortality risk of HIV-TB co-infection.
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Perrin C, Athersuch K, Elder G, Martin M, Alsalhani A. Recently developed drugs for the treatment of drug-resistant tuberculosis: a research and development case study. BMJ Glob Health 2022; 7:bmjgh-2021-007490. [PMID: 35440441 PMCID: PMC9020285 DOI: 10.1136/bmjgh-2021-007490] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 01/29/2022] [Indexed: 11/04/2022] Open
Abstract
Two drugs with novel mechanisms of action, the diarylquinoline bedaquiline and the nitroimidazole delamanid-as well as pretomanid from the same class of drugs as delamanid-have recently become available to treat drug-resistant tuberculosis (DR-TB) after many decades of little innovation in the field of DR-TB treatment. Despite evidence of improved efficacy and reduced toxicity of multidrug regimens including the two agents, access to bedaquiline and delamanid has been limited in many settings with a high burden of DR-TB and consistently poor treatment outcomes. Aside from regulatory, logistic and cost barriers at country level, uptake of the novel agents was complicated by gaps in knowledge for optimal use in clinical practice after initial market approval. The main incentives of the current pharmaceutical research and development paradigm are structured around obtaining regulatory approval, which in turn requires efficacy and safety data generated by clinical trials. Recently completed and ongoing clinical trials did not answer critical questions of how to provide shorter, less toxic treatment DR-TB treatment regimens containing bedaquiline and delamanid and improve patient outcomes. Voluntary generation of evidence that is not part of this process-yet essential from a clinical or policy perspective-has been left to non-sponsor partners and researchers, often without collaborative efforts to improve post-regulatory approval access to life-saving drugs. Additionally, these efforts are currently not recognised in the value chain of the research and development process, and there are no incentives to make this critical research happen in a coordinated way.
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Affiliation(s)
| | - Katy Athersuch
- Access Campaign, Medecins Sans Frontieres, Geneva, Switzerland
| | - Greg Elder
- Access Campaign, Medecins Sans Frontieres, Geneva, Switzerland
| | - Manuel Martin
- Access Campaign, Medecins Sans Frontieres, Geneva, Switzerland
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Huerga H, Khan U, Bastard M, Mitnick CD, Lachenal N, Khan PY, Seung KJ, Melikyan N, Ahmed S, Rich ML, Varaine F, Osso E, Rashitov M, Salahuddin N, Salia G, Sánchez E, Serobyan A, Siddiqui MR, Tefera DG, Vetushko D, Yeghiazaryan L, Holtzman D, Islam S, Kumsa A, Leblanc GJ, Leonovich O, Mamsa S, Manzur-Ul-Alam M, Myint Z, Padayachee S, Franke MF, Hewison C. Safety and effectiveness outcomes from a 14-country cohort of patients with multi-drug resistant tuberculosis treated concomitantly with bedaquiline, delamanid and other second-line drugs. Clin Infect Dis 2022; 75:1307-1314. [PMID: 35243494 PMCID: PMC9555840 DOI: 10.1093/cid/ciac176] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Indexed: 11/25/2022] Open
Abstract
Background Concomitant use of bedaquiline (Bdq) and delamanid (Dlm) for multi-drug/rifampicin resistant tuberculosis (MDR/RR-TB) has raised concerns about a potentially poor risk-benefit ratio. Yet this combination is an important alternative for patients infected with strains of TB with complex drug resistance profiles or who cannot tolerate other therapies. We assessed safety and treatment outcomes of MDR/RR-TB patients receiving concomitant Bdq and Dlm, along with other second-line anti-TB drugs. Methods We conducted a multi-centric, prospective observational cohort study across 14 countries among patients receiving concomitant Bdq-Dlm treatment. Patients were recruited between April 2015 and September 2018 and were followed until the end of treatment. All serious adverse events and adverse events of special interest (AESI), leading to a treatment change, or judged significant by a clinician, were systematically monitored and documented. Results Overall, 472 patients received Bdq and Dlm concomitantly. A large majority also received linezolid (89.6%) and clofazimine (84.5%). Nearly all (90.3%) had extensive disease; most (74.2%) had resistance to fluoroquinolones. The most common AESI were peripheral neuropathy (134, 28.4%) and electrolyte depletion (94, 19.9%). Acute kidney injury and myelosuppression were seen in 40 (8.5%) and 24 (5.1%) of patients, respectively. QT prolongation occurred in 7 patients (1.5%). Overall, 78.0% (358/458) had successful treatment outcomes, 8.9% died, and 7.2% experienced treatment failure. Conclusions Concomitant use of Bdq and Dlm, along with linezolid and clofazimine, is safe and effective for MDR/RR-TB patients with extensive disease. Using these drugs concomitantly is a good therapeutic option for patients with resistance to many anti-TB drugs.
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Affiliation(s)
- Helena Huerga
- Helena Huerga, Mathieu Bastard, Nara Melikyan: Field Epidemiology Department, Epicentre, Paris, France
| | - Uzma Khan
- Uzma Khan, Palwasha Y Khan: Interactive Research and Development (IRD) Global, Singapore, Singapore
| | - Mathieu Bastard
- Helena Huerga, Mathieu Bastard, Nara Melikyan: Field Epidemiology Department, Epicentre, Paris, France
| | - Carole D Mitnick
- Carole D. Mitnick, Kwonjune J. Seung, Michael L. Rich, Molly F. Franke, Elna Osso: Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA.,Carole D. Mitnick, Kwonjune J. Seung, Michael L. Rich: Partners In Health, Boston, USA.,Kwonjune J. Seung, Michael L. Rich, Carole D. Mitnick: Division of Global Health Equity, Brigham & Women's Hospital, Boston, USA
| | - Nathalie Lachenal
- Nathalie Lachenal, Elna Osso: Pharmacovigilance Unit, Médecins Sans Frontières, Geneva, Switzerland
| | - Palwasha Y Khan
- Uzma Khan, Palwasha Y Khan: Interactive Research and Development (IRD) Global, Singapore, Singapore.,Palwasha Y Khan: Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Kwonjune J Seung
- Carole D. Mitnick, Kwonjune J. Seung, Michael L. Rich, Molly F. Franke, Elna Osso: Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA.,Carole D. Mitnick, Kwonjune J. Seung, Michael L. Rich: Partners In Health, Boston, USA.,Kwonjune J. Seung, Michael L. Rich, Carole D. Mitnick: Division of Global Health Equity, Brigham & Women's Hospital, Boston, USA
| | - Nara Melikyan
- Helena Huerga, Mathieu Bastard, Nara Melikyan: Field Epidemiology Department, Epicentre, Paris, France
| | - Saman Ahmed
- Saman Ahmed: Interactive Research and Development (IRD), Karachi, Pakistan
| | - Michael L Rich
- Carole D. Mitnick, Kwonjune J. Seung, Michael L. Rich, Molly F. Franke, Elna Osso: Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA.,Carole D. Mitnick, Kwonjune J. Seung, Michael L. Rich: Partners In Health, Boston, USA.,Kwonjune J. Seung, Michael L. Rich, Carole D. Mitnick: Division of Global Health Equity, Brigham & Women's Hospital, Boston, USA
| | - Francis Varaine
- Francis Varaine, Catherine Hewison: Medical Department, Médecins Sans Frontières, Paris, France
| | - Elna Osso
- Carole D. Mitnick, Kwonjune J. Seung, Michael L. Rich, Molly F. Franke, Elna Osso: Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA.,Nathalie Lachenal, Elna Osso: Pharmacovigilance Unit, Médecins Sans Frontières, Geneva, Switzerland
| | | | - Naseem Salahuddin
- Naseem Salahuddin: Indus Hospital and Health Network (IHHN), Karachi, Pakistan
| | - Gocha Salia
- Gocha Salia: Medical Department, Médecins Sans Frontières, Tbilisi, Georgia
| | - Epifanio Sánchez
- Epifanio Sánchez: Hospital Nacional Sergio Bernales Hospital, Lima, Peru
| | - Armine Serobyan
- Armine Serobyan: Medical Department, Médecins Sans Frontières, Yerevan, Armenia
| | | | | | - Dmitry Vetushko
- Dmitry Vetushko: The Republican Scientific and Practical Centre for Pulmonology and TB, Minsk, Belarus
| | | | - David Holtzman
- David Holtzman: Partners In Health, Lesotho, Maseru, Lesotho
| | - Shirajul Islam
- Shirajul Islam, Shahid Mamsa: Indus Hospital and Health Network (IHHN), Karachi, Pakistan
| | | | | | - Olga Leonovich
- Olga Leonovich: Medical Department, Médecins Sans Frontières, Minsk, Belarus
| | - Shahid Mamsa
- Shirajul Islam, Shahid Mamsa: Indus Hospital and Health Network (IHHN), Karachi, Pakistan
| | - Mohammad Manzur-Ul-Alam
- Mohammad Manzur-ul-Alam, Shirajul Islam: Interactive Research and Development (IRD), Dhaka, Bangladesh
| | - Zaw Myint
- Zaw Myint: National Tuberculosis Program central, Yangon branch, Myanmar
| | - Shrivani Padayachee
- Shrivani Padayachee: Interactive Research and Development (IRD), Durban, South Africa
| | - Molly F Franke
- Carole D. Mitnick, Kwonjune J. Seung, Michael L. Rich, Molly F. Franke, Elna Osso: Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA
| | - Catherine Hewison
- Francis Varaine, Catherine Hewison: Medical Department, Médecins Sans Frontières, Paris, France
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Mohr-Holland E, Daniels J, Reuter A, Rodriguez CA, Mitnick C, Kock Y, Cox V, Furin J, Cox H. Early mortality during rifampicin-resistant TB treatment. Int J Tuberc Lung Dis 2022; 26:150-157. [PMID: 35086627 PMCID: PMC8802559 DOI: 10.5588/ijtld.21.0494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 09/30/2021] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND: Data suggest that treatment with newer TB drugs (linezolid [LZD], bedaquiline [BDQ] and delamanid [DLM]), used in Khayelitsha, South Africa, since 2012, reduces mortality due to rifampicin-resistant TB (RR-TB).METHODS: This was a retrospective cohort study to assess 6-month mortality among RR-TB patients diagnosed between 2008 and 2019.RESULTS: By 6 months, 236/2,008 (12%) patients died; 12% (78/651) among those diagnosed in 2008-2011, and respectively 8% (49/619) and 15% (109/738) with and without LZD/BDQ/DLM in 2012-2019. Multivariable analysis showed a small, non-significant mortality reduction with LZD/BDQ/DLM use compared to the 2008-2011 period (aOR 0.79, 95% CI 0.5-1.2). Inpatient treatment initiation (aOR 3.2, 95% CI 2.4-4.4), fluoroquinolone (FQ) resistance (aOR 2.7, 95% CI 1.8-4.2) and female sex (aOR 1.5, 95% CI 1.1-2.0) were also associated with mortality. When restricted to 2012-2019, use of LZD/BDQ/DLM was associated with lower mortality (aOR 0.58, 95% CI 0.39-0.87).CONCLUSIONS: While LZD/BDQ/DLM reduced 6-month mortality between 2012 and 2019, there was no significant effect overall. These findings may be due to initially restricted LZD/BDQ/DLM use for those with high-level resistance or treatment failure. Additional contributors include increased treatment initiation among individuals who would have otherwise died before treatment due to universal drug susceptibility testing from 2012, an effect that also likely contributed to higher mortality among females (survival through to care-seeking).
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Affiliation(s)
- E Mohr-Holland
- Khayelitsha Project, Médecins Sans Frontières (MSF), Cape Town, South Africa, Southern Africa Medical Unit, MSF, Cape Town, South Africa
| | - J Daniels
- Khayelitsha Project, Médecins Sans Frontières (MSF), Cape Town, South Africa
| | - A Reuter
- Khayelitsha Project, Médecins Sans Frontières (MSF), Cape Town, South Africa
| | - C A Rodriguez
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - C Mitnick
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - Y Kock
- National Department of Health, Pretoria, South Africa
| | - V Cox
- Center for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - J Furin
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - H Cox
- Division of Medical Microbiology, Department of Pathology, University of Cape Town, Cape Town, South Africa, Institute for Infectious Disease and Molecular Medicine and Wellcome Centre for Infectious Disease Research in Africa, University of Cape Town, Cape Town, South Africa
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Chaudhary KR, Puri V, Singh A, Singh C. A review on recent advances in nanomedicines for the treatment of pulmonary tuberculosis. J Drug Deliv Sci Technol 2022. [DOI: 10.1016/j.jddst.2021.103069] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Hewison C, Khan U, Bastard M, Lachenal N, Coutisson S, Osso E, Ahmed S, Khan P, Franke MF, Rich ML, Varaine F, Melikyan N, Seung KJ, Adenov M, Adnan S, Danielyan N, Islam S, Janmohamed A, Karakozian H, Kamene Kimenye M, Kirakosyan O, Kholikulov B, Krisnanda A, Kumsa A, Leblanc G, Lecca L, Nkuebe M, Mamsa S, Padayachee S, Thit P, Mitnick CD, Huerga H. Safety of Treatment Regimens Containing Bedaquiline and Delamanid in the endTB Cohort. Clin Infect Dis 2022; 75:1006-1013. [PMID: 35028659 PMCID: PMC9522425 DOI: 10.1093/cid/ciac019] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Safety of treatment for multidrug-resistant tuberculosis (MDR/RR-TB) can be an obstacle to treatment completion. Evaluate safety of longer MDR/RR-TB regimens containing bedaquiline and/or delamanid. METHODS Multicentre (16 countries), prospective, observational study reporting incidence and frequency of clinically relevant adverse events of special interest (AESIs) among patients who received MDR/RR-TB treatment containing bedaquiline and/or delamanid. The AESIs were defined a priori as important events caused by bedaquiline, delamanid, linezolid, injectables, and other commonly used drugs. Occurrence of these events was also reported by exposure to the likely causative agent. RESULTS Among 2296 patients, the most common clinically relevant AESIs were peripheral neuropathy (26.4%), electrolyte depletion (26.0%), and hearing loss (13.2%) with an incidence per 1000 person months of treatment, 1000 person-months of treatment 21.5 (95% confidence interval [CI]: 19.8-23.2), 20.7 (95% CI: 19.1-22.4), and 9.7 (95% CI: 8.6-10.8), respectively. QT interval was prolonged in 2.7% or 1.8 (95% CI: 1.4-2.3)/1000 person-months of treatment. Patients receiving injectables (N = 925) and linezolid (N = 1826) were most likely to experience events during exposure. Hearing loss, acute renal failure, or electrolyte depletion occurred in 36.8% or 72.8 (95% CI: 66.0-80.0) times/1000 person-months of injectable drug exposure. Peripheral neuropathy, optic neuritis, and/or myelosuppression occurred in 27.8% or 22.8 (95% CI: 20.9-24.8) times/1000 patient-months of linezolid exposure. CONCLUSIONS AEs often related to linezolid and injectable drugs were more common than those frequently attributed to bedaquiline and delamanid. MDR-TB treatment monitoring and drug durations should reflect expected safety profiles of drug combinations. CLINICAL TRIALS REGISTRATION NCT02754765.
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Affiliation(s)
- Catherine Hewison
- Correspondence: Catherine Hewison, Medical Department, Médecins Sans Frontières, 14-34 avenue Jean Jaurès, 75019, Paris, France () and ()
| | | | | | - Nathalie Lachenal
- Pharmacovigilance Unit, Médecins Sans Frontières, Geneva, Switzerland
| | - Sylvine Coutisson
- Pharmacovigilance Unit, Médecins Sans Frontières, Geneva, Switzerland
| | - Elna Osso
- Partners In Health, Boston, Massachusetts, USA, and Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Saman Ahmed
- Interactive Research and Development, Karachi, Pakistan
| | - Palwasha Khan
- Interactive Research and Development Global, Singapore, Singapore
| | - Molly F Franke
- Partners In Health, Boston, Massachusetts, USA, and Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael L Rich
- Partners In Health, Boston, Massachusetts, USA, and Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA,Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | | | - Nara Melikyan
- Field Epidemiology Department, Epicentre, Paris, France
| | - Kwonjune J Seung
- Partners In Health, Boston, Massachusetts, USA, and Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA,Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Malik Adenov
- National Scientific Center of Phthisiopulmonology, MOH RK (NSCP MOH RK), Almaty, Kazakhstan
| | | | | | | | | | - Hayk Karakozian
- Medical Department, Médecins Sans Frontières, Bishkek, Krygystan
| | | | | | | | - Aga Krisnanda
- Aga Krisnanda, Interactive Research and Development, Jakarta, Indonesia
| | | | | | | | | | | | | | - Phone Thit
- Medical Department, Médecins Sans Frontières, Yangon, Myanmar
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Black TA, Buchwald UK. The pipeline of new molecules and regimens against drug-resistant tuberculosis. J Clin Tuberc Other Mycobact Dis 2021; 25:100285. [PMID: 34816020 PMCID: PMC8593651 DOI: 10.1016/j.jctube.2021.100285] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
The clinical development and regulatory approval of bedaquiline, delamanid and pretomanid over the last decade brought about significant progress in the management of drug-resistant tuberculosis, providing all-oral regimens with favorable safety profiles. The Nix-TB and ZeNix trials of a bedaquiline - pretomanid - linezolid regimen demonstrated for the first time that certain forms of drug-resistant tuberculosis can be cured in the majority of patients within 6 months. Ongoing Phase 3 studies containing these drugs may further advance optimized regimen compositions. Investigational drugs in clinical development that target clinically validated mechanisms, such as second generation oxazolidinones (sutezolid, delpazolid, TBI-223) and diarylquinolines (TBAJ-876 and TBAJ-587) promise improved potency and/or safety compared to the first-in-class drugs. Compounds with novel targets involved in diverse bacterial functions such as cell wall synthesis (DrpE1, MmpL3), electron transport, DNA synthesis (GyrB), cholesterol metabolism and transcriptional regulation of ethionamide bioactivation pathways have advanced to early clinical studies with the potential to enhance antibacterial activity when added to new or established anti-TB drug regimens. Clinical validation of preclinical in vitro and animal model predictions of new anti-TB regimens may further improve the translational value of these models to identify optimal anti-TB therapies.
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Affiliation(s)
- Todd A. Black
- Global Alliance for TB Drug Development, 40 Wall Street, 24th Floor, New York, NY 10005, USA
| | - Ulrike K. Buchwald
- Global Alliance for TB Drug Development, 40 Wall Street, 24th Floor, New York, NY 10005, USA
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Das M, Dalal A, Laxmeshwar C, Ravi S, Mamnoon F, Meneguim AC, Paryani R, Mathur T, Singh P, Mansoor H, Kalon S, Hossain FN, Lachenal N, Coutisson S, Ferlazzo G, Isaakidis P. One Step Forward: Successful End-of-Treatment Outcomes of Patients With Drug-Resistant Tuberculosis Who Received Concomitant Bedaquiline and Delamanid in Mumbai, India. Clin Infect Dis 2021; 73:e3496-e3504. [PMID: 33079176 DOI: 10.1093/cid/ciaa1577] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 10/14/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The Médecins Sans Frontières Clinic in Mumbai, India, has been providing concomitant bedaquiline (BDQ) and delamanid (DLM) in treatment regimen for patients with drug-resistant tuberculosis (DR-TB) and limited therapeutic options, referred from other healthcare institutions, since 2016. The study documents the end-of-treatment outcomes, culture-conversion rates, and serious adverse events (SAEs) during treatment. METHODS This was a retrospective cohort study based on routinely collected program data. In clinic, treatment regimens are designed based on culture drug sensitivity test patterns and previous drug exposures, and are provided for 20-22 months. BDQ and DLM are extended beyond 24 weeks as off-label use. Patients who initiated DR-TB treatment including BDQ and DLM (concomitantly for at least 4 weeks) during February 2016-February 2018 were included. RESULTS Of the 70 patients included, the median age was 25 (interquartile range [IQR], 22-32) years and 56% were females. All except 1 were fluoroquinolone resistant. The median duration of exposure to BDQ and DLM was 77 (IQR, 43-96) weeks. Thirty-nine episodes of SAEs were reported among 30 (43%) patients, including 5 instances of QTc prolongation, assessed as possibly related to BDQ and/or DLM. The majority (69%) had culture conversion before 24 weeks of treatment. In 61 (87%), use of BDQ and DLM was extended beyond 24 weeks. Successful end-of-treatment outcomes were reported in 49 (70%) patients. CONCLUSIONS The successful treatment outcomes of this cohort show that regimens including concomitant BDQ and DLM for longer than 24 weeks are effective and can be safely administered on an ambulatory basis. National TB programs globally should scale up access to life-saving DR-TB regimens with new drugs.
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Affiliation(s)
| | - Alpa Dalal
- Jupiter Hospital, Thane, Maharashtra, India
| | | | | | | | | | | | | | | | | | | | | | - Nathalie Lachenal
- Pharmacovigilance Unit, Médecins Sans Frontières, Geneva, Switzerland
| | - Sylvine Coutisson
- Pharmacovigilance Unit, Médecins Sans Frontières, Geneva, Switzerland
| | - Gabriella Ferlazzo
- Southern Africa Medical Unit, Médecins Sans Frontières, Cape Town, South Africa
| | - Petros Isaakidis
- Southern Africa Medical Unit, Médecins Sans Frontières, Cape Town, South Africa
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Khoshnood S, Taki E, Sadeghifard N, Kaviar VH, Haddadi MH, Farshadzadeh Z, Kouhsari E, Goudarzi M, Heidary M. Mechanism of Action, Resistance, Synergism, and Clinical Implications of Delamanid Against Multidrug-Resistant Mycobacterium tuberculosis. Front Microbiol 2021; 12:717045. [PMID: 34690963 PMCID: PMC8529252 DOI: 10.3389/fmicb.2021.717045] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 09/02/2021] [Indexed: 11/21/2022] Open
Abstract
Multidrug-resistant (MDR) isolates of Mycobacterium tuberculosis (MTB) remain a primary global threat to the end of tuberculosis (TB) era. Delamanid (DLM) is a nitro-dihydro-imidazooxazole derivative utilized to treat MDR-TB. DLM has distinct mechanism of action, inhibiting methoxy- and keto-mycolic acid (MA) synthesis through the F420 coenzyme mycobacteria system and generating nitrous oxide. While DLM resistance among MTB strains is uncommon, there are increasing reports in Asia and Europe, and such resistance will prolong the treatment courses of patients infected with MDR-TB. In this review, we address the antimycobacterial properties of DLM, report the global prevalence of DLM resistance, discuss the synergism of DLM with other anti-TB drugs, and evaluate the documented clinical trials to provide new insights into the clinical use of this antibiotic.
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Affiliation(s)
- Saeed Khoshnood
- Clinical Microbiology Research Center, Ilam University of Medical Sciences, Ilam, Iran
| | - Elahe Taki
- Department of Microbiology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Nourkhoda Sadeghifard
- Clinical Microbiology Research Center, Ilam University of Medical Sciences, Ilam, Iran
| | - Vahab Hassan Kaviar
- Clinical Microbiology Research Center, Ilam University of Medical Sciences, Ilam, Iran
| | | | - Zahra Farshadzadeh
- Infectious and Tropical Diseases Research Center, Health Research Institute, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
- Department of Microbiology, School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Ebrahim Kouhsari
- Laboratory Sciences Research Center, Golestan University of Medical Sciences, Gorgan, Iran
| | - Mehdi Goudarzi
- Department of Microbiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohsen Heidary
- Department of Laboratory Sciences, School of Paramedical Sciences, Sabzevar University of Medical Sciences, Sabzevar, Iran
- Cellular and Molecular Research Center, Sabzevar University of Medical Sciences, Sabzevar, Iran
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Fekadu G, Chow DYW, You JHS. The pharmacotherapeutic management of pulmonary tuberculosis: an update of the state-of-the-art. Expert Opin Pharmacother 2021; 23:139-148. [PMID: 34402698 DOI: 10.1080/14656566.2021.1967930] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Pulmonary tuberculosis (TB) remains an important global health challenge of the 21st century, and the emerging resistance against anti-TB drugs is still a growing concern. And while there was a significant cumulative reduction in the incidence of TB between 2015 and 2019, 2.8% of all TB cases in 2019 were reported to be drug resistant. AREA COVERED This review provides the reader with an update on pharmacotherapy for patients with TB susceptible or resistant to drug therapy. The authors also include promising investigational drugs herein. Finally, the authors share with the reader their expert opinions on the current state of the art and their future perspectives. EXPERT OPINION The current pharmacotherapeutic management aims to enhance favorable treatment outcomes and reduce treatment-related adverse events. One approach is to use shorter and all-oral regimens for eligible patients. Traditional longer regimens for most patients are also optimized to lower incidence of treatment failure and serious adverse events.
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Affiliation(s)
- Ginenus Fekadu
- School of Pharmacy, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, NT, Hong Kong
| | - Dilys Yan-Wing Chow
- School of Pharmacy, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, NT, Hong Kong
| | - Joyce H S You
- School of Pharmacy, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, NT, Hong Kong
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Dooley KE, Rosenkranz SL, Conradie F, Moran L, Hafner R, von Groote-Bidlingmaier F, Lama JR, Shenje J, De Los Rios J, Comins K, Morganroth J, Diacon AH, Cramer YS, Donahue K, Maartens G. QT effects of bedaquiline, delamanid, or both in patients with rifampicin-resistant tuberculosis: a phase 2, open-label, randomised, controlled trial. THE LANCET. INFECTIOUS DISEASES 2021; 21:975-983. [PMID: 33587897 PMCID: PMC8312310 DOI: 10.1016/s1473-3099(20)30770-2] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 08/13/2020] [Accepted: 09/14/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Bedaquiline and delamanid are the first drugs of new classes registered for tuberculosis treatment in 40 years. Each can prolong the QTc interval, with maximum effects occurring weeks after drug initiation. The cardiac safety and microbiological activity of these drugs when co-administered are not well-established. Our aim was to characterise the effects of bedaquiline, delamanid, or both on the QTc interval, longitudinally over 6 months of multidrug treatment, among patients with multidrug-resistant or rifampicin-resistant tuberculosis taking multidrug background therapy. METHODS ACTG A5343 is a phase 2, open-label, randomised, controlled trial in which adults with multidrug-resistant or rifampicin-resistant tuberculosis receiving multidrug background treatment were randomly assigned 1:1:1 by centrally, computer-generated randomisation, by means of permuted blocks to receive bedaquiline, delamanid, or both for 24 weeks. Participants were enrolled at TASK in Cape Town and the South African Tuberculosis Vaccine Initiative in Worcester, both in South Africa, and Hospital Maria Auxiliadora in Peru. Individuals with QTc greater than 450 ms were excluded. HIV-positive participants received dolutegravir-based antiretroviral therapy. Clofazimine was disallowed, and levofloxacin replaced moxifloxacin. ECG in triplicate and sputum cultures were done fortnightly. The primary endpoint was mean QTcF change from baseline (averaged over weeks 8-24); cumulative culture conversation at week 8-24 was an exploratory endpoint. Analyses included all participants who initiated study tuberculosis treatment (modified intention-to-treat population). This trial is registered with ClinicalTrials.gov, NCT02583048 and is ongoing. FINDINGS Between Aug 26, 2016 and July 13, 2018, of 174 screened, 84 participants (28 in each treatment group, and 31 in total with HIV) were enrolled. Two participants did not initiate study treatment (one in the delamanid group withdrew consent and one in the bedaquiline plus delamanid group) did not meet the eligibility criterion). Mean change in QTc from baseline was 12·3 ms (95% CI 7·8-16·7; bedaquiline), 8·6 ms (4·0-13·1; delamanid), and 20·7 ms (16·1-25·3) (bedaquiline plus delamanid). There were no grade 3 or 4 adverse QTc prolongation events and no deaths during study treatment. Cumulative culture conversion by week 8 was 21 (88%) of 24 (95% CI 71-97; bedaquiline), 20 (83%) of 24 (65-95; delamanid), and 19 (95%) of 20 (79-100; bedaquiline plus delamanid) and was 92% (77-99) for bedaquiline, 91% (76-99), for delamanid, and 95% (79-100) for bedaquiline plus delamanid at 24 weeks. INTERPRETATION Combining bedaquiline and delamanid has a modest, no more than additive, effect on the QTc interval, and initial microbiology data are encouraging. This study provides supportive evidence for use of these agents together in patients with multidrug-resistant or rifampicin-resistant tuberculosis with normal baseline QTc values. FUNDING Division of AIDS, National Institutes of Health.
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Affiliation(s)
- Kelly E Dooley
- Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | | | | | - Laura Moran
- Social & Scientific Systems, Silver Spring, MD, USA
| | - Richard Hafner
- Division of AIDS, National Institute of Allergy and Infectious Diseases, Bethesda, MD, USA
| | | | - Javier R Lama
- Asociación Civil Impacta Salud y Educacion, Lima, Peru
| | - Justin Shenje
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease and Molecular Medicine, Cape Town, South Africa; Department of Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Kyla Comins
- TASK Applied Science, Cape Town, South Africa
| | | | - Andreas H Diacon
- TASK Applied Science, Cape Town, South Africa; Stellenbosch University, Cape Town, South Africa
| | | | - Kathleen Donahue
- Frontier Science and Technology Research Foundation, Amherst, NY, USA
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, Cape Town, South Africa
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Mondoni M, Saderi L, Sotgiu G. Novel treatments in multidrug-resistant tuberculosis. Curr Opin Pharmacol 2021; 59:103-115. [PMID: 34186381 DOI: 10.1016/j.coph.2021.05.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 05/17/2021] [Accepted: 05/25/2021] [Indexed: 02/07/2023]
Abstract
The management of multidrug-resistant tuberculosis (TB) is associated with low treatment success, high mortality and failure rates. New drugs and novel short-therapeutic regimens have only recently helped overcome these obstacles. We carried out a narrative literature review aimed at summarizing the scientific evidence on the recent therapeutic advances in the field of drug-resistant TB. Experimental and observational studies on novel (i.e. bedaquiline, delamanid, pretomanid) drugs and novel regimens and the main pharmacological characteristics of the newest compounds are described. We also highlight the main scientific evidence on therapeutic strategies complementary to standard chemotherapy (i.e. new approaches to drug delivery, host-directed therapy, surgery, new collapse therapy, rehabilitation, and palliative care).
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Affiliation(s)
- Michele Mondoni
- Respiratory Unit, ASST Santi Paolo e Carlo, San Paolo Hospital, Department of Health Sciences, Università degli Studi di Milano, Milan, Italy
| | - Laura Saderi
- Clinical Epidemiology and Medical Statistics Unit, Dept of Medical, Surgical and Experimental Medicine, University of Sassari, Sassari, Italy
| | - Giovanni Sotgiu
- Clinical Epidemiology and Medical Statistics Unit, Dept of Medical, Surgical and Experimental Medicine, University of Sassari, Sassari, Italy.
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Tesema E, Wares F, Bedru A, Negeri C, Molla Y, Gemechu D, Kassa A, Tsegaye F, Taye L. Experiences of introducing new drugs for drug-resistant TB at the ALERT Hospital, Addis Ababa, Ethiopia, 2017-2019. Public Health Action 2021; 11:50-52. [PMID: 34159060 DOI: 10.5588/pha.20.0065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 03/05/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Drug-resistant TB (DR-TB) remains a major public health concern. DR-TB patient data from ALERT (All Africa Leprosy, Tuberculosis and Rehabilitation Training Centre) Hospital, Addis Ababa, Ethiopia, who received bedaquiline (BDQ) and/or delamanid (DLM) containing regimens were analysed. RESULTS From 2017 to 2019, 51 DR-TB patients were enrolled. Of 33 patients, 31 (93.9%) had culture converted at 6 months. Of those with final outcomes, 77% (n = 10) were cured. Thirty (58.8%) developed adverse events, the most frequent of which were gastrointestinal disorders (70%), haematological disorders (16.7%) and QTc prolongation (16.7%). Twenty patients discontinued the offending drug permanently. CONCLUSION With close monitoring, introduction of new DR-TB regimens brought good early results, which encouraged wider programmatic implementation in Ethiopia.
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Affiliation(s)
- E Tesema
- Challenge TB/KNCV TB Foundation, Addis Ababa, Ethiopia
| | - F Wares
- Challenge TB/KNCV TB Foundation, The Hague, The Netherlands
| | - A Bedru
- Challenge TB/KNCV TB Foundation, Addis Ababa, Ethiopia
| | - C Negeri
- Challenge TB/KNCV TB Foundation, Addis Ababa, Ethiopia
| | - Y Molla
- Challenge TB/KNCV TB Foundation, Addis Ababa, Ethiopia
| | - D Gemechu
- Challenge TB/MSH, Addis Ababa, Ethiopia
| | - A Kassa
- ABT Associates, Federal Ministry of Health, Addis Ababa, Ethiopia
| | - F Tsegaye
- ALERT Hospital, Addis Ababa, Ethiopia
| | - L Taye
- National TB Programme, Federal Ministry of Health, Addis Ababa, Ethiopia
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Nguyen TVA, Anthony RM, Cao TTH, Bañuls AL, Nguyen VAT, Vu DH, Nguyen NV, Alffenaar JWC. Delamanid Resistance: Update and Clinical Management. Clin Infect Dis 2021; 71:3252-3259. [PMID: 32521000 DOI: 10.1093/cid/ciaa755] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 06/05/2020] [Indexed: 12/29/2022] Open
Abstract
Delamanid, a-first-in-class bicyclic nitroimidazole, was recently approved for multidrug-resistant tuberculosis treatment. Pitted against the hope for improving treatment outcomes is the threat of the rapid resistance emergence. This review provides information on the mechanisms of action, resistance emergence, and drug susceptibility testing (DST) for delamanid. Delamanid resistance has already been reported in both in vitro experiments and clinical settings. Although mutations conferring delamanid resistance have been identified in fbiA, fbiB, fbiC, ddn, and fgd1 genes of Mycobacterium tuberculosis, knowledge about the molecular resistance mechanisms is limited, and there remains no standardized DST method. The rapid acquisition of delamanid resistance emphasizes the need for optimal use of new drugs, the need for drug resistance surveillance, and a comprehensive understanding of drug resistance mechanisms. Further studies are necessary to investigate genetic and phenotypic changes that determine clinically relevant delamanid resistance to help develop a rapid delamanid DST.
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Affiliation(s)
- Thi Van Anh Nguyen
- Department of Life Sciences, University of Science and Technology of Hanoi (USTH), Vietnam Academy of Science and Technology (VAST), Hanoi, Vietnam.,LMI Drug Resistance in South East Asia, Hanoi, Vietnam
| | - Richard M Anthony
- Tuberculosis reference laboratory, National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands
| | - Thi Thu Huyen Cao
- The National Centre of Drug information and Adverse Drug Reaction Monitoring, Hanoi University of Pharmacy, Hanoi, Vietnam
| | - Anne-Laure Bañuls
- LMI Drug Resistance in South East Asia, Hanoi, Vietnam.,MIVEGEC, University of Montpellier-IRD-CNRS, Montpellier, France
| | - Van Anh Thi Nguyen
- Laboratory of Tuberculosis, Department of Bacteriology, National Institute of Hygiene and Epidemiology of Vietnam, Hanoi, Vietnam
| | - Dinh Hoa Vu
- The National Centre of Drug information and Adverse Drug Reaction Monitoring, Hanoi University of Pharmacy, Hanoi, Vietnam
| | | | - Jan-Willem C Alffenaar
- University of Sydney, Faculty of Medicine and Health, School of Pharmacy, Sydney, Australia.,Westmead hospital, Sydney, Australia.,Marie Bashir Institute of Infectious Diseases and Biosecurity, University of Sydney, Sydney, Australia
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Sturkenboom MGG, Märtson AG, Svensson EM, Sloan DJ, Dooley KE, van den Elsen SHJ, Denti P, Peloquin CA, Aarnoutse RE, Alffenaar JWC. Population Pharmacokinetics and Bayesian Dose Adjustment to Advance TDM of Anti-TB Drugs. Clin Pharmacokinet 2021; 60:685-710. [PMID: 33674941 PMCID: PMC7935699 DOI: 10.1007/s40262-021-00997-0] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/03/2021] [Indexed: 02/07/2023]
Abstract
Tuberculosis (TB) is still the number one cause of death due to an infectious disease. Pharmacokinetics and pharmacodynamics of anti-TB drugs are key in the optimization of TB treatment and help to prevent slow response to treatment, acquired drug resistance, and adverse drug effects. The aim of this review was to provide an update on the pharmacokinetics and pharmacodynamics of anti-TB drugs and to show how population pharmacokinetics and Bayesian dose adjustment can be used to optimize treatment. We cover aspects on preclinical, clinical, and population pharmacokinetics of different drugs used for drug-susceptible TB and multidrug-resistant TB. Moreover, we include available data to support therapeutic drug monitoring of these drugs and known pharmacokinetic and pharmacodynamic targets that can be used for optimization of therapy. We have identified a wide range of population pharmacokinetic models for first- and second-line drugs used for TB, which included models built on NONMEM, Pmetrics, ADAPT, MWPharm, Monolix, Phoenix, and NPEM2 software. The first population models were built for isoniazid and rifampicin; however, in recent years, more data have emerged for both new anti-TB drugs, but also for defining targets of older anti-TB drugs. Since the introduction of therapeutic drug monitoring for TB over 3 decades ago, further development of therapeutic drug monitoring in TB next steps will again depend on academic and clinical initiatives. We recommend close collaboration between researchers and the World Health Organization to provide important guideline updates regarding therapeutic drug monitoring and pharmacokinetics/pharmacodynamics.
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Affiliation(s)
- Marieke G G Sturkenboom
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Anne-Grete Märtson
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Elin M Svensson
- Department of Pharmacy, Uppsala University, Uppsala, Sweden.,Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Derek J Sloan
- Institute of Infection and Global Health, University of Liverpool, Liverpool, UK.,Liverpool School of Tropical Medicine, Liverpool, UK.,School of Medicine, University of St Andrews, St Andrews, UK
| | - Kelly E Dooley
- Department of Medicine, Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Simone H J van den Elsen
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.,Department of Clinical Pharmacy, Hospital Group Twente, Almelo, Hengelo, the Netherlands
| | - Paolo Denti
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Charles A Peloquin
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Rob E Aarnoutse
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Jan-Willem C Alffenaar
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands. .,Faculty of Medicine and Health, School of Pharmacy, The University of Sydney, Pharmacy Building (A15), Sydney, NSW, 2006, Australia. .,Westmead Hospital, Westmead, NSW, Australia. .,Marie Bashir Institute of Infectious Diseases and Biosecurity, University of Sydney, Sydney, NSW, Australia.
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Bedaquiline: Current status and future perspectives. J Glob Antimicrob Resist 2021; 25:48-59. [PMID: 33684606 DOI: 10.1016/j.jgar.2021.02.017] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 01/28/2021] [Accepted: 02/17/2021] [Indexed: 12/21/2022] Open
Abstract
The development of drug-resistant tuberculosis (TB) is a major threat worldwide. Based on World Health Organization (WHO) reports, it is estimated that more than 500 000 new cases of drug-resistant TB occur annually. In addition, there are alarming reports of increasing multidrug-resistant TB (MDR-TB) and the emergence of extensively drug-resistant TB (XDR-TB) from different countries of the world. Therefore, new options for TB therapy are required. Bedaquiline (BDQ), a novel anti-TB drug, has significant minimum inhibitory concentrations (MICs) both against drug-susceptible and drug-resistant TB. Moreover, BDQ was recently approved for therapy of MDR-TB. The current narrative review summarises the available data on BDQ resistance, describes its antimicrobial properties, and provides new perspectives on clinical use of this novel anti-TB agent.
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Kwon YS, Jeon D, Kang H, Yim JJ, Shim TS. Concurrent use of bedaquiline and delamanid for the treatment of fluoroquinolone-resistant multidrug-resistant tuberculosis: a nationwide cohort study in South Korea. Eur Respir J 2021; 57:13993003.03026-2020. [PMID: 33093123 DOI: 10.1183/13993003.03026-2020] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 10/11/2020] [Indexed: 11/05/2022]
Affiliation(s)
- Yong-Soo Kwon
- Dept of Internal Medicine, Chonnam National University Hospital, Gwangju, South Korea
| | - Doosoo Jeon
- Dept of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - Hyungseok Kang
- Dept of Chest Medicine, Masan National Tuberculosis Hospital, Masan, South Korea
| | - Jae-Joon Yim
- Division of Pulmonary and Critical Care Medicine, Dept of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Tae Sun Shim
- Division of Pulmonary and Critical Care Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
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Zhang M, Yu W, Zhou S, Zhang B, Lo ECM, Xu X, Zhang D. In vitro Antibacterial Activity of an FDA-Approved H +-ATPase Inhibitor, Bedaquiline, Against Streptococcus mutans in Acidic Milieus. Front Microbiol 2021; 12:647611. [PMID: 33717046 PMCID: PMC7947916 DOI: 10.3389/fmicb.2021.647611] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 01/29/2021] [Indexed: 12/28/2022] Open
Abstract
Background Dental caries is an acid-related disease. Current anti-caries agents mainly focus on the bacteriostatic effect in a neutral environment and do not target acid-resistant microorganisms related to caries in acidic milieus. Objectives To assess the in vitro antibacterial activities of bedaquiline against oral pathogens in acidic milieus. Methods Streptococcus mutans, Streptococcus sanguinis, and Streptococcus salivarius were used to prepare the mono-/multiple suspension and biofilm. The MIC and IC50 of bedaquiline against S. mutans were determined by the broth microdilution method. Bedaquiline was compared regarding (i) the inhibitory activity in pH 4–7 and at different time points against planktonic and biofilm; (ii) the effect on the production of lactic acid, extracellular polysaccharide, and pH of S. mutans biofilm; (iii) the cytotoxicity effects; and (iv) the activity on H+-ATPase enzyme of S. mutans. Results In pH 5 BHI, 2.5 mg/L (IC50) and 4 mg/L (MIC) of bedaquiline inhibited the proliferation and biofilm generation of S. mutans and Mix in a dose-dependent and time-dependent manner, but it was invalid in a neutral environment. The lactic acid production, polysaccharide production, and pH drop range reduced with the incorporation of bedaquiline in a pH 5 environment. Its inhibitory effect (>56 mg/L) against H+-ATPase enzyme in S. mutans and its non-toxic effect (<10 mg/L) on periodontal ligament stem cells were also confirmed. Conclusion Bedaquiline is efficient in inhibiting the proliferation and biofilm generation of S. mutans and other oral pathogens in an acidic environment. Its high targeting property and non-cytotoxicity also promote its clinical application potential in preventing caries. Further investigation of its specific action sites and drug modification are warranted.
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Affiliation(s)
- Meng Zhang
- Shandong Provincial Key Laboratory of Oral Tissue Regeneration, Shandong Engineering Laboratory for Dental Materials and Oral Tissue Regeneration, School and Hospital of Stomatology, Cheeloo College of Medicine, Shandong University, Jinan, China.,Faculty of Dentistry, University of Hong Kong, Sai Ying Pun, Hong Kong
| | - Wenqian Yu
- Shandong Provincial Key Laboratory of Oral Tissue Regeneration, Shandong Engineering Laboratory for Dental Materials and Oral Tissue Regeneration, School and Hospital of Stomatology, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Shujing Zhou
- Department of Stomatology, Maternal and Child Health Hospital of Liaocheng City, Liaocheng, China
| | - Bing Zhang
- Shandong Provincial Key Laboratory of Oral Tissue Regeneration, Shandong Engineering Laboratory for Dental Materials and Oral Tissue Regeneration, School and Hospital of Stomatology, Cheeloo College of Medicine, Shandong University, Jinan, China
| | | | - Xin Xu
- Shandong Provincial Key Laboratory of Oral Tissue Regeneration, Shandong Engineering Laboratory for Dental Materials and Oral Tissue Regeneration, School and Hospital of Stomatology, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Dongjiao Zhang
- Shandong Provincial Key Laboratory of Oral Tissue Regeneration, Shandong Engineering Laboratory for Dental Materials and Oral Tissue Regeneration, School and Hospital of Stomatology, Cheeloo College of Medicine, Shandong University, Jinan, China
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Measurement of the Intracellular Mycobacterium tuberculosis Drug Effect and Prediction of the Clinical Dose-Response Relationship Using Intracellular Pharmacodynamic Modeling (PD i). Methods Mol Biol 2021; 2296:393-408. [PMID: 33977461 DOI: 10.1007/978-1-0716-1358-0_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The human disease tuberculosis (TB) is the leading cause of death from a single infectious agent. A quarter of the world's population is estimated to be latently infected. Drug development and screening is slow and costly. We have developed a physiologically relevant assay to screen drugs against TB when inside immune cells. This chapter will describe a newly developed preclinical drug screening assay for TB, using high-content imaging and pharmacokinetic/pharmacodynamic modeling.
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Märtson AG, Burch G, Ghimire S, Alffenaar JWC, Peloquin CA. Therapeutic drug monitoring in patients with tuberculosis and concurrent medical problems. Expert Opin Drug Metab Toxicol 2020; 17:23-39. [PMID: 33040625 DOI: 10.1080/17425255.2021.1836158] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Therapeutic drug monitoring (TDM) has been recommended for treatment optimization in tuberculosis (TB) but is only is used in certain countries e.g. USA, Germany, the Netherlands, Sweden and Tanzania. Recently, new drugs have emerged and PK studies in TB are continuing, which contributes further evidence for TDM in TB. The aim of this review is to provide an update on drugs used in TB, treatment strategies for these drugs, and TDM to support broader implementation. AREAS COVERED This review describes the different drug classes used for TB, multidrug-resistant TB (MDR-TB) and extensively drug-resistant TB (XDR-TB), along with their pharmacokinetics, dosing strategies, TDM and sampling strategies. Moreover, the review discusses TDM for patient TB and renal or liver impairment, patients co-infected with HIV or hepatitis, and special patient populations - children and pregnant women. EXPERT OPINION TB treatment has a long history of using 'one size fits all.' This has contributed to treatment failures, treatment relapses, and the selection of drug-resistant isolates. While challenging in resource-limited circumstances, TDM offers the clinician the opportunity to individualize and optimize treatment early in treatment. This approach may help to refine treatment and thereby reduce adverse effects and poor treatment outcomes. Funding, training, and randomized controlled trials are needed to advance the use of TDM for patients with TB.
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Affiliation(s)
- Anne-Grete Märtson
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen , Groningen, The Netherlands
| | - Gena Burch
- Infectious Disease Pharmacokinetics Laboratory, College of Pharmacy and Emerging Pathogens Institute, University of Florida , Gainesville, FL, USA
| | - Samiksha Ghimire
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen , Groningen, The Netherlands
| | - Jan-Willem C Alffenaar
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen , Groningen, The Netherlands.,Department of Pharmacy, Westmead Hospital , Sydney, Australia.,Sydney Pharmacy School, The University of Sydney , Sydney, New South Wales, Australia.,Marie Bashir Institute of Infectious Diseases and Biosecurity, University of Sydney , Sydney, Australia
| | - Charles A Peloquin
- Infectious Disease Pharmacokinetics Laboratory, College of Pharmacy and Emerging Pathogens Institute, University of Florida , Gainesville, FL, USA
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Treatment interruption patterns and adverse events among patients on bedaquiline containing regimen under programmatic conditions in India. Pulmonology 2020; 28:203-209. [PMID: 33121945 DOI: 10.1016/j.pulmoe.2020.09.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Revised: 09/23/2020] [Accepted: 09/24/2020] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The study aimed to analyze frequency and severity of adverse events (AEs) and other reasons for interruption of treatment and loss to follow up (LTFU) during first six months of treatment among tuberculosis patients on bedaquiline containing regimens. METHODS This pilot exploratory observational study included 275 patients enrolled consecutively over two years who received bedaquiline containing regimen under programmatic conditions in India. RESULTS Among 275 patients with median age of 25 years, 86 (31.3%) patients had at least one interruption with 122 total episodes of interruption. Among these 70 were temporary, 35 were permanent interruptions and 17 were LTFU. The AEs due to drugs were the commonest reason for interruption observed in 81.4% of temporary interruption group and 97.1% of permanent interruption group. Among a total 192 adverse event episodes, (49.5%) were minor (grade 1-2) and (50.5%) were serious (grade 3-5). Personal factors were the commonest reason for interruption observed in LTFU (94.1%) group. The most common temporarily interrupted drug was bedaquiline in 8.7% and permanently stopped drug was linezolid in 5% of patients. CONCLUSIONS Our study observed that drug related AEs are important risk factors associated with treatment interruptions in bedaquiline containing regimens. Bedaquiline is the most common temporarily interrupted drug due to AEs.
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Characterization of Genomic Variants Associated with Resistance to Bedaquiline and Delamanid in Naive Mycobacterium tuberculosis Clinical Strains. J Clin Microbiol 2020; 58:JCM.01304-20. [PMID: 32907992 DOI: 10.1128/jcm.01304-20] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 09/02/2020] [Indexed: 02/06/2023] Open
Abstract
The role of mutations in genes associated with phenotypic resistance to bedaquiline (BDQ) and delamanid (DLM) in Mycobacterium tuberculosis complex (MTBc) strains is poorly characterized. A clear understanding of the genetic variants' role is crucial to guide the development of molecular-based drug susceptibility testing (DST). In this work, we analyzed all mutations in candidate genomic regions associated with BDQ- and DLM-resistant phenotypes using a whole-genome sequencing (WGS) data set from a collection of 4,795 MTBc clinical isolates from six countries with a high burden of tuberculosis (TB). From WGS analysis, we identified 61 and 163 unique mutations in genomic regions potentially involved in BDQ- and DLM-resistant phenotypes, respectively. Importantly, all strains were isolated from patients who likely have never been exposed to these medicines. To characterize the role of mutations, we calculated the free energy variation upon mutations in the available protein structures of Ddn (DLM), Fgd1 (DLM), and Rv0678 (BDQ) and performed MIC assays on a subset of MTBc strains carrying mutations to assess their phenotypic effect. The combination of structural and phenotypic data allowed for cataloguing the mutations clearly associated with resistance to BDQ (n = 4) and DLM (n = 35), only two of which were previously described, as well as about a hundred genetic variants without any correlation with resistance. Significantly, these results show that both BDQ and DLM resistance-related mutations are diverse and distributed across the entire region of each gene target, which is of critical importance for the development of comprehensive molecular diagnostic tools.
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Jang JG, Chung JH. Diagnosis and treatment of multidrug-resistant tuberculosis. Yeungnam Univ J Med 2020; 37:277-285. [PMID: 32883054 PMCID: PMC7606956 DOI: 10.12701/yujm.2020.00626] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 08/21/2020] [Accepted: 08/25/2020] [Indexed: 01/05/2023] Open
Abstract
Tuberculosis (TB) is still a major health problem worldwide. Especially, multidrug-resistant TB (MDR-TB), which is defined as TB that shows resistance to both isoniazid and rifampicin, is a barrier in the treatment of TB. Globally, approximately 3.4% of new TB patients and 20% of the patients with a history of previous treatment for TB were diagnosed with MDR-TB. The treatment of MDR-TB requires medications for a long duration (up to 20-24 months) with less effective and toxic second-line drugs and has unfavorable outcomes. However, treatment outcomes are expected to improve due to the introduction of a new agent (bedaquiline), repurposed drugs (linezolid, clofazimine, and cycloserine), and technological advancement in rapid drug sensitivity testing. The World Health Organization (WHO) released a rapid communication in 2018, followed by consolidated guidelines for the treatment of MDR-TB in 2019 based on clinical trials and an individual patient data meta-analysis. In these guidelines, the WHO suggested reclassification of second-line anti-TB drugs and recommended oral treatment regimens that included the new and repurposed agents. The aims of this article are to review the treatment strategies of MDR-TB based on the 2019 WHO guidelines regarding the management of MDR-TB and the diagnostic techniques for detecting resistance, including phenotypic and molecular drug sensitivity tests.
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Affiliation(s)
- Jong Geol Jang
- Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Jin Hong Chung
- Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
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Dousa KM, Kurz SG, Bark CM, Bonomo RA, Furin JJ. Drug-Resistant Tuberculosis: A Glance at Progress and Global Challenges. Infect Dis Clin North Am 2020; 34:863-886. [PMID: 33011048 DOI: 10.1016/j.idc.2020.06.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Multidrug-resistant Mycobacterium tuberculosis remains a major public health threat; its management poses a significant economic burden. Treatment requires a programmatic approach with access to laboratory services, second-line medications, and adequate clinical resources. In recent years, we have seen rapid developments in diagnostic techniques with whole genome sequencing-based drug susceptibility prediction now in reach, an array of new drugs that transform treatment regimens to purely oral formulations, and a steady stream of multinational trials that inform us about most efficient combinations. Our hope is that the current momentum keeps the ambitious goal to end tuberculosis in 2030 in reach.
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Affiliation(s)
- Khalid M Dousa
- Division of Infectious Diseases & HIV Medicine, University Hospitals Cleveland Medical Center, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, OH 44106, USA
| | - Sebastian G Kurz
- Mount Sinai National Jewish Health Respiratory Institute, 10 East 102nd Street, New York City, NY 10029, USA
| | - Charles M Bark
- Division of Infectious Diseases, MetroHealth Medical Center, 2500 MetroHealth Drive, Cleveland, OH 44109, USA
| | - Robert A Bonomo
- Department of Medicine, Case Western Reserve University School of Medicine, 10900 Euclid Avenue, Cleveland, OH 44106, USA; Department of Pharmacology, Case Western Reserve University School of Medicine, 10900 Euclid Avenue, Cleveland, OH 44106, USA; Department of Molecular Biology and Microbiology, Case Western Reserve University School of Medicine, 10900 Euclid Avenue, Cleveland, OH 44106, USA; Department of Biochemistry, Case Western Reserve University School of Medicine, 10900 Euclid Avenue, Cleveland, OH 44106, USA; Department of Proteomics and Bioinformatics, Case Western Reserve University School of Medicine, 10900 Euclid Avenue, Cleveland, OH 44106, USA; Medical Service and GRECC, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, OH, USA; CWRU-Cleveland VAMC Center for Antimicrobial Resistance and Epidemiology (Case VA CARES), Cleveland, OH, USA
| | - Jennifer J Furin
- Division of Infectious Diseases & HIV Medicine, University Hospitals Cleveland Medical Center, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, OH 44106, USA; Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Avenue, Boston, MA 02115, USA.
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Gils T, Laxmeshwar C, Duka M, Malakyan K, Siomak OV, Didik VS, Lytvynenko N, Terleeva Y, Donchuk D, Isaakidis P. Preparedness of outpatient health facilities for ambulatory treatment with all-oral short DR-TB treatment regimens in Zhytomyr, Ukraine: a cross-sectional study. BMC Health Serv Res 2020; 20:890. [PMID: 32957966 PMCID: PMC7507621 DOI: 10.1186/s12913-020-05735-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 09/15/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Ukraine has a high burden of drug-resistant tuberculosis (DR-TB). Mental health problems, including alcohol use disorder, are common co-morbidities. One in five DR-TB patients has human immunodeficiency virus (HIV). As part of health reform, the country is moving from inpatient care to ambulatory primary care for tuberculosis (TB). In Zhytomyr oblast, Médecins Sans Frontières (MSF) is supporting care for DR-TB patients on all-oral short DR-TB regimens. This study describes the preparedness of ambulatory care facilities in Zhytomyr oblast, Ukraine, to provide good quality ambulatory care. METHODS This is a retrospective analysis of routinely collected programme data. Before discharge of every patient from the hospital, MSF teams assess services available at outpatient facilities using a standardised questionnaire. The assessment evaluates access, human resources, availability of medicines, infection control measures, laboratory and diagnostic services, and psychosocial support. RESULTS We visited 68 outpatient facilities in 22 districts between June 2018 and September 2019. Twenty-seven health posts, 24 TB-units, 13 ambulatories, two family doctors and one polyclinic, serving 30% of DR-TB patients in the oblast by September 2019, were included. All facilities provided directly observed treatment, but only seven (10%) provided weekend-services. All facilities had at least one medical staff member, but TB-training was insufficient and mostly limited to TB-doctors. TB-treatment and adequate storage space were available in all facilities, but only five (8%) had ancillary medicines. HIV-positive patients had to visit a separate facility to access HIV-care. Personal protective equipment was unavailable in 32 (55%) facilities. Basic laboratory services were available in TB-units, but only four (17%) performed audiometry. Only ten (42%) TB-units had psychosocial support available, and nine (38%) offered psychiatric support. CONCLUSION Outpatient facilities in Zhytomyr oblast are not yet prepared to provide comprehensive care for DR-TB patients. Capacity of all facilities needs strengthening with trainings, infection control measures and infrastructure. Integration of psychosocial services, treatment of co-morbidities and adverse events at the same facility are essential for successful decentralisation. The health reform is an opportunity to establish quality, patient-centred care.
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Affiliation(s)
- Tinne Gils
- Médecins Sans Frontières, 64 Berdychivska St., Huiva, Zhytomyr, Oblast, Ukraine.
| | - Chinmay Laxmeshwar
- Médecins Sans Frontières, 64 Berdychivska St., Huiva, Zhytomyr, Oblast, Ukraine
| | - Marve Duka
- Médecins Sans Frontières, 64 Berdychivska St., Huiva, Zhytomyr, Oblast, Ukraine
| | - Khachatur Malakyan
- Médecins Sans Frontières, 64 Berdychivska St., Huiva, Zhytomyr, Oblast, Ukraine
| | | | | | - Natalia Lytvynenko
- National Institute of Phthisiology and Pulmonology named after F.G. Yanovsky of National Academy of Medical Sciences of Ukraine, Kyiv, Ukraine
| | - Yana Terleeva
- Department of Tuberculosis Programme Coordination, Public Health Centre of the Ministry of Health of Ukraine, Kyiv, Ukraine
| | - Dmytri Donchuk
- Southern Africa Medical Unit, Médecins Sans Frontières, Cape Town, South Africa
| | - Petros Isaakidis
- Southern Africa Medical Unit, Médecins Sans Frontières, Cape Town, South Africa
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Guglielmetti L, Chiesi S, Eimer J, Dominguez J, Masini T, Varaine F, Veziris N, Ader F, Robert J. Bedaquiline and delamanid for drug-resistant tuberculosis: a clinician's perspective. Future Microbiol 2020; 15:779-799. [PMID: 32700565 DOI: 10.2217/fmb-2019-0309] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Drug-resistant tuberculosis (TB) represents a substantial threat to the global efforts to control this disease. After decades of stagnation, the treatment of drug-resistant TB is undergoing major changes: two drugs with a new mechanism of action, bedaquiline and delamanid, have been approved by stringent regulatory authorities and are recommended by the WHO. This narrative review summarizes the evidence, originating from both observational studies and clinical trials, which is available to support the use of these drugs, with a focus on special populations. Areas of uncertainty, including the use of the two drugs together or for prolonged duration, are discussed. Ongoing clinical trials are aiming to optimize the use of bedaquiline and delamanid to shorten the treatment of drug-resistant TB.
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Affiliation(s)
- Lorenzo Guglielmetti
- APHP, Groupe Hospitalier Universitaire Sorbonne Université, Hôpital Pitié-Salpêtrière, Centre National de Référence des Mycobactéries et de la Résistance des Mycobactéries aux Antituberculeux, F-75013 Paris, France.,Sorbonne Université, INSERM, U1135, Centre d'Immunologie et des Maladies Infectieuses, Cimi-Paris, équipe 2, F-75013, Paris, France.,Médecins Sans Frontières, France
| | - Sheila Chiesi
- Department of Infectious Diseases, 'GB Rossi' Hospital, Verona, Italy.,University of Verona, Verona, Italy
| | - Johannes Eimer
- Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Jose Dominguez
- Research Institute Germans Trias i Pujol, CIBER Respiratory Diseases, Universitat Autònoma de Barcelona, Badalona, Spain
| | | | | | - Nicolas Veziris
- Sorbonne Université, INSERM, U1135, Centre d'Immunologie et des Maladies Infectieuses, Cimi-Paris, équipe 2, F-75013, Paris, France.,APHP, Département de Bactériologie, Centre National de Référence des Mycobactéries et de la Résistance des Mycobactéries aux Antituberculeux (CNR-MyRMA), Hôpitaux Universitaires de l'Est Parisien, F-75012, Paris, France
| | - Florence Ader
- Département des Maladies infectieuses et tropicales, Hospices Civils de Lyon, F-69004, Lyon, France.,Centre International de Recherche en Infectiologie (CIRI), Inserm 1111, Université Claude Bernard Lyon 1, CNRS, UMR5308, Ecole Normale Supérieure de Lyon, Univ Lyon, F-69007 Lyon, France
| | - Jérôme Robert
- APHP, Groupe Hospitalier Universitaire Sorbonne Université, Hôpital Pitié-Salpêtrière, Centre National de Référence des Mycobactéries et de la Résistance des Mycobactéries aux Antituberculeux, F-75013 Paris, France.,Sorbonne Université, INSERM, U1135, Centre d'Immunologie et des Maladies Infectieuses, Cimi-Paris, équipe 2, F-75013, Paris, France
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Lee HH, Jo KW, Yim JJ, Jeon D, Kang H, Shim TS. Interim treatment outcomes in multidrug-resistant tuberculosis patients treated sequentially with bedaquiline and delamanid. Int J Infect Dis 2020; 98:478-485. [PMID: 32640367 DOI: 10.1016/j.ijid.2020.07.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 06/30/2020] [Accepted: 07/01/2020] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES The objective of this study was to evaluate the efficacy and safety of the sequential use of bedaquiline (Bdq) and delamanid (Dlm) in patients with multidrug-resistant tuberculosis (MDR-TB) and limited treatment options. METHODS This study evaluated 74 MDR-TB patients treated between March 2016 and December 2018 with Bdq followed by Dlm (n = 22), or vice versa (n= 52), combined with optimized background regimens. RESULTS The mean age of the participants was 49.0 ± 15.8 years. Fifty-one (68.9%) of the participants were male. Fluoroquinolone resistance was identified in 54 (72.9%) patients, including 20 (27.0%) with extensively drug-resistant TB. Of the 47 (63.5%) patients with positive cultures at the commencement of the first new drug, culture conversion occurred in 44 (93.6%). The interim treatment outcome after 12 months was favourable in 68/74 patients (91.9%). Twenty-four weeks of treatment were completed in 137 of 148 episodes of new drug use (92.3%). Regarding the 11 early discontinuation events, six patients stopped using a new drug due to adverse drug reactions that were not life-threatening, including one (1.4%) who stopped Bdq due to QT-prolongation. CONCLUSIONS Sequential use of the two new drugs appears to be an effective and safe option for MDR-TB patients with few treatment options.
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Affiliation(s)
- Hoon Hee Lee
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Kyung-Wook Jo
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Jae-Joon Yim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Doosoo Jeon
- Department of Internal Medicine, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, South Korea
| | - Hyungseok Kang
- Department of Chest Medicine, Masan National Tuberculosis Hospital, Changwon, South Korea
| | - Tae Sun Shim
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea.
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Barvaliya SV, Desai MK, Panchal JR, Solanki RN. Early treatment outcome of bedaquiline plus optimised background regimen in drug resistant tuberculosis patients. Indian J Tuberc 2020; 67:222-230. [PMID: 32553316 DOI: 10.1016/j.ijtb.2020.03.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 11/20/2019] [Accepted: 03/06/2020] [Indexed: 10/24/2022]
Abstract
AIMS Bedaquiline (BDQ) has been recently approved for drug resistant tuberculosis with active drug safety monitoring under programmatic condition. The present study was conducted to evaluate safety, tolerability and efficacy of bedaquiline plus optimised background regimen. METHODS A prospective study was conducted on cohort of pre-extensively drug resistant (XDR) and XDR pulmonary TB patients. Eligible patients were closely monitored for cardiac safety, adverse events (AEs), clinical and microbiological improvement during BDQ (6 months) and post BDQ phase for twelve months. RESULTS Of 127 patients enrolled, a significant increase in mean QTc interval was observed on 13th day and 3rd week as compared to baseline (p < 0.0001). Mean maximum increase of QTc was 37.92ms (95% CI, 14.1-61.74ms). Concomitant anti-TB medications, age, gender, low body mass index (BMI) had significant effect on QTc prolongation (p < 0.0001, p < 0.05). However, none of the patient required discontinuation of BDQ. Majority of AEs (86.3%) were non-serious and not preventable 108 (87.1%). The median time for sputum-culture conversion was 40.89 ± 3.5 days (95% CI, 34-48 days) and the treatment outcome was successful in 102 (80.3%) patients with negative sputum culture conversion. CONCLUSIONS Bedaquiline containing regimen achieved favourable outcome. Although, bedaquiline along with concomitant anti-TB medications has the potential to prolong QTc interval, the benefit certainly outweighs the risk. This calls for a through pre-treatment cardiovascular and biochemical evaluation as a preventive measure and appropriate selection of patients for safe use of BDQ and successful outcome.
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Affiliation(s)
- Sandip V Barvaliya
- Department of Pharmacology, B. J. Medical College & Civil Hospital, Ahmedabad, 380016, India
| | - Mira K Desai
- Department of Pharmacology, B. J. Medical College & Civil Hospital, Ahmedabad, 380016, India
| | - Jigar R Panchal
- Department of Pharmacology, B. J. Medical College & Civil Hospital, Ahmedabad, 380016, India.
| | - Rajesh N Solanki
- Department of Pulmonary Medicine, B. J. Medical College & Civil Hospital, Ahmedabad, 380016, India
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Mohr E, Ferlazzo G, Hewison C, De Azevedo V, Isaakidis P. Bedaquiline and delamanid in combination for treatment of drug-resistant tuberculosis. THE LANCET. INFECTIOUS DISEASES 2020; 19:470. [PMID: 31034392 DOI: 10.1016/s1473-3099(19)30168-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Accepted: 03/20/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Erika Mohr
- Médecins Sans Frontières, Khayelitsha, Cape Town, South Africa; Médecins Sans Frontières, Southern Africa Medical Unit, Cape Town, South Africa
| | - Gabriella Ferlazzo
- Médecins Sans Frontières, Southern Africa Medical Unit, Cape Town, South Africa; Médecins Sans Frontières, Paris, France
| | - Cathy Hewison
- Médecins Sans Frontières, Southern Africa Medical Unit, Cape Town, South Africa
| | | | - Petros Isaakidis
- Médecins Sans Frontières, Southern Africa Medical Unit, Cape Town, South Africa.
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