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Naidoo K, Perumal R, Cox H, Mathema B, Loveday M, Ismail N, Omar SV, Georghiou SB, Daftary A, O'Donnell M, Ndjeka N. The epidemiology, transmission, diagnosis, and management of drug-resistant tuberculosis-lessons from the South African experience. THE LANCET. INFECTIOUS DISEASES 2024; 24:e559-e575. [PMID: 38527475 DOI: 10.1016/s1473-3099(24)00144-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 01/29/2024] [Accepted: 02/20/2024] [Indexed: 03/27/2024]
Abstract
Drug-resistant tuberculosis (DR-TB) threatens to derail tuberculosis control efforts, particularly in Africa where the disease remains out of control. The dogma that DR-TB epidemics are fueled by unchecked rates of acquired resistance in inadequately treated or non-adherent individuals is no longer valid in most high DR-TB burden settings, where community transmission is now widespread. A large burden of DR-TB in Africa remains undiagnosed due to inadequate access to diagnostic tools that simultaneously detect tuberculosis and screen for resistance. Furthermore, acquisition of drug resistance to new and repurposed drugs, for which diagnostic solutions are not yet available, presents a major challenge for the implementation of novel, all-oral, shortened (6-9 months) treatment. Structural challenges including poverty, stigma, and social distress disrupt engagement in care, promote poor treatment outcomes, and reduce the quality of life for people with DR-TB. We reflect on the lessons learnt from the South African experience in implementing state-of-the-art advances in diagnostic solutions, deploying recent innovations in pharmacotherapeutic approaches for rapid cure, understanding local transmission dynamics and implementing interventions to curtail DR-TB transmission, and in mitigating the catastrophic socioeconomic costs of DR-TB. We also highlight globally relevant and locally responsive research priorities for achieving DR-TB control in South Africa.
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Affiliation(s)
- Kogieleum Naidoo
- SAMRC-CAPRISA HIV/TB Pathogenesis and Treatment Research Unit, Centre for the AIDS Programme of Research in South Africa, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa.
| | - Rubeshan Perumal
- SAMRC-CAPRISA HIV/TB Pathogenesis and Treatment Research Unit, Centre for the AIDS Programme of Research in South Africa, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Helen Cox
- Institute of Infectious Diseases and Molecular Medicine, Wellcome Centre for Infectious Disease Research and Division of Medical Microbiology, University of Cape Town, Cape Town, South Africa
| | - Barun Mathema
- Mailman School of Public Health, Columbia University, New York City, NY, USA
| | - Marian Loveday
- South African Medical Research Council, Durban, South Africa
| | - Nazir Ismail
- School of Pathology, University of Witwatersrand, Johannesburg, South Africa
| | - Shaheed Vally Omar
- Centre for Tuberculosis, National & WHO Supranational TB Reference Laboratory, National Institute for Communicable Diseases, Division of the National Health Laboratory Service, Johannesburg, South Africa
| | | | - Amrita Daftary
- SAMRC-CAPRISA HIV/TB Pathogenesis and Treatment Research Unit, Centre for the AIDS Programme of Research in South Africa, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa; School of Global Health and Dahdaleh Institute of Global Health Research, York University, Toronto, ON, Canada
| | - Max O'Donnell
- SAMRC-CAPRISA HIV/TB Pathogenesis and Treatment Research Unit, Centre for the AIDS Programme of Research in South Africa, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa; Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Irving Medical Center, New York City, NY, USA; Department of Epidemiology, Columbia University Irving Medical Center, New York City, NY, USA
| | - Norbert Ndjeka
- TB Control and Management, Republic of South Africa National Department of Health, Pretoria, South Africa
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Ryckman TS, McQuaid CF, Cohen T, Menzies NA, Kendall EA. Projected health and economic effects of a pan-tuberculosis treatment regimen: a modelling study. Lancet Glob Health 2024:S2214-109X(24)00284-5. [PMID: 39159654 DOI: 10.1016/s2214-109x(24)00284-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Revised: 06/28/2024] [Accepted: 06/30/2024] [Indexed: 08/21/2024]
Abstract
BACKGROUND A pan-tuberculosis regimen that could be initiated without knowledge of drug susceptibility has been proposed as an objective of tuberculosis regimen development. We modelled the health and economic benefits of such a regimen and analysed which of its features contribute most to impact and savings. METHODS We constructed a mathematical model of tuberculosis treatment parameterised with data from the published literature specific to three countries with a high tuberculosis burden (India, the Philippines, and South Africa). Our model simulated cohorts of newly diagnosed tuberculosis patients, including drug susceptibility testing if performed, regimen assignment, discontinuation, adherence, costs, and resulting outcomes of durable cure (microbiological cure without relapse), need for retreatment, or death. We compared a pan-tuberculosis regimen meeting the WHO 2023 target regimen profile against the standard of care of separate rifampicin-susceptible and rifampicin-resistant regimens. We estimated incremental cures; averted deaths, secondary cases, and costs; and prices below which a pan-tuberculosis regimen would be cost saving. We also assessed scenarios intended to describe which mechanisms of benefit from a pan-tuberculosis regimen (including improved characteristics compared with the current rifampicin-susceptible and rifampicin-resistant regimens and improved regimen assignment and retention in care for patients with rifampicin-resistant tuberculosis) would be most impactful. Results are presented as a range of means across countries with the most extreme 95% uncertainty intervals (UIs) from the three UI ranges. FINDINGS Compared with the standard of care, a pan-tuberculosis regimen could increase the proportion of patients durably cured after an initial treatment attempt from 69-71% (95% UI 57-80) to 75-76% (68-83), preventing 30-32% of the deaths (20-43) and 17-20% of the transmission (9-29) that occur after initial tuberculosis diagnosis. Considering savings to the health system and patients during and after the initial treatment attempt, the regimen could reduce non-drug costs by 32-42% (22-49) and would be cost saving at prices below US$170-340 (130-510). A rifamycin-containing regimen that otherwise met pan-tuberculosis targets yielded only slightly less impact, indicating that most of the benefits from a pan-tuberculosis regimen resulted from its improvements upon the rifampicin-susceptible standard of care. Eliminating non-adherence and treatment discontinuation, for example via a long-acting injectable regimen, increased health impact and savings. INTERPRETATION In countries with a high tuberculosis burden, a shorter, highly efficacious, safe, and tolerable regimen to treat all tuberculosis could yield substantial health improvements and savings. FUNDING Bill & Melinda Gates Foundation.
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Affiliation(s)
- Theresa S Ryckman
- Division of Infectious Diseases, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - C Finn McQuaid
- TB Modelling Group, TB Centre and Centre for Mathematical Modelling of Infectious Diseases, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Ted Cohen
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
| | - Nicolas A Menzies
- Department of Global Health and Population and Center for Health Decision Science, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Emily A Kendall
- Division of Infectious Diseases, Johns Hopkins School of Medicine, Baltimore, MD, USA
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3
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Roberts LW, Malone KM, Hunt M, Joseph L, Wintringer P, Knaggs J, Crook D, Farhat MR, Iqbal Z, Omar SV. MmpR5 protein truncation and bedaquiline resistance in Mycobacterium tuberculosis isolates from South Africa: a genomic analysis. THE LANCET. MICROBE 2024; 5:100847. [PMID: 38851206 DOI: 10.1016/s2666-5247(24)00053-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 02/15/2024] [Accepted: 02/21/2024] [Indexed: 06/10/2024]
Abstract
BACKGROUND The antibiotic bedaquiline is a key component of new WHO regimens for drug-resistant tuberculosis; however, predicting bedaquiline resistance from bacterial genotypes remains challenging. We aimed to understand the genetic mechanisms of bedaquiline resistance by analysing Mycobacterium tuberculosis isolates from South Africa. METHODS For this genomic analysis, we conducted whole-genome sequencing of Mycobacterium tuberculosis samples collected at two referral laboratories in Cape Town and Johannesburg, covering regions of South Africa with a high prevalence of tuberculosis. We used the tool ARIBA to measure the status of predefined genes that are associated with bedaquiline resistance. To produce a broad genetic landscape of M tuberculosis in South Africa, we extended our analysis to include all publicly available isolates from the European Nucleotide Archive, including isolates obtained by the CRyPTIC consortium, for which minimum inhibitory concentrations of bedaquiline were available. FINDINGS Between Jan 10, 2019, and July, 22, 2020, we sequenced 505 M tuberculosis isolates from 461 patients. Of the 64 isolates with mutations within the mmpR5 regulatory gene, we found 53 (83%) had independent acquisition of 31 different mutations, with a particular enrichment of truncated MmpR5 in bedaquiline-resistant isolates resulting from either frameshift mutations or the introduction of an insertion element. Truncation occurred across three M tuberculosis lineages, and were present in 66% of bedaquiline-resistant isolates. Although the distributions overlapped, the median minimum inhibitory concentration of bedaquiline was 0·25 mg/L (IQR 0·12-0·25) in mmpR5-disrupted isolates, compared with 0·06 mg/L (0·03-0·06) in wild-type M tuberculosis. INTERPRETATION Reduction in the susceptibility of M tuberculosis to bedaquiline has evolved repeatedly across the phylogeny. In our data, we see no evidence that this reduction has led to the spread of a successful strain in South Africa. Binary phenotyping based on the bedaquiline breakpoint might be inappropriate to monitor resistance to this drug. We recommend the use of minimum inhibitory concentrations in addition to MmpR5 truncation screening to identify moderate increases in resistance to bedaquiline. FUNDING US Centers for Disease Control and Prevention.
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Affiliation(s)
- Leah W Roberts
- European Molecular Biology Laboratory, European Bioinformatics Institute, Hinxton, UK; Department of Medicine, University of Cambridge, Cambridge, UK; Centre for Immunology and Infection Control, Queensland University of Technology, Brisbane, QLD, Australia
| | - Kerri M Malone
- European Molecular Biology Laboratory, European Bioinformatics Institute, Hinxton, UK; Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Martin Hunt
- European Molecular Biology Laboratory, European Bioinformatics Institute, Hinxton, UK; Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Lavania Joseph
- Centre for Tuberculosis, National and Supranational TB Reference Laboratory, National Institute for Communicable Diseases, a division of the National Health Laboratory Service, Johannesburg, South Africa
| | - Penelope Wintringer
- European Molecular Biology Laboratory, European Bioinformatics Institute, Hinxton, UK
| | - Jeff Knaggs
- European Molecular Biology Laboratory, European Bioinformatics Institute, Hinxton, UK; Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Derrick Crook
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Maha R Farhat
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA, USA; Division of Pulmonary and Critical Care, Massachusetts General Hospital, Boston, MA, USA
| | - Zamin Iqbal
- European Molecular Biology Laboratory, European Bioinformatics Institute, Hinxton, UK; The Milner Centre for Evolution, University of Bath, Bath, UK.
| | - Shaheed V Omar
- Centre for Tuberculosis, National and Supranational TB Reference Laboratory, National Institute for Communicable Diseases, a division of the National Health Laboratory Service, Johannesburg, South Africa
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Snobre J, Gasana J, Ngabonziza JCS, Cuella-Martin I, Rigouts L, Jacobs BK, de Viron E, Herssens N, Ntihumby JB, Klibazayre A, Ndayishimiye C, Van Deun A, Affolabi D, Merle CS, Muvunyi C, Sturkenboom MGG, Migambi P, de Jong BC, Mucyo Y, Decroo T. Safety of high-dose amikacin in the first week of all-oral rifampicin-resistant tuberculosis treatment for the prevention of acquired resistance (STAKE): protocol for a single-arm clinical trial. BMJ Open 2024; 14:e078379. [PMID: 39053960 PMCID: PMC11284928 DOI: 10.1136/bmjopen-2023-078379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 06/28/2024] [Indexed: 07/27/2024] Open
Abstract
INTRODUCTION An effective rifampicin-resistant tuberculosis (RR-TB) treatment regimen should include prevention of resistance amplification. While bedaquiline (BDQ) has been recommended in all-oral RR-TB treatment regimen since 2019, resistance is rising at alarming rates. This may be due to BDQ's delayed bactericidal effect, which increases the risk of selecting for resistance to fluoroquinolones and/or BDQ in the first week of treatment when the bacterial load is highest. We aim to strengthen the first week of treatment with the injectable drug amikacin (AMK). To limit the ototoxicity risk while maximising the bactericidal effect, we will evaluate the safety of adding a 30 mg/kg AMK injection on the first and fourth day of treatment. METHODS AND ANALYSIS We will conduct a single-arm clinical trial on 20 RR-TB patients nested within an operational study called ShoRRT (All oral Shorter Treatment Regimen for Drug resistant Tuberculosis). In addition to all-oral RR-TB treatment, patients will receive two doses of AMK. The primary safety endpoint is any grade 3-4 adverse event during the first 2 weeks of treatment related to the use of AMK. With a sample size of 20 patients, we will have at least 80% statistical power to support the alternative hypothesis, indicating that less than 14% of patients treated with AMK experience a grade 3-4 adverse event related to its use. Safety data obtained from this study will inform a larger multicountry study on using two high doses of AMK to prevent acquired resistance. ETHICS AND DISSEMINATION Approval was obtained from the ethics committee of Rwanda, Rwanda Food and Drug Authority, Universitair Ziekenhuis, the Institute of Tropical Medicine ethics review board. All participants will provide informed consent. Study results will be disseminated through peer-reviewed journals and conferences. TRIAL REGISTRATION NUMBER NCT05555303.
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Affiliation(s)
- Jihad Snobre
- Institute of Tropical Medicine, Antwerp, Belgium
- Vrije Universiteit Brussel, Brussels, Belgium
| | | | | | | | - Leen Rigouts
- Institute of Tropical Medicine, Antwerp, Belgium
| | | | | | | | | | | | | | | | - Dissou Affolabi
- Centre National Hospitalier Universitaire de Pneumo-Phtisiologie, Cotonou, Benin
| | - Corinne S Merle
- Special Programme for Research & Training In Tropical Diseases (TDR), World Health Organization, Geneva, Switzerland
| | | | | | | | | | - Yves Mucyo
- Rwanda Biomedical Centre, Kigali, Rwanda
| | - Tom Decroo
- Institute of Tropical Medicine, Antwerp, Belgium
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Duffey M, Shafer RW, Timm J, Burrows JN, Fotouhi N, Cockett M, Leroy D. Combating antimicrobial resistance in malaria, HIV and tuberculosis. Nat Rev Drug Discov 2024; 23:461-479. [PMID: 38750260 DOI: 10.1038/s41573-024-00933-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/15/2024] [Indexed: 06/07/2024]
Abstract
Antimicrobial resistance poses a significant threat to the sustainability of effective treatments against the three most prevalent infectious diseases: malaria, human immunodeficiency virus (HIV) infection and tuberculosis. Therefore, there is an urgent need to develop novel drugs and treatment protocols capable of reducing the emergence of resistance and combating it when it does occur. In this Review, we present an overview of the status and underlying molecular mechanisms of drug resistance in these three diseases. We also discuss current strategies to address resistance during the research and development of next-generation therapies. These strategies vary depending on the infectious agent and the array of resistance mechanisms involved. Furthermore, we explore the potential for cross-fertilization of knowledge and technology among these diseases to create innovative approaches for minimizing drug resistance and advancing the discovery and development of new anti-infective treatments. In conclusion, we advocate for the implementation of well-defined strategies to effectively mitigate and manage resistance in all interventions against infectious diseases.
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Affiliation(s)
- Maëlle Duffey
- Medicines for Malaria Venture (MMV), R&D Department/Drug Discovery, ICC, Geneva, Switzerland
- The Global Antibiotic Research & Development Partnership, Geneva, Switzerland
| | - Robert W Shafer
- Department of Medicine/Infectious Diseases, Stanford University, Palo Alto, CA, USA
| | | | - Jeremy N Burrows
- Medicines for Malaria Venture (MMV), R&D Department/Drug Discovery, ICC, Geneva, Switzerland
| | | | | | - Didier Leroy
- Medicines for Malaria Venture (MMV), R&D Department/Drug Discovery, ICC, Geneva, Switzerland.
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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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7
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Villellas C, Stevenaert F, Remmerie B, Andries K. Sub-MIC levels of bedaquiline and clofazimine can select Mycobacterium tuberculosis mutants with increased MIC. Antimicrob Agents Chemother 2024; 68:e0127523. [PMID: 38470194 PMCID: PMC10989023 DOI: 10.1128/aac.01275-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 02/18/2024] [Indexed: 03/13/2024] Open
Abstract
Multidrug-resistant tuberculosis (MDR-TB) patients not cured at the time of stopping treatment are exposed to Minimum Inhibitory Concentration (MIC) and sub-MIC levels for many months after discontinuing bedaquiline (BDQ) or clofazimine (CFZ) treatment. In vitro cultures treated with BDQ and CFZ sub-MIC concentrations clearly showed enrichment in the Rv0678 mutant population, demonstrating that pre-existing Rv0678 mutants can be selected by sub-MIC concentrations of BDQ and CFZ if not protected by an alternative MDR-TB treatment.
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Affiliation(s)
| | | | | | - Koen Andries
- Janssen Research and Development, Beerse, Belgium
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Dahl VN, Butova T, Rosenthal A, Grinev A, Gabrielian A, Vashakidze S, Shubladze N, Toxanbayeva B, Chingissova L, Crudu V, Chesov D, Kalmambetova G, Saparova G, Wejse CM, Butov D. Drug-Resistant Tuberculosis, Georgia, Kazakhstan, Kyrgyzstan, Moldova, and Ukraine, 2017-2022. Emerg Infect Dis 2024; 30:831-833. [PMID: 38526186 PMCID: PMC10977852 DOI: 10.3201/eid3004.231732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/26/2024] Open
Abstract
In 2021, the World Health Organization recommended new extensively drug-resistant (XDR) and pre-XDR tuberculosis (TB) definitions. In a recent cohort of TB patients in Eastern Europe, we show that XDR TB as currently defined is associated with exceptionally poor treatment outcomes, considerably worse than for the former definition (31% vs. 54% treatment success).
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Farhat M, Cox H, Ghanem M, Denkinger CM, Rodrigues C, Abd El Aziz MS, Enkh-Amgalan H, Vambe D, Ugarte-Gil C, Furin J, Pai M. Drug-resistant tuberculosis: a persistent global health concern. Nat Rev Microbiol 2024:10.1038/s41579-024-01025-1. [PMID: 38519618 DOI: 10.1038/s41579-024-01025-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/12/2024] [Indexed: 03/25/2024]
Abstract
Drug-resistant tuberculosis (TB) is estimated to cause 13% of all antimicrobial resistance-attributable deaths worldwide and is driven by both ongoing resistance acquisition and person-to-person transmission. Poor outcomes are exacerbated by late diagnosis and inadequate access to effective treatment. Advances in rapid molecular testing have recently improved the diagnosis of TB and drug resistance. Next-generation sequencing of Mycobacterium tuberculosis has increased our understanding of genetic resistance mechanisms and can now detect mutations associated with resistance phenotypes. All-oral, shorter drug regimens that can achieve high cure rates of drug-resistant TB within 6-9 months are now available and recommended but have yet to be scaled to global clinical use. Promising regimens for the prevention of drug-resistant TB among high-risk contacts are supported by early clinical trial data but final results are pending. A person-centred approach is crucial in managing drug-resistant TB to reduce the risk of poor treatment outcomes, side effects, stigma and mental health burden associated with the diagnosis. In this Review, we describe current surveillance of drug-resistant TB and the causes, risk factors and determinants of drug resistance as well as the stigma and mental health considerations associated with it. We discuss recent advances in diagnostics and drug-susceptibility testing and outline the progress in developing better treatment and preventive therapies.
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Affiliation(s)
- Maha Farhat
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA, USA
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Helen Cox
- Institute of Infectious Disease and Molecular Medicine, Wellcome Centre for Infectious Disease Research and Division of Medical Microbiology, University of Cape Town, Cape Town, South Africa
| | - Marwan Ghanem
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA, USA
| | - Claudia M Denkinger
- Division of Infectious Disease and Tropical Medicine, Heidelberg University Hospital, Heidelberg, Germany
- German Center for Infection Research (DZIF), partner site Heidelberg University Hospital, Heidelberg, Germany
| | | | - Mirna S Abd El Aziz
- Division of Infectious Disease and Tropical Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | | | - Debrah Vambe
- National TB Control Programme, Manzini, Eswatini
| | - Cesar Ugarte-Gil
- School of Public and Population Health, University of Texas Medical Branch, Galveston, TX, USA
| | - Jennifer Furin
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - Madhukar Pai
- McGill International TB Centre, McGill University, Montreal, Quebec, Canada.
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Blankson HNA, Kamara RF, Barilar I, Andres S, Conteh OS, Dallenga T, Foray L, Maurer F, Kranzer K, Utpatel C, Niemann S. Molecular determinants of multidrug-resistant tuberculosis in Sierra Leone. Microbiol Spectr 2024; 12:e0240523. [PMID: 38289066 PMCID: PMC10923214 DOI: 10.1128/spectrum.02405-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 10/28/2023] [Indexed: 03/06/2024] Open
Abstract
Multidrug-resistant tuberculosis (MDR-TB) management has become a serious global health challenge. Understanding its epidemic determinants on the regional level is crucial for developing effective control measures. We used whole genome sequencing data of 238 of Mycobacterium tuberculosis complex (MTBC) strains to determine drug resistance profiles, phylogeny, and transmission dynamics of MDR/rifampicin-resistant (RR) MTBC strains from Sierra Leone. Forty-two strains were classified as RR, 196 as MDR, 5 were resistant to bedaquiline (BDQ) and clofazimine (CFZ), but none was found to be resistant to fluoroquinolones. Sixty-one (26%) strains were resistant to all first-line drugs, three of which had additional resistance to BDQ/CFZ. The strains were classified into six major MTBC lineages (L), with strains of L4 being the most prevalent, 62% (n = 147), followed by L6 (Mycobacterium africanum) strains, (21%, n = 50). The overall clustering rate (using ≤d12 single-nucleotide polymorphism threshold) was 44%, stratified into 31 clusters ranging from 2 to 16 strains. The largest cluster (n = 16) was formed by sublineage 2.2.1 Beijing Ancestral 3 strains, which developed MDR several times. Meanwhile, 10 of the L6 strains had a primary MDR transmission. We observed a high diversity of drug resistance mutations, including borderline resistance mutations to isoniazid and rifampicin, and mutations were not detected by commercial assays. In conclusion, one in five strains investigated was resistant to all first-line drugs, three of which had evidence of BDQ/CFZ resistance. Implementation of interventions such as rapid diagnostics that prevent further resistance development and stop MDR-TB transmission chains in the country is urgently needed. IMPORTANCE A substantial proportion of MDR-TB strains in Sierra Leone were resistant against all first line drugs; however this makes the all-oral-six-month BPaLM regimen or other 6-9 months all oral regimens still viable, mainly because there was no FQ resistance.Resistance to BDQ was detected, as well as RR, due to mutations outside of the hotspot region. While the prevalence of those resistances was low, it is still cause for concern and needs to be closely monitored.
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Affiliation(s)
- Harriet N. A. Blankson
- Molecular and Experimental Mycobacteriology, Research Center Borstel Leibniz Lung Center, Borstel, Germany
- German Center for Infection Research, Partner Site Hamburg-Lübeck-Borstel-Reims, Borstel, Germany
- School of Biomedical and Allied Health Sciences, College of Health Sciences, University of Ghana, Korle-Bu, Accra, Ghana
| | - Rashidatu Fouad Kamara
- National Leprosy and Tuberculosis Control Programme Sierra Leone, Freetown, Sierra Leone
| | - Ivan Barilar
- Molecular and Experimental Mycobacteriology, Research Center Borstel Leibniz Lung Center, Borstel, Germany
- German Center for Infection Research, Partner Site Hamburg-Lübeck-Borstel-Reims, Borstel, Germany
| | - Sönke Andres
- National and WHO Supranational Reference Center for Mycobacteria, Research Center Borstel Leibniz Lung Center, Borstel, Germany
| | - Ousman S. Conteh
- National Leprosy and Tuberculosis Control Programme Sierra Leone, Freetown, Sierra Leone
| | - Tobias Dallenga
- German Center for Infection Research, Partner Site Hamburg-Lübeck-Borstel-Reims, Borstel, Germany
- Cellular Microbiology, Research Center Borstel Leibniz Lung Center, Borstel, Germany
| | - Lynda Foray
- National Leprosy and Tuberculosis Control Programme Sierra Leone, Freetown, Sierra Leone
| | - Florian Maurer
- German Center for Infection Research, Partner Site Hamburg-Lübeck-Borstel-Reims, Borstel, Germany
- National and WHO Supranational Reference Center for Mycobacteria, Research Center Borstel Leibniz Lung Center, Borstel, Germany
- Institute of Medical Microbiology, Virology and Hygiene, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Katharina Kranzer
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Christian Utpatel
- Molecular and Experimental Mycobacteriology, Research Center Borstel Leibniz Lung Center, Borstel, Germany
- German Center for Infection Research, Partner Site Hamburg-Lübeck-Borstel-Reims, Borstel, Germany
| | - Stefan Niemann
- Molecular and Experimental Mycobacteriology, Research Center Borstel Leibniz Lung Center, Borstel, Germany
- German Center for Infection Research, Partner Site Hamburg-Lübeck-Borstel-Reims, Borstel, Germany
- National and WHO Supranational Reference Center for Mycobacteria, Research Center Borstel Leibniz Lung Center, Borstel, Germany
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11
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Koele SE, Dorlo TPC, Upton CM, Aarnoutse RE, Svensson EM. Power to identify exposure-response relationships in phase IIa pulmonary tuberculosis trials with multi-dimensional bacterial load modeling. CPT Pharmacometrics Syst Pharmacol 2024; 13:374-385. [PMID: 38102814 PMCID: PMC10941589 DOI: 10.1002/psp4.13089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 10/04/2023] [Accepted: 11/15/2023] [Indexed: 12/17/2023] Open
Abstract
Adequate power to identify an exposure-response relationship in a phase IIa clinical trial for pulmonary tuberculosis (TB) is important for dose selection and design of follow-up studies. Currently, it is not known what response marker provides the pharmacokinetic-pharmacodynamic (PK-PD) model more power to identify an exposure-response relationship. We simulated colony-forming units (CFU) and time-to-positivity (TTP) measurements for four hypothetical drugs with different activity profiles for 14 days. The power to identify exposure-response relationships when analyzing CFU, TTP, or combined CFU + TTP data was determined at 60 total participants, or with 25 out of 60 participants in the lowest and highest dosing groups (unbalanced design). For drugs with moderate bactericidal activity, power was low (<59%), irrespective of the data analyzed. Power was 1.9% to 29.4% higher when analyzing TTP data compared to CFU data. Combined analysis of CFU and TTP further improved the power, on average by 4.2%. For a drug with a medium-high activity, the total sample size needed to achieve 80% power was 136 for CFU, 72 for TTP, and 68 for combined CFU + TTP data. The unbalanced design improved the power by 16% over the balanced design. In conclusion, the power to identify an exposure-response relationship is low for TB drugs with moderate bactericidal activity or with a slow onset of activity. TTP provides the PK-PD model with more power to identify exposure-response relationships compared to CFU, and combined analysis or an unbalanced dosing group study design offers modest further improvement.
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Affiliation(s)
- Simon E. Koele
- Department of Pharmacy, Radboudumc Research Institute for Medical Innovation (RIMI)Radboud University Medical CenterNijmegenThe Netherlands
| | | | | | - Rob E. Aarnoutse
- Department of Pharmacy, Radboudumc Research Institute for Medical Innovation (RIMI)Radboud University Medical CenterNijmegenThe Netherlands
| | - Elin M. Svensson
- Department of Pharmacy, Radboudumc Research Institute for Medical Innovation (RIMI)Radboud University Medical CenterNijmegenThe Netherlands
- Department of PharmacyUppsala UniversityUppsalaSweden
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12
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Barilar I, Fernando T, Utpatel C, Abujate C, Madeira CM, José B, Mutaquiha C, Kranzer K, Niemann T, Ismael N, de Araujo L, Wirth T, Niemann S, Viegas S. Emergence of bedaquiline-resistant tuberculosis and of multidrug-resistant and extensively drug-resistant Mycobacterium tuberculosis strains with rpoB Ile491Phe mutation not detected by Xpert MTB/RIF in Mozambique: a retrospective observational study. THE LANCET. INFECTIOUS DISEASES 2024; 24:297-307. [PMID: 37956677 DOI: 10.1016/s1473-3099(23)00498-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 07/18/2023] [Accepted: 07/26/2023] [Indexed: 11/15/2023]
Abstract
BACKGROUND In 2021, an estimated 4800 people developed rifampicin-resistant tuberculosis in Mozambique, 75% of which went undiagnosed. Detailed molecular data on rifampicin-resistant and multidrug-resistant (MDR) tuberculosis are not available. Here, we aimed at gaining precise data on the determinants of rifampicin-resistant and MDR tuberculosis in Mozambique. METHODS In this retrospective observational study, we performed whole-genome sequencing of 704 rifampicin-resistant Mycobacterium tuberculosis complex (Mtbc) strains submitted to the National Tuberculosis Reference Laboratory (NTRL) in Maputo, Mozambique, between 2015 and 2021. Phylogenetic strain classification, genomic resistance prediction, and cluster analysis were performed. FINDINGS Between Jan 1, 2015, and July 31, 2021, 2606 Mtbc isolates with an isoniazid or rifampicin resistance were identified in the NTRL biobank, of which, 1483 (56·9%) were from men, 1114 (42·7%) from women, and nine (0·4%) were unknown. Genome-based drug-resistant prediction classified 704 Mtbc strains as rifampicin resistant. 628 (89%) of the 704 Mtbc strains were classified MDR; of those, 146 (23%) were pre-extensively drug resistant (pre-XDR; additional fluoroquinolone resistance), and 24 (4%) extensively drug resistant (XDR; combined fluoroquinolone and bedaquiline resistance). Overall, 61 (9%) of 704 strains revealed resistance to bedaquiline: five (7%) of 76 rifampicin resistant plus bedaquiline resistant, 32 (7%) of 458 MDR plus bedaquiline resistant, and 24 (100%) of 24 XDR. Prevalence of bedaquiline resistance increased from 3% in 2016 to 14% in 2021. The cluster rate (12 single-nucleotide polymorphism threshold) was 42% for rifampicin-resistant strains, 78% for MDR strains, 94% for pre-XDR strains, and 96% for XDR Mtbc strains. 31 (4%) of 704 Mtbc strains, belonging to a diagnostic escape outbreak strain previously described in Eswatini (group_56), had an rpoB Ile491Phe mutation which is not detected by Xpert MTB/RIF (no other rpoB mutation). Of these, 23 (74%) showed additional resistance to bedaquiline, 13 (42%) had bedaquiline and fluoroquinolone resistance, and two (6%) were bedaquiline, fluoroquinolone, and delamanid resistant. INTERPRETATION Pre-XDR resistance is highly prevalent among MDR Mtbc strains in Mozambique and so is bedaquiline resistance; and the frequency of bedaquiline resistance quadrupled over time and was found even in Mtbc strains without fluoroquinolone resistance. Importantly, strains with Ile491Phe mutation were frequent, accounting for 31% (n=10) of MDR plus bedaquiline-resistant strains and 54% (n=13) of XDR Mtbc strains. Given the current diagnostic algorithms and treatment regimens, both the emergence of rifampicin resistance due to Ile491Phe and bedaquiline resistance might jeopardise MDR tuberculosis prevention and care unless sequencing-based technology is rolled out. The potential cross border spread of diagnostic escape strains needs further investigation. FUNDING The German Ministry of Health through the Seq_MDRTB-Net project, the Deutsche Forschungsgemeinschaft under Germany's Excellence Strategy Precision Medicine in Inflammation and the Research Training Group 2501 TransEvo, the Leibniz Science Campus Evolutionary Medicine of the Lung, and the German Ministry of Education and Research via the German Center for Infection Research.
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Affiliation(s)
- Ivan Barilar
- Molecular and Experimental Mycobacteriology, Research Center Borstel, Borstel, Germany; German Center for Infection Research, Partner Site Hamburg-Lübeck-Borstel-Riems, Borstel, Germany
| | | | - Christian Utpatel
- Molecular and Experimental Mycobacteriology, Research Center Borstel, Borstel, Germany; German Center for Infection Research, Partner Site Hamburg-Lübeck-Borstel-Riems, Borstel, Germany
| | | | | | - Benedita José
- National Tuberculosis Control Program, Directorate of Public Health, Ministry of Health, Maputo, Mozambique
| | - Claudia Mutaquiha
- National Tuberculosis Control Program, Directorate of Public Health, Ministry of Health, Maputo, Mozambique
| | - Katharina Kranzer
- Biomedical Research and Training Institute, Harare, Zimbabwe; Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK; Division of Infectious Diseases and Tropical Medicine, University Hospital, Ludwig-Maximilians-Universität, Munich, Munich, Germany
| | - Tanja Niemann
- Molecular and Experimental Mycobacteriology, Research Center Borstel, Borstel, Germany; German Center for Infection Research, Partner Site Hamburg-Lübeck-Borstel-Riems, Borstel, Germany
| | - Nalia Ismael
- Instituto Nacional de Saúde, Marracuene, Mozambique
| | - Leonardo de Araujo
- Molecular and Experimental Mycobacteriology, Research Center Borstel, Borstel, Germany; German Center for Infection Research, Partner Site Hamburg-Lübeck-Borstel-Riems, Borstel, Germany
| | - Thierry Wirth
- Ecole Pratique des Hautes Etudes, Paris Sciences et Lettres University, Paris, France; Institut de Systématique, Evolution, Biodiversite, Muséum National d'Histoire Naturelle, Centre National de la Recherche Scientifique, Sorbonne Université, Paris, France; Ecole Pratique des Hautes Etudes, Université des Antilles, Paris, France
| | - Stefan Niemann
- Molecular and Experimental Mycobacteriology, Research Center Borstel, Borstel, Germany; German Center for Infection Research, Partner Site Hamburg-Lübeck-Borstel-Riems, Borstel, Germany; Department of Human, Biological and Translational Medical Sciences, School of Medicine, University of Namibia, Windhoek, Namibia.
| | - Sofia Viegas
- Instituto Nacional de Saúde, Marracuene, Mozambique
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13
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Zemanay W, Cox H. Minimising the threat of bedaquiline-resistant tuberculosis: better diagnosis as prevention. THE LANCET. INFECTIOUS DISEASES 2024; 24:226-228. [PMID: 37956678 DOI: 10.1016/s1473-3099(23)00550-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 08/22/2023] [Indexed: 11/15/2023]
Affiliation(s)
- Widaad Zemanay
- Division of Medical Microbiology, Department of Pathology, University of Cape Town, Cape Town 7925, South Africa
| | - Helen Cox
- Division of Medical Microbiology, Department of Pathology, University of Cape Town, Cape Town 7925, South Africa; Wellcome Centre for Infectious Diseases Research in Africa, University of Cape Town, Cape Town 7925, South Africa; Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town 7925, South Africa.
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14
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Brown TS, Tang L, Omar SV, Joseph L, Meintjes G, Maartens G, Wasserman S, Shah NS, Farhat MR, Gandhi NR, Ismail N, Brust JCM, Mathema B. Genotype-Phenotype Characterization of Serial Mycobacterium tuberculosis Isolates in Bedaquiline-Resistant Tuberculosis. Clin Infect Dis 2024; 78:269-276. [PMID: 37874928 DOI: 10.1093/cid/ciad596] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Indexed: 10/26/2023] Open
Abstract
BACKGROUND Emerging resistance to bedaquiline (BDQ) threatens to undermine advances in the treatment of drug-resistant tuberculosis (DRTB). Characterizing serial Mycobacterium tuberculosis (Mtb) isolates collected during BDQ-based treatment can provide insights into the etiologies of BDQ resistance in this important group of DRTB patients. METHODS We measured mycobacteria growth indicator tube (MGIT)-based BDQ minimum inhibitory concentrations (MICs) of Mtb isolates collected from 195 individuals with no prior BDQ exposure who were receiving BDQ-based treatment for DRTB. We conducted whole-genome sequencing on serial Mtb isolates from all participants who had any isolate with a BDQ MIC >1 collected before or after starting treatment (95 total Mtb isolates from 24 participants). RESULTS Sixteen of 24 participants had BDQ-resistant TB (MGIT MIC ≥4 µg/mL) and 8 had BDQ-intermediate infections (MGIT MIC = 2 µg/mL). Participants with pre-existing resistance outnumbered those with resistance acquired during treatment, and 8 of 24 participants had polyclonal infections. BDQ resistance was observed across multiple Mtb strain types and involved a diverse catalog of mmpR5 (Rv0678) mutations, but no mutations in atpE or pepQ. Nine pairs of participants shared genetically similar isolates separated by <5 single nucleotide polymorphisms, concerning for potential transmitted BDQ resistance. CONCLUSIONS BDQ-resistant TB can arise via multiple, overlapping processes, including transmission of strains with pre-existing resistance. Capturing the within-host diversity of these infections could potentially improve clinical diagnosis, population-level surveillance, and molecular diagnostic test development.
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Affiliation(s)
- Tyler S Brown
- Section of Infectious Diseases, Boston University School of Medicine, Boston, Massachusetts, USA
- Center for Communicable Disease Dynamics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Linrui Tang
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York, USA
| | - Shaheed Vally Omar
- Centre for Tuberculosis, National Institute for Communicable Diseases, Johannesburg, South Africa
- Department of Molecular Medicine & Hematology, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Lavania Joseph
- Centre for Tuberculosis, National Institute for Communicable Diseases, Johannesburg, South Africa
| | - Graeme Meintjes
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, and Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Gary Maartens
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, and Department of Medicine, University of Cape Town, Cape Town, South Africa
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Sean Wasserman
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, and Department of Medicine, University of Cape Town, Cape Town, South Africa
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - N Sarita Shah
- Departments of Epidemiology and Global Health and Medicine, Rollins School of Public Health and Emory School of Medicine, Atlanta, Georgia, USA
| | - Maha R Farhat
- Department of Biomedical Informatics, Harvard Medical School, Boston, Massachusetts, USA
| | - Neel R Gandhi
- Departments of Epidemiology and Global Health and Medicine, Rollins School of Public Health and Emory School of Medicine, Atlanta, Georgia, USA
| | - Nazir Ismail
- Centre for Tuberculosis, National Institute for Communicable Diseases, Johannesburg, South Africa
| | - James C M Brust
- Department of Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York, USA
| | - Barun Mathema
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York, USA
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15
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Islam MM, Alam MS, Liu Z, Khatun MS, Yusuf B, Hameed HMA, Tian X, Chhotaray C, Basnet R, Abraha H, Zhang X, Khan SA, Fang C, Li C, Hasan S, Tan S, Zhong N, Hu J, Zhang T. Molecular mechanisms of resistance and treatment efficacy of clofazimine and bedaquiline against Mycobacterium tuberculosis. Front Med (Lausanne) 2024; 10:1304857. [PMID: 38274444 PMCID: PMC10809401 DOI: 10.3389/fmed.2023.1304857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Accepted: 11/21/2023] [Indexed: 01/27/2024] Open
Abstract
Clofazimine (CFZ) and bedaquiline (BDQ) are currently used for the treatment of multidrug-resistant (MDR) Mycobacterium tuberculosis (Mtb) strains. In recent years, adding CFZ and BDQ to tuberculosis (TB) drug regimens against MDR Mtb strains has significantly improved treatment results, but these improvements are threatened by the emergence of MDR and extensively drug-resistant (XDR) Mtb strains. Recently, CFZ and BDQ have attracted much attention for their strong clinical efficacy, although very little is known about the mechanisms of action, drug susceptibility test (DST), resistance mechanisms, cross-resistance, and pharmacokinetics of these two drugs. In this current review, we provide recent updates on the mechanisms of action, DST, associated mutations with individual resistance and cross-resistance, clinical efficacy, and pharmacokinetics of CFZ and BDQ against Mtb strains. Presently, known mechanisms of resistance for CFZ and/or BDQ include mutations within the Rv0678, pepQ, Rv1979c, and atpE genes. The cross-resistance between CFZ and BDQ may reduce available MDR-/XDR-TB treatment options. The use of CFZ and BDQ for treatment in the setting of limited DST could allow further spread of drug resistance. The DST and resistance knowledge are urgently needed where CFZ and BDQ resistance do emerge. Therefore, an in-depth understanding of clinical efficacy, DST, cross-resistance, and pharmacokinetics for CFZ and BDQ against Mtb can provide new ideas for improving treatment outcomes, reducing mortality, preventing drug resistance, and TB transmission. Along with this, it will also help to develop rapid molecular diagnostic tools as well as novel therapeutic drugs for TB.
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Affiliation(s)
- Md Mahmudul Islam
- State Key Laboratory of Respiratory Disease, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, Guangzhou, China
- Guangdong-Hong Kong-Macao Joint Laboratory of Respiratory Infectious Diseases, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, Guangzhou, China
- University of Chinese Academy of Sciences, Beijing, China
- China-New Zealand Joint Laboratory on Biomedicine and Health, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, Guangzhou, China
- Department of Microbiology, Shaheed Shamsuzzoha Institute of Biosciences, Affiliated with University of Rajshahi, Rajshahi, Bangladesh
| | - Md Shah Alam
- State Key Laboratory of Respiratory Disease, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, Guangzhou, China
- Guangdong-Hong Kong-Macao Joint Laboratory of Respiratory Infectious Diseases, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, Guangzhou, China
- University of Chinese Academy of Sciences, Beijing, China
- China-New Zealand Joint Laboratory on Biomedicine and Health, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, Guangzhou, China
| | - Zhiyong Liu
- State Key Laboratory of Respiratory Disease, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, Guangzhou, China
- Guangdong-Hong Kong-Macao Joint Laboratory of Respiratory Infectious Diseases, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, Guangzhou, China
- China-New Zealand Joint Laboratory on Biomedicine and Health, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, Guangzhou, China
- Guangzhou Medical University, Guangzhou, China
- Guangzhou National Laboratory, Guangzhou, China
| | - Mst Sumaia Khatun
- State Key Laboratory of Respiratory Disease, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, Guangzhou, China
- Guangdong-Hong Kong-Macao Joint Laboratory of Respiratory Infectious Diseases, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, Guangzhou, China
- University of Chinese Academy of Sciences, Beijing, China
- China-New Zealand Joint Laboratory on Biomedicine and Health, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, Guangzhou, China
| | - Buhari Yusuf
- State Key Laboratory of Respiratory Disease, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, Guangzhou, China
- Guangdong-Hong Kong-Macao Joint Laboratory of Respiratory Infectious Diseases, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, Guangzhou, China
- University of Chinese Academy of Sciences, Beijing, China
- China-New Zealand Joint Laboratory on Biomedicine and Health, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, Guangzhou, China
| | - H. M. Adnan Hameed
- State Key Laboratory of Respiratory Disease, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, Guangzhou, China
- Guangdong-Hong Kong-Macao Joint Laboratory of Respiratory Infectious Diseases, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, Guangzhou, China
- University of Chinese Academy of Sciences, Beijing, China
- China-New Zealand Joint Laboratory on Biomedicine and Health, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, Guangzhou, China
| | - Xirong Tian
- State Key Laboratory of Respiratory Disease, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, Guangzhou, China
- Guangdong-Hong Kong-Macao Joint Laboratory of Respiratory Infectious Diseases, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, Guangzhou, China
- University of Chinese Academy of Sciences, Beijing, China
- China-New Zealand Joint Laboratory on Biomedicine and Health, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, Guangzhou, China
| | - Chiranjibi Chhotaray
- Department of Medicine, Center for Emerging Pathogens, Rutgers-New Jersey Medical School, Newark, NJ, United States
| | - Rajesh Basnet
- State Key Laboratory of Respiratory Disease, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, Guangzhou, China
- Guangdong-Hong Kong-Macao Joint Laboratory of Respiratory Infectious Diseases, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, Guangzhou, China
- University of Chinese Academy of Sciences, Beijing, China
- China-New Zealand Joint Laboratory on Biomedicine and Health, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, Guangzhou, China
| | - Haftay Abraha
- State Key Laboratory of Respiratory Disease, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, Guangzhou, China
- Guangdong-Hong Kong-Macao Joint Laboratory of Respiratory Infectious Diseases, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, Guangzhou, China
- University of Chinese Academy of Sciences, Beijing, China
- China-New Zealand Joint Laboratory on Biomedicine and Health, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, Guangzhou, China
| | - Xiaofan Zhang
- State Key Laboratory of Respiratory Disease, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, Guangzhou, China
- Guangdong-Hong Kong-Macao Joint Laboratory of Respiratory Infectious Diseases, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, Guangzhou, China
- University of Chinese Academy of Sciences, Beijing, China
- China-New Zealand Joint Laboratory on Biomedicine and Health, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, Guangzhou, China
| | - Shahzad Akbar Khan
- State Key Laboratory of Respiratory Disease, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, Guangzhou, China
- Guangdong-Hong Kong-Macao Joint Laboratory of Respiratory Infectious Diseases, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, Guangzhou, China
- University of Chinese Academy of Sciences, Beijing, China
- China-New Zealand Joint Laboratory on Biomedicine and Health, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, Guangzhou, China
- Laboratory of Pathology, Department of Pathobiology, University of Poonch Rawalakot, Azad Kashmir, Pakistan
| | - Cuiting Fang
- State Key Laboratory of Respiratory Disease, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, Guangzhou, China
- Guangdong-Hong Kong-Macao Joint Laboratory of Respiratory Infectious Diseases, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, Guangzhou, China
- University of Chinese Academy of Sciences, Beijing, China
- China-New Zealand Joint Laboratory on Biomedicine and Health, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, Guangzhou, China
| | - Chunyu Li
- State Key Laboratory of Respiratory Disease, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, Guangzhou, China
- Guangdong-Hong Kong-Macao Joint Laboratory of Respiratory Infectious Diseases, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, Guangzhou, China
- University of Chinese Academy of Sciences, Beijing, China
- China-New Zealand Joint Laboratory on Biomedicine and Health, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, Guangzhou, China
| | - Sohel Hasan
- Department of Biochemistry and Molecular Biology, University of Rajshahi, Rajshahi, Bangladesh
| | - Shouyong Tan
- Guangzhou National Laboratory, Guangzhou, China
- State Key Laboratory of Respiratory Disease, Guangzhou Chest Hospital, Guangzhou, China
| | - Nanshan Zhong
- Guangdong-Hong Kong-Macao Joint Laboratory of Respiratory Infectious Diseases, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, Guangzhou, China
- Guangzhou National Laboratory, Guangzhou, China
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, The National Center for Respiratory Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Jinxing Hu
- Guangzhou National Laboratory, Guangzhou, China
- State Key Laboratory of Respiratory Disease, Guangzhou Chest Hospital, Guangzhou, China
| | - Tianyu Zhang
- State Key Laboratory of Respiratory Disease, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, Guangzhou, China
- Guangdong-Hong Kong-Macao Joint Laboratory of Respiratory Infectious Diseases, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, Guangzhou, China
- University of Chinese Academy of Sciences, Beijing, China
- China-New Zealand Joint Laboratory on Biomedicine and Health, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, Guangzhou, China
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16
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Suman SK, Chandrasekaran N, Priya Doss CG. Micro-nanoemulsion and nanoparticle-assisted drug delivery against drug-resistant tuberculosis: recent developments. Clin Microbiol Rev 2023; 36:e0008823. [PMID: 38032192 PMCID: PMC10732062 DOI: 10.1128/cmr.00088-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2023] Open
Abstract
Tuberculosis (TB) is a major global health problem and the second most prevalent infectious killer after COVID-19. It is caused by Mycobacterium tuberculosis (Mtb) and has become increasingly challenging to treat due to drug resistance. The World Health Organization declared TB a global health emergency in 1993. Drug resistance in TB is driven by mutations in the bacterial genome that can be influenced by prolonged drug exposure and poor patient adherence. The development of drug-resistant forms of TB, such as multidrug resistant, extensively drug resistant, and totally drug resistant, poses significant therapeutic challenges. Researchers are exploring new drugs and novel drug delivery systems, such as nanotechnology-based therapies, to combat drug resistance. Nanodrug delivery offers targeted and precise drug delivery, improves treatment efficacy, and reduces adverse effects. Along with nanoscale drug delivery, a new generation of antibiotics with potent therapeutic efficacy, drug repurposing, and new treatment regimens (combinations) that can tackle the problem of drug resistance in a shorter duration could be promising therapies in clinical settings. However, the clinical translation of nanomedicines faces challenges such as safety, large-scale production, regulatory frameworks, and intellectual property issues. In this review, we present the current status, most recent findings, challenges, and limiting barriers to the use of emulsions and nanoparticles against drug-resistant TB.
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Affiliation(s)
- Simpal Kumar Suman
- School of Bio Sciences & Technology (SBST), Vellore Institute of Technology, Vellore, Tamil Nadu, India
| | - Natarajan Chandrasekaran
- Centre for Nano Biotechnology (CNBT), Vellore Institute of Technology, Vellore, Tamil Nadu, India
| | - C. George Priya Doss
- Laboratory for Integrative Genomics, Department of Integrative Biology, School of Bio Sciences & Technology, Vellore Institute of Technology, Vellore, Tamil Nadu, India
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17
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Georghiou SB, de Vos M, Velen K, Miotto P, Colman RE, Cirillo DM, Ismail N, Rodwell TC, Suresh A, Ruhwald M. Designing molecular diagnostics for current tuberculosis drug regimens. Emerg Microbes Infect 2023; 12:2178243. [PMID: 36752055 PMCID: PMC9980415 DOI: 10.1080/22221751.2023.2178243] [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: 02/09/2023]
Abstract
Diagnostic development must occur in parallel with drug development to ensure the longevity of new treatment compounds. Despite an increasing number of novel and repurposed anti-tuberculosis compounds and regimens, there remains a large number of drugs for which no rapid and accurate molecular diagnostic option exists. The lack of rapid drug susceptibility testing for linezolid, bedaquiline, clofazimine, the nitroimidazoles (i.e pretomanid and delamanid) and pyrazinamide at any level of the healthcare system compromises the effectiveness of current tuberculosis and drug-resistant tuberculosis treatment regimens. In the context of current WHO tuberculosis treatment guidelines as well as promising new regimens, we identify the key diagnostic gaps for initial and follow-on tests to diagnose emerging drug resistance and aid in regimen selection. Additionally, we comment on potential gene targets for inclusion in rapid molecular drug susceptibility assays and sequencing assays for novel and repurposed drug compounds currently prioritized in current regimens, and evaluate the feasibility of mutation detection given the design of existing technologies. Based on current knowledge, we also propose design priorities for next generation molecular assays to support triage of tuberculosis patients to appropriate and effective treatment regimens. We encourage assay developers to prioritize development of these key molecular assays and support the continued evolution, uptake, and utility of sequencing to build knowledge of tuberculosis resistance mechanisms and further inform rapid treatment decisions in order to curb resistance to critical drugs in current regimens and achieve End TB targets.Trial registration: ClinicalTrials.gov identifier: NCT05117788..
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Affiliation(s)
| | | | | | - Paolo Miotto
- IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Rebecca E. Colman
- FIND, the Global Alliance for Diagnostics, Geneva, Switzerland,Department of Medicine, University of California, San Diego, La Jolla, CA, USA
| | | | | | - Timothy C. Rodwell
- FIND, the Global Alliance for Diagnostics, Geneva, Switzerland,Department of Medicine, University of California, San Diego, La Jolla, CA, USA
| | - Anita Suresh
- FIND, the Global Alliance for Diagnostics, Geneva, Switzerland
| | - Morten Ruhwald
- FIND, the Global Alliance for Diagnostics, Geneva, Switzerland, Morten Ruhwald FIND, the Global Alliance for Diagnostics, Campus Biotech, 9 Chemin des Mines, Geneva1202, Switzerland
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18
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Perumal R, Bionghi N, Nimmo C, Letsoalo M, Cummings MJ, Hopson M, Wolf A, Jubaer SA, Padayatchi N, Naidoo K, Larsen MH, O'Donnell M. Baseline and treatment-emergent bedaquiline resistance in drug-resistant tuberculosis: a systematic review and meta-analysis. Eur Respir J 2023; 62:2300639. [PMID: 37945030 PMCID: PMC11035900 DOI: 10.1183/13993003.00639-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Accepted: 10/22/2023] [Indexed: 11/12/2023]
Abstract
Bedaquiline resistance is a major threat to drug-resistant tuberculosis control strategies. This analysis found a pooled prevalence of baseline bedaquiline resistance of 2.4% and a pooled prevalence of treatment-emergent bedaquiline resistance of 2.1%. https://bit.ly/3FC6yio
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Affiliation(s)
- Rubeshan Perumal
- CAPRISA MRC-HIV-TB Pathogenesis and Treatment Research Unit, Centre for the AIDS Programme of Research in South Africa, Durban, South Africa
- Division of Pulmonology and Critical Care, Department of Medicine, University of KwaZulu-Natal, Durban, South Africa
- These authors contributed equally to this work
| | - Neda Bionghi
- Department of Medicine, Columbia University Irving Medical Center and New York-Presbyterian Hospital, New York, NY, USA
- These authors contributed equally to this work
| | | | - Marothi Letsoalo
- CAPRISA MRC-HIV-TB Pathogenesis and Treatment Research Unit, Centre for the AIDS Programme of Research in South Africa, Durban, South Africa
| | - Matthew J Cummings
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Madeleine Hopson
- Department of Medicine, Columbia University Irving Medical Center and New York-Presbyterian Hospital, New York, NY, USA
| | - Allison Wolf
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Shamim Al Jubaer
- Department of Microbiology and Immunology, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Nesri Padayatchi
- CAPRISA MRC-HIV-TB Pathogenesis and Treatment Research Unit, Centre for the AIDS Programme of Research in South Africa, Durban, South Africa
| | - Kogieleum Naidoo
- CAPRISA MRC-HIV-TB Pathogenesis and Treatment Research Unit, Centre for the AIDS Programme of Research in South Africa, Durban, South Africa
| | - Michelle H Larsen
- Department of Microbiology and Immunology, Albert Einstein College of Medicine, Bronx, NY, USA
- These authors contributed equally to this work
| | - Max O'Donnell
- CAPRISA MRC-HIV-TB Pathogenesis and Treatment Research Unit, Centre for the AIDS Programme of Research in South Africa, Durban, South Africa
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University Irving Medical Center, New York, NY, USA
- These authors contributed equally to this work
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19
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Achar J, Seddon JA, Knight GM, Dodd PJ, Esmail H, Hughes J, McQuaid CF. Guiding pragmatic treatment choices for rifampicin-resistant tuberculosis in the absence of second-line drug susceptibility testing. Eur Respir J 2023; 62:2300969. [PMID: 37945035 DOI: 10.1183/13993003.00969-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 10/20/2023] [Indexed: 11/12/2023]
Affiliation(s)
- Jay Achar
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - James A Seddon
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Section of Paediatric Infectious Disease, Department of Infectious Disease, Imperial College London, London, UK
| | - Gwenan M Knight
- TB Modelling Group, TB Centre, Centre for Mathematical Modelling of Infectious Diseases and AMR Centre, Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Peter J Dodd
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Hanif Esmail
- MRC Clinical Trials Unit, University College London, London, UK
- Institute for Global Health, University College London, London, UK
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, and Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Jennifer Hughes
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - C Finn McQuaid
- TB Modelling Group, TB Centre, Centre for Mathematical Modelling of Infectious Diseases and AMR Centre, Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
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20
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Timm J, Bateson A, Solanki P, Paleckyte A, Witney AA, Rofael SAD, Fabiane S, Olugbosi M, McHugh TD, Sun E. Baseline and acquired resistance to bedaquiline, linezolid and pretomanid, and impact on treatment outcomes in four tuberculosis clinical trials containing pretomanid. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0002283. [PMID: 37851685 PMCID: PMC10584172 DOI: 10.1371/journal.pgph.0002283] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 09/14/2023] [Indexed: 10/20/2023]
Abstract
Bedaquiline (B), pretomanid (Pa) and linezolid (L) are key components of new regimens for treating rifampicin-resistant tuberculosis (TB). However, there is limited information on the global prevalence of resistance to these drugs and the impact of resistance on treatment outcomes. Mycobacterium tuberculosis (MTB) phenotypic drug susceptibility and whole-genome sequence (WGS) data, as well as patient profiles from 4 pretomanid-containing trials-STAND, Nix-TB, ZeNix and SimpliciTB-were used to investigate the rates of baseline resistance (BR) and acquired resistance (AR) to BPaL drugs, as well as their genetic basis, risk factors and impact on treatment outcomes. Data from >1,000 TB patients enrolled from 2015 to 2020 in 12 countries was assessed. We identified 2 (0.3%) participants with linezolid BR. Pretomanid BR was also rare, with similar rates across TB drug resistance types (0-2.1%). In contrast, bedaquiline BR was more prevalent among participants with highly resistant TB or longer prior treatment histories than those with newly diagnosed disease (5.2-6.3% vs. 0-0.3%). Bedaquiline BR was a risk factor for bacteriological failure or relapse in Nix-TB/ZeNix; 3/12 (25%, 95% CI 5-57%) participants with vs. 6/185 (3.2%, 1.2-6.9%) without bedaquiline BR. Across trials, we observed no linezolid AR, and only 3 cases of bedaquiline AR, including 2 participants with poor adherence. Overall, pretomanid AR was also rare, except in ZeNix patients with bedaquiline BR. WGS analyses revealed novel mutations in canonical resistant genes and, in 7 MTB isolates, the genetic determinants could not be identified. The overall low rates of BR to linezolid and pretomanid, and to a lesser extent to bedaquiline, observed in the pretomanid trials are in support of the worldwide implementation of BPaL-based regimens. Similarly, the overall low AR rates observed suggest BPaL drugs are better protected in the regimens trialed here than in other regimens combining bedaquiline with more, but less effective drugs.
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Affiliation(s)
- Juliano Timm
- TB Alliance, New York City, New York, United States of America
| | - Anna Bateson
- Centre for Clinical Microbiology, University College London, Royal Free Campus, London, United Kingdom
| | - Priya Solanki
- Centre for Clinical Microbiology, University College London, Royal Free Campus, London, United Kingdom
| | - Ana Paleckyte
- Centre for Clinical Microbiology, University College London, Royal Free Campus, London, United Kingdom
| | - Adam A. Witney
- Institute of Infection and Immunity, St George’s, University of London, London, United Kingdom
| | - Sylvia A. D. Rofael
- Centre for Clinical Microbiology, University College London, Royal Free Campus, London, United Kingdom
- Faculty of Pharmacy, University of Alexandria, Alexandria, Egypt
| | - Stella Fabiane
- MRC Clinical Trials Unit at University College London, London, United Kingdom
| | | | - Timothy D. McHugh
- Centre for Clinical Microbiology, University College London, Royal Free Campus, London, United Kingdom
| | - Eugene Sun
- TB Alliance, New York City, New York, United States of America
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21
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Pavlova EN, Lepekha LN, Rybalkina EY, Tarasov RV, Sychevskaya KA, Voronezhskaya EE, Masyutin AG, Ergeshov AE, Erokhina MV. High and Low Levels of ABCB1 Expression Are Associated with Two Distinct Gene Signatures in Lung Tissue of Pulmonary TB Patients with High Inflammation Activity. Int J Mol Sci 2023; 24:14839. [PMID: 37834286 PMCID: PMC10573207 DOI: 10.3390/ijms241914839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 09/23/2023] [Accepted: 09/27/2023] [Indexed: 10/15/2023] Open
Abstract
P-glycoprotein (encoded by the ABCB1 gene) has a dual role in regulating inflammation and reducing chemotherapy efficacy in various diseases, but there are few studies focused on pulmonary TB patients. In this study, our objective was to identify a list of genes that correlate with high and low levels of ABCB1 gene expression in the lungs of pulmonary TB patients with different activity of chronic granulomatous inflammation. We compared gene expression in two groups of samples (with moderate and high activity of tuberculomas) to identify their characteristic gene signatures. Gene expression levels were determined using quantitative PCR in samples of perifocal area of granulomas, which were obtained from 65 patients after surgical intervention. Subsequently, two distinct gene signatures associated with high inflammation activity were identified. The first signature demonstrated increased expression of HIF1a, TGM2, IL6, SOCS3, and STAT3, which correlated with high ABCB1 expression. The second signature was characterized by high expression of TNFa and CD163 and low expression of ABCB1. These results provide insight into various inflammatory mechanisms and association with P-gp gene expression in lung tissue of pulmonary TB patients and will be useful in the development of a host-directed therapy approach to improving the effectiveness of anti-TB treatment.
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Affiliation(s)
- Ekaterina N. Pavlova
- Central Tuberculosis Research Institute, 107564 Moscow, Russia; (E.N.P.); (A.G.M.)
- Faculty of Biology, Lomonosov Moscow State University, 119234 Moscow, Russia
| | - Larisa N. Lepekha
- Central Tuberculosis Research Institute, 107564 Moscow, Russia; (E.N.P.); (A.G.M.)
| | - Ekaterina Yu. Rybalkina
- Central Tuberculosis Research Institute, 107564 Moscow, Russia; (E.N.P.); (A.G.M.)
- FSBI N.N. Blokhin National Medical Research Center of Oncology, 115478 Moscow, Russia
| | - Ruslan V. Tarasov
- Central Tuberculosis Research Institute, 107564 Moscow, Russia; (E.N.P.); (A.G.M.)
| | - Ksenia A. Sychevskaya
- Central Tuberculosis Research Institute, 107564 Moscow, Russia; (E.N.P.); (A.G.M.)
- FSBI N.N. Blokhin National Medical Research Center of Oncology, 115478 Moscow, Russia
| | - Elena E. Voronezhskaya
- Koltzov Institute of Developmental Biology of Russian Academy of Sciences, 119334 Moscow, Russia
| | - Alexander G. Masyutin
- Central Tuberculosis Research Institute, 107564 Moscow, Russia; (E.N.P.); (A.G.M.)
- Faculty of Biology, Lomonosov Moscow State University, 119234 Moscow, Russia
| | - Atadzhan E. Ergeshov
- Director of the Institute, Central Tuberculosis Research Institute, 2 Yauzskaya Alleya, 107564 Moscow, Russia;
| | - Maria V. Erokhina
- Central Tuberculosis Research Institute, 107564 Moscow, Russia; (E.N.P.); (A.G.M.)
- Faculty of Biology, Lomonosov Moscow State University, 119234 Moscow, Russia
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22
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Chakraborty G, Nath I V A, Sharma M, Sheth J, Kori M, Tiwari A, Patra N. In silico structural and mechanical insights into bedaquiline resistance associated with high-grade non-synonymous mutations in atpE, mmpR5, and pepQ. J Biomol Struct Dyn 2023:1-13. [PMID: 37728541 DOI: 10.1080/07391102.2023.2259486] [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: 04/09/2023] [Accepted: 09/09/2023] [Indexed: 09/21/2023]
Abstract
Clinical resistance against bedaquiline (BDQ) remains intractable to anti-tuberculosis therapies since its introduction to the market over a decade ago. Herein, we investigated the structural and mechanical aspects of BDQ resistance in AtpE, MmpR5, and PepQ. The known target-specific resistant single non-synonymous mutations were refined to high-grade candidates. Thus, 7 (AtpE), 5 (MmpR5), and 1 (PepQ) single nucleotide polymorphisms (SNPs) and one insertion frameshift mutation in MmpR5 were recreated at the molecular level, and these phenotypic models were then directed to stringent dynamics to define time-scaled changes. The AtpE variants destabilized the structure; mainly, L59V, E61D, and I66M were detrimental to the complex fitness, while L74V and L114P boosted the BDQ binding to MmpR5. The first three and last two alterations gave rise to loss- and gain-of-function to AtpE and MmpR5, respectively. Hence, these five mutants are functionally relevant and therapeutically targetable hotspots of BDQ resistance. There were no noticeable changes in PepQ data analysis. The present study revealed that MmpR5 mutations confer BDQ resistance, whereas AtpE and PepQ SNPs display low susceptibility. These results were tallied with the published findings, which testified to the pursued method's reliability and accuracy. We hope these data and inferences could be helpful for the futuristic design of novel TB drugs.Communicated by Ramaswamy H. Sarma.
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Affiliation(s)
| | | | - Mukta Sharma
- AarogyaAI Innovations Private Limited, Bengaluru, India
| | - Jigar Sheth
- AarogyaAI Innovations Private Limited, Bengaluru, India
| | - Mahima Kori
- AarogyaAI Innovations Private Limited, Bengaluru, India
| | | | - Niladri Patra
- Indian Institute of Technology (Indian School of Mines), Dhanbad, India
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23
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Saluzzo F, Adepoju VA, Duarte R, Lange C, Phillips PP. Treatment-shortening regimens for tuberculosis: updates and future priorities. Breathe (Sheff) 2023; 19:230028. [PMID: 37830101 PMCID: PMC10567072 DOI: 10.1183/20734735.0028-2023] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 06/27/2023] [Indexed: 10/14/2023] Open
Abstract
In the past 2 years, remarkable advances have been made in shortening tuberculosis (TB) treatment. In particular, four clinical trials (Study 31/A5349, Nix-TB, ZeNix and TB-PRACTECAL) have provided evidence of the efficacy of regimens based on new and repurposed drugs: the 4-month regimen for drug-susceptible TB, and the 6-month bedaquiline-pretomanid-linezolid regimen with or without moxifloxacin for multidrug-resistant/rifampicin-resistant TB. Even if the evidence at the basis of these new regimens is compelling, several questions remain open, particularly concerning linezolid dose finding, the upsurging threat of bedaquiline-resistant Mycobacterium tuberculosis and the feasibility of applying these results to the paediatric population. Several ongoing trials may fill the remaining gaps and produce further reliable evidence to address the outstanding questions in TB treatment shortening.
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Affiliation(s)
- Francesca Saluzzo
- Vita-Salute San Raffaele University, Milan, Italy
- Contributed equally as first authors
| | - Victor Abiola Adepoju
- Department of HIV and Infectious Diseases, Jhpiego (an affiliate of Johns Hopkins University), Abuja, Nigeria
- Contributed equally as first authors
| | - Raquel Duarte
- EPI Unit, Instituto de Saúde Pública da Universidade do Porto, Porto, Portugal
- Unidade de Investigação Clínica da Administração Regional de Saúde do Norte, Porto, Portugal
- ICBAS – Instituto de Ciências Biomédicas de Abel Salazar, Universidade do Porto, Porto, Portugal
- Serviço de Pneumologia, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
| | - Christoph Lange
- Division of Clinical Infectious Diseases, Research Center Borstel, Borstel, Germany
- German Center for Infection Research (DZIF), TTU-TB, Borstel, Germany
- Respiratory Medicine and International Health, University of Lübeck, Lübeck, Germany
- Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - Patrick P.J. Phillips
- University of California, San Francisco, Center for Tuberculosis, San Francisco, CA, USA
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24
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Ahmed S, Prabahar AE, Saxena AK. Molecular docking-based interaction studies on imidazo[1,2-a] pyridine ethers and squaramides as anti-tubercular agents. SAR AND QSAR IN ENVIRONMENTAL RESEARCH 2023:1-23. [PMID: 37365919 DOI: 10.1080/1062936x.2023.2225872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 06/12/2023] [Indexed: 06/28/2023]
Abstract
Development of new anti-tubercular agents is required in the wake of resistance to the existing and newly approved drugs through novel-validated targets like ATP synthase, etc. The major limitation of poor correlation between docking scores and biological activity by SBDD was overcome by a novel approach of quantitatively correlating the interactions of different amino acid residues present in the target protein structure with the activity. This approach well predicted the ATP synthase inhibitory activity of imidazo[1,2-a] pyridine ethers and squaramides (r = 0.84) in terms of Glu65b interactions. Hence, the models were developed on combined (r = 0.78), and training (r = 0.82) sets of 52, and 27 molecules, respectively. The training set model well predicted the diverse dataset (r = 0.84), test set (r = 0.755), and, external dataset (rext = 0.76). This model predicted three compounds from a focused library generated by incorporating the essential features of the ATP synthase inhibition with the pIC50 values in the range of 0.0508-0.1494 µM. Molecular dynamics simulation studies ascertain the stability of the protein structure and the docked poses of the ligands. The developed model(s) may be useful in the identification and optimization of novel compounds against TB.
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Affiliation(s)
- S Ahmed
- Department of Pharmaceutical Chemistry, Global Institute of Pharmaceutical Education and Research, Kashipur, India
- Department of Pharmaceutical Chemistry, Teerthanker Mahaveer College of Pharmacy, Moradabad, India
| | - A E Prabahar
- Department of Pharmaceutical Chemistry, Teerthanker Mahaveer College of Pharmacy, Moradabad, India
| | - A K Saxena
- Department of Pharmaceutical Chemistry, Global Institute of Pharmaceutical Education and Research, Kashipur, India
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25
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Snobre J, Villellas MC, Coeck N, Mulders W, Tzfadia O, de Jong BC, Andries K, Rigouts L. Bedaquiline- and clofazimine- selected Mycobacterium tuberculosis mutants: further insights on resistance driven largely by Rv0678. Sci Rep 2023; 13:10444. [PMID: 37369740 DOI: 10.1038/s41598-023-36955-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 06/13/2023] [Indexed: 06/29/2023] Open
Abstract
Drug-resistant tuberculosis is a serious global health threat. Bedaquiline (BDQ) is a relatively new core drug, targeting the respiratory chain in Mycobacterium tuberculosis (Mtb). While mutations in the BDQ target gene, atpE, are rare in clinical isolates, mutations in the Rv0678 gene, a transcriptional repressor regulating the efflux pump MmpS5-MmpL5, are increasingly observed, and have been linked to worse treatment outcomes. Nevertheless, underlying mechanisms of (cross)-resistance remain incompletely resolved. Our study aims to distinguish resistance associated variants from other polymorphisms, by assessing the in vitro onset of mutations under drug pressure, combined with their impact on minimum inhibitory concentrations (MICs) and on protein stability. For this purpose, isolates were exposed in vitro to sub-lethal concentrations of BDQ or clofazimine (CFZ). Selected colonies had BDQ- and CFZ-MICs determined on 7H10 and 7H11 agar. Sanger sequencing and additional Deeplex Myc-TB and whole genome sequencing (WGS) for a subset of isolates were used to search for mutations in Rv0678, atpE and pepQ. In silico characterization of relevant mutations was performed using computational tools. We found that colonies that grew on BDQ medium had mutations in Rv0678, atpE or pepQ, while CFZ-exposed isolates presented mutations in Rv0678 and pepQ, but none in atpE. Twenty-eight Rv0678 mutations had previously been described among in vitro selected mutants or in patients' isolates, while 85 were new. Mutations were scattered across the Rv0678 gene without apparent hotspot. While most Rv0678 mutations led to an increased BDQ- and/or CFZ-MIC, only a part of them surpassed the critical concentration (69.1% for BDQ and 87.9% for CFZ). Among the mutations leading to elevated MICs for BDQ and CFZ, we report a synonymous Val1Val mutation in the Rv0678 start codon. Finally, in silico characterization of Rv0678 mutations suggests that especially the C46R mutant may render Rv0678 less stable.
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Affiliation(s)
- J Snobre
- Mycobacteriology Unit, Biomedical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
- Internal Medicine Department, UZ Brussel, Brussels, Belgium
- Doctoral School of Life Sciences & Medicine, Vrije Universiteit Brussel, Brussels, Belgium
| | - M C Villellas
- Department of Infectious Diseases, Janssen Pharmaceutica, Beerse, Belgium
| | - N Coeck
- Mycobacteriology Unit, Biomedical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - W Mulders
- Mycobacteriology Unit, Biomedical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - O Tzfadia
- Mycobacteriology Unit, Biomedical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - B C de Jong
- Mycobacteriology Unit, Biomedical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - K Andries
- Department of Infectious Diseases, Janssen Pharmaceutica, Beerse, Belgium
| | - L Rigouts
- Mycobacteriology Unit, Biomedical Sciences, Institute of Tropical Medicine, Antwerp, Belgium.
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26
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Graciaa DS, Schechter MC, Fetalvero KB, Cranmer LM, Kempker RR, Castro KG. Updated considerations in the diagnosis and management of tuberculosis infection and disease: integrating the latest evidence-based strategies. Expert Rev Anti Infect Ther 2023; 21:595-616. [PMID: 37128947 PMCID: PMC10227769 DOI: 10.1080/14787210.2023.2207820] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 04/24/2023] [Indexed: 05/03/2023]
Abstract
INTRODUCTION Tuberculosis (TB) is a leading infectious cause of global morbidity and mortality, affecting nearly a quarter of the human population and accounting for over 10 million deaths each year. Over the past several decades, TB incidence and mortality have gradually declined, but 2021 marked a threatening reversal of this trend highlighting the importance of accurate diagnosis and effective treatment of all forms of TB. AREAS COVERED This review summarizes advances in TB diagnostics, addresses the treatment of people with TB infection and TB disease including recent evidence for treatment regimens for drug-susceptible and drug-resistant TB, and draws attention to special considerations in children and during pregnancy. EXPERT OPINION Improvements in diagnosis and management of TB have expanded the available options for TB control. Molecular testing has enhanced the detection of TB disease, but better diagnostics are still needed, particularly for certain populations such as children. Novel treatment regimens have shortened treatment and improved outcomes for people with TB. However, important questions remain regarding the optimal management of TB. Work must continue to ensure the potential of the latest developments is realized for all people affected by TB.
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Affiliation(s)
- Daniel S. Graciaa
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Marcos Coutinho Schechter
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Krystle B. Fetalvero
- Angelo King Medical Research Center-De La Salle Medical and Health Science Institute, Cavite, Philippines
- Department of Family and Community Medicine, Calamba Medical Center, Laguna, Philippines
| | - Lisa Marie Cranmer
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Children’s Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Russell R. Kempker
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Kenneth G. Castro
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
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27
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Ness T, Van LH, Petermane I, Duarte R, Lange C, Menzies D, Cirillo DM. Rolling out new anti-tuberculosis drugs without diagnostic capacity. Breathe (Sheff) 2023; 19:230084. [PMID: 37492347 PMCID: PMC10365078 DOI: 10.1183/20734735.0084-2023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 05/25/2023] [Indexed: 07/27/2023] Open
Abstract
Deaths from tuberculosis (TB) reached over 1.6 million in 2021 with 10.6 million people becoming ill. Multidrug-resistant TB, defined as the Mycobacterium tuberculosis organism having resistance to at least isoniazid and rifampicin, represented 3.9% of new TB cases and 18% of previously treated cases. While new drug regimens continue to be developed and introduced to improve treatment of drug-resistant forms of TB, diagnostic capability to identify drug resistance lags woefully behind. While significant mortality benefits exist for these newer drug regimens, implementing them without proper drug resistance diagnostic capacity could lead to development of more drug resistances and exhaust these new therapeutic tools. Moving forward, the roll-out of new TB drugs and regimens must be paired with implementation of diagnostics to ensure judicious use of resources and the best chance for improving TB worldwide.
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Affiliation(s)
- Tara Ness
- Baylor College of Medicine, Department of Pediatrics, Global TB Program, Houston, TX, USA
- Contributed equally as first authors
| | - Le Hong Van
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
- Contributed equally as first authors
| | - Ilze Petermane
- Riga East Clinical University Hospital Centre of Tuberculosis and Lung Diseases, Riga, Latvia
| | - Raquel Duarte
- Instituto de Ciências Biomédicas Abel Salazar (ICBAS), Universidade do Porto, Porto, Portugal
- EPI Unit, Instituto de Saúde Pública da Universidade do Porto, Porto, Portugal
- Unidade de Investigação Clínica da Administração Regional de Saúde do Norte, Porto, Portugal
- Serviço de Pneumologia, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
| | - Christoph Lange
- Baylor College of Medicine, Department of Pediatrics, Global TB Program, Houston, TX, USA
- Division of Clinical Infectious Diseases, Research Center Borstel, Borstel, Germany
- German Center for Infection Research (DZIF) Partner Site Borstel-Hamburg-Lübeck-Riems, Borstel, Germany
- Respiratory Medicine and International Health, University of Lübeck, Lübeck, Germany
| | - Dick Menzies
- McGill International TB Centre, Montreal Chest Institute, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
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Domínguez J, Boeree MJ, Cambau E, Chesov D, Conradie F, Cox V, Dheda K, Dudnyk A, Farhat MR, Gagneux S, Grobusch MP, Gröschel MI, Guglielmetti L, Kontsevaya I, Lange B, van Leth F, Lienhardt C, Mandalakas AM, Maurer FP, Merker M, Miotto P, Molina-Moya B, Morel F, Niemann S, Veziris N, Whitelaw A, Horsburgh CR, Lange C. Clinical implications of molecular drug resistance testing for Mycobacterium tuberculosis: a 2023 TBnet/RESIST-TB consensus statement. THE LANCET. INFECTIOUS DISEASES 2023; 23:e122-e137. [PMID: 36868253 DOI: 10.1016/s1473-3099(22)00875-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 12/16/2022] [Accepted: 12/16/2022] [Indexed: 03/05/2023]
Abstract
Drug-resistant tuberculosis is a substantial health-care concern worldwide. Despite culture-based methods being considered the gold standard for drug susceptibility testing, molecular methods provide rapid information about the Mycobacterium tuberculosis mutations associated with resistance to anti-tuberculosis drugs. This consensus document was developed on the basis of a comprehensive literature search, by the TBnet and RESIST-TB networks, about reporting standards for the clinical use of molecular drug susceptibility testing. Review and the search for evidence included hand-searching journals and searching electronic databases. The panel identified studies that linked mutations in genomic regions of M tuberculosis with treatment outcome data. Implementation of molecular testing for the prediction of drug resistance in M tuberculosis is key. Detection of mutations in clinical isolates has implications for the clinical management of patients with multidrug-resistant or rifampicin-resistant tuberculosis, especially in situations when phenotypic drug susceptibility testing is not available. A multidisciplinary team including clinicians, microbiologists, and laboratory scientists reached a consensus on key questions relevant to molecular prediction of drug susceptibility or resistance to M tuberculosis, and their implications for clinical practice. This consensus document should help clinicians in the management of patients with tuberculosis, providing guidance for the design of treatment regimens and optimising outcomes.
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Affiliation(s)
- José Domínguez
- Institut d'Investigació Germans Trias i Pujol, Universitat Autònoma de Barcelona, CIBER Enfermedades Respiratorias, INNOVA4TB Consortium, Barcelona, Spain.
| | - Martin J Boeree
- Department of Lung Diseases, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Emmanuelle Cambau
- Centre National de Référence des Mycobactéries et de la Résistance des Mycobactéries aux Antituberculeux, Paris, France, APHP-Hôpital Bichat, Mycobacteriology Laboratory, INSERM, University Paris Cite, IAME UMR1137, Paris, France
| | - Dumitru Chesov
- Department of Pneumology and Allergology, Nicolae Testemițanu State University of Medicine and Pharmacy, Chisinau, Moldova; Division of Clinical Infectious Diseases, Research Center Borstel, Leibniz Lung Center, Borstel, Germany; German Center for Infection Research (DZIF), Partner Site Hamburg- Lübeck-Borstel-Riems, Borstel, Germany; Respiratory Medicine & International Health, University of Lübeck, Lübeck, Germany
| | - Francesca Conradie
- Department of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Vivian Cox
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Keertan Dheda
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and UCT Lung Institute & South African MRC/UCT Centre for the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa; Faculty of Infectious and Tropical Diseases, Department of Immunology and Infection, London School of Hygiene & Tropical Medicine, London, UK
| | - Andrii Dudnyk
- Department of Tuberculosis, Clinical Immunology and Allergy, National Pirogov Memorial Medical University, Vinnytsia, Ukraine; Public Health Center, Ministry of Health of Ukraine, Kyiv, Ukraine
| | - Maha R Farhat
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA, USA; Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Sebastien Gagneux
- Department of Medical Parasitology and Infection Biology, Swiss Tropical and Public Health Institute, Allschwil, Switzerland; University of Basel, Basel, Switzerland
| | - Martin P Grobusch
- Center of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Amsterdam University Medical Centers, Amsterdam Infection & Immunity, Amsterdam Public Health, University of Amsterdam, Amsterdam, Netherlands
| | - Matthias I Gröschel
- Department of Infectious Diseases and Respiratory Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany; Department of Biomedical Informatics, Harvard Medical School, Boston, MA, USA
| | - Lorenzo Guglielmetti
- Sorbonne Université, INSERM, U1135, Centre d'Immunologie et des Maladies Infectieuses, (Cimi-Paris), APHP Sorbonne Université, Department of Bacteriology Hôpital Pitié-Salpêtrière, Centre National de Référence des Mycobactéries et de la Résistance des Mycobactéries aux Antituberculeux, Paris, France
| | - Irina Kontsevaya
- Division of Clinical Infectious Diseases, Research Center Borstel, Leibniz Lung Center, Borstel, Germany; German Center for Infection Research (DZIF), Partner Site Hamburg- Lübeck-Borstel-Riems, Borstel, Germany; Respiratory Medicine & International Health, University of Lübeck, Lübeck, Germany; Department of Infectious Disease, Faculty of Medicine, Imperial College London, London, UK
| | - Berit Lange
- Department for Epidemiology, Helmholtz Centre for Infection Research, Braunschweig, Germany; German Centre for Infection Research, TI BBD, Braunschweig, Germany
| | - Frank van Leth
- Department of Health Sciences, Vrije Universiteit Amsterdam, Amsterdam, Netherlands; Amsterdam Public Health Research Institute, Amsterdam, Netherlands
| | - Christian Lienhardt
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK; UMI 233 IRD-U1175 INSERM - Université de Montpellier, Institut de Recherche pour le Développement, Montpellier, France
| | - Anna M Mandalakas
- Division of Clinical Infectious Diseases, Research Center Borstel, Leibniz Lung Center, Borstel, Germany; German Center for Infection Research (DZIF), Partner Site Hamburg- Lübeck-Borstel-Riems, Borstel, Germany; Respiratory Medicine & International Health, University of Lübeck, Lübeck, Germany; Global TB Program, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - Florian P Maurer
- National and Supranational Reference Center for Mycobacteria, Research Center Borstel, Leibniz Lung Center, Borstel, Germany; German Center for Infection Research (DZIF), Partner Site Hamburg- Lübeck-Borstel-Riems, Borstel, Germany; Institute of Medical Microbiology, Virology and Hygiene, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias Merker
- Division of Evolution of the Resistome, Research Center Borstel, Leibniz Lung Center, Borstel, Germany; German Center for Infection Research (DZIF), Partner Site Hamburg- Lübeck-Borstel-Riems, Borstel, Germany
| | - Paolo Miotto
- Emerging Bacterial Pathogens Unit, Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Barbara Molina-Moya
- Institut d'Investigació Germans Trias i Pujol, Universitat Autònoma de Barcelona, CIBER Enfermedades Respiratorias, INNOVA4TB Consortium, Barcelona, Spain
| | - Florence Morel
- Sorbonne Université, INSERM, U1135, Centre d'Immunologie et des Maladies Infectieuses, (Cimi-Paris), APHP Sorbonne Université, Department of Bacteriology Hôpital Pitié-Salpêtrière, Centre National de Référence des Mycobactéries et de la Résistance des Mycobactéries aux Antituberculeux, Paris, France
| | - Stefan Niemann
- Division of Molecular and Experimental Mycobacteriology, Research Center Borstel, Leibniz Lung Center, Borstel, Germany; German Center for Infection Research (DZIF), Partner Site Hamburg- Lübeck-Borstel-Riems, Borstel, Germany; Department of Human, Biological and Translational Medical Sciences, School of Medicine, University of Namibia, Windhoek, Namibia
| | - Nicolas Veziris
- Sorbonne Université, INSERM, U1135, Centre d'Immunologie et des Maladies Infectieuses, (Cimi-Paris), APHP Sorbonne Université, Department of Bacteriology Hôpital Pitié-Salpêtrière, Centre National de Référence des Mycobactéries et de la Résistance des Mycobactéries aux Antituberculeux, Paris, France
| | - Andrew Whitelaw
- Division of Medical Microbiology, Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa; National Health Laboratory Service, Tygerberg Hospital, Cape Town, South Africa
| | - Charles R Horsburgh
- Departments of Epidemiology, Biostatistics, Global Health and Medicine, Boston University Schools of Public Health and Medicine, Boston, MA, USA
| | - Christoph Lange
- Division of Clinical Infectious Diseases, Research Center Borstel, Leibniz Lung Center, Borstel, Germany; German Center for Infection Research (DZIF), Partner Site Hamburg- Lübeck-Borstel-Riems, Borstel, Germany; Respiratory Medicine & International Health, University of Lübeck, Lübeck, Germany; Global TB Program, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
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Paton NI, Cousins C, Suresh C, Burhan E, Chew KL, Dalay VB, Lu Q, Kusmiati T, Balanag VM, Lee SL, Ruslami R, Pokharkar Y, Djaharuddin I, Sugiri JJR, Veto RS, Sekaggya-Wiltshire C, Avihingsanon A, Sarin R, Papineni P, Nunn AJ, Crook AM. Treatment Strategy for Rifampin-Susceptible Tuberculosis. N Engl J Med 2023; 388:873-887. [PMID: 36808186 DOI: 10.1056/nejmoa2212537] [Citation(s) in RCA: 35] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
BACKGROUND Tuberculosis is usually treated with a 6-month rifampin-based regimen. Whether a strategy involving shorter initial treatment may lead to similar outcomes is unclear. METHODS In this adaptive, open-label, noninferiority trial, we randomly assigned participants with rifampin-susceptible pulmonary tuberculosis to undergo either standard treatment (rifampin and isoniazid for 24 weeks with pyrazinamide and ethambutol for the first 8 weeks) or a strategy involving initial treatment with an 8-week regimen, extended treatment for persistent clinical disease, monitoring after treatment, and retreatment for relapse. There were four strategy groups with different initial regimens; noninferiority was assessed in the two strategy groups with complete enrollment, which had initial regimens of high-dose rifampin-linezolid and bedaquiline-linezolid (each with isoniazid, pyrazinamide, and ethambutol). The primary outcome was a composite of death, ongoing treatment, or active disease at week 96. The noninferiority margin was 12 percentage points. RESULTS Of the 674 participants in the intention-to-treat population, 4 (0.6%) withdrew consent or were lost to follow-up. A primary-outcome event occurred in 7 of the 181 participants (3.9%) in the standard-treatment group, as compared with 21 of the 184 participants (11.4%) in the strategy group with an initial rifampin-linezolid regimen (adjusted difference, 7.4 percentage points; 97.5% confidence interval [CI], 1.7 to 13.2; noninferiority not met) and 11 of the 189 participants (5.8%) in the strategy group with an initial bedaquiline-linezolid regimen (adjusted difference, 0.8 percentage points; 97.5% CI, -3.4 to 5.1; noninferiority met). The mean total duration of treatment was 180 days in the standard-treatment group, 106 days in the rifampin-linezolid strategy group, and 85 days in the bedaquiline-linezolid strategy group. The incidences of grade 3 or 4 adverse events and serious adverse events were similar in the three groups. CONCLUSIONS A strategy involving initial treatment with an 8-week bedaquiline-linezolid regimen was noninferior to standard treatment for tuberculosis with respect to clinical outcomes. The strategy was associated with a shorter total duration of treatment and with no evident safety concerns. (Funded by the Singapore National Medical Research Council and others; TRUNCATE-TB ClinicalTrials.gov number, NCT03474198.).
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Affiliation(s)
- Nicholas I Paton
- From the Infectious Diseases Translational Research Programme and Yong Loo Lin School of Medicine, National University of Singapore (N.I.P., C.C., C.S., P.P.), National University Hospital (K.L.C.), and Singapore Clinical Research Institute (Q.L., S.L.L., Y.P.) - all in Singapore; the Faculty of Medicine, Universitas Indonesia, and Persahabatan General Hospital, Jakarta (E.B.), Dr. Soetomo Hospital, Surabaya (T.K.), Universitas Padjadjaran, Bandung (R.R.), Dr. Wahidin Sudirohusodo Hospital, Makassar (I.D.), and Saiful Anwar Hospital, Malang (J.J.R.S.) - all in Indonesia; De La Salle Medical and Health Sciences Institute, Cavite (V.B.D.), the Lung Centre of the Philippines, Quezon City (V.M.B.), and the Tropical Disease Foundation, Makati (R.S.V.) - all in the Philippines; the Infectious Diseases Institute, Makerere University, Kampala, Uganda (C.S.-W.); HIV-NAT, Thai Red Cross AIDS Research Center and Center of Excellence in Tuberculosis, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand (A.A.); the National Institute of TB and Respiratory Diseases, New Delhi, India (R.S.); and the London School of Hygiene and Tropical Medicine (N.I.P.) and the Medical Research Council Clinical Trials Unit at University College London (N.I.P., A.J.N., A.M.C.) - both in London
| | - Christopher Cousins
- From the Infectious Diseases Translational Research Programme and Yong Loo Lin School of Medicine, National University of Singapore (N.I.P., C.C., C.S., P.P.), National University Hospital (K.L.C.), and Singapore Clinical Research Institute (Q.L., S.L.L., Y.P.) - all in Singapore; the Faculty of Medicine, Universitas Indonesia, and Persahabatan General Hospital, Jakarta (E.B.), Dr. Soetomo Hospital, Surabaya (T.K.), Universitas Padjadjaran, Bandung (R.R.), Dr. Wahidin Sudirohusodo Hospital, Makassar (I.D.), and Saiful Anwar Hospital, Malang (J.J.R.S.) - all in Indonesia; De La Salle Medical and Health Sciences Institute, Cavite (V.B.D.), the Lung Centre of the Philippines, Quezon City (V.M.B.), and the Tropical Disease Foundation, Makati (R.S.V.) - all in the Philippines; the Infectious Diseases Institute, Makerere University, Kampala, Uganda (C.S.-W.); HIV-NAT, Thai Red Cross AIDS Research Center and Center of Excellence in Tuberculosis, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand (A.A.); the National Institute of TB and Respiratory Diseases, New Delhi, India (R.S.); and the London School of Hygiene and Tropical Medicine (N.I.P.) and the Medical Research Council Clinical Trials Unit at University College London (N.I.P., A.J.N., A.M.C.) - both in London
| | - Celina Suresh
- From the Infectious Diseases Translational Research Programme and Yong Loo Lin School of Medicine, National University of Singapore (N.I.P., C.C., C.S., P.P.), National University Hospital (K.L.C.), and Singapore Clinical Research Institute (Q.L., S.L.L., Y.P.) - all in Singapore; the Faculty of Medicine, Universitas Indonesia, and Persahabatan General Hospital, Jakarta (E.B.), Dr. Soetomo Hospital, Surabaya (T.K.), Universitas Padjadjaran, Bandung (R.R.), Dr. Wahidin Sudirohusodo Hospital, Makassar (I.D.), and Saiful Anwar Hospital, Malang (J.J.R.S.) - all in Indonesia; De La Salle Medical and Health Sciences Institute, Cavite (V.B.D.), the Lung Centre of the Philippines, Quezon City (V.M.B.), and the Tropical Disease Foundation, Makati (R.S.V.) - all in the Philippines; the Infectious Diseases Institute, Makerere University, Kampala, Uganda (C.S.-W.); HIV-NAT, Thai Red Cross AIDS Research Center and Center of Excellence in Tuberculosis, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand (A.A.); the National Institute of TB and Respiratory Diseases, New Delhi, India (R.S.); and the London School of Hygiene and Tropical Medicine (N.I.P.) and the Medical Research Council Clinical Trials Unit at University College London (N.I.P., A.J.N., A.M.C.) - both in London
| | - Erlina Burhan
- From the Infectious Diseases Translational Research Programme and Yong Loo Lin School of Medicine, National University of Singapore (N.I.P., C.C., C.S., P.P.), National University Hospital (K.L.C.), and Singapore Clinical Research Institute (Q.L., S.L.L., Y.P.) - all in Singapore; the Faculty of Medicine, Universitas Indonesia, and Persahabatan General Hospital, Jakarta (E.B.), Dr. Soetomo Hospital, Surabaya (T.K.), Universitas Padjadjaran, Bandung (R.R.), Dr. Wahidin Sudirohusodo Hospital, Makassar (I.D.), and Saiful Anwar Hospital, Malang (J.J.R.S.) - all in Indonesia; De La Salle Medical and Health Sciences Institute, Cavite (V.B.D.), the Lung Centre of the Philippines, Quezon City (V.M.B.), and the Tropical Disease Foundation, Makati (R.S.V.) - all in the Philippines; the Infectious Diseases Institute, Makerere University, Kampala, Uganda (C.S.-W.); HIV-NAT, Thai Red Cross AIDS Research Center and Center of Excellence in Tuberculosis, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand (A.A.); the National Institute of TB and Respiratory Diseases, New Delhi, India (R.S.); and the London School of Hygiene and Tropical Medicine (N.I.P.) and the Medical Research Council Clinical Trials Unit at University College London (N.I.P., A.J.N., A.M.C.) - both in London
| | - Ka Lip Chew
- From the Infectious Diseases Translational Research Programme and Yong Loo Lin School of Medicine, National University of Singapore (N.I.P., C.C., C.S., P.P.), National University Hospital (K.L.C.), and Singapore Clinical Research Institute (Q.L., S.L.L., Y.P.) - all in Singapore; the Faculty of Medicine, Universitas Indonesia, and Persahabatan General Hospital, Jakarta (E.B.), Dr. Soetomo Hospital, Surabaya (T.K.), Universitas Padjadjaran, Bandung (R.R.), Dr. Wahidin Sudirohusodo Hospital, Makassar (I.D.), and Saiful Anwar Hospital, Malang (J.J.R.S.) - all in Indonesia; De La Salle Medical and Health Sciences Institute, Cavite (V.B.D.), the Lung Centre of the Philippines, Quezon City (V.M.B.), and the Tropical Disease Foundation, Makati (R.S.V.) - all in the Philippines; the Infectious Diseases Institute, Makerere University, Kampala, Uganda (C.S.-W.); HIV-NAT, Thai Red Cross AIDS Research Center and Center of Excellence in Tuberculosis, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand (A.A.); the National Institute of TB and Respiratory Diseases, New Delhi, India (R.S.); and the London School of Hygiene and Tropical Medicine (N.I.P.) and the Medical Research Council Clinical Trials Unit at University College London (N.I.P., A.J.N., A.M.C.) - both in London
| | - Victoria B Dalay
- From the Infectious Diseases Translational Research Programme and Yong Loo Lin School of Medicine, National University of Singapore (N.I.P., C.C., C.S., P.P.), National University Hospital (K.L.C.), and Singapore Clinical Research Institute (Q.L., S.L.L., Y.P.) - all in Singapore; the Faculty of Medicine, Universitas Indonesia, and Persahabatan General Hospital, Jakarta (E.B.), Dr. Soetomo Hospital, Surabaya (T.K.), Universitas Padjadjaran, Bandung (R.R.), Dr. Wahidin Sudirohusodo Hospital, Makassar (I.D.), and Saiful Anwar Hospital, Malang (J.J.R.S.) - all in Indonesia; De La Salle Medical and Health Sciences Institute, Cavite (V.B.D.), the Lung Centre of the Philippines, Quezon City (V.M.B.), and the Tropical Disease Foundation, Makati (R.S.V.) - all in the Philippines; the Infectious Diseases Institute, Makerere University, Kampala, Uganda (C.S.-W.); HIV-NAT, Thai Red Cross AIDS Research Center and Center of Excellence in Tuberculosis, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand (A.A.); the National Institute of TB and Respiratory Diseases, New Delhi, India (R.S.); and the London School of Hygiene and Tropical Medicine (N.I.P.) and the Medical Research Council Clinical Trials Unit at University College London (N.I.P., A.J.N., A.M.C.) - both in London
| | - Qingshu Lu
- From the Infectious Diseases Translational Research Programme and Yong Loo Lin School of Medicine, National University of Singapore (N.I.P., C.C., C.S., P.P.), National University Hospital (K.L.C.), and Singapore Clinical Research Institute (Q.L., S.L.L., Y.P.) - all in Singapore; the Faculty of Medicine, Universitas Indonesia, and Persahabatan General Hospital, Jakarta (E.B.), Dr. Soetomo Hospital, Surabaya (T.K.), Universitas Padjadjaran, Bandung (R.R.), Dr. Wahidin Sudirohusodo Hospital, Makassar (I.D.), and Saiful Anwar Hospital, Malang (J.J.R.S.) - all in Indonesia; De La Salle Medical and Health Sciences Institute, Cavite (V.B.D.), the Lung Centre of the Philippines, Quezon City (V.M.B.), and the Tropical Disease Foundation, Makati (R.S.V.) - all in the Philippines; the Infectious Diseases Institute, Makerere University, Kampala, Uganda (C.S.-W.); HIV-NAT, Thai Red Cross AIDS Research Center and Center of Excellence in Tuberculosis, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand (A.A.); the National Institute of TB and Respiratory Diseases, New Delhi, India (R.S.); and the London School of Hygiene and Tropical Medicine (N.I.P.) and the Medical Research Council Clinical Trials Unit at University College London (N.I.P., A.J.N., A.M.C.) - both in London
| | - Tutik Kusmiati
- From the Infectious Diseases Translational Research Programme and Yong Loo Lin School of Medicine, National University of Singapore (N.I.P., C.C., C.S., P.P.), National University Hospital (K.L.C.), and Singapore Clinical Research Institute (Q.L., S.L.L., Y.P.) - all in Singapore; the Faculty of Medicine, Universitas Indonesia, and Persahabatan General Hospital, Jakarta (E.B.), Dr. Soetomo Hospital, Surabaya (T.K.), Universitas Padjadjaran, Bandung (R.R.), Dr. Wahidin Sudirohusodo Hospital, Makassar (I.D.), and Saiful Anwar Hospital, Malang (J.J.R.S.) - all in Indonesia; De La Salle Medical and Health Sciences Institute, Cavite (V.B.D.), the Lung Centre of the Philippines, Quezon City (V.M.B.), and the Tropical Disease Foundation, Makati (R.S.V.) - all in the Philippines; the Infectious Diseases Institute, Makerere University, Kampala, Uganda (C.S.-W.); HIV-NAT, Thai Red Cross AIDS Research Center and Center of Excellence in Tuberculosis, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand (A.A.); the National Institute of TB and Respiratory Diseases, New Delhi, India (R.S.); and the London School of Hygiene and Tropical Medicine (N.I.P.) and the Medical Research Council Clinical Trials Unit at University College London (N.I.P., A.J.N., A.M.C.) - both in London
| | - Vincent M Balanag
- From the Infectious Diseases Translational Research Programme and Yong Loo Lin School of Medicine, National University of Singapore (N.I.P., C.C., C.S., P.P.), National University Hospital (K.L.C.), and Singapore Clinical Research Institute (Q.L., S.L.L., Y.P.) - all in Singapore; the Faculty of Medicine, Universitas Indonesia, and Persahabatan General Hospital, Jakarta (E.B.), Dr. Soetomo Hospital, Surabaya (T.K.), Universitas Padjadjaran, Bandung (R.R.), Dr. Wahidin Sudirohusodo Hospital, Makassar (I.D.), and Saiful Anwar Hospital, Malang (J.J.R.S.) - all in Indonesia; De La Salle Medical and Health Sciences Institute, Cavite (V.B.D.), the Lung Centre of the Philippines, Quezon City (V.M.B.), and the Tropical Disease Foundation, Makati (R.S.V.) - all in the Philippines; the Infectious Diseases Institute, Makerere University, Kampala, Uganda (C.S.-W.); HIV-NAT, Thai Red Cross AIDS Research Center and Center of Excellence in Tuberculosis, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand (A.A.); the National Institute of TB and Respiratory Diseases, New Delhi, India (R.S.); and the London School of Hygiene and Tropical Medicine (N.I.P.) and the Medical Research Council Clinical Trials Unit at University College London (N.I.P., A.J.N., A.M.C.) - both in London
| | - Shu Ling Lee
- From the Infectious Diseases Translational Research Programme and Yong Loo Lin School of Medicine, National University of Singapore (N.I.P., C.C., C.S., P.P.), National University Hospital (K.L.C.), and Singapore Clinical Research Institute (Q.L., S.L.L., Y.P.) - all in Singapore; the Faculty of Medicine, Universitas Indonesia, and Persahabatan General Hospital, Jakarta (E.B.), Dr. Soetomo Hospital, Surabaya (T.K.), Universitas Padjadjaran, Bandung (R.R.), Dr. Wahidin Sudirohusodo Hospital, Makassar (I.D.), and Saiful Anwar Hospital, Malang (J.J.R.S.) - all in Indonesia; De La Salle Medical and Health Sciences Institute, Cavite (V.B.D.), the Lung Centre of the Philippines, Quezon City (V.M.B.), and the Tropical Disease Foundation, Makati (R.S.V.) - all in the Philippines; the Infectious Diseases Institute, Makerere University, Kampala, Uganda (C.S.-W.); HIV-NAT, Thai Red Cross AIDS Research Center and Center of Excellence in Tuberculosis, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand (A.A.); the National Institute of TB and Respiratory Diseases, New Delhi, India (R.S.); and the London School of Hygiene and Tropical Medicine (N.I.P.) and the Medical Research Council Clinical Trials Unit at University College London (N.I.P., A.J.N., A.M.C.) - both in London
| | - Rovina Ruslami
- From the Infectious Diseases Translational Research Programme and Yong Loo Lin School of Medicine, National University of Singapore (N.I.P., C.C., C.S., P.P.), National University Hospital (K.L.C.), and Singapore Clinical Research Institute (Q.L., S.L.L., Y.P.) - all in Singapore; the Faculty of Medicine, Universitas Indonesia, and Persahabatan General Hospital, Jakarta (E.B.), Dr. Soetomo Hospital, Surabaya (T.K.), Universitas Padjadjaran, Bandung (R.R.), Dr. Wahidin Sudirohusodo Hospital, Makassar (I.D.), and Saiful Anwar Hospital, Malang (J.J.R.S.) - all in Indonesia; De La Salle Medical and Health Sciences Institute, Cavite (V.B.D.), the Lung Centre of the Philippines, Quezon City (V.M.B.), and the Tropical Disease Foundation, Makati (R.S.V.) - all in the Philippines; the Infectious Diseases Institute, Makerere University, Kampala, Uganda (C.S.-W.); HIV-NAT, Thai Red Cross AIDS Research Center and Center of Excellence in Tuberculosis, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand (A.A.); the National Institute of TB and Respiratory Diseases, New Delhi, India (R.S.); and the London School of Hygiene and Tropical Medicine (N.I.P.) and the Medical Research Council Clinical Trials Unit at University College London (N.I.P., A.J.N., A.M.C.) - both in London
| | - Yogesh Pokharkar
- From the Infectious Diseases Translational Research Programme and Yong Loo Lin School of Medicine, National University of Singapore (N.I.P., C.C., C.S., P.P.), National University Hospital (K.L.C.), and Singapore Clinical Research Institute (Q.L., S.L.L., Y.P.) - all in Singapore; the Faculty of Medicine, Universitas Indonesia, and Persahabatan General Hospital, Jakarta (E.B.), Dr. Soetomo Hospital, Surabaya (T.K.), Universitas Padjadjaran, Bandung (R.R.), Dr. Wahidin Sudirohusodo Hospital, Makassar (I.D.), and Saiful Anwar Hospital, Malang (J.J.R.S.) - all in Indonesia; De La Salle Medical and Health Sciences Institute, Cavite (V.B.D.), the Lung Centre of the Philippines, Quezon City (V.M.B.), and the Tropical Disease Foundation, Makati (R.S.V.) - all in the Philippines; the Infectious Diseases Institute, Makerere University, Kampala, Uganda (C.S.-W.); HIV-NAT, Thai Red Cross AIDS Research Center and Center of Excellence in Tuberculosis, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand (A.A.); the National Institute of TB and Respiratory Diseases, New Delhi, India (R.S.); and the London School of Hygiene and Tropical Medicine (N.I.P.) and the Medical Research Council Clinical Trials Unit at University College London (N.I.P., A.J.N., A.M.C.) - both in London
| | - Irawaty Djaharuddin
- From the Infectious Diseases Translational Research Programme and Yong Loo Lin School of Medicine, National University of Singapore (N.I.P., C.C., C.S., P.P.), National University Hospital (K.L.C.), and Singapore Clinical Research Institute (Q.L., S.L.L., Y.P.) - all in Singapore; the Faculty of Medicine, Universitas Indonesia, and Persahabatan General Hospital, Jakarta (E.B.), Dr. Soetomo Hospital, Surabaya (T.K.), Universitas Padjadjaran, Bandung (R.R.), Dr. Wahidin Sudirohusodo Hospital, Makassar (I.D.), and Saiful Anwar Hospital, Malang (J.J.R.S.) - all in Indonesia; De La Salle Medical and Health Sciences Institute, Cavite (V.B.D.), the Lung Centre of the Philippines, Quezon City (V.M.B.), and the Tropical Disease Foundation, Makati (R.S.V.) - all in the Philippines; the Infectious Diseases Institute, Makerere University, Kampala, Uganda (C.S.-W.); HIV-NAT, Thai Red Cross AIDS Research Center and Center of Excellence in Tuberculosis, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand (A.A.); the National Institute of TB and Respiratory Diseases, New Delhi, India (R.S.); and the London School of Hygiene and Tropical Medicine (N.I.P.) and the Medical Research Council Clinical Trials Unit at University College London (N.I.P., A.J.N., A.M.C.) - both in London
| | - Jani J R Sugiri
- From the Infectious Diseases Translational Research Programme and Yong Loo Lin School of Medicine, National University of Singapore (N.I.P., C.C., C.S., P.P.), National University Hospital (K.L.C.), and Singapore Clinical Research Institute (Q.L., S.L.L., Y.P.) - all in Singapore; the Faculty of Medicine, Universitas Indonesia, and Persahabatan General Hospital, Jakarta (E.B.), Dr. Soetomo Hospital, Surabaya (T.K.), Universitas Padjadjaran, Bandung (R.R.), Dr. Wahidin Sudirohusodo Hospital, Makassar (I.D.), and Saiful Anwar Hospital, Malang (J.J.R.S.) - all in Indonesia; De La Salle Medical and Health Sciences Institute, Cavite (V.B.D.), the Lung Centre of the Philippines, Quezon City (V.M.B.), and the Tropical Disease Foundation, Makati (R.S.V.) - all in the Philippines; the Infectious Diseases Institute, Makerere University, Kampala, Uganda (C.S.-W.); HIV-NAT, Thai Red Cross AIDS Research Center and Center of Excellence in Tuberculosis, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand (A.A.); the National Institute of TB and Respiratory Diseases, New Delhi, India (R.S.); and the London School of Hygiene and Tropical Medicine (N.I.P.) and the Medical Research Council Clinical Trials Unit at University College London (N.I.P., A.J.N., A.M.C.) - both in London
| | - Rholine S Veto
- From the Infectious Diseases Translational Research Programme and Yong Loo Lin School of Medicine, National University of Singapore (N.I.P., C.C., C.S., P.P.), National University Hospital (K.L.C.), and Singapore Clinical Research Institute (Q.L., S.L.L., Y.P.) - all in Singapore; the Faculty of Medicine, Universitas Indonesia, and Persahabatan General Hospital, Jakarta (E.B.), Dr. Soetomo Hospital, Surabaya (T.K.), Universitas Padjadjaran, Bandung (R.R.), Dr. Wahidin Sudirohusodo Hospital, Makassar (I.D.), and Saiful Anwar Hospital, Malang (J.J.R.S.) - all in Indonesia; De La Salle Medical and Health Sciences Institute, Cavite (V.B.D.), the Lung Centre of the Philippines, Quezon City (V.M.B.), and the Tropical Disease Foundation, Makati (R.S.V.) - all in the Philippines; the Infectious Diseases Institute, Makerere University, Kampala, Uganda (C.S.-W.); HIV-NAT, Thai Red Cross AIDS Research Center and Center of Excellence in Tuberculosis, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand (A.A.); the National Institute of TB and Respiratory Diseases, New Delhi, India (R.S.); and the London School of Hygiene and Tropical Medicine (N.I.P.) and the Medical Research Council Clinical Trials Unit at University College London (N.I.P., A.J.N., A.M.C.) - both in London
| | - Christine Sekaggya-Wiltshire
- From the Infectious Diseases Translational Research Programme and Yong Loo Lin School of Medicine, National University of Singapore (N.I.P., C.C., C.S., P.P.), National University Hospital (K.L.C.), and Singapore Clinical Research Institute (Q.L., S.L.L., Y.P.) - all in Singapore; the Faculty of Medicine, Universitas Indonesia, and Persahabatan General Hospital, Jakarta (E.B.), Dr. Soetomo Hospital, Surabaya (T.K.), Universitas Padjadjaran, Bandung (R.R.), Dr. Wahidin Sudirohusodo Hospital, Makassar (I.D.), and Saiful Anwar Hospital, Malang (J.J.R.S.) - all in Indonesia; De La Salle Medical and Health Sciences Institute, Cavite (V.B.D.), the Lung Centre of the Philippines, Quezon City (V.M.B.), and the Tropical Disease Foundation, Makati (R.S.V.) - all in the Philippines; the Infectious Diseases Institute, Makerere University, Kampala, Uganda (C.S.-W.); HIV-NAT, Thai Red Cross AIDS Research Center and Center of Excellence in Tuberculosis, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand (A.A.); the National Institute of TB and Respiratory Diseases, New Delhi, India (R.S.); and the London School of Hygiene and Tropical Medicine (N.I.P.) and the Medical Research Council Clinical Trials Unit at University College London (N.I.P., A.J.N., A.M.C.) - both in London
| | - Anchalee Avihingsanon
- From the Infectious Diseases Translational Research Programme and Yong Loo Lin School of Medicine, National University of Singapore (N.I.P., C.C., C.S., P.P.), National University Hospital (K.L.C.), and Singapore Clinical Research Institute (Q.L., S.L.L., Y.P.) - all in Singapore; the Faculty of Medicine, Universitas Indonesia, and Persahabatan General Hospital, Jakarta (E.B.), Dr. Soetomo Hospital, Surabaya (T.K.), Universitas Padjadjaran, Bandung (R.R.), Dr. Wahidin Sudirohusodo Hospital, Makassar (I.D.), and Saiful Anwar Hospital, Malang (J.J.R.S.) - all in Indonesia; De La Salle Medical and Health Sciences Institute, Cavite (V.B.D.), the Lung Centre of the Philippines, Quezon City (V.M.B.), and the Tropical Disease Foundation, Makati (R.S.V.) - all in the Philippines; the Infectious Diseases Institute, Makerere University, Kampala, Uganda (C.S.-W.); HIV-NAT, Thai Red Cross AIDS Research Center and Center of Excellence in Tuberculosis, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand (A.A.); the National Institute of TB and Respiratory Diseases, New Delhi, India (R.S.); and the London School of Hygiene and Tropical Medicine (N.I.P.) and the Medical Research Council Clinical Trials Unit at University College London (N.I.P., A.J.N., A.M.C.) - both in London
| | - Rohit Sarin
- From the Infectious Diseases Translational Research Programme and Yong Loo Lin School of Medicine, National University of Singapore (N.I.P., C.C., C.S., P.P.), National University Hospital (K.L.C.), and Singapore Clinical Research Institute (Q.L., S.L.L., Y.P.) - all in Singapore; the Faculty of Medicine, Universitas Indonesia, and Persahabatan General Hospital, Jakarta (E.B.), Dr. Soetomo Hospital, Surabaya (T.K.), Universitas Padjadjaran, Bandung (R.R.), Dr. Wahidin Sudirohusodo Hospital, Makassar (I.D.), and Saiful Anwar Hospital, Malang (J.J.R.S.) - all in Indonesia; De La Salle Medical and Health Sciences Institute, Cavite (V.B.D.), the Lung Centre of the Philippines, Quezon City (V.M.B.), and the Tropical Disease Foundation, Makati (R.S.V.) - all in the Philippines; the Infectious Diseases Institute, Makerere University, Kampala, Uganda (C.S.-W.); HIV-NAT, Thai Red Cross AIDS Research Center and Center of Excellence in Tuberculosis, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand (A.A.); the National Institute of TB and Respiratory Diseases, New Delhi, India (R.S.); and the London School of Hygiene and Tropical Medicine (N.I.P.) and the Medical Research Council Clinical Trials Unit at University College London (N.I.P., A.J.N., A.M.C.) - both in London
| | - Padmasayee Papineni
- From the Infectious Diseases Translational Research Programme and Yong Loo Lin School of Medicine, National University of Singapore (N.I.P., C.C., C.S., P.P.), National University Hospital (K.L.C.), and Singapore Clinical Research Institute (Q.L., S.L.L., Y.P.) - all in Singapore; the Faculty of Medicine, Universitas Indonesia, and Persahabatan General Hospital, Jakarta (E.B.), Dr. Soetomo Hospital, Surabaya (T.K.), Universitas Padjadjaran, Bandung (R.R.), Dr. Wahidin Sudirohusodo Hospital, Makassar (I.D.), and Saiful Anwar Hospital, Malang (J.J.R.S.) - all in Indonesia; De La Salle Medical and Health Sciences Institute, Cavite (V.B.D.), the Lung Centre of the Philippines, Quezon City (V.M.B.), and the Tropical Disease Foundation, Makati (R.S.V.) - all in the Philippines; the Infectious Diseases Institute, Makerere University, Kampala, Uganda (C.S.-W.); HIV-NAT, Thai Red Cross AIDS Research Center and Center of Excellence in Tuberculosis, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand (A.A.); the National Institute of TB and Respiratory Diseases, New Delhi, India (R.S.); and the London School of Hygiene and Tropical Medicine (N.I.P.) and the Medical Research Council Clinical Trials Unit at University College London (N.I.P., A.J.N., A.M.C.) - both in London
| | - Andrew J Nunn
- From the Infectious Diseases Translational Research Programme and Yong Loo Lin School of Medicine, National University of Singapore (N.I.P., C.C., C.S., P.P.), National University Hospital (K.L.C.), and Singapore Clinical Research Institute (Q.L., S.L.L., Y.P.) - all in Singapore; the Faculty of Medicine, Universitas Indonesia, and Persahabatan General Hospital, Jakarta (E.B.), Dr. Soetomo Hospital, Surabaya (T.K.), Universitas Padjadjaran, Bandung (R.R.), Dr. Wahidin Sudirohusodo Hospital, Makassar (I.D.), and Saiful Anwar Hospital, Malang (J.J.R.S.) - all in Indonesia; De La Salle Medical and Health Sciences Institute, Cavite (V.B.D.), the Lung Centre of the Philippines, Quezon City (V.M.B.), and the Tropical Disease Foundation, Makati (R.S.V.) - all in the Philippines; the Infectious Diseases Institute, Makerere University, Kampala, Uganda (C.S.-W.); HIV-NAT, Thai Red Cross AIDS Research Center and Center of Excellence in Tuberculosis, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand (A.A.); the National Institute of TB and Respiratory Diseases, New Delhi, India (R.S.); and the London School of Hygiene and Tropical Medicine (N.I.P.) and the Medical Research Council Clinical Trials Unit at University College London (N.I.P., A.J.N., A.M.C.) - both in London
| | - Angela M Crook
- From the Infectious Diseases Translational Research Programme and Yong Loo Lin School of Medicine, National University of Singapore (N.I.P., C.C., C.S., P.P.), National University Hospital (K.L.C.), and Singapore Clinical Research Institute (Q.L., S.L.L., Y.P.) - all in Singapore; the Faculty of Medicine, Universitas Indonesia, and Persahabatan General Hospital, Jakarta (E.B.), Dr. Soetomo Hospital, Surabaya (T.K.), Universitas Padjadjaran, Bandung (R.R.), Dr. Wahidin Sudirohusodo Hospital, Makassar (I.D.), and Saiful Anwar Hospital, Malang (J.J.R.S.) - all in Indonesia; De La Salle Medical and Health Sciences Institute, Cavite (V.B.D.), the Lung Centre of the Philippines, Quezon City (V.M.B.), and the Tropical Disease Foundation, Makati (R.S.V.) - all in the Philippines; the Infectious Diseases Institute, Makerere University, Kampala, Uganda (C.S.-W.); HIV-NAT, Thai Red Cross AIDS Research Center and Center of Excellence in Tuberculosis, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand (A.A.); the National Institute of TB and Respiratory Diseases, New Delhi, India (R.S.); and the London School of Hygiene and Tropical Medicine (N.I.P.) and the Medical Research Council Clinical Trials Unit at University College London (N.I.P., A.J.N., A.M.C.) - both in London
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Saluzzo F, Maria Cirillo D. Mind the gap. Rolling out new Drug Resistant Tuberculosis regimens with limited diagnostic tools. J Clin Tuberc Other Mycobact Dis 2023. [DOI: 10.1016/j.jctube.2023.100350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
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Souleymane MB, Decroo T, Soumana A, Maman Lawan I, Gagara-Issoufou A, Halidou-Moussa S, Ortuño-Gutiérrez N, Adehossi E, Mamadou S, Van Deun A, Piubello A. Safety, effectiveness, and adherence of a short and all-oral treatment regimen for the treatment of rifampicin-resistant tuberculosis in Niger: a study protocol of a pragmatic randomised clinical trial with stratified block randomisation. Trials 2022; 23:1011. [PMID: 36514153 PMCID: PMC9746149 DOI: 10.1186/s13063-022-06912-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 11/10/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Rifampicin-resistant tuberculosis (RR-TB) treatment requires combination treatment, which frequently causes serious adverse events and globally results in not much more than 60% treatment success. In Niger, a high cure rate was obtained with a RR-TB treatment strategy based on a second-line injectable drug (SLID)-containing Short Treatment Regimen (STR), with linezolid replacing the SLID in patients with ototoxicity. Given the availability of novel anti-tuberculosis drugs, WHO recommends all-oral RR-TB treatment. Considering the high level of success with the Niger treatment strategy, it would only be justified to replace it in case robust evidence shows that the WHO all-oral bedaquiline/linezolid (BDQ/LZD)-containing STR (experimental arm) performs better than the Niger RR-TB treatment strategy, (control arm) in terms of safety, effectiveness and adherence. METHODS A pragmatic randomised clinical trial (RCT) using stratified block randomisation, conducted between April 2021 and March 2024, prospectively enrols participants diagnosed with RR-TB in one of the four RR-TB units of the nation. Depending of the month in which patients are diagnosed with RR-TB, patients with FQ-susceptible RR-TB are enrolled in either the experimental arm or control arm. DISCUSSION To increase the feasibility of conducting a RCT, embedded in routine activities of all Niger's RR-TB Units, we used a creative trial design. We randomised by monthly blocks, whereby the regimen used changes every month, using the month of RR-TB diagnosis as stratifying variable. This approach was deemed feasible for Niger's national tuberculosis programme, as it simplifies the work of the clinicians running the RR-TB units. Our creative design may serve as an example for other national programs. Findings will inform national and international RR-TB treatment guidelines, and will also strengthen the evidence-base on how to develop robust RR-TB treatment regimens. TRIAL REGISTRATION Pan African Clinical Trial Register PACTR202203645724919 . Registered on 15 March 2022.
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Affiliation(s)
| | - Tom Decroo
- grid.11505.300000 0001 2153 5088Institute of Tropical Medicine, Antwerp, Belgium ,grid.434261.60000 0000 8597 7208Research Foundation Flanders, Brussels, Belgium
| | - Alphazazi Soumana
- Programme National de Lutte contre la Tuberculose, Programme, Niamey, Niger
| | | | - Assiatou Gagara-Issoufou
- grid.10733.360000 0001 1457 1638Université Abdou Moumouni de Niamey, Faculté des Science de la Santé, Niamey, Niger
| | - Souleymane Halidou-Moussa
- grid.414237.70000 0004 0635 4264Hopital National Amirou Boubacar Diallo, Pneumo-phtysiologie, Niamey, Niger
| | | | - Eric Adehossi
- grid.10733.360000 0001 1457 1638Université Abdou Moumouni de Niamey, Faculté des Science de la Santé, Niamey, Niger
| | - Saïdou Mamadou
- grid.10733.360000 0001 1457 1638Université Abdou Moumouni de Niamey, Faculté des Science de la Santé, Niamey, Niger
| | | | - Alberto Piubello
- Damien Foundation, Niamey, Niger ,Damien Foundation, Brussels, Belgium
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Tu PHT, Anlay DZ, Dippenaar A, Conceição EC, Loos J, Van Rie A. Bedaquiline resistance probability to guide treatment decision making for rifampicin-resistant tuberculosis: insights from a qualitative study. BMC Infect Dis 2022; 22:876. [PMID: 36418994 PMCID: PMC9682818 DOI: 10.1186/s12879-022-07865-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 11/10/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Bedaquiline (BDQ) is a core drug for rifampicin-resistant tuberculosis (RR-TB) treatment. Accurate prediction of a BDQ-resistant phenotype from genomic data is not yet possible. A Bayesian method to predict BDQ resistance probability from next-generation sequencing data has been proposed as an alternative. METHODS We performed a qualitative study to investigate the decision-making of physicians when facing different levels of BDQ resistance probability. Fourteen semi-structured interviews were conducted with physicians experienced in treating RR-TB, sampled purposefully from eight countries with varying income levels and burden of RR-TB. Five simulated patient scenarios were used as a trigger for discussion. Factors influencing the decision of physicians to prescribe BDQ at macro-, meso- and micro levels were explored using thematic analysis. RESULTS The perception and interpretation of BDQ resistance probability values varied widely between physicians. The limited availability of other RR-TB drugs and the high cost of BDQ hindered physicians from altering the BDQ-containing regimen and incorporating BDQ resistance probability in their decision-making. The little experience with BDQ susceptibility testing and whole-genome sequencing results, and the discordance between phenotypic susceptibility and resistance probability were other barriers for physicians to interpret the resistance probability estimates. Especially for BDQ resistance probabilities between 25% and 70%, physicians interpreted the resistance probability value dynamically, and other factors such as clinical and bacteriological treatment response, history of exposure to BDQ, and resistance profile were often considered more important than the BDQ probability value for the decision to continue or stop BDQ. In this grey zone, some physicians opted to continue BDQ but added other drugs to strengthen the regimen. CONCLUSIONS This study highlights the complexity of physicians' decision-making regarding the use of BDQ in RR-TB regimens for different levels of BDQ resistance probability.. Ensuring sufficient access to BDQ and companion drugs, improving knowledge of the genotype-phenotype association for BDQ resistance, availability of a rapid molecular test, building next-generation sequencing capacity, and developing a clinical decision support system incorporating BDQ resistance probability will all be essential to facilitate the implementation of BDQ resistance probability in personalizing treatment for patients with RR-TB.
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Affiliation(s)
- Pham Hien Trang Tu
- Department of Family Medicine and Population Health, Faculty of Medicine and Health Sciences, University of Antwerp, Doornstraat 331, 2610, Antwerp, Belgium.
| | - Degefaye Zelalem Anlay
- Department of Family Medicine and Population Health, Faculty of Medicine and Health Sciences, University of Antwerp, Doornstraat 331, 2610, Antwerp, Belgium
- Department of Community Health Nursing, School of Nursing, College of Medicine and Health Science, University of Gondar, Gondar, Ethiopia
| | - Anzaan Dippenaar
- Department of Family Medicine and Population Health, Faculty of Medicine and Health Sciences, University of Antwerp, Doornstraat 331, 2610, Antwerp, Belgium
| | - Emilyn Costa Conceição
- Department of Science and Innovation, National Research Foundation Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Jasna Loos
- Dean's Office, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Annelies Van Rie
- Department of Family Medicine and Population Health, Faculty of Medicine and Health Sciences, University of Antwerp, Doornstraat 331, 2610, Antwerp, Belgium
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Pai H, Ndjeka N, Mbuagbaw L, Kaniga K, Birmingham E, Mao G, Alquier L, Davis K, Bodard A, Williams A, Van Tongel M, Thoret-Bauchet F, Omar SV, Bakare N. Bedaquiline safety, efficacy, utilization and emergence of resistance following treatment of multidrug-resistant tuberculosis patients in South Africa: a retrospective cohort analysis. BMC Infect Dis 2022; 22:870. [DOI: 10.1186/s12879-022-07861-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 11/09/2022] [Indexed: 11/23/2022] Open
Abstract
Abstract
Background
This retrospective cohort study assessed benefits and risks of bedaquiline treatment in multidrug-resistant-tuberculosis (MDR-TB) combination therapy by evaluating safety, effectiveness, drug utilization and emergence of resistance to bedaquiline.
Methods
Data were extracted from a register of South African drug-resistant-tuberculosis (DR-TB) patients (Electronic DR-TB Register [EDRWeb]) for newly diagnosed patients with MDR-TB (including pre-extensively drug-resistant [XDR]-TB and XDR-TB and excluding rifampicin-mono-resistant [RR]-TB, as these patients are by definition not multidrug-resistant), receiving either a bedaquiline-containing or non-bedaquiline-containing regimen, at 14 sites in South Africa. Total duration of treatment and follow-up was up to 30 months, including 6 months’ bedaquiline treatment. WHO treatment outcomes within 6 months after end-of-treatment were assessed in both patient groups. Longer term mortality (up to 30 months from treatment start) was evaluated through matching to the South African National Vital Statistics Register. Multivariable Cox proportional hazards analyses were used to predict association between receiving a bedaquiline-containing regimen and treatment outcome.
Results
Data were extracted from EDRWeb for 5981 MDR-TB patients (N = 3747 bedaquiline-treated; N = 2234 non-bedaquiline-treated) who initiated treatment between 2015 and 2017, of whom 40.7% versus 80.6% had MDR-TB. More bedaquiline-treated than non-bedaquiline-treated patients had pre-XDR-TB (27.7% versus 9.5%) and XDR-TB (31.5% versus 9.9%) per pre-2021 WHO definitions. Most patients with treatment duration data (94.3%) received bedaquiline for 6 months. Treatment success (per pre-2021 WHO definitions) was achieved in 66.9% of bedaquiline-treated and 49.4% of non-bedaquiline-treated patients. Death was reported in fewer bedaquiline-treated (15.4%) than non-bedaquiline-treated (25.6%) patients. Bedaquiline-treated patients had increased likelihood of treatment success and decreased risk of mortality versus non-bedaquiline-treated patients. In patients with evaluable drug susceptibility testing data, 3.5% of bedaquiline-susceptible isolates at baseline acquired phenotypic resistance. Few patients reported bedaquiline-related treatment-emergent adverse events (TEAEs) (1.8%), TEAE-related bedaquiline discontinuations (1.4%) and QTcF values > 500 ms (2.5%) during treatment.
Conclusion
Data from this large cohort of South African patients with MDR-TB showed treatment with bedaquiline-containing regimens was associated with survival and effectiveness benefit compared with non-bedaquiline-containing regimens. No new safety signals were detected. These data are consistent with the positive risk–benefit profile of bedaquiline and warrant continued implementation in combination therapy for MDR-TB treatment.
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Mok J, Lee M, Kim DK, Kim JS, Jhun BW, Jo KW, Jeon D, Lee T, Lee JY, Park JS, Lee SH, Kang YA, Lee JK, Kwak N, Ahn JH, Shim TS, Kim SY, Kim S, Kim K, Seok KH, Yoon S, Kim YR, Kim J, Yim D, Hahn S, Cho SN, Yim JJ. 9 months of delamanid, linezolid, levofloxacin, and pyrazinamide versus conventional therapy for treatment of fluoroquinolone-sensitive multidrug-resistant tuberculosis (MDR-END): a multicentre, randomised, open-label phase 2/3 non-inferiority trial in South Korea. Lancet 2022; 400:1522-1530. [PMID: 36522208 DOI: 10.1016/s0140-6736(22)01883-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 08/22/2022] [Accepted: 09/21/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND With the introduction of new anti-tuberculosis drugs, all-oral regimens with shorter treatment durations for multidrug-resistant tuberculosis have been anticipated. We aimed to investigate whether a new all-oral regimen was non-inferior to the conventional regimen including second-line anti-tuberculosis drugs for 20-24 months in the treatment of fluoroquinolone-sensitive multidrug-resistant tuberculosis. METHODS In this multicentre, randomised, open-label phase 2/3 non-inferiority trial, we enrolled men and women aged 19-85 years with multidrug-resistant tuberculosis confirmed by phenotypic or genotypic drug susceptibility tests or rifampicin-resistant tuberculosis by genotypic tests at 12 participating hospitals throughout South Korea. Participants with fluoroquinolone-resistant multidrug-resistant tuberculosis were excluded. Participants were randomly assigned (1:1) to two groups using a block randomisation, stratified by the presence of diabetes and cavitation on baseline chest radiographs. The investigational group received delamanid, linezolid, levofloxacin, and pyrazinamide for 9 months, and the control group received a conventional 20-24-month regimen, according to the 2014 WHO guidelines. The primary outcome was the treatment success rate at 24 months after treatment initiation in the modified intention-to-treat population and the per-protocol population. Participants who were "cured" and "treatment completed" were defined as treatment success following the 2014 WHO guidelines. Non-inferiority was confirmed if the lower limit of a 97·5% one-sided CI of the difference between the groups was greater than -10%. Safety data were collected for 24 months in participants who received a predefined regimen at least once. This study is registered with ClinicalTrials.gov, NCT02619994. FINDINGS Between March 4, 2016, and Sept 14, 2019, 214 participants were enrolled, 168 (78·5%) of whom were included in the modified intention-to-treat population. At 24 months after treatment initiation, 60 (70·6%) of 85 participants in the control group had treatment success, as did 54 (75·0%) of 72 participants in the shorter-regimen group (between-group difference 4·4% [97·5% one-sided CI -9·5% to ∞]), satisfying the predefined non-inferiority margin. No difference in safety outcomes was identified between the control group and the shorter-regimen group. INTERPRETATION 9-month treatment with oral delamanid, linezolid, levofloxacin, and pyrazinamide could represent a new treatment option for participants with fluoroquinolone-sensitive multidrug-resistant tuberculosis. FUNDING Korea Disease Control and Prevention Agency, South Korea.
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Affiliation(s)
- Jeongha Mok
- Division of Pulmonology, Allergy and Critical Care Medicine, Department of Internal Medicine, Pusan National University Hospital, Busan, South Korea; Department of Internal Medicine, Pusan National University School of Medicine, Yangsan, South Korea
| | - Myungsun Lee
- Division of Clinical Research, International Tuberculosis Research Centre, Seoul, South Korea
| | - Deog Kyeom Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Centre, Seoul, South Korea; Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Ju Sang Kim
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Incheon St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Byung Woo Jhun
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Centre, Sungkyunkwan University School of Medicine, 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
| | - Doosoo Jeon
- Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, South Korea; Department of Internal Medicine, Pusan National University School of Medicine, Yangsan, South Korea
| | - Taehoon Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, South Korea
| | - Ji Yeon Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, National Medical Centre, Seoul, South Korea
| | - Jae Seuk Park
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Dankook University Hospital, Cheonan, South Korea
| | - Seung Heon Lee
- Department of Pulmonology, Korea University Ansan Hospital, Ansan, South Korea
| | - Young Ae Kang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Jung-Kyu Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Centre, Seoul, South Korea
| | - Nakwon Kwak
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Joong Hyun Ahn
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Incheon St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, 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
| | - Song Yee Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Seungmo Kim
- Department of Laboratory Medicine, The Korean Institute of Tuberculosis, Cheongju, South Korea
| | - Kyungjong Kim
- Department of R&D, The Korean Institute of Tuberculosis, Cheongju, South Korea; DNA Analysis Division, Seoul Institute, National Forensic Service, Seoul, South Korea
| | - Kwang-Hyuk Seok
- Department of Laboratory Medicine, The Korean Institute of Tuberculosis, Cheongju, South Korea
| | - Soyeong Yoon
- Division of Clinical Research, International Tuberculosis Research Centre, Seoul, South Korea
| | - Young Ran Kim
- Division of Clinical Research, International Tuberculosis Research Centre, Seoul, South Korea
| | - Jisu Kim
- Medical Research Collaborating Centre, Seoul National University Hospital, Seoul, South Korea
| | - Dahae Yim
- Medical Research Collaborating Centre, Seoul National University Hospital, Seoul, South Korea
| | - Seokyung Hahn
- Department of Human Systems Medicine, Seoul National University College of Medicine, Seoul, South Korea; Medical Research Collaborating Centre, Seoul National University Hospital, Seoul, South Korea
| | - Sang Nae Cho
- Division of Clinical Research, International Tuberculosis Research Centre, Seoul, South Korea
| | - Jae-Joon Yim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea; Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea.
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Whole-Genome Sequencing for Resistance Prediction and Transmission Analysis of Mycobacterium tuberculosis Complex Strains from Namibia. Microbiol Spectr 2022; 10:e0158622. [PMID: 36165641 PMCID: PMC9603870 DOI: 10.1128/spectrum.01586-22] [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: 12/31/2022] Open
Abstract
Namibia is among 30 countries with a high burden of tuberculosis (TB), with an estimated incidence of 460 per 100,000 population and around 800 new multidrug-resistant (MDR) TB cases per year. Still, data on the transmission and evolution of drug-resistant Mycobacterium tuberculosis complex (Mtbc) strains are not available. Whole-genome sequencing data of 136 rifampicin-resistant (RIFr) Mtbc strains obtained from 2016 to 2018 were used for phylogenetic classification, resistance prediction, and cluster analysis and linked with phenotypic drug susceptibility testing (pDST) data. Roughly 50% of the strains investigated were resistant to all first-line drugs. Furthermore, 13% of the MDR Mtbc strains were already pre-extensively drug resistant (pre-XDR). The cluster rates were high, at 74.6% among MDR and 85% among pre-XDR strains. A significant proportion of strains had borderline resistance-conferring mutations, e.g., inhA promoter mutations or rpoB L430P. Accordingly, 25% of the RIFr strains tested susceptible by pDST. Finally, we determined a potentially new bedaquiline resistance mutation (Rv0678 D88G) occurring in two independent clusters. High rates of resistance to first-line drugs in line with emerging pre-XDR and likely bedaquiline resistance linked with the ongoing recent transmission of MDR Mtbc clones underline the urgent need for the implementation of interventions that allow rapid diagnostics to break MDR TB transmission chains in the country. A borderline RIFr mutation in the dominant outbreak strain causing discrepancies between phenotypic and genotypic resistance testing results may require breakpoint adjustments but also may allow individualized regimens with high-dose treatment. IMPORTANCE The transmission of drug-resistant tuberculosis (TB) is a major problem for global TB control. Using genome sequencing, we showed that 13% of the multidrug-resistant (MDR) M. tuberculosis complex strains from Namibia are already pre-extensively drug resistant (pre-XDR), which is substantial in an African setting. Our data also indicate that the ongoing transmission of MDR and pre-XDR strains contributes significantly to the problem. In contrast to other settings with higher rates of drug resistance, we found a high proportion of strains having so-called borderline low-level resistance mutations, e.g., inhA promoter mutations or rpoB L430P. This led to the misclassification of 25% of the rifampicin-resistant strains as susceptible by phenotypic drug susceptibility testing. This observation potentially allows individualized regimens with high-dose treatment as a potential option for patients with few treatment options. We also found a potentially new bedaquiline resistance mutation in rv0678.
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Nimmo C, Millard J, Faulkner V, Monteserin J, Pugh H, Johnson EO. Evolution of Mycobacterium tuberculosis drug resistance in the genomic era. Front Cell Infect Microbiol 2022; 12:954074. [PMID: 36275027 PMCID: PMC9585206 DOI: 10.3389/fcimb.2022.954074] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 09/20/2022] [Indexed: 12/02/2022] Open
Abstract
Mycobacterium tuberculosis has acquired drug resistance to all drugs that have been used against it, including those only recently introduced into clinical practice. Compared to other bacteria, it has a well conserved genome due to its role as an obligate human pathogen that has adapted to a niche over five to ten thousand years. These features facilitate reconstruction and dating of M. tuberculosis phylogenies, giving key insights into how resistance has been acquired and spread globally. Resistance to each new drug has occurred within five to ten years of clinical use and has occurred even more rapidly with recently introduced drugs. In most cases, resistance-conferring mutations come with a fitness cost, but this can be overcome by compensatory mutations which restore fitness to that of wild-type bacteria. It is likely that M. tuberculosis acquires drug resistance while maintaining limited genomic variability due the generation of low frequency within-host variation, combined with ongoing purifying selection causing loss of variants without a clear fitness advantage. However, variants that do confer an advantage, such as drug resistance, can increase in prevalence amongst all bacteria within a host and become the dominant clone. These resistant strains can then be transmitted leading to primary drug resistant infection in a new host. As many countries move towards genomic methods for diagnosis of M. tuberculosis infection and drug resistance, it is important to be aware of the implications for the evolution of resistance. Currently, understanding of resistance-conferring mutations is incomplete, and some targeted genetic diagnostics create their own selective pressures. We discuss an example where a rifampicin resistance-conferring mutation which was not routinely covered by standard testing became dominant. Finally, resistance to new drugs such as bedaquiline and delamanid is caused by individually rare mutations occurring across a large mutational genomic target that have been detected over a short time, and do not provide statistical power for genotype-phenotype correlation – in contrast to longer-established drugs that form the backbone of drug-sensitive antituberculosis therapy. Therefore, we need a different approach to identify resistance-conferring mutations of new drugs before their resistance becomes widespread, abrogating their usefulness.
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Affiliation(s)
- Camus Nimmo
- Systems Chemical Biology of Infection and Resistance Laboratory, Francis Crick Institute, London, United Kingdom
- *Correspondence: Camus Nimmo,
| | - James Millard
- Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
| | - Valwynne Faulkner
- Systems Chemical Biology of Infection and Resistance Laboratory, Francis Crick Institute, London, United Kingdom
| | - Johana Monteserin
- Systems Chemical Biology of Infection and Resistance Laboratory, Francis Crick Institute, London, United Kingdom
| | - Hannah Pugh
- Systems Chemical Biology of Infection and Resistance Laboratory, Francis Crick Institute, London, United Kingdom
| | - Eachan Oliver Johnson
- Systems Chemical Biology of Infection and Resistance Laboratory, Francis Crick Institute, London, United Kingdom
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Poulton NC, Azadian ZA, DeJesus MA, Rock JM. Mutations in rv0678 Confer Low-Level Resistance to Benzothiazinone DprE1 Inhibitors in Mycobacterium tuberculosis. Antimicrob Agents Chemother 2022; 66:e0090422. [PMID: 35920665 PMCID: PMC9487612 DOI: 10.1128/aac.00904-22] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Tuberculosis (TB) is the leading cause of death from any bacterial infection, causing 1.5 million deaths worldwide each year. Due to the emergence of drug-resistant strains of Mycobacterium tuberculosis (Mtb) there have been significant efforts aimed at developing novel drugs to treat TB. One promising drug target in Mtb is the arabinogalactan biosynthetic enzyme DprE1, and there have been over a dozen unique chemical scaffolds identified which inhibit the activity of this protein. Among the most promising lead compounds are the benzothiazinones BTZ043 and PBTZ169, both of which are currently in or have completed phase IIa clinical trials. Due to the potential clinical utility of these drugs, we sought to identify potential synergistic interactions and new mechanisms of resistance using a genome-scale CRISPRi chemical-genetic screen with PBTZ169. We found that knockdown of rv0678, the negative regulator of the mmpS5/L5 drug efflux pump, confers resistance to PBTZ169. Mutations in rv0678 are the most common form of resistance to bedaquiline and there is already abundant evidence of these mutations emerging in bedaquiline-treated patients. We confirmed that rv0678 mutations from clinical isolates confer low level cross-resistance to BTZ043 and PBTZ169. While it is yet unclear whether rv0678 mutations would render benzothiazinones ineffective in treating TB, these results highlight the importance of monitoring for clinically prevalent rv0678 mutations during ongoing BTZ043 and PBTZ169 clinical trials.
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Affiliation(s)
- Nicholas C. Poulton
- Laboratory of Host-Pathogen Biology, The Rockefeller University, New York, New York, USA
| | - Zachary A. Azadian
- Laboratory of Host-Pathogen Biology, The Rockefeller University, New York, New York, USA
| | - Michael A. DeJesus
- Laboratory of Host-Pathogen Biology, The Rockefeller University, New York, New York, USA
| | - Jeremy M. Rock
- Laboratory of Host-Pathogen Biology, The Rockefeller University, New York, New York, USA
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Deshkar AT, Shirure PA. Bedaquiline: A Novel Diarylquinoline for Multidrug-Resistant Pulmonary Tuberculosis. Cureus 2022; 14:e28519. [PMID: 36185922 PMCID: PMC9516320 DOI: 10.7759/cureus.28519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Accepted: 08/26/2022] [Indexed: 11/05/2022] Open
Abstract
A new drug Bedaquiline, a diarylquinoline agent has been approved by the Food and Drug Administration for the treatment of pulmonary multidrug-resistant tuberculosis. It has been given approval for use along with the basic regimen with only conditional access through the National Program for tuberculosis in India. The major problem with existing antitubercular drugs used for the treatment of multi-drug resistant tuberculosis is antimicrobial resistance, less efficacy, and poor side effect profile. Bedaquiline might be a solution to these issues. Bedaquiline is a first of its class drug with a unique and specific mechanism of action. It inhibits mycobacterial adenosine triphosphate (ATP) synthase's proton pump. There are many randomized clinical trials and cohort studies that reported a higher culture conversion rate with bedaquiline treatment as compared to the control group. Many meta-analyses and systematic reviews have reported higher culture conversion rate, higher cure rate, and lower mortality rate in patients with drug-resistant tuberculosis treated with a bedaquiline-containing regimen. Here is a detailed drug profile of bedaquiline to help health care workers treat tuberculosis patients. Keywords:
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Variants in Bedaquiline-Candidate-Resistance Genes: Prevalence in Bedaquiline-Naive Patients, Effect on MIC, and Association with Mycobacterium tuberculosis Lineage. Antimicrob Agents Chemother 2022; 66:e0032222. [PMID: 35758754 PMCID: PMC9295546 DOI: 10.1128/aac.00322-22] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Studies have shown that variants in bedaquiline-resistance genes can occur in isolates from bedaquiline-naive patients. We assessed the prevalence of variants in all bedaquiline-candidate-resistance genes in bedaquiline-naive patients, investigated the association between these variants and lineage, and the effect on phenotype. We used whole-genome sequencing to identify variants in bedaquiline-resistance genes in isolates from 509 bedaquiline treatment naive South African tuberculosis patients. A phylogenetic tree was constructed to investigate the association with the isolate lineage background. Bedaquiline MIC was determined using the UKMYC6 microtiter assay. Variants were identified in 502 of 509 isolates (98.6%), with the highest (85%) prevalence of variants in the Rv0676c (mmpL5) gene. We identified 36 unique variants, including 19 variants not reported previously. Only four isolates had a bedaquiline MIC equal to or above the epidemiological cut-off value of 0.25 μg/mL. Phylogenetic analysis showed that 14 of the 15 variants observed more than once occurred monophyletically in one Mycobacterium tuberculosis (sub)lineage. The bedaquiline MIC differed between isolates belonging to lineage 2 and 4 (Fisher's exact test, P = 0.0004). The prevalence of variants in bedaquiline-resistance genes in isolates from bedaquiline-naive patients is high, but very few (<2%) isolates were phenotypically resistant. We found an association between variants in bedaquiline resistance genes and Mycobacterium tuberculosis (sub)lineage, resulting in a lineage-dependent difference in bedaquiline phenotype. Future studies should investigate the impact of the presence of variants on bedaquiline-resistance acquisition and treatment outcome.
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Lange C, Barry CE, Horsburgh CR. Treatments of Multidrug-Resistant Tuberculosis: Light at the End of the Tunnel. Am J Respir Crit Care Med 2022; 205:1142-1144. [PMID: 35320062 PMCID: PMC9872807 DOI: 10.1164/rccm.202202-0393ed] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Affiliation(s)
- Christoph Lange
- Division of Clinical Infectious Diseases Research Center Borstel Borstel, Germany
- Clinical Tuberculosis Unit German Center for Infection Research (DZIF) Borstel, Germany
- Respiratory Medicine and International Health University of Lübeck Lübeck, Germany
- Department of Pediatrics Baylor College of Medicine Houston, Texas
| | - Clifton E Barry
- National Institute of Allergy and Infectious Disease National Institutes of Health Bethesda, Maryland
| | - C Robert Horsburgh
- Department of Epidemiology Department of Biostatistics
- Department of Global Health Boston University School of Public Health Boston, Massachusetts
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Ahmed S, Prabahar AE, Saxena AK. Molecular docking-based interactions in QSAR studies on Mycobacterium tuberculosis ATP synthase inhibitors. SAR AND QSAR IN ENVIRONMENTAL RESEARCH 2022; 33:289-305. [PMID: 35532308 DOI: 10.1080/1062936x.2022.2066175] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 04/09/2022] [Indexed: 05/19/2023]
Abstract
Tuberculosis (TB) is a global threat with a large burden across the continents in terms of mortality, morbidity, and financial losses. The disease has evolved into multi-drug-resistant (MDR-TB) and extensively drug-resistant (XDR-TB) tuberculosis owing to numerous factors ranging from patients' non-compliance to demographical implications. There have been very few new drugs for resistant TB. Resistance has already been reported even for the newly introduced drug bedaquiline. An attempt has been made to integrate both structure-based and QSAR drug design techniques (QSAR-SBDD) for the identification of novel leads. The docking scores normally do not correlate with the activity. Hence, the docking results have been analysed in terms of the number of interactions rather than docking scores. The parameters derived from interactions have been used in developing the QSAR models. The best model shows a good correlation (r = 0.908) between the activity and interaction parameter 'C' describing the sum of all the interactions with each amino acid residue. This model also predicts external dataset with a good correlation (rext = 0.851) and can be used for the identification of novel chemical entities (NCEs) and repurposed drugs for TB therapeutics.
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Affiliation(s)
- S Ahmed
- Department of Pharmaceutical Chemistry, Global Institute of Pharmaceutical Education and Research, Kashipur, India
- Department of Pharmaceutical Chemistry, Teerthanker Mahaveer College of Pharmacy, Moradabad, India
| | - A E Prabahar
- Department of Pharmaceutical Chemistry, Teerthanker Mahaveer College of Pharmacy, Moradabad, India
| | - A K Saxena
- Department of Pharmaceutical Chemistry, Global Institute of Pharmaceutical Education and Research, Kashipur, India
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Implications of bedaquiline-resistant tuberculosis. THE LANCET INFECTIOUS DISEASES 2022; 22:166. [DOI: 10.1016/s1473-3099(22)00007-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 12/21/2021] [Indexed: 11/20/2022]
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Decroo T, van Deun A. Implications of bedaquiline-resistant tuberculosis. THE LANCET. INFECTIOUS DISEASES 2022; 22:166-167. [PMID: 35092789 DOI: 10.1016/s1473-3099(22)00008-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 12/21/2021] [Indexed: 06/14/2023]
Affiliation(s)
- Tom Decroo
- Unit of HIV and TB, Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp 2000, Belgium.
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44
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Van Deun A, Bola V, Lebeke R, Kaswa M, Hossain MA, Gumusboga M, Torrea G, De Jong BC, Rigouts L, Decroo T. OUP accepted manuscript. JAC Antimicrob Resist 2022; 4:dlac037. [PMID: 35415609 PMCID: PMC8994197 DOI: 10.1093/jacamr/dlac037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 03/13/2022] [Indexed: 11/14/2022] Open
Abstract
Background Objectives Methods Results Conclusions
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Affiliation(s)
| | - Valentin Bola
- Programme National de Lutte contre la Tuberculose, Direction Provinciale de Kinshasa, Kinshasa, République Démocratique du Congo
| | - Rossin Lebeke
- Programme National de Lutte contre la Tuberculose, Direction Provinciale de Kinshasa, Kinshasa, République Démocratique du Congo
| | - Michel Kaswa
- Programme National de Lutte contre la Tuberculose, Direction Nationale, Kinshasa, République Démocratique du Congo
| | | | - Mourad Gumusboga
- Institute of Tropical Medicine, Unit of Mycobacteriology, Department of Biomedical Sciences, 2000 Antwerp, Belgium
| | - Gabriela Torrea
- Institute of Tropical Medicine, Unit of Mycobacteriology, Department of Biomedical Sciences, 2000 Antwerp, Belgium
| | - Bouke Catharine De Jong
- Institute of Tropical Medicine, Unit of Mycobacteriology, Department of Biomedical Sciences, 2000 Antwerp, Belgium
| | - Leen Rigouts
- Institute of Tropical Medicine, Unit of Mycobacteriology, Department of Biomedical Sciences, 2000 Antwerp, Belgium
| | - Tom Decroo
- Institute of Tropical Medicine, Unit of HIV and TB, Department of Clinical Sciences, 2000 Antwerp, Belgium
- Corresponding author. E-mail:
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