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Karakitsios E, Dokoumetzidis A. Extrapolation of lung pharmacokinetics of antitubercular drugs from preclinical species to humans using PBPK modelling. J Antimicrob Chemother 2024; 79:1362-1371. [PMID: 38598449 PMCID: PMC11144487 DOI: 10.1093/jac/dkae109] [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: 11/10/2023] [Accepted: 03/21/2024] [Indexed: 04/12/2024] Open
Abstract
OBJECTIVES To develop physiologically based pharmacokinetic (PBPK) models for widely used anti-TB drugs, namely rifampicin, pyrazinamide, isoniazid, ethambutol and moxifloxacin lung pharmacokinetics (PK)-regarding both healthy and TB-infected tissue (cellular lesion and caseum)-in preclinical species and to extrapolate to humans. METHODS Empirical models were used for the plasma PK of each species, which were connected to multicompartment permeability-limited lung models within a middle-out PBPK approach with an appropriate physiological parameterization that was scalable across species. Lung's extracellular water (EW) was assumed to be the linking component between healthy and infected tissue, while passive diffusion was assumed for the drug transferring between cellular lesion and caseum. RESULTS In rabbits, optimized unbound fractions in intracellular water of rifampicin, moxifloxacin and ethambutol were 0.015, 0.056 and 0.08, respectively, while the optimized unbound fractions in EW of pyrazinamide and isoniazid in mice were 0.25 and 0.17, respectively. In humans, all mean extrapolated daily AUC and Cmax values of various lung regions were within 2-fold of the observed ones. Unbound concentrations in the caseum were lower than unbound plasma concentrations for both rifampicin and moxifloxacin. For rifampicin, unbound concentrations in cellular rim are slightly lower, while for moxifloxacin they are significantly higher than unbound plasma concentrations. CONCLUSIONS The developed PBPK approach was able to extrapolate lung PK from preclinical species to humans and to predict unbound concentrations in the various TB-infected regions, unlike empirical lung models. We found that plasma free drug PK is not always a good surrogate for TB-infected tissue unbound PK.
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Affiliation(s)
- Evangelos Karakitsios
- Department of Pharmacy, University of Athens, Panepistimiopolis Zografou, 15784 Athens, Greece
- Pharma-Informatics Unit, Athena Research Center, Artemidos 6 & Epidavrou, 15125 Marousi, Greece
- Institute for Applied Computing “Mauro Picone”, National Research Council (CNR), Via dei Taurini 19, 00185 Rome, Italy
| | - Aristides Dokoumetzidis
- Department of Pharmacy, University of Athens, Panepistimiopolis Zografou, 15784 Athens, Greece
- Pharma-Informatics Unit, Athena Research Center, Artemidos 6 & Epidavrou, 15125 Marousi, Greece
- Institute for Applied Computing “Mauro Picone”, National Research Council (CNR), Via dei Taurini 19, 00185 Rome, Italy
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2
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Dodd M, Carpenter J, Thompson JA, Williamson E, Fielding K, Elbourne D. Assessing efficacy in non-inferiority trials with non-adherence to interventions: Are intention-to-treat and per-protocol analyses fit for purpose? Stat Med 2024; 43:2314-2331. [PMID: 38561927 DOI: 10.1002/sim.10067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 02/19/2024] [Accepted: 03/15/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND Non-inferiority trials comparing different active drugs are often subject to treatment non-adherence. Intention-to-treat (ITT) and per-protocol (PP) analyses have been advocated in such studies but are not guaranteed to be unbiased in the presence of differential non-adherence. METHODS The REMoxTB trial evaluated two 4-month experimental regimens compared with a 6-month control regimen for newly diagnosed drug-susceptible TB. The primary endpoint was a composite unfavorable outcome of treatment failure or recurrence within 18 months post-randomization. We conducted a simulation study based on REMoxTB to assess the performance of statistical methods for handling non-adherence in non-inferiority trials, including: ITT and PP analyses, adjustment for observed adherence, multiple imputation (MI) of outcomes, inverse-probability-of-treatment weighting (IPTW), and a doubly-robust (DR) estimator. RESULTS When non-adherence differed between trial arms, ITT, and PP analyses often resulted in non-trivial bias in the estimated treatment effect, which consequently under- or over-inflated the type I error rate. Adjustment for observed adherence led to similar issues, whereas the MI, IPTW and DR approaches were able to correct bias under most non-adherence scenarios; they could not always eliminate bias entirely in the presence of unobserved confounding. The IPTW and DR methods were generally unbiased and maintained desired type I error rates and statistical power. CONCLUSIONS When non-adherence differs between trial arms, ITT and PP analyses can produce biased estimates of efficacy, potentially leading to the acceptance of inferior treatments or efficacious regimens being missed. IPTW and the DR estimator are relatively straightforward methods to supplement ITT and PP approaches.
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Affiliation(s)
- Matthew Dodd
- Department of Medical Statistics, The London School of Hygiene & Tropical Medicine, London, UK
| | - James Carpenter
- Department of Medical Statistics, The London School of Hygiene & Tropical Medicine, London, UK
- The Medical Research Council Clinical Trials Unit (MRC CTU), UCL, London, UK
| | - Jennifer A Thompson
- Department of Infectious Disease Epidemiology, The London School of Hygiene & Tropical Medicine, London, UK
| | - Elizabeth Williamson
- Department of Medical Statistics, The London School of Hygiene & Tropical Medicine, London, UK
| | - Katherine Fielding
- Department of Infectious Disease Epidemiology, The London School of Hygiene & Tropical Medicine, London, UK
| | - Diana Elbourne
- Department of Medical Statistics, The London School of Hygiene & Tropical Medicine, London, UK
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3
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Namale PE, Boloko L, Vermeulen M, Haigh KA, Bagula F, Maseko A, Sossen B, Lee-Jones S, Msomi Y, McIlleron H, Mnguni AT, Crede T, Szymanski P, Naude J, Ebrahim S, Vallie Y, Moosa MS, Bandeker I, Hoosain S, Nicol MP, Samodien N, Centner C, Dowling W, Denti P, Gumedze F, Little F, Parker A, Price B, Schietekat D, Simmons B, Hill A, Wilkinson RJ, Oliphant I, Hlungulu S, Apolisi I, Toleni M, Asare Z, Mpalali MK, Boshoff E, Prinsloo D, Lakay F, Bekiswa A, Jackson A, Barnes A, Johnson R, Wasserman S, Maartens G, Barr D, Schutz C, Meintjes G. Testing novel strategies for patients hospitalised with HIV-associated disseminated tuberculosis (NewStrat-TB): protocol for a randomised controlled trial. Trials 2024; 25:311. [PMID: 38720383 PMCID: PMC11077808 DOI: 10.1186/s13063-024-08119-4] [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: 01/16/2024] [Accepted: 04/16/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND HIV-associated tuberculosis (TB) contributes disproportionately to global tuberculosis mortality. Patients hospitalised at the time of the diagnosis of HIV-associated disseminated TB are typically severely ill and have a high mortality risk despite initiation of tuberculosis treatment. The objective of the study is to assess the safety and efficacy of both intensified TB treatment (high dose rifampicin plus levofloxacin) and immunomodulation with corticosteroids as interventions to reduce early mortality in hospitalised patients with HIV-associated disseminated TB. METHODS This is a phase III randomised controlled superiority trial, evaluating two interventions in a 2 × 2 factorial design: (1) high dose rifampicin (35 mg/kg/day) plus levofloxacin added to standard TB treatment for the first 14 days versus standard tuberculosis treatment and (2) adjunctive corticosteroids (prednisone 1.5 mg/kg/day) versus identical placebo for the first 14 days of TB treatment. The study population is HIV-positive patients diagnosed with disseminated TB (defined as being positive by at least one of the following assays: urine Alere LAM, urine Xpert MTB/RIF Ultra or blood Xpert MTB/RIF Ultra) during a hospital admission. The primary endpoint is all-cause mortality at 12 weeks comparing, first, patients receiving intensified TB treatment to standard of care and, second, patients receiving corticosteroids to those receiving placebo. Analysis of the primary endpoint will be by intention to treat. Secondary endpoints include all-cause mortality at 2 and 24 weeks. Safety and tolerability endpoints include hepatoxicity evaluations and corticosteroid-related adverse events. DISCUSSION Disseminated TB is characterised by a high mycobacterial load and patients are often critically ill at presentation, with features of sepsis, which carries a high mortality risk. Interventions that reduce this high mycobacterial load or modulate associated immune activation could potentially reduce mortality. If found to be safe and effective, the interventions being evaluated in this trial could be easily implemented in clinical practice. TRIAL REGISTRATION ClinicalTrials.gov NCT04951986. Registered on 7 July 2021 https://clinicaltrials.gov/study/NCT04951986.
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Affiliation(s)
- Phiona E Namale
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa.
- Department of Medicine, University of Cape Town, Cape Town, South Africa.
| | - Linda Boloko
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Marcia Vermeulen
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Kate A Haigh
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK
| | - Fortuna Bagula
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Alexis Maseko
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Bianca Sossen
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Scott Lee-Jones
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Yoliswa Msomi
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Helen McIlleron
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Ayanda Trevor Mnguni
- Department of Medicine, Khayelitsha Hospital, Cape Town, South Africa
- Department of Medicine, Stellenbosch University, Stellenbosch, South Africa
| | - Thomas Crede
- Department of Medicine, University of Cape Town, Cape Town, South Africa
- Department of Medicine, Mitchells Plain Hospital, Cape Town, South Africa
| | - Patryk Szymanski
- Department of Medicine, University of Cape Town, Cape Town, South Africa
- Department of Medicine, Mitchells Plain Hospital, Cape Town, South Africa
| | - Jonathan Naude
- Department of Medicine, University of Cape Town, Cape Town, South Africa
- Department of Medicine, Mitchells Plain Hospital, Cape Town, South Africa
| | - Sakeena Ebrahim
- Department of Medicine, University of Cape Town, Cape Town, South Africa
- Department of Medicine, Mitchells Plain Hospital, Cape Town, South Africa
| | - Yakoob Vallie
- Department of Medicine, New Somerset Hospital, Cape Town, South Africa
| | | | - Ismail Bandeker
- Department of Medicine, New Somerset Hospital, Cape Town, South Africa
| | - Shakeel Hoosain
- Department of Medicine, New Somerset Hospital, Cape Town, South Africa
| | - Mark P Nicol
- Division of Medical Microbiology, Department of Pathology, University of Cape Town, Cape Town, South Africa
- Division of Infection and Immunity School of Biomedical Sciences, University of Western Australia, Perth, Australia
| | - Nazlee Samodien
- Division of Medical Microbiology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Chad Centner
- Division of Medical Microbiology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Wentzel Dowling
- Division of Medical Microbiology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Paolo Denti
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Freedom Gumedze
- Department of Statistical Sciences, University of Cape Town, Cape Town, South Africa
| | - Francesca Little
- Department of Statistical Sciences, University of Cape Town, Cape Town, South Africa
| | - Arifa Parker
- Department of Medicine, Stellenbosch University, Stellenbosch, South Africa
| | - Brendon Price
- Division of Anatomical Pathology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Denzil Schietekat
- Department of Medicine, Khayelitsha Hospital, Cape Town, South Africa
- Department of Medicine, Stellenbosch University, Stellenbosch, South Africa
| | - Bryony Simmons
- LSE Health, London School of Economics and Political Science, London, UK
| | - Andrew Hill
- LSE Health, London School of Economics and Political Science, London, UK
| | - Robert J Wilkinson
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
- Francis Crick Institute, London, UK
- Department of Medicine, Imperial College London, London, UK
| | - Ida Oliphant
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Siphokazi Hlungulu
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Ivy Apolisi
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Monica Toleni
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Zimkhitha Asare
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Mkanyiseli Kenneth Mpalali
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Erica Boshoff
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Denise Prinsloo
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Francisco Lakay
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Abulele Bekiswa
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Amanda Jackson
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Ashleigh Barnes
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Ryan Johnson
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Sean Wasserman
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Gary Maartens
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - David Barr
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Charlotte Schutz
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Graeme Meintjes
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
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Teo AKJ, MacLean ELH, Fox GJ. Subclinical tuberculosis: a meta-analysis of prevalence and scoping review of definitions, prevalence and clinical characteristics. Eur Respir Rev 2024; 33:230208. [PMID: 38719737 PMCID: PMC11078153 DOI: 10.1183/16000617.0208-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 02/12/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND This scoping review aimed to characterise definitions used to describe subclinical tuberculosis (TB), estimate the prevalence in different populations and describe the clinical characteristics and treatment outcomes in the scientific literature. METHODS A systematic literature search was conducted using PubMed. We included studies published in English between January 1990 and August 2022 that defined "subclinical" or "asymptomatic" pulmonary TB disease, regardless of age, HIV status and comorbidities. We estimated the weighted pooled proportions of subclinical TB using a random-effects model by World Health Organization reported TB incidence, populations and settings. We also pooled the proportion of subclinical TB according to definitions described in published prevalence surveys. RESULTS We identified 29 prevalence surveys and 71 other studies. Prevalence survey data (2002-2022) using "absence of cough of any duration" criteria reported higher subclinical TB prevalence than those using the stricter "completely asymptomatic" threshold. Prevalence estimates overlap in studies using other symptoms and cough duration. Subclinical TB in studies was commonly defined as asymptomatic TB disease. Higher prevalence was reported in high TB burden areas, community settings and immunocompetent populations. People with subclinical TB showed less extensive radiographic abnormalities, higher treatment success rates and lower mortality, although studies were few. CONCLUSION A substantial proportion of TB is subclinical. However, prevalence estimates were highly heterogeneous between settings. Most published studies incompletely characterised the phenotype of people with subclinical TB. Standardised definitions and diagnostic criteria are needed to characterise this phenotype. Further research is required to enhance case finding, screening, diagnostics and treatment options for subclinical TB.
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Affiliation(s)
- Alvin Kuo Jing Teo
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Singapore
- Both authors contributed equally
| | - Emily Lai-Ho MacLean
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
- Both authors contributed equally
| | - Greg J Fox
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
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Budak M, Via LE, Weiner DM, Barry CE, Nanda P, Michael G, Mdluli K, Kirschner D. A systematic efficacy analysis of tuberculosis treatment with BPaL-containing regimens using a multiscale modeling approach. CPT Pharmacometrics Syst Pharmacol 2024; 13:673-685. [PMID: 38404200 PMCID: PMC11015080 DOI: 10.1002/psp4.13117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 12/22/2023] [Accepted: 02/07/2024] [Indexed: 02/27/2024] Open
Abstract
Tuberculosis (TB) is a life-threatening infectious disease. The standard treatment is up to 90% effective; however, it requires the administration of four antibiotics (isoniazid, rifampicin, pyrazinamide, and ethambutol [HRZE]) over long time periods. This harsh treatment process causes adherence issues for patients because of the long treatment times and a myriad of adverse effects. Therefore, the World Health Organization has focused goals of shortening standard treatment regimens for TB in their End TB Strategy efforts, which aim to reduce TB-related deaths by 95% by 2035. For this purpose, many novel and promising combination antibiotics are being explored that have recently been discovered, such as the bedaquiline, pretomanid, and linezolid (BPaL) regimen. As a result, testing the number of possible combinations with all possible novel regimens is beyond the limit of experimental resources. In this study, we present a unique framework that uses a primate granuloma modeling approach to screen many combination regimens that are currently under clinical and experimental exploration and assesses their efficacies to inform future studies. We tested well-studied regimens such as HRZE and BPaL to evaluate the validity and accuracy of our framework. We also simulated additional promising combination regimens that have not been sufficiently studied clinically or experimentally, and we provide a pipeline for regimen ranking based on their efficacies in granulomas. Furthermore, we showed a correlation between simulation rankings and new marmoset data rankings, providing evidence for the credibility of our framework. This framework can be adapted to any TB regimen and can rank any number of single or combination regimens.
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Affiliation(s)
- Maral Budak
- Department of Microbiology and ImmunologyUniversity of Michigan Medical SchoolAnn ArborMichiganUSA
| | - Laura E. Via
- Tuberculosis Research Section, Laboratory of Clinical Immunology and MicrobiologyNational Institute of Allergy and Infectious Diseases (NIAID)BethesdaMarylandUSA
- Tuberculosis Imaging Program, Division of Intramural ResearchNIAIDBethesdaMarylandUSA
| | - Danielle M. Weiner
- Tuberculosis Research Section, Laboratory of Clinical Immunology and MicrobiologyNational Institute of Allergy and Infectious Diseases (NIAID)BethesdaMarylandUSA
- Tuberculosis Imaging Program, Division of Intramural ResearchNIAIDBethesdaMarylandUSA
| | - Clifton E. Barry
- Tuberculosis Research Section, Laboratory of Clinical Immunology and MicrobiologyNational Institute of Allergy and Infectious Diseases (NIAID)BethesdaMarylandUSA
- Centre for Infectious Diseases Research in AfricaInstitute of Infectious Disease and Molecular MedicineObservatoryRepublic of South Africa
- Department of MedicineUniversity of Cape TownObservatoryRepublic of South Africa
| | - Pariksheet Nanda
- Department of Microbiology and ImmunologyUniversity of Michigan Medical SchoolAnn ArborMichiganUSA
| | - Gabrielle Michael
- Molecular, Cellular and Developmental BiologyUniversity of MichiganAnn ArborMichiganUSA
| | - Khisimuzi Mdluli
- Bill & Melinda Gates Medical Research InstituteCambridgeMassachusettsUSA
| | - Denise Kirschner
- Department of Microbiology and ImmunologyUniversity of Michigan Medical SchoolAnn ArborMichiganUSA
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6
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Weir IR, Dufault SM, Phillips PPJ. Estimands for clinical endpoints in tuberculosis treatment randomized controlled trials: a retrospective application in a completed trial. Trials 2024; 25:180. [PMID: 38468320 PMCID: PMC10929173 DOI: 10.1186/s13063-024-07999-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 02/21/2024] [Indexed: 03/13/2024] Open
Abstract
BACKGROUND Randomized trials for the treatment of tuberculosis (TB) rely on a composite primary outcome to capture unfavorable treatment responses. However, variability between trials in the outcome definition and estimation methods complicates across-trial comparisons and hinders the advancement of treatment guidelines. The International Council for Harmonization (ICH) provides international regulatory standards for clinical trials. The estimand framework outlined in the recent ICH E9(R1) addendum offers a timely opportunity for randomized trials of TB treatment to adopt broadly standardized outcome definitions and analytic approaches. We previously proposed and defined four estimands for use in this context. Our objective was to evaluate how the use of these estimands and choice of estimation method impacts results and interpretation of a large phase III TB trial. METHODS We reanalyzed participant-level data from the REMoxTB trial. We applied four estimands and various methods of estimation to assess non-inferiority of both novel 4-month treatment regimens against standard of care. RESULTS With each of the four estimands, we reached the same conclusion as the original trial analysis that the novel regimens were not non-inferior to standard of care. Each estimand and method of estimation gave similar estimates of the treatment effect with fluctuations in variance and differences driven by the methods applied for handling intercurrent events. CONCLUSIONS Our application of estimands defined by the ICH E9 (R1) addendum offers a formalized framework for addressing the primary TB treatment trial objective and can promote uniformity in future trials by limiting heterogeneity in trial outcome definitions. We demonstrated the utility of our proposal using data from the REMoxTB randomized trial. We outlined methods for estimating each estimand and found consistent conclusions across estimands. We recommend future late-phase TB treatment trials to implement some or all of our estimands to promote rigorous outcome definitions and reduce variability between trials. TRIAL REGISTRATION ClinicalTrials.gov NCT00864383. Registered on March 2009.
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Affiliation(s)
- Isabelle R Weir
- Center for Biostatistics in AIDS Research in the Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Suzanne M Dufault
- UCSF Center for Tuberculosis, University of California, San Francisco, San Francisco, CA, USA
- Division of Biostatistics, Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - Patrick P J Phillips
- UCSF Center for Tuberculosis, University of California, San Francisco, San Francisco, CA, USA.
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7
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Chen RT, Liu CY, Lin SY, Shu CC, Sheng WH. The prevalence, clinical reasoning and impact of non-standard anti-tuberculosis regimens at the initial prescription. Sci Rep 2024; 14:5631. [PMID: 38453976 PMCID: PMC10920864 DOI: 10.1038/s41598-024-55273-5] [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: 09/02/2023] [Accepted: 02/21/2024] [Indexed: 03/09/2024] Open
Abstract
Regarding clinically-concerning non-standard initial anti-tuberculous (TB) regimens, few studies have examined their prevalence, risk factors and impacts. We recruited patients with drug susceptible TB and non-standard initial anti-TB regimens (NSTB group) and matched them with patients with standard initial regimens (STB group) in a 1:1 ratio. The risk factors and outcomes were analyzed. During the 11-year study period, we analyzed 50 (3.7%) patients with NSTB from a total set of 1337 patients with drug-susceptible TB. Pyrazinamide (60%) was the drug most commonly not prescribed in the NSTB group, followed by ethambutol (34%). Multivariable logistic regression identified independent risk factors as underlying eye disease (adjusted odds ratio [aOR]: 8.869; 95% CI 2.542-30.949; p = 0.001), gout/hyperuricemia (aOR: 4.012 [1.196-13.425]; p = 0.024), and liver disease (aOR: 12.790 [3.981-41.089]; p < 0.001). The NSTB group had longer treatment durations (281 ± 121 vs. 223 ± 63 days; p = 0.003) and more occurrences of treatment interruption (26% vs. 8%; p = 0.021) than the STB group. In conclusion, NSTB occurs in around 3.7% of patients and is associated with longer treatment and more treatment interruption. The risk factors might include underlying liver and eye diseases, and gout. Further studies to improve non-standard initial regimens and prevent negative outcomes are warranted.
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Affiliation(s)
- Rou-Tsern Chen
- Department of Nursing, National Taiwan University Hospital, Taipei, Taiwan
| | - Chih-Yu Liu
- Department of Nursing, National Taiwan University Hospital, Taipei, Taiwan
| | - Shu-Yung Lin
- College of Medicine, National Taiwan University, Taipei, Taiwan
- Department of Internal Medicine, National Taiwan University Hospital, No 7, Chung Shan South Road, Taipei, Taiwan
| | - Chin-Chung Shu
- College of Medicine, National Taiwan University, Taipei, Taiwan.
- Department of Internal Medicine, National Taiwan University Hospital, No 7, Chung Shan South Road, Taipei, Taiwan.
| | - Wang-Huei Sheng
- College of Medicine, National Taiwan University, Taipei, Taiwan
- Department of Internal Medicine, National Taiwan University Hospital, No 7, Chung Shan South Road, Taipei, Taiwan
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Perumal Kannabiran B, Palaniappan NA, Manoharan T, Paramasivam PK, Saini JK, Ansari MS, Jayabal L, Aggarwal AN, Garg R, Subramanyam B, Thakur D, Pantula S, P M R, GS V, Natarajan S, Ammayappan RK, Manpreet B, Ganesan M, Angamuthu D, Chinnaiyan P, Singh M, Chandrasekaran P, Swaminathan S. Safety and Efficacy of 25 mg/kg and 35 mg/kg vs 10 mg/kg Rifampicin in Pulmonary TB: A Phase IIb Randomized Controlled Trial. Open Forum Infect Dis 2024; 11:ofae034. [PMID: 38444824 PMCID: PMC10914527 DOI: 10.1093/ofid/ofae034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 01/24/2024] [Indexed: 03/07/2024] Open
Abstract
Background Globally, no trial data are available on head-to-head comparison between 10 mg/kg and 25/35 mg/kg rifampicin in treating pulmonary tuberculosis during study initiation. Methods A multicentric, phase IIb randomized trial recruited 333 new culture-positive, drug-sensitive adult patients with pulmonary tuberculosis to compare safety and efficacy of high-dose rifampicin (R25/R35), against conventional dose (R10) given daily for 8 weeks followed by standard doses for 16 weeks. Main outcomes were treatment-emergent grade 3/4 adverse events (AEs) and time-to-culture conversion in liquid media, assessed by division of AIDS system for grading the severity of adverse events division of AIDS criteria and Kaplan-Meier methods. Results In a modified intention-to-treat population of 323 patients (R10: 105/R25: 112/R35: 106), grade 3/4 AEs were reported in 34 patients (R10: 9.5% [10/105], R25: 9.8% [11/112], R35: 12.3% [13/106]) during the intensive phase. Among 23 patients (R10: 3.8% [4/105], R25: 6.3% [7/112], R35: 11.3% [12/106]) with grade 3/4 hepatotoxicity, 15 (R10: 1.9% [2/105], R25: 3.6% [4/112], R35: 8.5% [9/106]) had grade 3/4 hyperbilirubinemia and 9 patients (R10: 1.0% [1/105], R25: 0.9% [1/112], R35: 6.6% [7/106]) developed clinical jaundice. Significant differences observed only between R10 and R35 with hepatotoxicity (P = .039), hyperbilirubinemia (P = .031), clinical jaundice (P = .032), and treatment interruption (P = .039). Eighteen serious AEs and 6 deaths (R10: 3/R25: 1/R35: 2) occurred during study period. Time to stable culture conversion in liquid media was faster in R25 (adjusted hazard ratio, 1.71; 95% confidence interval [CI], 1.26-2.31 [solid: 1.97; 95% CI, 1.46-2.67]) and R35 (1.81; 95% CI, 1.33-2.48 [solid: 2.24; 95% CI, 1.64-3.06]), than R10 (34 vs 44 days). R25 had no failure/relapse. Conclusions Hepatotoxicity, clinical jaundice, and treatment interruptions occurred significantly higher with R35 than R10. Because R25 was comparably safe as R10 and also highly efficacious than R10, it may be considered for implementation. Clinical Trials Registration. CTRI/2017/12/010951.
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Affiliation(s)
| | | | - Tamizhselvan Manoharan
- Department of Clinical Resarch, ICMR - National Institute for Research in Tuberculosis, Chennai, India
| | - Paul Kumaran Paramasivam
- Department of Clinical Resarch, ICMR - National Institute for Research in Tuberculosis, Chennai, India
| | - Jitendra Kumar Saini
- Department of Pulmonary Oncology, National Institute for Tuberculosis and Respiratory Diseases, New Delhi, India
| | - Mohammed Soheb Ansari
- Department of Respiratory Medicine, Bhagwan Mahavir Medical Hospital and Research Centre, Hyderabad, India
| | - Lavanya Jayabal
- District TB office, Greater Chennai Corporation, Chennai, India
| | - Ashutosh N Aggarwal
- Department of Respiratory Medicine, Post Graduate Institute of Medical Research, Chandigarh, India
| | - Rajiv Garg
- Department of Respiratory Medicine, King George's Medical University, Lucknow, India
| | - Balaji Subramanyam
- Department of Clinical Resarch, ICMR - National Institute for Research in Tuberculosis, Chennai, India
| | - Deepika Thakur
- Department of Respiratory Medicine, Post Graduate Institute of Medical Research, Chandigarh, India
| | - Shilpa Pantula
- Department of Respiratory Medicine, Bhagwan Mahavir Medical Hospital and Research Centre, Hyderabad, India
| | - Ramesh P M
- Department of Respiratory Medicine, Government Thiruvotteeswarar Hospital of Thoracic Medicine, Chennai, India
| | - Vijayachandar GS
- Department of Respiratory Medicine, Institute of Thoracic Medicine, Chennai, India
| | - Saravanan Natarajan
- Department of Clinical Resarch, ICMR - National Institute for Research in Tuberculosis, Chennai, India
| | - Radha Krishnan Ammayappan
- Department of Clinical Resarch, ICMR - National Institute for Research in Tuberculosis, Chennai, India
| | - Bhalla Manpreet
- Department of Pulmonary Oncology, National Institute for Tuberculosis and Respiratory Diseases, New Delhi, India
| | - Mangalambal Ganesan
- Department of Clinical Resarch, ICMR - National Institute for Research in Tuberculosis, Chennai, India
| | - Dhanalakshmi Angamuthu
- Department of Clinical Resarch, ICMR - National Institute for Research in Tuberculosis, Chennai, India
| | - Ponnuraja Chinnaiyan
- Department of Clinical Resarch, ICMR - National Institute for Research in Tuberculosis, Chennai, India
| | - Manjula Singh
- Division of Communicable Diseases, Indian Council of Medical Research, New Delhi, India
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Abdillah AH, Rangkuti AAM, Pangestu D, Az-Zahra S, Supiono S. Efficacy and safety of quinolones as potential first line therapy in pulmonary tuberculosis: a meta-analysis. Folia Med (Plovdiv) 2024; 66:26-34. [PMID: 38426462 DOI: 10.3897/folmed.66.e115239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Accepted: 02/01/2024] [Indexed: 03/02/2024] Open
Abstract
INTRODUCTION Tuberculosis is an infectious disease that continues to plague the world today, causing concerns due to its high mortality rate. The therapy regimens used for the treatment of tuberculosis today have demonstrated high efficacy and safety, potentially reducing the disease's burden, but the use of some standardized medications has caused many resistances to emerge. Over the last decade, researchers have been looking for suitable alternatives, with quinolones emerging as the most promising candidate due to their efficacy, safety, and availability. However, their efficacy as a first-line treatment remains debatable.
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10
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Bark CM, Boom WH, Furin JJ. More Tailored Approaches to Tuberculosis Treatment and Prevention. Annu Rev Med 2024; 75:177-188. [PMID: 37983385 DOI: 10.1146/annurev-med-100622-024848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2023]
Abstract
Recent advances in the treatment of tuberculosis (TB) have led to improvements unprecedented in our lifetime. Decades of research in developing new drugs, especially for multidrug-resistant TB, have created not only multiple new antituberculous agents but also a new approach to development and treatment, with a focus on maximizing the benefit to the individual patient. Prevention of TB disease has also been improved and recognized as a critical component of global TB control. While the momentum is positive, it will take continued investment at all levels, especially training of new dedicated TB researchers and advocates around the world, to maintain this progress.
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Affiliation(s)
- Charles M Bark
- Division of Infectious Diseases, MetroHealth Medical Center, Cleveland, Ohio, USA;
| | - W Henry Boom
- Division of Infectious Diseases and HIV Medicine, Case Western Reserve University and University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Jennifer J Furin
- Division of Infectious Diseases and HIV Medicine, Case Western Reserve University and University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
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11
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Sauer SM, Mitnick CD, Khan U, Hewison C, Bastard M, Holtzman D, Law S, Khan M, Padayachee S, Ahmed S, Isani AK, Krisnanda A, Vilbrun SC, Bektasov S, Kumsa A, Docteur W, Tintaya K, McNicol M, Atshemyan H, Voynilo T, Thwe TT, Seung K, Rich M, Huerga H, Khan P, Franke M. Estimating Post-treatment Recurrence After Multidrug-Resistant Tuberculosis Treatment Among Patients With and Without Human Immunodeficiency Virus: The Impact of Assumptions About Death and Missing Follow-up. Clin Infect Dis 2024; 78:164-171. [PMID: 37773767 PMCID: PMC10810712 DOI: 10.1093/cid/ciad589] [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: 05/22/2023] [Revised: 08/22/2023] [Accepted: 09/26/2023] [Indexed: 10/01/2023] Open
Abstract
BACKGROUND Quantification of recurrence risk following successful treatment is crucial to evaluating regimens for multidrug- or rifampicin-resistant (MDR/RR) tuberculosis (TB). However, such analyses are complicated when some patients die or become lost during post-treatment follow-up. METHODS We analyzed data on 1991 patients who successfully completed a longer MDR/RR-TB regimen containing bedaquiline and/or delamanid between 2015 and 2018 in 16 countries. Using 5 approaches for handling post-treatment deaths, we estimated 6-month post-treatment TB recurrence risk overall and by HIV status. We used inverse-probability weighting to account for patients with missing follow-up and investigated the impact of potential bias from excluding these patients without applying inverse-probability weights. RESULTS The estimated TB recurrence risk was 7.4/1000 (95% credible interval: 3.3-12.8) when deaths were handled as non-recurrences and 7.6/1000 (3.3-13.0) when deaths were censored and inverse-probability weights were applied to account for the excluded deaths. The estimated risks of composite recurrence outcomes were 25.5 (15.3-38.1), 11.7 (6.4-18.2), and 8.6 (4.1-14.4) per 1000 for recurrence or (1) any death, (2) death with unknown or TB-related cause, or (3) TB-related death, respectively. Corresponding relative risks for HIV status varied in direction and magnitude. Exclusion of patients with missing follow-up without inverse-probability weighting had a small impact on estimates. CONCLUSIONS The estimated 6-month TB recurrence risk was low, and the association with HIV status was inconclusive due to few recurrence events. Estimation of post-treatment recurrence will be enhanced by explicit assumptions about deaths and appropriate adjustment for missing follow-up data.
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Affiliation(s)
- Sara M Sauer
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Carole D Mitnick
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Uzma Khan
- Interactive Research and Development (IRD) Global, Singapore, Singapore
| | | | | | | | - Stephanie Law
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | | | | | | | - Afshan K Isani
- Centers for Disease Control and Prevention, Directorate General Health Services, Sindh, Pakistan
| | | | - Stalz Charles Vilbrun
- The Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | | | | | | | | | | | | | | | | | - Kwonjune Seung
- Partners in Health, Boston, Massachusetts, USA
- Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Michael Rich
- Partners in Health, Boston, Massachusetts, USA
- Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | - Palwasha Khan
- Interactive Research and Development (IRD) Global, Singapore, Singapore
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Molly Franke
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
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12
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Reali F, Fochesato A, Kaddi C, Visintainer R, Watson S, Levi M, Dartois V, Azer K, Marchetti L. A minimal PBPK model to accelerate preclinical development of drugs against tuberculosis. Front Pharmacol 2024; 14:1272091. [PMID: 38239195 PMCID: PMC10794428 DOI: 10.3389/fphar.2023.1272091] [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: 08/03/2023] [Accepted: 12/04/2023] [Indexed: 01/22/2024] Open
Abstract
Introduction: Understanding drug exposure at disease target sites is pivotal to profiling new drug candidates in terms of tolerability and efficacy. Such quantification is particularly tedious for anti-tuberculosis (TB) compounds as the heterogeneous pulmonary microenvironment due to the infection may alter lung permeability and affect drug disposition. Murine models have been a longstanding support in TB research so far and are here used as human surrogates to unveil the distribution of several anti-TB compounds at the site-of-action via a novel and centralized PBPK design framework. Methods: As an intermediate approach between data-driven pharmacokinetic (PK) models and whole-body physiologically based (PB) PK models, we propose a parsimonious framework for PK investigation (minimal PBPK approach) that retains key physiological processes involved in TB disease, while reducing computational costs and prior knowledge requirements. By lumping together pulmonary TB-unessential organs, our minimal PBPK model counts 9 equations compared to the 36 of published full models, accelerating the simulation more than 3-folds in Matlab 2022b. Results: The model has been successfully tested and validated against 11 anti-TB compounds-rifampicin, rifapentine, pyrazinamide, ethambutol, isoniazid, moxifloxacin, delamanid, pretomanid, bedaquiline, OPC-167832, GSK2556286 - showing robust predictability power in recapitulating PK dynamics in mice. Structural inspections on the proposed design have ensured global identifiability and listed free fraction in plasma and blood-to-plasma ratio as top sensitive parameters for PK metrics. The platform-oriented implementation allows fast comparison of the compounds in terms of exposure and target attainment. Discrepancies in plasma and lung levels for the latest BPaMZ and HPMZ regimens have been analyzed in terms of their impact on preclinical experiment design and on PK/PD indices. Conclusion: The framework we developed requires limited drug- and species-specific information to reconstruct accurate PK dynamics, delivering a unified viewpoint on anti-TB drug distribution at the site-of-action and a flexible fit-for-purpose tool to accelerate model-informed drug design pipelines and facilitate translation into the clinic.
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Affiliation(s)
- Federico Reali
- Fondazione The Microsoft Research—University of Trento Centre for Computational and Systems Biology (COSBI), Rovereto, Italy
| | - Anna Fochesato
- Fondazione The Microsoft Research—University of Trento Centre for Computational and Systems Biology (COSBI), Rovereto, Italy
- Department of Mathematics, University of Trento, Povo, Italy
| | - Chanchala Kaddi
- Gates Medical Research Institute, Cambridge, MD, United States
| | - Roberto Visintainer
- Fondazione The Microsoft Research—University of Trento Centre for Computational and Systems Biology (COSBI), Rovereto, Italy
| | - Shayne Watson
- Gates Medical Research Institute, Cambridge, MD, United States
| | - Micha Levi
- Gates Medical Research Institute, Cambridge, MD, United States
| | | | - Karim Azer
- Gates Medical Research Institute, Cambridge, MD, United States
| | - Luca Marchetti
- Fondazione The Microsoft Research—University of Trento Centre for Computational and Systems Biology (COSBI), Rovereto, Italy
- Department of Cellular, Computational and Integrative Biology (CIBIO), University of Trento, Povo, Italy
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13
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Asif M, Qusty NF, Alghamdi S. An Overview of Various Rifampicin Analogs against Mycobacterium tuberculosis and their Drug Interactions. Med Chem 2024; 20:268-292. [PMID: 37855280 DOI: 10.2174/0115734064260853230926080134] [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: 06/10/2023] [Revised: 07/14/2023] [Accepted: 08/12/2023] [Indexed: 10/20/2023]
Abstract
The success of the TB control program is hampered by the major issue of drug-resistant tuberculosis (DR-TB). The situation has undoubtedly been made more difficult by the widespread and multidrug-resistant (XDR) strains of TB. The modification of existing anti-TB medications to produce derivatives that can function on resistant TB bacilli is one of the potential techniques to overcome drug resistance affordably and straightforwardly. In comparison to novel pharmaceuticals for drug research and progress, these may have a better half-life and greater bioavailability, be more efficient, and serve as inexpensive alternatives. Mycobacterium tuberculosis, which is drugsusceptible or drug-resistant, is effectively treated by several already prescribed medications and their derivatives. Due to this, the current review attempts to give a brief overview of the rifampicin derivatives that can overcome the parent drug's resistance and could, hence, act as useful substitutes. It has been found that one-third of the global population is affected by M. tuberculosis. The most common cause of infection-related death can range from latent TB to TB illness. Antibiotics in the rifamycin class, including rifampicin or rifampin (RIF), rifapentine (RPT), and others, have a special sterilizing effect on M. tuberculosis. We examine research focused on evaluating the safety, effectiveness, pharmacokinetics, pharmacodynamics, risk of medication interactions, and other characteristics of RIF analogs. Drug interactions are especially difficult with RIF because it must be taken every day for four months to treat latent TB infection. RIF continues to be the gold standard of treatment for drug-sensitive TB illness. RIF's safety profile is well known, and the two medicines' adverse reactions have varying degrees of frequency. The authorized once-weekly RPT regimen is insufficient, but greater dosages of either medication may reduce the amount of time needed to treat TB effectively.
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Affiliation(s)
- Mohammad Asif
- Department of Pharmaceutical Chemistry, Era College of Pharmacy, Era University, Lucknow, 226003, Uttar Pradesh, India
| | - Naeem F Qusty
- Laboratory Medicine Department, Faculty of Applied Medical Sciences, Umm Al‒Qura University, Makkah, 21955, Saudi Arabia
| | - Saad Alghamdi
- Laboratory Medicine Department, Faculty of Applied Medical Sciences, Umm Al‒Qura University, Makkah, 21955, Saudi Arabia
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14
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du Cros P, Greig J, Alffenaar JWC, Cross GB, Cousins C, Berry C, Khan U, Phillips PPJ, Velásquez GE, Furin J, Spigelman M, Denholm JT, Thi SS, Tiberi S, Huang GKL, Marks GB, Turkova A, Guglielmetti L, Chew KL, Nguyen HT, Ong CWM, Brigden G, Singh KP, Motta I, Lange C, Seddon JA, Nyang'wa BT, Maug AKJ, Gler MT, Dooley KE, Quelapio M, Tsogt B, Menzies D, Cox V, Upton CM, Skrahina A, McKenna L, Horsburgh CR, Dheda K, Marais BJ. Standards for clinical trials for treating TB. Int J Tuberc Lung Dis 2023; 27:885-898. [PMID: 38042969 PMCID: PMC10719894 DOI: 10.5588/ijtld.23.0341] [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: 07/25/2023] [Accepted: 08/21/2023] [Indexed: 12/04/2023] Open
Abstract
BACKGROUND: The value, speed of completion and robustness of the evidence generated by TB treatment trials could be improved by implementing standards for best practice.METHODS: A global panel of experts participated in a Delphi process, using a 7-point Likert scale to score and revise draft standards until consensus was reached.RESULTS: Eleven standards were defined: Standard 1, high quality data on TB regimens are essential to inform clinical and programmatic management; Standard 2, the research questions addressed by TB trials should be relevant to affected communities, who should be included in all trial stages; Standard 3, trials should make every effort to be as inclusive as possible; Standard 4, the most efficient trial designs should be considered to improve the evidence base as quickly and cost effectively as possible, without compromising quality; Standard 5, trial governance should be in line with accepted good clinical practice; Standard 6, trials should investigate and report strategies that promote optimal engagement in care; Standard 7, where possible, TB trials should include pharmacokinetic and pharmacodynamic components; Standard 8, outcomes should include frequency of disease recurrence and post-treatment sequelae; Standard 9, TB trials should aim to harmonise key outcomes and data structures across studies; Standard 10, TB trials should include biobanking; Standard 11, treatment trials should invest in capacity strengthening of local trial and TB programme staff.CONCLUSION: These standards should improve the efficiency and effectiveness of evidence generation, as well as the translation of research into policy and practice.
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Affiliation(s)
- P du Cros
- Burnet Institute, Melbourne, VIC, Monash Infectious Diseases, Monash Health, Melbourne, VIC, Australia
| | - J Greig
- Burnet Institute, Melbourne, VIC, Médecins Sans Frontières (MSF), Manson Unit, London, UK
| | - J-W C Alffenaar
- Sydney Infectious Diseases Institute (Sydney ID), and, School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Westmead Hospital, Sydney, NSW
| | - G B Cross
- Burnet Institute, Melbourne, VIC, Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| | - C Cousins
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, Institute of Clinical Trials and Methodology, University College London, London, UK
| | - C Berry
- Médecins Sans Frontières (MSF), Manson Unit, London, UK
| | - U Khan
- Interactive Research and Development Global, Singapore City, Singapore
| | - P P J Phillips
- UCSF Center for Tuberculosis, Division of Pulmonary and Critical Care Medicine, and
| | - G E Velásquez
- UCSF Center for Tuberculosis, Division of HIV, Infectious Diseases, and Global Medicine, University of California, San Francisco, San Francisco, CA
| | - J Furin
- Harvard Medical School, Department of Global Health and Social Medicine, Boston, MA
| | - M Spigelman
- Global Alliance for TB Drug Development, New York, NY, USA
| | - J T Denholm
- Victorian Tuberculosis Program, Melbourne Health, Melbourne, VIC, Department of Infectious Diseases, Peter Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne, VIC, Australia
| | - S S Thi
- Eswatini National TB Control Program, Mbabane, Kingdom of Eswatini
| | - S Tiberi
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, GlaxoSmithKline, London, UK
| | - G K L Huang
- Burnet Institute, Melbourne, VIC, Northern Health Infectious Diseases, Northern Health, Melbourne, VIC
| | - G B Marks
- School of Clinical Medicine, University of New South Wales, Sydney, NSW, Australia
| | - A Turkova
- Medical Research Council Clinical Trials Unit at University College London, London, UK
| | - L Guglielmetti
- Médecins Sans Frontières (MSF), Paris, Sorbonne Université, Institut national de la santé et de la recherche médicale, Unité 1135, Centre d'Immunologie et des Maladies Infectieuses, Paris, Assistance Publique Hôpitaux de Paris (APHP), Groupe Hospitalier Universitaire Sorbonne Université, Hôpital Pitié-Salpêtrière, Centre National de Référence des Mycobactéries et de la Résistance des Mycobactéries, Paris, France
| | - K L Chew
- Department of Laboratory Medicine, National University Hospital, Singapore City, Singapore
| | - H T Nguyen
- Research Department, Friends for International TB Relief, Ha Noi, Vietnam
| | - C W M Ong
- Infectious Diseases Translational Research Programme, Department of Medicine, National University of Singapore, Singapore City, Division of Infectious Diseases, Department of Medicine, National University Hospital, Singapore City, Institute of Healthcare Innovation & Technology, National University of Singapore, Singapore City, Singapore
| | - G Brigden
- The Global Fund, Geneva, Switzerland
| | - K P Singh
- Department of Infectious Diseases, Peter Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne, VIC, Australia, Victorian Infectious Disease Unit, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | | | - C Lange
- Division of Clinical Infectious Diseases, Research Center Borstel, Borstel, German Center for Infection Research (DZIF), TTU-TB, Borstel, Respiratory Medicine & International Health, University of Lübeck, Lübeck, Germany, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - J A Seddon
- Department of Infectious Disease, Imperial College London, London, UK, Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg, South Africa
| | - B-T Nyang'wa
- Public Health Department, Operational Center Amsterdam (OCA), MSF, Amsterdam, The Netherlands
| | - A K J Maug
- Damien Foundation Bangladesh, Dhaka, Bangladesh
| | - M T Gler
- De La Salle Medical and Health Sciences Institute, Dasmariñas, the Philippines
| | - K E Dooley
- Division of Infectious Diseases, Vanderbilt University Medical Center, Nashville, TN, USA
| | - M Quelapio
- Tropical Disease Foundation, Makati City, Manila, the Philippines, KNCV Tuberculosis Foundation, The Hague, The Netherlands
| | - B Tsogt
- Mongolian Anti-TB Coalition, Ulaanbaatar, Mongolia
| | - D Menzies
- Respiratory Epidemiology and Clinical Research Unit, Montreal Chest Institute & McGill International TB Centre, Montreal, QC, Canada
| | - V Cox
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town
| | - C M Upton
- TASK Applied Science, Cape Town, South Africa
| | - A Skrahina
- The Republican Scientific and Practical Center for Pulmonology and TB, Minsk, Belarus
| | - L McKenna
- Treatment Action Group, New York, NY
| | - C R Horsburgh
- Departments of Global Health, Epidemiology, Biostatistics and Medicine, Schools of Public Health and Medicine, Boston University, Boston MA, USA
| | - K 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
| | - B J Marais
- Sydney Infectious Diseases Institute (Sydney ID), and, The Children's Hospital at Westmead, Sydney, NSW, WHO Collaborating Centre in Tuberculosis, The University of Sydney, Sydney, NSW, Australia
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15
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Weir IR, Dufault SM, Phillips PP. Estimands for clinical endpoints in Tuberculosis treatment randomized controlled trials: a retrospective application in a completed trial. RESEARCH SQUARE 2023:rs.3.rs-3486707. [PMID: 37986887 PMCID: PMC10659528 DOI: 10.21203/rs.3.rs-3486707/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2023]
Abstract
Background Randomized trials for the treatment of tuberculosis (TB) rely on a composite primary outcome to capture unfavorable treatment responses. However, variability between trials in the outcome definition and estimation methods complicates across-trial comparisons and hinders the advancement of treatment guidelines. The International Council for Harmonization (ICH) provides international regulatory standards for clinical trials. The estimand framework outlined in the recent ICH E9(R1) addendum offers a timely opportunity for randomized trials of TB treatment to adopt broadly standardized outcome definitions and analytic approaches. We previously proposed and defined four estimands for use in this context. Our objective was to evaluate how the use of these estimands and choice of estimation method impacts results and interpretation of a large phase III TB trial. Methods We reanalyzed participant level data from the REMoxTB trial. We applied four estimands and various methods of estimation to assess non-inferiority of both novel 4-month treatment regimens against standard of care. Results With each of the four estimands we reached the same conclusion as the original trial analysis; that the novel regimens were not non-inferior to standard of care. Each estimand and method of estimation gave similar estimates of the treatment effect with fluctuations in variance and differences driven by the methods applied for handling intercurrent events. Conclusions Our application of estimands defined by the ICH E9(R1) addendum offers a formalized framework for addressing the primary TB treatment trial objective and can promote uniformity in future trials by limiting heterogeneity in trial outcome definitions. We demonstrated the utility of our proposal using data from the REMoxTB randomized trial. We outlined methods for estimating each estimand and found consistent conclusions across estimands. We recommend future late-phase TB treatment trials to implement some or all of our estimands to promote rigorous outcome definitions and reduce variability between trials.Trial registration: NCT00864383.
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16
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Kim H, Shin SJ. Revolutionizing control strategies against Mycobacterium tuberculosis infection through selected targeting of lipid metabolism. Cell Mol Life Sci 2023; 80:291. [PMID: 37704889 PMCID: PMC11072447 DOI: 10.1007/s00018-023-04914-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 04/12/2023] [Accepted: 08/07/2023] [Indexed: 09/15/2023]
Abstract
Lipid species play a critical role in the growth and virulence expression of Mycobacterium tuberculosis (Mtb), the causative agent of tuberculosis (TB). During Mtb infection, foamy macrophages accumulate lipids in granulomas, providing metabolic adaptation and survival strategies for Mtb against multiple stresses. Host-derived lipid species, including triacylglycerol and cholesterol, can also contribute to the development of drug-tolerant Mtb, leading to reduced efficacy of antibiotics targeting the bacterial cell wall or transcription. Transcriptional and metabolic analyses indicate that lipid metabolism-associated factors of Mtb are highly regulated by antibiotics and ultimately affect treatment outcomes. Despite the well-known association between major antibiotics and lipid metabolites in TB treatment, a comprehensive understanding of how altered lipid metabolites in both host and Mtb influence treatment outcomes in a drug-specific manner is necessary to overcome drug tolerance. The current review explores the controversies and correlations between lipids and drug efficacy in various Mtb infection models and proposes novel approaches to enhance the efficacy of anti-TB drugs. Moreover, the review provides insights into the efficacious control of Mtb infection by elucidating the impact of lipids on drug efficacy. This review aims to improve the effectiveness of current anti-TB drugs and facilitate the development of innovative therapeutic strategies against Mtb infection by making reverse use of Mtb-favoring lipid species.
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Affiliation(s)
- Hagyu Kim
- Department of Microbiology, Institute for Immunology and Immunological Disease, Graduate School of Medical Science, Brain Korea 21 Project, Yonsei University College of Medicine, Seoul, South Korea
| | - Sung Jae Shin
- Department of Microbiology, Institute for Immunology and Immunological Disease, Graduate School of Medical Science, Brain Korea 21 Project, Yonsei University College of Medicine, Seoul, South Korea.
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17
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Jindani A, Atwine D, Grint D, Bah B, Adams J, Ticona ER, Shrestha B, Agizew T, Hamid S, Jamil B, Byamukama A, Kananura K, Mugisha Taremwa I, Bonnet M, Camara LM, Bah-Sow OY, Bah KS, Bah NM, Sow M, Ticona Huaroto CE, Mugruza Pineda R, Tandukar B, Raya BB, Shrestha N, Mathoma A, Mathebula-Modongo UP, Basotli J, Irfan M, Begum D, Muzammil A, Ahmed I, Hasan R, Burgos MV, Sultan F, Hassan M, Masood I, Robb C, Decker J, Grubnic S, Butcher PD, Witney A, Dhillon J, Munshi T, Fielding K, Harrison TS. Four-Month High-Dose Rifampicin Regimens for Pulmonary Tuberculosis. NEJM EVIDENCE 2023; 2:EVIDoa2300054. [PMID: 38320155 DOI: 10.1056/evidoa2300054] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
BACKGROUND: Shorter but effective tuberculosis treatment regimens would be of value to the tuberculosis treatment community. High-dose rifampicin has been associated with more rapid and secure lung sterilization and may enable shorter tuberculosis treatment regimens. METHODS: We randomly assigned adults who were given a diagnosis of rifampicin-susceptible pulmonary tuberculosis to a 6-month control regimen, a similar 4-month regimen of rifampicin at 1200 mg/d (study regimen 1 [SR1]), or a 4-month regimen of rifampicin at 1800 mg/d (study regimen 2 [SR2]). Sputum specimens were collected at regular intervals. The primary end point was a composite of treatment failure and relapse in participants who were sputum smear positive at baseline. The noninferiority margin was 8 percentage points. Using a sequence of ordered hypotheses, noninferiority of SR2 was tested first. RESULTS: Between January 2017 and December 2020, 672 patients were enrolled in six countries, including 191 in the control group, 192 in the SR1 group, and 195 in the SR2 group. Noninferiority was not shown. Favorable responses rates were 93, 90, and 87% in the control, SR1, and SR2 groups, respectively, for a country-adjusted absolute risk difference of 6.3 percentage points (90% confidence interval, 1.1 to 11.5) comparing SR2 with the control group. The proportions of participants experiencing a grade 3 or 4 adverse event were 4.0, 4.5, and 4.4% in the control, SR1, and SR2 groups, respectively. CONCLUSIONS: Four-month high-dose rifampicin regimens did not have dose-limiting toxicities or side effects but failed to meet noninferiority criteria compared with the standard 6-month control regimen for treatment of pulmonary tuberculosis. (Funded by the MRC/Wellcome Trust/DFID Joint Global Health Trials Scheme; ClinicalTrials.gov number, NCT02581527.)
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Affiliation(s)
- Amina Jindani
- Institute for Infection and Immunity, St. George's, University of London, London
| | - Daniel Atwine
- Epicentre/Mbarara Research Base, Mbarara, Uganda
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Daniel Grint
- London School of Hygiene and Tropical Medicine, London
| | - Boubacar Bah
- Centre Hospitalier Universitaire Ignace Deen, Conakry, Guinea
| | - Jack Adams
- Institute for Infection and Immunity, St. George's, University of London, London
| | | | - Bhabana Shrestha
- German Nepal TB Project (GENETUP)/Nepal Anti TB Association (NATA), Kathmandu, Nepal
| | | | - Saeed Hamid
- Aga Khan University Hospital, Karachi, Pakistan
| | | | | | | | | | - Maryline Bonnet
- Epicentre/Mbarara Research Base, Mbarara, Uganda
- University of Montpellier, Recherche translationelles sur le virus de l'immunodéficience humaine et les maladies infectieuses, Institut de recherche pour le developpement, Institut national de la santé et de la recherche médicale, Montpellier, France
| | | | | | - Kindy Sadio Bah
- Centre Hospitalier Universitaire Ignace Deen, Conakry, Guinea
| | - Nene Mamata Bah
- Centre Hospitalier Universitaire Ignace Deen, Conakry, Guinea
| | - Maimouna Sow
- Centre Hospitalier Universitaire Ignace Deen, Conakry, Guinea
| | | | | | - Bijesh Tandukar
- German Nepal TB Project (GENETUP)/Nepal Anti TB Association (NATA), Kathmandu, Nepal
| | - Bijendra Bhakta Raya
- German Nepal TB Project (GENETUP)/Nepal Anti TB Association (NATA), Kathmandu, Nepal
| | - Neko Shrestha
- German Nepal TB Project (GENETUP)/Nepal Anti TB Association (NATA), Kathmandu, Nepal
| | | | | | | | | | | | | | - Imran Ahmed
- Aga Khan University Hospital, Karachi, Pakistan
| | | | - Marcos V Burgos
- Division of Infectious Diseases, University of New Mexico, Albuquerque, NM
| | - Faisal Sultan
- Shaukat Khanum Research Centre and Cancer Hospital, Lahore, Pakistan
| | - Mariam Hassan
- Shaukat Khanum Research Centre and Cancer Hospital, Lahore, Pakistan
| | - Iqra Masood
- Shaukat Khanum Research Centre and Cancer Hospital, Lahore, Pakistan
| | - Claire Robb
- Institute for Infection and Immunity, St. George's, University of London, London
| | - Jonathan Decker
- Department of Respiratory Sciences, University of Leicester, Leicester, United Kingdom
| | - Sisa Grubnic
- Clinical Academic Group in Infection and Immunity, St. George's University Hospitals National Health Service Foundation Trust, London
| | - Philip D Butcher
- Institute for Infection and Immunity, St. George's, University of London, London
| | - Adam Witney
- Institute for Infection and Immunity, St. George's, University of London, London
| | - Jasvir Dhillon
- Institute for Infection and Immunity, St. George's, University of London, London
| | - Tulika Munshi
- Institute for Infection and Immunity, St. George's, University of London, London
| | | | - Thomas S Harrison
- Institute for Infection and Immunity, St. George's, University of London, London
- Clinical Academic Group in Infection and Immunity, St. George's University Hospitals National Health Service Foundation Trust, London
- Medical Reserach Council Centre for Medical Mycology, University of Exeter, Exeter, United Kingdom
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18
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Günther G, Kuhns M, Friesen I. [Update: Diagnostics and treatment of pulmonary tuberculosis]. Dtsch Med Wochenschr 2023; 148:1227-1235. [PMID: 37793615 DOI: 10.1055/a-1937-8337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/06/2023]
Abstract
Molecular diagnostic tools have changed the approach to the detection of Mycobacterium tuberculosis and associated drug-resistance substantially. PCR-based technologies allow a more rapid detection with higher diagnostic sensitivity in pulmonary and extrapulmonary specimens. However, a real point of care test, which needs minimal technical resources remains missing. Genome sequencing technologies are currently changing tuberculosis drug resistance testing, and for some questions are replacing phenotypic drug resistance testing, based on culture.New evidence on treatment for drug-sensitive tuberculosis allows shortening of treatment to 4 months, or in selected cases even to 2 months based on the use of fluoroquinolones, high dose rifamycins and newly developed TB medicines.Such developments will very likely simplify the management of tuberculosis, although prevention remains the most important pillar of any tuberculosis related public health strategy.
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19
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Motta I, Boeree M, Chesov D, Dheda K, Günther G, Horsburgh CR, Kherabi Y, Lange C, Lienhardt C, McIlleron HM, Paton NI, Stagg HR, Thwaites G, Udwadia Z, Van Crevel R, Velásquez GE, Wilkinson RJ, Guglielmetti L. Recent advances in the treatment of tuberculosis. Clin Microbiol Infect 2023:S1198-743X(23)00339-7. [PMID: 37482332 DOI: 10.1016/j.cmi.2023.07.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 07/12/2023] [Accepted: 07/18/2023] [Indexed: 07/25/2023]
Abstract
BACKGROUND Tuberculosis (TB) is a global health challenge and one of the leading causes of death worldwide. In the last decade, the TB treatment landscape has dramatically changed. After long years of stagnation, new compounds entered the market (bedaquiline, delamanid, and pretomanid) and phase III clinical trials have shown promising results towards shortening duration of treatment for both drug-susceptible (Study 31/A5349, TRUNCATE-TB, and SHINE) and drug-resistant TB (STREAM, NiX-TB, ZeNix, and TB-PRACTECAL). Dose optimization of rifamycins and repurposed drugs has also brought hopes of further development of safe and effective regimens. Consequently, international and WHO clinical guidelines have been updated multiple times in the last years to keep pace with these advances. OBJECTIVES This narrative review aims to summarize the state-of-the-art on treatment of drug-susceptible and drug-resistant TB, as well as recent trial results and an overview of ongoing clinical trials. SOURCES A non-systematic literature review was conducted in PubMed and MEDLINE, focusing on the treatment of TB. Ongoing clinical trials were listed according to the authors' knowledge and completed consulting clinicaltrials.gov and other publicly available websites (www.resisttb.org/clinical-trials-progress-report, www.newtbdrugs.org/pipeline/trials). CONTENT This review summarizes the recent, major changes in the landscape for drug-susceptible and drug-resistant treatment, with a specific focus on their potential impact on patient outcomes and programmatic TB management. Moreover, insights in host-directed therapies, and advances in pharmacokinetics and pharmacogenomics are discussed. A thorough outline of ongoing therapeutic clinical trials is presented, highlighting different approaches and goals in current TB clinical research. IMPLICATIONS Future research should be directed to individualize regimens and protect these recent breakthroughs by preventing and identifying the selection of drug resistance and providing widespread, affordable, patient-centred access to new treatment options for all people affected by TB.
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Affiliation(s)
- Ilaria Motta
- Médecins Sans Frontières, Manson Unit, London, United Kingdom
| | - Martin Boeree
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Dumitru Chesov
- Chiril Draganiuc Phthisiopneumology Institute, Chisinau, Moldova; Department of Pulmonology and Allergology, Nicolae Testemitanu State University of Medicine and Pharmacy, Chisinau, Moldova; Division of Clinical Infectious Diseases, Research Center Borstel, Borstel, Germany
| | - Keertan Dheda
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and UCT Lung Institute and South African MRC/UCT Centre for the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa; Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa; Faculty of Infectious and Tropical Diseases, Department of Immunology and Infection, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Gunar Günther
- Department of Pulmonology and Allergology, Inselspital, Bern University Hospital, Bern, Switzerland; Department of Medical Sciences, Faculty of Health Sciences, University of Namibia, Windhoek, Namibia
| | - Charles Robert Horsburgh
- Departments of Epidemiology, Biostatistics, Global Health and Medicine, Boston University, Boston, MA, United States
| | - Yousra Kherabi
- Infectious, and Tropical Diseases Department, Bichat-Claude Bernard Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Christoph Lange
- Division of Clinical Infectious Diseases, Research Center Borstel, Borstel, Germany; German Center for Infection Research (DZIF), Respiratory Medicine & International Health, University of Lübeck, Lübeck, Germany; Department of International Health/Infectious Diseases, University of Lübeck, Lübeck, Germany; Department of Pediatrics-Global Immigrant, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, United States
| | - Christian Lienhardt
- Department of Translational Research Applied to HIV and Infectious Diseases, Institut de Recherche pour le Développement, Montpellier, France; Department of Infectious Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Helen M McIlleron
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa; Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Nicholas I Paton
- Department of Infectious Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom; Department of Medicine, National University of Singapore, Singapore, Singapore
| | - Helen R Stagg
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Guy Thwaites
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Oxford University, Oxford, United Kingdom
| | - Zarir Udwadia
- Department of Internal Medicine and Pulmonology, Hinduja Hospital & Research Centre, Mumbai, India
| | - Reinout Van Crevel
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Oxford University, Oxford, United Kingdom
| | - Gustavo E Velásquez
- UCSF Center for Tuberculosis, University of California, San Francisco, San Francisco, CA, United States; Division of HIV, Infectious Diseases, and Global Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Robert J Wilkinson
- Francis Crick Institute, London, United Kingdom; Department of Infectious Diseases, Imperial College London, United Kingdom
| | - Lorenzo Guglielmetti
- Sorbonne Université, INSERM, U1135, Centre d'Immunologie et des Maladies Infectieuses (CIMI-Paris), Paris, France; AP-HP Sorbonne Université, Hôpital Pitié-Salpêtrière, Laboratoire de Bactériologie-Hygiène, Centre National de Référence des Mycobactéries et de la Résistance des Mycobactéries aux Antituberculeux, Paris, France.
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20
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Kim HJ, Lee YJ, Song MJ, Kwon BS, Kim YW, Lim SY, Lee YJ, Park JS, Cho YJ, Lee CT, Lee JH. Real-world experience of adverse reactions-necessitated rifampicin-sparing treatment for drug-susceptible pulmonary tuberculosis. Sci Rep 2023; 13:11275. [PMID: 37438379 DOI: 10.1038/s41598-023-38394-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 07/07/2023] [Indexed: 07/14/2023] Open
Abstract
Rifampicin is an important agent for tuberculosis treatment; however, it is often discontinued because of adverse reactions. The treatment regimen then can be administered as that for rifampicin-resistant tuberculosis, which can be toxic. We retrospectively reviewed 114 patients with drug-susceptible pulmonary tuberculosis who discontinued rifampicin due to adverse reactions during an 18 year period at a tertiary referral center, of which 92 (80.7%) exhibited favorable response. Hepatotoxicity was the leading cause of intolerance. Patients with a favorable response were younger and less likely to have comorbidities. The majority of patients were administered four medications during the intensive phase and three to four during the consolidative phase. For those with a favorable response, the median duration of treatment was 10.2 months and the most common intensive regimen was a combination of isoniazid, ethambutol, pyrazinamide, and fluoroquinolone (25%). The most common consolidation regimen was a combination of isoniazid, ethambutol, and fluoroquinolone (22.8%). Among the patients with a favorable response, two (2.2%) experienced recurrence after a follow-up of 3.4 (interquartile range 1.8-6.8) years. For patients with drug-susceptible pulmonary tuberculosis who do not tolerate rifampicin owing to its toxicity, a shorter regimen may be a useful alternative.
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Affiliation(s)
- Hyung-Jun Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ye Jin Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Myung Jin Song
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Byoung Soo Kwon
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Yeon Wook Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Sung Yoon Lim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Yeon-Joo Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jong Sun Park
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Young-Jae Cho
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Choon-Taek Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jae Ho Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea.
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea.
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21
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Lanni A, Iacobino A, Fattorini L, Giannoni F. Eradication of Drug-Tolerant Mycobacterium tuberculosis 2022: Where We Stand. Microorganisms 2023; 11:1511. [PMID: 37375013 DOI: 10.3390/microorganisms11061511] [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: 04/28/2023] [Revised: 05/26/2023] [Accepted: 06/03/2023] [Indexed: 06/29/2023] Open
Abstract
The lungs of tuberculosis (TB) patients contain a spectrum of granulomatous lesions, ranging from solid and well-vascularized cellular granulomas to avascular caseous granulomas. In solid granulomas, current therapy kills actively replicating (AR) intracellular bacilli, while in low-vascularized caseous granulomas the low-oxygen tension stimulates aerobic and microaerophilic AR bacilli to transit into non-replicating (NR), drug-tolerant and extracellular stages. These stages, which do not have genetic mutations and are often referred to as persisters, are difficult to eradicate due to low drug penetration inside the caseum and mycobacterial cell walls. The sputum of TB patients also contains viable bacilli called differentially detectable (DD) cells that, unlike persisters, grow in liquid, but not in solid media. This review provides a comprehensive update on drug combinations killing in vitro AR and drug-tolerant bacilli (persisters and DD cells), and sterilizing Mycobacterium tuberculosis-infected BALB/c and caseum-forming C3HeB/FeJ mice. These observations have been important for testing new drug combinations in noninferiority clinical trials, in order to shorten the duration of current regimens against TB. In 2022, the World Health Organization, following the results of one of these trials, supported the use of a 4-month regimen for the treatment of drug-susceptible TB as a possible alternative to the current 6-month regimen.
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Affiliation(s)
- Alessio Lanni
- Department of Infectious Diseases, Istituto Superiore di Sanità, Via Regina Elena 299, 00161 Rome, Italy
| | - Angelo Iacobino
- Department of Infectious Diseases, Istituto Superiore di Sanità, Via Regina Elena 299, 00161 Rome, Italy
| | - Lanfranco Fattorini
- Department of Infectious Diseases, Istituto Superiore di Sanità, Via Regina Elena 299, 00161 Rome, Italy
| | - Federico Giannoni
- Department of Infectious Diseases, Istituto Superiore di Sanità, Via Regina Elena 299, 00161 Rome, Italy
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22
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Budak M, Cicchese JM, Maiello P, Borish HJ, White AG, Chishti HB, Tomko J, Frye LJ, Fillmore D, Kracinovsky K, Sakal J, Scanga CA, Lin PL, Dartois V, Linderman JJ, Flynn JL, Kirschner DE. Optimizing tuberculosis treatment efficacy: Comparing the standard regimen with Moxifloxacin-containing regimens. PLoS Comput Biol 2023; 19:e1010823. [PMID: 37319311 PMCID: PMC10306236 DOI: 10.1371/journal.pcbi.1010823] [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: 12/15/2022] [Revised: 06/28/2023] [Accepted: 05/17/2023] [Indexed: 06/17/2023] Open
Abstract
Tuberculosis (TB) continues to be one of the deadliest infectious diseases in the world, causing ~1.5 million deaths every year. The World Health Organization initiated an End TB Strategy that aims to reduce TB-related deaths in 2035 by 95%. Recent research goals have focused on discovering more effective and more patient-friendly antibiotic drug regimens to increase patient compliance and decrease emergence of resistant TB. Moxifloxacin is one promising antibiotic that may improve the current standard regimen by shortening treatment time. Clinical trials and in vivo mouse studies suggest that regimens containing moxifloxacin have better bactericidal activity. However, testing every possible combination regimen with moxifloxacin either in vivo or clinically is not feasible due to experimental and clinical limitations. To identify better regimens more systematically, we simulated pharmacokinetics/pharmacodynamics of various regimens (with and without moxifloxacin) to evaluate efficacies, and then compared our predictions to both clinical trials and nonhuman primate studies performed herein. We used GranSim, our well-established hybrid agent-based model that simulates granuloma formation and antibiotic treatment, for this task. In addition, we established a multiple-objective optimization pipeline using GranSim to discover optimized regimens based on treatment objectives of interest, i.e., minimizing total drug dosage and lowering time needed to sterilize granulomas. Our approach can efficiently test many regimens and successfully identify optimal regimens to inform pre-clinical studies or clinical trials and ultimately accelerate the TB regimen discovery process.
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Affiliation(s)
- Maral Budak
- Department of Microbiology and Immunology, University of Michigan Medical School, Ann Arbor, Michigan, United States of America
| | - Joseph M. Cicchese
- Department of Chemical Engineering, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Pauline Maiello
- Department of Microbiology and Molecular Genetics and Center for Vaccine Research, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States of America
| | - H. Jacob Borish
- Department of Microbiology and Molecular Genetics and Center for Vaccine Research, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States of America
| | - Alexander G. White
- Department of Microbiology and Molecular Genetics and Center for Vaccine Research, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States of America
| | - Harris B. Chishti
- Department of Microbiology and Molecular Genetics and Center for Vaccine Research, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States of America
| | - Jaime Tomko
- Department of Microbiology and Molecular Genetics and Center for Vaccine Research, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States of America
| | - L. James Frye
- Department of Microbiology and Molecular Genetics and Center for Vaccine Research, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States of America
| | - Daniel Fillmore
- Department of Microbiology and Molecular Genetics and Center for Vaccine Research, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States of America
| | - Kara Kracinovsky
- Department of Microbiology and Molecular Genetics and Center for Vaccine Research, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States of America
| | - Jennifer Sakal
- Department of Microbiology and Molecular Genetics and Center for Vaccine Research, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States of America
| | - Charles A. Scanga
- Department of Microbiology and Molecular Genetics and Center for Vaccine Research, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States of America
| | - Philana Ling Lin
- Department of Microbiology and Molecular Genetics and Center for Vaccine Research, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States of America
| | - Véronique Dartois
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, New Jersey, United States of America
- Department of Medical Sciences, Hackensack Meridian School of Medicine, Nutley, New Jersey, United States of America
| | - Jennifer J. Linderman
- Department of Chemical Engineering, University of Michigan, Ann Arbor, Michigan, United States of America
| | - JoAnne L. Flynn
- Department of Microbiology and Molecular Genetics and Center for Vaccine Research, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States of America
| | - Denise E. Kirschner
- Department of Microbiology and Immunology, University of Michigan Medical School, Ann Arbor, Michigan, United States of America
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23
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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: 0] [Impact Index Per Article: 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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Sauer SM, Mitnick CD, Khan U, Hewison C, Bastard M, Holtzman D, Law S, Khan M, Padayachee S, Ahmed S, Isani AK, Krisnanda A, Vilbrun SC, Bektasov S, Kumsa A, Docteur W, Tintaya K, McNicol M, Atshemyan H, Voynilo T, Thwe TT, Seung K, Rich M, Huerga H, Khan P, Franke M. Estimating post-treatment recurrence after multidrug-resistant tuberculosis treatment among patients with and without HIV: the impact of assumptions about death and missing follow-up. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.05.24.23290472. [PMID: 37398252 PMCID: PMC10312883 DOI: 10.1101/2023.05.24.23290472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/04/2023]
Abstract
Background Quantification of recurrence risk following successful treatment is crucial to evaluating regimens for multidrug- or rifampicin-resistant (MDR/RR) tuberculosis (TB). However, such analyses are complicated when some patients die or become lost during post-treatment-follow-up. Methods We analyzed data on 1,991 patients who successfully completed a longer MDR/RR-TB regimen containing bedaquiline and/or delamanid between 2015 and 2018 in 16 countries. Using five approaches for handling post-treatment deaths, we estimated the six-month post-treatment TB recurrence risk overall, and by HIV status. We used inverse-probability-weighting to account for patients with missing follow-up and investigated the impact of potential bias from excluding these patients without applying inverse-probability weights. Results The estimated TB recurrence risk was 6.6 per 1000 (95% confidence interval (CI):3.2,11.2) when deaths were handled as non-recurrences, and 6.7 per 1000 (95% CI:2.8,12.2) when deaths were censored and inverse-probability weights were applied to account for the excluded deaths. The estimated risk of composite recurrence outcomes were 24.2 (95% CI:14.1,37.0), 10.5 (95% CI:5.6,16.6), and 7.8 (95% CI:3.9,13.2) per 1000 for recurrence or 1) any death, 2) death with unknown or TB-related cause, 3) TB-related death, respectively. Corresponding relative risks for HIV status varied in direction and magnitude. Exclusion of patients with missing follow-up without inverse-probability-weighting had a small but apparent impact on estimates. Conclusion The estimated six-month TB recurrence risk was low, and the association with HIV status was inconclusive due to few recurrence events. Estimation of post-treatment recurrence will be enhanced by explicit assumptions about deaths and appropriate adjustment for missing follow-up data.
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Feng Z, Miao Y, Peng Y, Sun F, Zhang Y, Li R, Ge S, Chen X, Song L, Li Y, Wang X, Zhang W. Optimizing (O) rifapentine-based (RI) regimen and shortening (EN) the treatment of drug-susceptible tuberculosis (T) (ORIENT) using an adaptive seamless design: study protocol of a multicenter randomized controlled trial. BMC Infect Dis 2023; 23:300. [PMID: 37158831 PMCID: PMC10165810 DOI: 10.1186/s12879-023-08264-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 04/18/2023] [Indexed: 05/10/2023] Open
Abstract
BACKGROUND Standard treatment for drug-susceptible tuberculosis (DS-TB) includes a multidrug regimen requiring at least 6 months of treatment, and this lengthy treatment easily leads to poor adherence. There is an urgent need to simplify and shorten treatment regimens to reduce interruption and adverse event rates, improve compliance, and reduce costs. METHODS ORIENT is a multicenter, randomized controlled, open-label, phase II/III, non-inferiority trial involving DS-TB patients to evaluate the safety and efficacy of short-term regimens compared with the standardized six-month treatment regimen. In stage 1, corresponding to a phase II trial, a total of 400 patients are randomly divided into four arms, stratified by site and the presence of lung cavitation. Investigational arms include 3 short-term regimens with rifapentine 10 mg/kg, 15 mg/kg, and 20 mg/kg, while the control arm uses the standardized six-month treatment regimen. A combination of rifapentine, isoniazid, pyrazinamide, and moxifloxacin is administered for 17 or 26 weeks in rifapentine arms, while a 26-week regimen containing rifampicin, isoniazid, pyrazinamide, and ethambutol is applied in the control arm. After the safety and preliminary effectiveness analysis of patients in stage 1, the control arm and the investigational arm meeting the conditions will enter into stage 2, which is equivalent to a phase III trial and will be expanded to recruit DS-TB patients. If all investigational arms do not meet the safety conditions, stage 2 will be canceled. In stage 1, the primary safety endpoint is permanent regimen discontinuation at 8 weeks after the first dose. The primary efficacy endpoint is the proportion of favorable outcomes at 78 weeks after the first dose for both two stages. DISCUSSION This trial will contribute to the optimal dose of rifapentine in the Chinese population and suggest the feasibility of the short-course treatment regimen containing high-dose rifapentine and moxifloxacin for DS-TB. TRIAL REGISTRATION The trial has been registered on ClinicalTrials.gov on 28 May 2022 with the identifier NCT05401071.
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Affiliation(s)
- Zhen Feng
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, National Medical Center for Infectious Diseases, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Yan Miao
- Shanghai Huashen Institute of Microbes and Infections, Shanghai, China
| | - Ying Peng
- Department of Tuberculosis Control and Prevention, Zhejiang Provincial Center for Disease Control and Prevention, Zhejiang Province, Hangzhou, People's Republic of China
| | - Feng Sun
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, National Medical Center for Infectious Diseases, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Yilin Zhang
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, National Medical Center for Infectious Diseases, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Rong Li
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, National Medical Center for Infectious Diseases, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Shijia Ge
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, National Medical Center for Infectious Diseases, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Xinchang Chen
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, National Medical Center for Infectious Diseases, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Lingyun Song
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, National Medical Center for Infectious Diseases, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Yang Li
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, National Medical Center for Infectious Diseases, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China.
| | - Xiaomeng Wang
- Department of Tuberculosis Control and Prevention, Zhejiang Provincial Center for Disease Control and Prevention, Zhejiang Province, Hangzhou, People's Republic of China.
| | - Wenhong Zhang
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, National Medical Center for Infectious Diseases, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China.
- Shanghai Huashen Institute of Microbes and Infections, Shanghai, China.
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26
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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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Cross GB, Sari IP, Kityo C, Lu Q, Pokharkar Y, Moorakonda RB, Thi HN, Do Q, Dalay VB, Gutierrez E, Balanag VM, Castillo RJ, Mugerwa H, Fanusi F, Kwan P, Chew KL, Paton NI, Kityo C, Mugerwa H, Tumukunde D, Akol J, Quyet D, Nguyen H, Hoang XS, Doan TH, Dalay V, Gutierrez E, Balanag V, Castillo RJ, Barcelo M, Veto RGMS, Baliwagan MBR, Balane G, Geronimo A, Flores RR, Pokharkar Y, Moorakonda RB, Lu Q, Ng X, Tan S, Paton NI, Cross GB, Sari IP, Chew KL, Fanusi F, Kwan P, Kelleher AD, Chang C. Rosuvastatin adjunctive therapy for rifampicin-susceptible pulmonary tuberculosis: a phase 2b, randomised, open-label, multicentre trial. THE LANCET INFECTIOUS DISEASES 2023:S1473-3099(23)00067-1. [DOI: 10.1016/s1473-3099(23)00067-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 01/16/2023] [Accepted: 01/30/2023] [Indexed: 04/01/2023]
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Manika K, Loukeri A, Sionidou M, Moschos C, Papavasileiou A. Treatment for tuberculosis due to sensitive strains: To shorten or not to shorten? PNEUMON 2023. [DOI: 10.18332/pne/156697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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Stagg HR, Thompson JA, Lipman MCI, Sloan DJ, Flook M, Fielding KL. Forgiveness Is the Attribute of the Strong: Nonadherence and Regimen Shortening in Drug-sensitive Tuberculosis. Am J Respir Crit Care Med 2023; 207:193-205. [PMID: 35952354 PMCID: PMC9893326 DOI: 10.1164/rccm.202201-0144oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 08/11/2022] [Indexed: 02/02/2023] Open
Abstract
Rationale: "Forgiveness" charts the ability of a drug or regimen to withstand nonadherence without negative clinical consequences. Objectives: We aimed to determine the influence of regimen length, regimen drugs, and dosing, and when during treatment nonadherence occurs on the forgiveness of antituberculosis regimens. Methods: Using data from three randomized controlled trials comparing experimental 4-month regimens for drug-sensitive tuberculosis with the standard 6-month regimen, we used generalized linear models to examine how the risk of a negative composite outcome changed as dose-taking decreased. The percentage of doses taken and the absolute number of doses missed were calculated during the intensive and continuation phases of treatment, and overall. A mediation analysis was undertaken to determine how much the association between intensive phase dose-taking and the negative composite outcome was mediated through continuation phase dose-taking. Measurements and Main Results: Forgiveness of the 4- and 6-month regimens did not differ for any treatment period. Importantly, 4-month regimens were no less forgiving of small numbers of absolute missed doses than the 6-month regimen (e.g., for 3-7 missed doses vs. no missed doses [baseline], 6-month regimen adjusted risk ratio 1.65 [95% confidence interval, 0.80-3.41] and 4-month regimens 1.80 [1.33-2.45]). No 4-month regimen was conclusively more forgiving than another. We found evidence of mediation by continuation phase dose-taking on the intensive phase dose-taking and negative composite outcome relationship. Conclusions: With the current appetite for, and progress toward, shorter drug-sensitive tuberculosis regimens worldwide, we offer reassurance that shorter regimens are not necessarily less forgiving of nonadherence. Given the importance of continuation phase adherence, patient support during this period should not be neglected.
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Affiliation(s)
- Helen R. Stagg
- Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Jennifer A. Thompson
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Marc C. I. Lipman
- Division of Medicine, University College London, London, United Kingdom
| | - Derek J. Sloan
- School of Medicine, University of St. Andrews, St. Andrews, United Kingdom; and
| | - Mary Flook
- Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Katherine L. Fielding
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
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Larkins-Ford J, Aldridge BB. Advances in the design of combination therapies for the treatment of tuberculosis. Expert Opin Drug Discov 2023; 18:83-97. [PMID: 36538813 PMCID: PMC9892364 DOI: 10.1080/17460441.2023.2157811] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 12/08/2022] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Tuberculosis requires lengthy multi-drug therapy. Mycobacterium tuberculosis occupies different tissue compartments during infection, making drug access and susceptibility patterns variable. Antibiotic combinations are needed to ensure each compartment of infection is reached with effective drug treatment. Despite drug combinations' role in treating tuberculosis, the design of such combinations has been tackled relatively late in the drug development process, limiting the number of drug combinations tested. In recent years, there has been significant progress using in vitro, in vivo, and computational methodologies to interrogate combination drug effects. AREAS COVERED This review discusses the advances in these methodologies and how they may be used in conjunction with new successful clinical trials of novel drug combinations to design optimized combination therapies for tuberculosis. Literature searches for approaches and experimental models used to evaluate drug combination effects were undertaken. EXPERT OPINION We are entering an era richer in combination drug effect and pharmacokinetic/pharmacodynamic data, genetic tools, and outcome measurement types. Application of computational modeling approaches that integrate these data and produce predictive models of clinical outcomes may enable the field to generate novel, effective multidrug therapies using existing and new drug combination backbones.
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Affiliation(s)
- Jonah Larkins-Ford
- Department of Molecular Biology and Microbiology and Tufts University School of Graduate Biomedical Sciences, Tufts University School of Medicine, Boston, MA, USA
- Stuart B. Levy Center for Integrated Management of Antimicrobial Resistance (CIMAR), Tufts University, Boston, MA, USA
- Current address: MarvelBiome Inc, Woburn, MA, USA
| | - Bree B. Aldridge
- Department of Molecular Biology and Microbiology and Tufts University School of Graduate Biomedical Sciences, Tufts University School of Medicine, Boston, MA, USA
- Stuart B. Levy Center for Integrated Management of Antimicrobial Resistance (CIMAR), Tufts University, Boston, MA, USA
- Department of Biomedical Engineering, Tufts University School of Engineering, Medford, MA, USA
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Liu Q, Zhu J, Dulberger CL, Stanley S, Wilson S, Chung ES, Wang X, Culviner P, Liu YJ, Hicks ND, Babunovic GH, Giffen SR, Aldridge BB, Garner EC, Rubin EJ, Chao MC, Fortune SM. Tuberculosis treatment failure associated with evolution of antibiotic resilience. Science 2022; 378:1111-1118. [PMID: 36480634 PMCID: PMC9968493 DOI: 10.1126/science.abq2787] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The widespread use of antibiotics has placed bacterial pathogens under intense pressure to evolve new survival mechanisms. Genomic analysis of 51,229 Mycobacterium tuberculosis (Mtb)clinical isolates has identified an essential transcriptional regulator, Rv1830, herein called resR for resilience regulator, as a frequent target of positive (adaptive) selection. resR mutants do not show canonical drug resistance or drug tolerance but instead shorten the post-antibiotic effect, meaning that they enable Mtb to resume growth after drug exposure substantially faster than wild-type strains. We refer to this phenotype as antibiotic resilience. ResR acts in a regulatory cascade with other transcription factors controlling cell growth and division, which are also under positive selection in clinical isolates of Mtb. Mutations of these genes are associated with treatment failure and the acquisition of canonical drug resistance.
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Affiliation(s)
- Qingyun Liu
- Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, Boston, MA 02115, USA
| | - Junhao Zhu
- Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, Boston, MA 02115, USA
| | - Charles L. Dulberger
- Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, Boston, MA 02115, USA,Department of Molecular and Cellular Biology, Harvard University, Boston, MA, USA
| | - Sydney Stanley
- Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, Boston, MA 02115, USA
| | - Sean Wilson
- Department of Molecular and Cellular Biology, Harvard University, Boston, MA, USA
| | - Eun Seon Chung
- Department of Molecular Biology and Microbiology, Tufts University School of Medicine, Boston, MA 02111, USA,Department of Biomedical Engineering, Tufts University School of Engineering, Medford, MA 02115, USA
| | - Xin Wang
- Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, Boston, MA 02115, USA
| | - Peter Culviner
- Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, Boston, MA 02115, USA
| | - Yue J. Liu
- Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, Boston, MA 02115, USA
| | - Nathan D. Hicks
- Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, Boston, MA 02115, USA
| | - Gregory H. Babunovic
- Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, Boston, MA 02115, USA
| | - Samantha R. Giffen
- Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, Boston, MA 02115, USA
| | - Bree B. Aldridge
- Department of Molecular Biology and Microbiology, Tufts University School of Medicine, Boston, MA 02111, USA,Department of Biomedical Engineering, Tufts University School of Engineering, Medford, MA 02115, USA
| | - Ethan C. Garner
- Department of Molecular and Cellular Biology, Harvard University, Boston, MA, USA
| | - Eric J. Rubin
- Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, Boston, MA 02115, USA
| | - Michael C. Chao
- Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, Boston, MA 02115, USA
| | - Sarah M. Fortune
- Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, Boston, MA 02115, USA,Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA,Corresponding author.
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Mishra S, Saito K. Clinically encountered growth phenotypes of tuberculosis-causing bacilli and their in vitro study: A review. Front Cell Infect Microbiol 2022; 12:1029111. [DOI: 10.3389/fcimb.2022.1029111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 10/20/2022] [Indexed: 11/11/2022] Open
Abstract
The clinical manifestations of tuberculosis (TB) vary widely in severity, site of infection, and outcomes of treatment—leading to simultaneous efforts to individualize therapy safely and to search for shorter regimens that can be successfully used across the clinical spectrum. In these endeavors, clinicians and researchers alike employ mycobacterial culture in rich media. However, even within the same patient, individual bacilli among the population can exhibit substantial variability in their culturability. Bacilli in vitro also demonstrate substantial heterogeneity in replication rate and cultivation requirements, as well as susceptibility to killing by antimicrobials. Understanding parallels in clinical, ex vivo and in vitro growth phenotype diversity may be key to identifying those phenotypes responsible for treatment failure, relapse, and the reactivation of bacilli that progresses TB infection to disease. This review briefly summarizes the current role of mycobacterial culture in the care of patients with TB and the ex vivo evidence of variability in TB culturability. We then discuss current advances in in vitro models that study heterogenous subpopulations within a genetically identical bulk culture, with an emphasis on the effect of oxidative stress on bacillary cultivation requirements. The review highlights the complexity that heterogeneity in mycobacterial growth brings to the interpretation of culture in clinical settings and research. It also underscores the intricacies present in the interplay between growth phenotypes and antimicrobial susceptibility. Better understanding of population dynamics and growth requirements over time and space promises to aid both the attempts to individualize TB treatment and to find uniformly effective therapies.
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Stanley S, Liu Q, Fortune SM. Mycobacterium tuberculosis functional genetic diversity, altered drug sensitivity, and precision medicine. Front Cell Infect Microbiol 2022; 12:1007958. [PMID: 36262182 PMCID: PMC9574059 DOI: 10.3389/fcimb.2022.1007958] [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] [Received: 07/31/2022] [Accepted: 09/14/2022] [Indexed: 01/27/2023] Open
Abstract
In the face of the unrelenting global burden of tuberculosis (TB), antibiotics remain our most effective tools to save lives and control the spread of Mycobacterium tuberculosis (Mtb). However, we confront a dual challenge in our use of antibiotics: simplifying and shortening the TB drug regimen while also limiting the emergence and propagation of antibiotic resistance. This task is now more feasible due to the increasing availability of bacterial genomic data at or near the point of care. These resources create an opportunity to envision how integration of bacterial genetic determinants of antibiotic response into treatment algorithms might transform TB care. Historically, Mtb drug resistance studies focused on mutations in genes encoding antibiotic targets and the resulting increases in the minimal inhibitory concentrations (MICs) above a breakpoint value. But recent progress in elucidating the effects of functional genetic diversity in Mtb has revealed various genetic loci that are associated with drug phenotypes such as low-level MIC increases and tolerance which predict the development of resistance and treatment failure. As a result, we are now poised to advance precision medicine approaches in TB treatment. By incorporating information regarding Mtb genetic characteristics into the development of drug regimens, clinical care which tailors antibiotic treatment to maximize the likelihood of success has come into reach.
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Affiliation(s)
- Sydney Stanley
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, MA, United States
| | - Qingyun Liu
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, MA, United States
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Pham TM, Tweed CD, Carpenter JR, Kahan BC, Nunn AJ, Crook AM, Esmail H, Goodall R, Phillips PPJ, White IR. Rethinking intercurrent events in defining estimands for tuberculosis trials. Clin Trials 2022; 19:522-533. [PMID: 35850542 PMCID: PMC9523802 DOI: 10.1177/17407745221103853] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
BACKGROUND/AIMS Tuberculosis remains one of the leading causes of death from an infectious disease globally. Both choices of outcome definitions and approaches to handling events happening post-randomisation can change the treatment effect being estimated, but these are often inconsistently described, thus inhibiting clear interpretation and comparison across trials. METHODS Starting from the ICH E9(R1) addendum's definition of an estimand, we use our experience of conducting large Phase III tuberculosis treatment trials and our understanding of the estimand framework to identify the key decisions regarding how different event types are handled in the primary outcome definition, and the important points that should be considered in making such decisions. A key issue is the handling of intercurrent (i.e. post-randomisation) events (ICEs) which affect interpretation of or preclude measurement of the intended final outcome. We consider common ICEs including treatment changes and treatment extension, poor adherence to randomised treatment, re-infection with a new strain of tuberculosis which is different from the original infection, and death. We use two completed tuberculosis trials (REMoxTB and STREAM Stage 1) as illustrative examples. These trials tested non-inferiority of new tuberculosis treatment regimens versus a control regimen. The primary outcome was a binary composite endpoint, 'favourable' or 'unfavourable', which was constructed from several components. RESULTS We propose the following improvements in handling the above-mentioned ICEs and loss to follow-up (a post-randomisation event that is not in itself an ICE). First, changes to allocated regimens should not necessarily be viewed as an unfavourable outcome; from the patient perspective, the potential harms associated with a change in the regimen should instead be directly quantified. Second, handling poor adherence to randomised treatment using a per-protocol analysis does not necessarily target a clear estimand; instead, it would be desirable to develop ways to estimate the treatment effects more relevant to programmatic settings. Third, re-infection with a new strain of tuberculosis could be handled with different strategies, depending on whether the outcome of interest is the ability to attain culture negativity from infection with any strain of tuberculosis, or specifically the presenting strain of tuberculosis. Fourth, where possible, death could be separated into tuberculosis-related and non-tuberculosis-related and handled using appropriate strategies. Finally, although some losses to follow-up would result in early treatment discontinuation, patients lost to follow-up before the end of the trial should not always be classified as having an unfavourable outcome. Instead, loss to follow-up should be separated from not completing the treatment, which is an ICE and may be considered as an unfavourable outcome. CONCLUSION The estimand framework clarifies many issues in tuberculosis trials but also challenges trialists to justify and improve their outcome definitions. Future trialists should consider all the above points in defining their outcomes.
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Affiliation(s)
| | | | - James R Carpenter
- MRC Clinical Trials Unit at UCL, London, UK
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | | | | | | | | | | | - Patrick PJ Phillips
- UCSF Center for Tuberculosis, University of California San Francisco, San Francisco, CA, USA
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Shah S, Khan A, Shahzad M, Mokhtar JA, Harakeh S, Kibria Z, Mehr A, Bano B, Ali A, Yousafzai YM. Determinants of Response at 2 Months of Treatment in a Cohort of Pakistani Patients with Pulmonary Tuberculosis. Antibiotics (Basel) 2022; 11:1307. [PMID: 36289965 PMCID: PMC9598398 DOI: 10.3390/antibiotics11101307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Revised: 09/16/2022] [Accepted: 09/21/2022] [Indexed: 04/06/2024] Open
Abstract
Mycobacterium tuberculosis infection continues to be a major global challenge. All patients with pulmonary tuberculosis are treated with a standard 6-month treatment regimen. Historical data suggest that even with shortened treatment, most patients achieve long-term remission. Risk stratification is a goal for reducing potentially toxic prolonged treatment. This study aimed to determine the factors associated with the early clearance of sputum acid-fast bacilli (AFB). A total of 297 freshly diagnosed patients with pulmonary tuberculosis were included and enrolled in this study. Information related to their ethno-demographic and anthropometric characteristics was collected. We also assessed their complete blood counts, and blood iron, folate, and vitamin B12 levels. We found that the presence of higher levels of acid-fast bacilli (AFB) in diagnostic sputum microscopy was the single most significant prognostic factor associated with early clearance of sputum AFB after 2 months of treatment. All of our patients achieved treatment success after 6 months of treatment and were disease free. Our results support the data obtained from previous studies indicating that AFB clearance at 2 months is unlikely to be a clinically useful biomarker or indicator for therapeutic stratification. Furthermore, demographic, anthropometric, and nutritional factors are not clinically useful biomarkers.
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Affiliation(s)
- Saeed Shah
- Institute of Pathology and Diagnostic Medicine, Khyber Medical University, Peshawar 25120, Pakistan; (S.S.); (A.K.); (A.A.)
| | - Asghar Khan
- Institute of Pathology and Diagnostic Medicine, Khyber Medical University, Peshawar 25120, Pakistan; (S.S.); (A.K.); (A.A.)
| | - Muhammad Shahzad
- Institute of Basic Medical Sciences, Khyber Medical University, Peshawar 25120, Pakistan; (M.S.); (A.M.); (B.B.)
- School of Biological Sciences, Health and Life Sciences Building, University of Reading, Whiteknights, Reading RG6 6AX, UK
| | - Jawahir A. Mokhtar
- Department of Medical Microbiology and Parasitology, Faculty of Medicine, King Abdulaziz University, Jeddah 21589, Saudi Arabia;
- Vaccine and Immunotherapy Unit, King Fahd Medical Research Center, King Abdulaziz University, Jeddah 21589, Saudi Arabia
| | - Steve Harakeh
- King Fahd Medical Research Center and Yousef Abdullatif Jameel Chair of Prophetic Medicine Application, Faculty of Medicine, King Abdulaziz University, Jeddah 21589, Saudi Arabia;
| | - Zeeshan Kibria
- Institute of Public Health and Social Sciences, Khyber Medical University, Peshawar 25120, Pakistan;
| | - Aneela Mehr
- Institute of Basic Medical Sciences, Khyber Medical University, Peshawar 25120, Pakistan; (M.S.); (A.M.); (B.B.)
| | - Bushra Bano
- Institute of Basic Medical Sciences, Khyber Medical University, Peshawar 25120, Pakistan; (M.S.); (A.M.); (B.B.)
| | - Asif Ali
- Institute of Pathology and Diagnostic Medicine, Khyber Medical University, Peshawar 25120, Pakistan; (S.S.); (A.K.); (A.A.)
- College of Medical Veterinary and Life Sciences, University of Glasgow, Glasgow G12 8QQ, UK
| | - Yasar Mehmood Yousafzai
- Institute of Pathology and Diagnostic Medicine, Khyber Medical University, Peshawar 25120, Pakistan; (S.S.); (A.K.); (A.A.)
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow G12 8QQ, UK
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Moxifloxacin-Mediated Killing of Mycobacterium tuberculosis Involves Respiratory Downshift, Reductive Stress, and Accumulation of Reactive Oxygen Species. Antimicrob Agents Chemother 2022; 66:e0059222. [PMID: 35975988 PMCID: PMC9487606 DOI: 10.1128/aac.00592-22] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Moxifloxacin is central to treatment of multidrug-resistant tuberculosis. Effects of moxifloxacin on the Mycobacterium tuberculosis redox state were explored to identify strategies for increasing lethality and reducing the prevalence of extensively resistant tuberculosis. A noninvasive redox biosensor and a reactive oxygen species (ROS)-sensitive dye revealed that moxifloxacin induces oxidative stress correlated with M. tuberculosis death. Moxifloxacin lethality was mitigated by supplementing bacterial cultures with an ROS scavenger (thiourea), an iron chelator (bipyridyl), and, after drug removal, an antioxidant enzyme (catalase). Lethality was also reduced by hypoxia and nutrient starvation. Moxifloxacin increased the expression of genes involved in the oxidative stress response, iron-sulfur cluster biogenesis, and DNA repair. Surprisingly, and in contrast with Escherichia coli studies, moxifloxacin decreased expression of genes involved in respiration, suppressed oxygen consumption, increased the NADH/NAD+ ratio, and increased the labile iron pool in M. tuberculosis. Lowering the NADH/NAD+ ratio in M. tuberculosis revealed that NADH-reductive stress facilitates an iron-mediated ROS surge and moxifloxacin lethality. Treatment with N-acetyl cysteine (NAC) accelerated respiration and ROS production, increased moxifloxacin lethality, and lowered the mutant prevention concentration. Moxifloxacin induced redox stress in M. tuberculosis inside macrophages, and cotreatment with NAC potentiated the antimycobacterial efficacy of moxifloxacin during nutrient starvation, inside macrophages, and in mice, where NAC restricted the emergence of resistance. Thus, NADH-reductive stress contributes to moxifloxacin-mediated killing of M. tuberculosis, and the respiration stimulator (NAC) enhances lethality and suppresses the emergence of drug resistance.
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Podany AT, Pham M, Sizemore E, Martinson N, Samaneka W, Mohapi L, Badal-Faesen S, Dawson R, Johnson JL, Mayanja H, Lalloo U, Whitworth WC, Pettit A, Campbell K, Phillips PPJ, Bryant K, Scott N, Vernon A, Kurbatova EV, Chaisson RE, Dorman SE, Nahid P, Swindells S, Dooley KE, Fletcher CV. Efavirenz Pharmacokinetics and Human Immunodeficiency Virus Type 1 (HIV-1) Viral Suppression Among Patients Receiving Tuberculosis Treatment Containing Daily High-Dose Rifapentine. Clin Infect Dis 2022; 75:560-566. [PMID: 34918028 PMCID: PMC9890454 DOI: 10.1093/cid/ciab1037] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND A 4-month regimen containing rifapentine and moxifloxacin has noninferior efficacy compared to the standard 6-month regimen for drug-sensitive tuberculosis. We evaluated the effect of regimens containing daily, high-dose rifapentine on efavirenz pharmacokinetics and viral suppression in patients with human immunodeficiency virus (HIV)-associated tuberculosis (TB). METHODS In the context of a Phase 3 randomized controlled trial, HIV-positive individuals already virally suppressed on efavirenz--containing antiretroviral therapy (ART) (EFV1), or newly initiating efavirenz (EFV2) received TB treatment containing rifapentine (1200 mg), isoniazid, pyrazinamide, and either ethambutol or moxifloxacin. Mid-interval efavirenz concentrations were measured (a) during ART and TB cotreatment (Weeks 4, 8, 12, and 17, different by EFV group) and (b) when ART was taken alone (pre- or post-TB treatment, Weeks 0 and 22). Apparent oral clearance (CL/F) was estimated and compared. Target mid-interval efavirenz concentrations were > 1 mg/L. Co-treatment was considered acceptable if > 80% of participants had mid-interval efavirenz concentrations meeting this target. RESULTS EFV1 and EFV2 included 70 and 41 evaluable participants, respectively. The geometric mean ratio comparing efavirenz CL/F with vs without TB drugs was 0.79 (90% confidence interval [CI] .72-.85) in EFV1 and 0.84 [90% CI .69-.97] in EFV2. The percent of participants with mid-interval efavirenz concentrations > 1mg/L in EFV1 at Weeks 0, 4, 8, and 17 was 96%, 96%, 88%, and 89%, respectively. In EFV2, at approximately 4 and 8 weeks post efavirenz initiation, the value was 98%. CONCLUSIONS TB treatment containing high-dose daily rifapentine modestly decreased (rather than increased) efavirenz clearance and therapeutic targets were met supporting the use of efavirenz with these regimens, without dose adjustment. CLINICAL TRIALS REGISTRATION NCT02410772.
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Affiliation(s)
| | - Michelle Pham
- University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Erin Sizemore
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Neil Martinson
- Perinatal HIV Research Unit (PHRU), University of the Witwatersrand, Johannesburg, South Africa
| | | | - Lerato Mohapi
- Perinatal HIV Research Unit (PHRU), University of the Witwatersrand, Johannesburg, South Africa
| | | | - Rod Dawson
- University of Cape Town Lung Institute, Cape Town, South Africa
| | | | - Harriet Mayanja
- Uganda- Case Western Reserve University Research Collaboration, Kampala, Uganda
| | - Umesh Lalloo
- Durban International Clinical Research Site, Durban, South Africa
| | | | - April Pettit
- Vanderbilt University, Nashville, Tennessee, USA
| | - Kayla Campbell
- University of Nebraska Medical Center, Omaha, Nebraska, USA
- University of Colorado, Denver, Colorado, USA
| | - Patrick P J Phillips
- University of California, San Francisco Center for Tuberculosis, San Francisco, California, USA
| | - Kia Bryant
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Nigel Scott
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Andrew Vernon
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | | | | | - Susan E Dorman
- Medical University of South Carolina, Columbia, South Carolina, USA
| | - Payam Nahid
- University of California, San Francisco Center for Tuberculosis, San Francisco, California, USA
| | | | - Kelly E Dooley
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Fox WS, Strydom N, Imperial MZ, Jarlsberg L, Savic RM. Examining non-adherence in the treatment of tuberculosis; the patterns that lead to failure. Br J Clin Pharmacol 2022. [PMID: 36036095 DOI: 10.1111/bcp.15515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 08/12/2022] [Accepted: 08/21/2022] [Indexed: 11/26/2022] Open
Abstract
AIM Adherence has been shown to be a major predictor of tuberculosis treatment failure and relapse. The current adherence metrics can be improved to provide higher resolution of adherence patterns and identify patients in need of alternative treatment interventions. We investigated how adherence patterns affect treatment outcomes, when adherence is likely to decrease during treatment and which patients are at risk of being non-adherent. METHODS Individual-level data were pooled from three clinical trials (N=3724) for treatment of drug susceptible tuberculosis where monthly or weekly adherence patterns were collected and adherence patterns were quantified to assess the impact of clustered missed doses versus randomly missed doses on tuberculosis treatment outcomes. Significance was determined through univariate and multivariate cox regression models. RESULTS Patients who miss doses in clusters have an increased hazard risk for unfavorable outcomes and missing as little as 4 treatment days in one month resulted in 61% higher risk of unfavorable outcomes compared to patients who missed no treatment days (p < 0.01). Patients older than 50, and patients that experienced an adverse event were associated with lower adherence. CONCLUSION Our results show that the pattern in which patients miss their drugs is important to their overall outcomes and missing treatment days in clusters rather than randomly increases the risk of poor outcomes. In the future more intensive and longitudinal adherence measurements will be valuable for clinical trials and regimen design and interpretation.
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Affiliation(s)
- William S Fox
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, CA, USA
| | - Natasha Strydom
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, CA, USA
| | - Marjorie Z Imperial
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, CA, USA
| | - Leah Jarlsberg
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, CA, USA
| | - Radojka M Savic
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, CA, USA
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Gallagher SK, Wang J, Lumbard K, Dodd LE, Proschan M. Noninferiority testing with censoring when the event rate is low. Stat Med 2022; 41:5102-5112. [PMID: 35995145 DOI: 10.1002/sim.9556] [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: 04/07/2021] [Revised: 07/19/2022] [Accepted: 07/29/2022] [Indexed: 11/09/2022]
Abstract
The PREDICT TB trial tests noninferiority of an abbreviated treatment regimen (arm A) vs a conventional treatment regimen (arm C). Treatment trials of drug-susceptible tuberculosis are expected to have low event rates (ie, relapse probabilities around 3-5%). We examine the question of what is the "best" way to test for noninferiority in a setting with low event rates. In a series of simulations supported by theoretical arguments, we examine operating characteristics of five tests, including normal approximation, exact, and simulation-based tests. Two of these tests are constructed from Kaplan-Meier based-estimators, which account for variable follow-up time (and those lost to follow-up). We evaluate the effect of loss to follow-up via simulations. We also examine the results of the five tests on a data set similar to PREDICT TB, the REMoxTB trial. We find that the normal approximation tests perform well, albeit with small type I error rate inflation. We also find that the Kaplan-Meier methods generally have larger power than the other tests, especially when there is between 10-30% loss to follow-up.
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Affiliation(s)
- Shannon K Gallagher
- Biostatistics Research Branch, Division of Clinical Research, National Institute of Allergy and Infectious Diseases, Rockville, Maryland, USA
| | - Jing Wang
- Clinical Monitoring Research Program Directorate, Frederick National Laboratory for Cancer Research, Frederick, Maryland, USA
| | - Keith Lumbard
- Clinical Monitoring Research Program Directorate, Frederick National Laboratory for Cancer Research, Frederick, Maryland, USA
| | - Lori E Dodd
- Biostatistics Research Branch, Division of Clinical Research, National Institute of Allergy and Infectious Diseases, Rockville, Maryland, USA
| | - Michael Proschan
- Biostatistics Research Branch, Division of Clinical Research, National Institute of Allergy and Infectious Diseases, Rockville, Maryland, USA
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Samuels AN, Wang ER, Harrison GA, Valenta JC, Stallings CL. Understanding the contribution of metabolism to Mycobacterium tuberculosis drug tolerance. Front Cell Infect Microbiol 2022; 12:958555. [PMID: 36072222 PMCID: PMC9441742 DOI: 10.3389/fcimb.2022.958555] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 07/29/2022] [Indexed: 11/29/2022] Open
Abstract
Treatment of Mycobacterium tuberculosis (Mtb) infections is particularly arduous. One challenge to effectively treating tuberculosis is that drug efficacy in vivo often fails to match drug efficacy in vitro. This is due to multiple reasons, including inadequate drug concentrations reaching Mtb at the site of infection and physiological changes of Mtb in response to host derived stresses that render the bacteria more tolerant to antibiotics. To more effectively and efficiently treat tuberculosis, it is necessary to better understand the physiologic state of Mtb that promotes drug tolerance in the host. Towards this end, multiple studies have converged on bacterial central carbon metabolism as a critical contributor to Mtb drug tolerance. In this review, we present the evidence that changes in central carbon metabolism can promote drug tolerance, depending on the environment surrounding Mtb. We posit that these metabolic pathways could be potential drug targets to stymie the development of drug tolerance and enhance the efficacy of current antimicrobial therapy.
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Affiliation(s)
| | | | | | | | - Christina L. Stallings
- Department of Molecular Microbiology, Washington University School of Medicine, Saint Louis, MO, United States
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Kwak N, Jeon D, Park Y, Kang YA, Kim KJ, Kim YR, Kwon BS, Kwon YS, Kim HJ, Lee JH, Lee JY, Lee JK, Mok J, Cheon M, Park J, Hahn S, Yim JJ. Treatment shortening of drug-sensitive pulmonary tuberculosis using high-dose rifampicin for 3 months after culture conversion (Hi-DoRi-3): a study protocol for an open-label randomized clinical trial. Trials 2022; 23:666. [PMID: 35978342 PMCID: PMC9387084 DOI: 10.1186/s13063-022-06631-z] [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] [Received: 11/30/2021] [Accepted: 08/03/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The standard treatment regimen for drug-sensitive tuberculosis (TB), comprising four companion drugs, requires a minimum duration of 6 months, and this lengthy treatment leads to poor adherence and increased toxicity. To improve rates of adherence, reduce adverse events, and lower costs, a simplified and shortened treatment regimen is warranted. METHODS This study is a multicenter, open-label randomized clinical trial of non-inferiority design that compares a new regimen with the conventional regimen for drug-sensitive pulmonary TB. The investigational group will use a regimen of high-dose rifampicin (30 mg/kg/day) with isoniazid and pyrazinamide, and the treatment will be maintained for 12 weeks after the achievement of negative conversion of sputum culture. The control group will be treated for 6 months with a World Health Organization-endorsed regimen consisting of isoniazid, rifampicin (10 mg/kg/day), ethambutol, and pyrazinamide. The primary endpoint is the proportion of unfavorable outcomes at 18 months after randomization. Secondary outcomes include time to unfavorable treatment outcome, time to culture conversion on liquid medium, treatment success rate at the end of treatment, proportion of recurrence at 18 months after randomization, time to recurrence after treatment completion, and adverse events of grade 3 or higher during the treatment. We predict a 10% unfavorable outcome for the control group, and 0% difference from the investigational group. Based on 80% verification power and a 2.5% one-sided significance level for a non-inferiority margin of 6%, 393 participants per group are required. Considering the 15% dropout rate, a total of 926 participants (463 in each group) will be recruited. DISCUSSION This study will inform on the feasibility of the treatment regimen using high-dose rifampicin with a shortened and individualized treatment duration for pulmonary TB. TRIAL REGISTRATION ClinicalTrials.gov NCT04485156 . Registered on July 24, 2020.
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Affiliation(s)
- Nakwon Kwak
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Doosoo Jeon
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - Youngmok Park
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Yonsei University College of Medicine, Severance Hospital, Seoul, South Korea
| | - Young Ae Kang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Yonsei University College of Medicine, Severance Hospital, Seoul, South Korea
| | - Kyung Jong Kim
- Department of R&D, Korean Institute of Tuberculosis, Cheongju, South Korea
| | - Young Ran Kim
- Clinical Research Section, International Tuberculosis Research Center, Seoul, South Korea
| | - Byoung Soo Kwon
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Yong-Soo Kwon
- Department of Internal Medicine, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, South Korea
| | - Hyung-Jun Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Jae Ho Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Ji Yeon Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, National Medical Center, Seoul, South Korea
| | - Jung-Kyu Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul, South Korea
| | - Jeongha Mok
- Division of Pulmonology, Allergy and Critical Care Medicine, Department of Internal Medicine, Pusan National University Hospital, Busan, South Korea
| | - Minkyoung Cheon
- Medical Research Collaborating Center, Seoul National University Hospital, Seoul, South Korea
| | - Jiwon Park
- Medical Research Collaborating Center, Seoul National University Hospital, Seoul, South Korea
| | - Seokyung Hahn
- Medical Research Collaborating Center, Seoul National University Hospital, Seoul, South Korea.,Department of Human Systems Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Jae-Joon Yim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea.
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Lu Q, Liu J, Yu Y, Liang HF, Zhang SQ, Li ZB, Chen JX, Xu QG, Li JC. ALB, HP, OAF and RBP4 as novel protein biomarkers for identifying cured patients with pulmonary tuberculosis by DIA. Clin Chim Acta 2022; 535:82-91. [PMID: 35964702 DOI: 10.1016/j.cca.2022.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 07/09/2022] [Accepted: 08/01/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND Pulmonary tuberculosis (TB) is a serious infectious disease that lacks robust blood-based biomarkers to identify cured TB. Some discharged patients are not fully cured and may relapse or even develop multidrug-resistant TB. This study is committed to finding proteomic-based plasma biomarkers to support establishing laboratory standards for clinical TB cure. METHODS Data-independent acquisition (DIA) was used to obtain the plasma protein expression profiles of TB patients at different treatment stages compared with healthy controls. Multivariate statistical methods and bioinformatics were used to analyze the data. RESULTS Bioinformatic analysis suggests coagulation dysfunction and vitamin and lipid metabolism disturbances in TB. Albumin (ALB), haptoglobin (HP), out at first protein homolog (OAF), and retinol-binding protein 4 (RBP4) can be used to establish a diagnostic model for the efficacy evaluation of TB with an area under the curve of 0.963, which could effectively distinguish untreated TB patients from cured patients. CONCLUSIONS Our research demonstrated that ALB, HP, OAF and RBP4 can be potential biomarkers for evaluating the efficacy of TB. These findings may provide experimental data for establishing the laboratory indicators of clinical TB cure and providing clinicians with new targets for exploring the underlying mechanisms of TB pathogenesis.
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Affiliation(s)
- Qiqi Lu
- The Medical Research Center, Yue Bei People's Hospital, Shantou University Medical College, Shaoguan 512025, China
| | - Jun Liu
- The Medical Research Center, Yue Bei People's Hospital, Shantou University Medical College, Shaoguan 512025, China
| | - Yi Yu
- The Medical Research Center, Yue Bei People's Hospital, Shantou University Medical College, Shaoguan 512025, China; The Central Laboratory, Yangjiang People's Hospital, Yangjiang 529500, China
| | - Hong-Feng Liang
- The Central Laboratory, Yangjiang People's Hospital, Yangjiang 529500, China
| | - Shan-Qiang Zhang
- The Medical Research Center, Yue Bei People's Hospital, Shantou University Medical College, Shaoguan 512025, China
| | - Zhi-Bin Li
- The Medical Research Center, Yue Bei People's Hospital, Shantou University Medical College, Shaoguan 512025, China; The Central Laboratory, Yangjiang People's Hospital, Yangjiang 529500, China; Institute of Cell Biology, Zhejiang University School of Medicine, Hangzhou 310058, China
| | - Jia-Xi Chen
- Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Taizhou 318050, China; Institute of Cell Biology, Zhejiang University School of Medicine, Hangzhou 310058, China
| | - Qiu-Gui Xu
- The Central Laboratory, Yangjiang People's Hospital, Yangjiang 529500, China
| | - Ji-Cheng Li
- The Medical Research Center, Yue Bei People's Hospital, Shantou University Medical College, Shaoguan 512025, China
- The Central Laboratory, Yangjiang People's Hospital, Yangjiang 529500, China
- Institute of Cell Biology, Zhejiang University School of Medicine, Hangzhou 310058, China
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LaHood A, Rahman R, McKenna L, Frick M, Mitnick CD. Comparing timelines and evidence available to support new TB, HIV, and HCV drug approvals: The same, only different. PLoS One 2022; 17:e0271102. [PMID: 35877601 PMCID: PMC9312388 DOI: 10.1371/journal.pone.0271102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 06/24/2022] [Indexed: 11/18/2022] Open
Abstract
Background Tuberculosis (TB), human immunodeficiency virus (HIV), and hepatitis C virus (HCV) share a global presence and propensity to disproportionately affect marginalized populations. However, over recent decades, many fewer drugs have been brought to market for TB than for the others. Although three new anti-TB drugs have been approved in the US or Europe in the last 10 years, uptake of these drugs has been limited. Using case examples of drugs developed recently for TB, HIV, and HCV, we explore possible reasons. We examine the use and effect of regulatory pathways intended to address weak economic incentives in the face of urgent, unmet needs; evaluate the extent of data underpinning authorizations for these indications; document development timelines and evidence available at the time of each approval; consider explanations for observed differences; and discuss the implications for clinical guidelines and use. Methods and findings For each indication, we selected two drugs: one recently approved and one approved between 2012 and 2014, when the first new anti-TB drug from a novel class in more than 40 years received marketing authorization. We calculated time from first published peer-reviewed evidence of activity to date of approval; the number of phase 1, 2, and 3 trials; the number of trial participants randomized to treatment arms containing the drug; and the total number of participants in each trial from the individual drug approval packages. We found that the two TB drugs took longer to gain approval (8.0 and 19.2 years for bedaquiline and pretomanid, respectively) despite availing of special regulatory pathways meant to expedite approval, when compared to the HIV (2.6 years for dolutegravir and 4.7 years for doravirine) and HCV drugs (3.2 and 1.6 years for sofosbuvir and glecaprevir/pibrentasvir, respectively). Moreover, fewer participants were studied prior to TB drug approvals (380 and 879) than prior to approvals for HIV (1598 and 979) and for HCV (2291 and 2448) drugs. Conclusions The dramatic disparities observed in TB drug development reaffirm the importance of several actions. Increased investment in TB research and development is necessary to rapidly advance drugs through the pipeline. Development plans and partnerships must provide safety and efficacy evidence on combinations and durations that are relevant to real-world use in heterogeneous populations. Reliable, validated surrogate markers of relapse-free cure are essential to decrease the duration and cost of TB treatment trials and increase the confidence and speed with which new regimens can advance. Lastly, regulators and normative bodies must maintain high evidentiary standards for authorization while ensuring timely and broad approval for TB drugs and regimens.
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Affiliation(s)
- Allison LaHood
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Rifat Rahman
- Harvard Medical School, Boston, Massachusetts, United States of America
| | - Lindsay McKenna
- Treatment Action Group, New York, New York, United States of America
| | - Mike Frick
- Treatment Action Group, New York, New York, United States of America
| | - Carole D. Mitnick
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
- * E-mail:
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Fehily SR, Al-Ani AH, Abdelmalak J, Rentch C, Zhang E, Denholm JT, Johnson D, Ng SC, Sharma V, Rubin DT, Gibson PR, Christensen B. Review article: latent tuberculosis in patients with inflammatory bowel diseases receiving immunosuppression-risks, screening, diagnosis and management. Aliment Pharmacol Ther 2022; 56:6-27. [PMID: 35596242 PMCID: PMC9325436 DOI: 10.1111/apt.16952] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 04/14/2022] [Accepted: 04/18/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND One quarter of the world's population has latent tuberculosis infection (LTBI). Systemic immunosuppression is a risk factor for LTBI reactivation and the development of active tuberculosis. Such reactivation carries a risk of significant morbidity and mortality. Despite the increasing global incidence of inflammatory bowel disease (IBD) and the use of immune-based therapies, current guidelines on the testing and treatment of LTBI in patients with IBD are haphazard with a paucity of evidence. AIM To review the screening, diagnostic practices and medical management of LTBI in patients with IBD. METHODS Published literature was reviewed, and recommendations for testing and treatment were synthesised by experts in both infectious diseases and IBD. RESULTS Screening for LTBI should be performed proactively and includes assessment of risk factors, an interferon-gamma releasing assay or tuberculin skin test and chest X-ray. LTBI treatment in patients with IBD is scenario-dependent, related to geographical endemicity, travel and other factors. Ideally, LTBI therapy should be used prior to immune suppression but can be applied concurrently where urgent IBD medical treatment is required. Management is best directed by a multidisciplinary team involving gastroenterologists, infectious diseases specialists and pharmacists. Ongoing surveillance is recommended during therapy. Newer LTBI therapies show promise, but medication interactions need to be considered. There are major gaps in evidence, particularly with specific newer therapeutic approaches to IBD. CONCLUSIONS Proactive screening for LTBI is essential in patients with IBD undergoing immune-suppressing therapy and several therapeutic strategies are available. Reporting of real-world experience is essential to refining current management recommendations.
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Affiliation(s)
- Sasha R Fehily
- Gastroenterology Department, St Vincent's Hospital, Melbourne, Victoria, Australia.,Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
| | - Aysha H Al-Ani
- Department of Medicine, University of Melbourne, Parkville, Victoria, Australia.,Gastroenterology Department, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Jonathan Abdelmalak
- Gastroenterology Department, Alfred Hospital, Melbourne, Victoria, Australia
| | - Clarissa Rentch
- Gastroenterology Department, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Eva Zhang
- Gastroenterology Department, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Justin T Denholm
- Department of Medicine, University of Melbourne, Parkville, Victoria, Australia.,Infectious Diseases Department, Royal Melbourne Hospital, Parkville, Victoria, Australia.,Victorian Tuberculosis Program, Melbourne, Victoria, Australia.,Department of Infectious Diseases, Doherty Institute, Parkville, Victoria, Australia
| | - Douglas Johnson
- Department of Medicine, University of Melbourne, Parkville, Victoria, Australia.,Infectious Diseases Department, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Siew C Ng
- Department of Medicine and Therapeutics, Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Vishal Sharma
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - David T Rubin
- University of Chicago Medicine Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, Illinois, USA
| | - Peter R Gibson
- Department of Gastroenterology, Monash University and Alfred Health, Melbourne, Victoria, Australia
| | - Britt Christensen
- Department of Medicine, University of Melbourne, Parkville, Victoria, Australia.,Gastroenterology Department, Royal Melbourne Hospital, Parkville, Victoria, Australia
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45
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Cantrell JM, Chung CH, Chandrasekaran S. Machine learning to design antimicrobial combination therapies: promises and pitfalls. Drug Discov Today 2022; 27:1639-1651. [DOI: 10.1016/j.drudis.2022.04.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 01/20/2022] [Accepted: 04/04/2022] [Indexed: 01/13/2023]
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46
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Esmail H, Macpherson L, Coussens AK, Houben RMGJ. Mind the gap - Managing tuberculosis across the disease spectrum. EBioMedicine 2022; 78:103928. [PMID: 35339424 PMCID: PMC9044004 DOI: 10.1016/j.ebiom.2022.103928] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 12/22/2021] [Accepted: 02/24/2022] [Indexed: 11/18/2022] Open
Abstract
We currently have a binomial approach to managing tuberculosis. Those with active disease, ideally confirmed microbiologically, are treated with a standard 6-month, multi-drug regimen and those with latent infection and no evidence of disease with shorter, one or two drug regimens. Clinicians frequently encounter patients that fall between these two management pathways with some but not all features of disease and this will occur more often with the increasing emphasis on chest X-ray-based systematic screening. The view of tuberculosis as a spectrum of disease states is being increasingly recognised and is leading to new diagnostic approaches for early disease. However, the 6-month regimen for treating disease was driven by the duration required to treat the most extensive forms of pulmonary TB and shorter durations appear sufficient for less extensive disease. It is time undertake clinical trials to better define the optimal treatment for tuberculosis across the disease spectrum.
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Affiliation(s)
- Hanif Esmail
- MRC Clinical Trials Unit at University College London, UK; Institute for Global Health, University College London, UK; Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, South Africa.
| | | | - Anna K Coussens
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, South Africa; Infectious Diseases and Immune Defense Division, The Walter and Eliza Hall Institute of Medical Research, Parkville, Australia; Department of Medical Biology, University of Melbourne, Parkville, Australia
| | - Rein M G J Houben
- TB Modelling Group, TB Centre, London School of Hygiene and Tropical Medicine, UK; Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, UK
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Kokesch-Himmelreich J, Treu A, Race AM, Walter K, Hölscher C, Römpp A. Do Anti-tuberculosis Drugs Reach Their Target?─High-Resolution Matrix-Assisted Laser Desorption/Ionization Mass Spectrometry Imaging Provides Information on Drug Penetration into Necrotic Granulomas. Anal Chem 2022; 94:5483-5492. [PMID: 35344339 DOI: 10.1021/acs.analchem.1c03462] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Tuberculosis (TB) is characterized by mycobacteria-harboring centrally necrotizing granulomas. The efficacy of anti-TB drugs depends on their ability to reach the bacteria in the center of these lesions. Therefore, we developed a mass spectrometry (MS) imaging workflow to evaluate drug penetration in tissue. We employed a specific mouse model that─in contrast to regular inbred mice─strongly resembles human TB pathology. Mycobacterium tuberculosis was inactivated in lung sections of these mice by γ-irradiation using a protocol that was optimized to be compatible with high spatial resolution MS imaging. Different distributions in necrotic granulomas could be observed for the anti-TB drugs clofazimine, pyrazinamide, and rifampicin at a pixel size of 30 μm. Clofazimine, imaged here for the first time in necrotic granulomas of mice, showed higher intensities in the surrounding tissue than in necrotic granulomas, confirming data observed in TB patients. Using high spatial resolution drug and lipid imaging (5 μm pixel size) in combination with a newly developed data analysis tool, we found that clofazimine does penetrate to some extent into necrotic granulomas and accumulates in the macrophages inside the granulomas. These results demonstrate that our imaging platform improves the predictive power of preclinical animal models. Our workflow is currently being applied in preclinical studies for novel anti-TB drugs within the German Center for Infection Research (DZIF). It can also be extended to other applications in drug development and beyond. In particular, our data analysis approach can be used to investigate diffusion processes by MS imaging in general.
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Affiliation(s)
- Julia Kokesch-Himmelreich
- Bioanalytical Sciences and Food Analysis, University of Bayreuth, Bayreuth 95447, Germany.,German Center for Infection Research (DZIF), Braunschweig 38124, Germany
| | - Axel Treu
- Bioanalytical Sciences and Food Analysis, University of Bayreuth, Bayreuth 95447, Germany.,German Center for Infection Research (DZIF), Braunschweig 38124, Germany
| | - Alan M Race
- Bioanalytical Sciences and Food Analysis, University of Bayreuth, Bayreuth 95447, Germany
| | - Kerstin Walter
- Infection Immunology, Leibniz Lung Center, Research Center Borstel, Borstel 23845, Germany.,German Center for Infection Research (DZIF), Braunschweig 38124, Germany
| | - Christoph Hölscher
- Infection Immunology, Leibniz Lung Center, Research Center Borstel, Borstel 23845, Germany.,German Center for Infection Research (DZIF), Braunschweig 38124, Germany
| | - Andreas Römpp
- Bioanalytical Sciences and Food Analysis, University of Bayreuth, Bayreuth 95447, Germany.,German Center for Infection Research (DZIF), Braunschweig 38124, Germany
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Ekqvist D, Bornefall A, Augustinsson D, Sönnerbrandt M, Nordvall MJ, Fredrikson M, Carlsson B, Sandstedt M, Simonsson USH, Alffenaar JWC, Paues J, Niward K. Safety and pharmacokinetics-pharmacodynamics of a shorter tuberculosis treatment with high-dose pyrazinamide and rifampicin: a study protocol of a phase II clinical trial (HighShort-RP). BMJ Open 2022; 12:e054788. [PMID: 35273049 PMCID: PMC8915351 DOI: 10.1136/bmjopen-2021-054788] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Increased dosing of rifampicin and pyrazinamide seems a viable strategy to shorten treatment and prevent relapse of drug-susceptible tuberculosis (TB), but safety and efficacy remains to be confirmed. This clinical trial aims to explore safety and pharmacokinetics-pharmacodynamics of a high-dose pyrazinamide-rifampicin regimen. METHODS AND ANALYSIS Adult patients with pulmonary TB admitted to six hospitals in Sweden and subjected to receive first-line treatment are included. Patients are randomised (1:3) to either 6-month standardised TB treatment or a 4-month regimen based on high-dose pyrazinamide (40 mg/kg) and rifampicin (35 mg/kg) along with standard doses of isoniazid and ethambutol. Plasma samples for measurement of drug exposure determined by liquid chromatography tandem-mass spectrometry are obtained at 0, 1, 2, 4, 6, 8, 12 and 24 hours, at day 1 and 14. Maximal drug concentration (Cmax) and area under the concentration-time curve (AUC0-24h) are estimated by non-compartmental analysis. Conditions for early model-informed precision dosing of high-dose pyrazinamide-rifampicin are pharmacometrically explored. Adverse drug effects are monitored throughout the study and graded according to Common Terminology Criteria for Adverse Events V.5.0. Early bactericidal activity is assessed by time to positivity in BACTEC MGIT 960 of induced sputum collected at day 0, 5, 8, 15 and week 8. Minimum inhibitory concentrations of first-line drugs are determined using broth microdilution. Disease severity is assessed with X-ray grading and a validated clinical scoring tool (TBscore II). Clinical outcome is registered according to WHO definitions (2020) in addition to occurrence of relapse after end of treatment. Primary endpoint is pyrazinamide AUC0-24h and main secondary endpoint is safety. ETHICS AND DISSEMINATION The study is approved by the Swedish Ethical Review Authority and the Swedish Medical Products Agency. Informed written consent is collected before study enrolment. The study results will be submitted to a peer-reviewed journal. TRIAL REGISTRATION NUMBER NCT04694586.
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Affiliation(s)
- David Ekqvist
- Department of Infectious Diseases, Region Östergötland, Linköping University, Linköping, Sweden
| | - Anna Bornefall
- Department of Infectious Diseases, Region Östergötland, Linköping, Sweden
| | | | | | - Michaela Jonsson Nordvall
- Department of Clinical Microbiology, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | | | - Björn Carlsson
- Department of Clinical Pharmacology, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Mårten Sandstedt
- Department of Radiology in Linköping, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | | | - Jan-Willem C Alffenaar
- School of Pharmacy, The University of Sydney Faculty of Medicine and Health, Sydney, New South Wales, Australia
- Sydney Institute for Infectious Diseases, The University of Sydney, Sydney, New South Wales, Australia
- Westmead Hospital, Sydney, New South Wales, Australia
| | - Jakob Paues
- Department of Infectious Diseases, and Department of Biomedical and Clinical Sciences, Linköping University, Linkoping, Sweden
| | - Katarina Niward
- Department of Infectious Diseases, and Department of Biomedical and Clinical Sciences, Linköping University, Linkoping, Sweden
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Abstract
Childhood tuberculosis (TB) has been underreported and underrepresented in TB statistics across the globe. Contributing factors include health system barriers, diagnostic barriers, and community barriers leading to an underdetected epidemic of childhood tuberculosis. Despite considerable progress in childhood TB management, there is a concerning gap in policy and practice in high-burden countries leading to missed opportunities for active case detection, early diagnosis and treatment of TB exposure, and infection and disease in children regardless of human immunodeficiency virus status. Bridging this gap requires multisectoral coordination and political commitment along with an eye to research and innovation with potential to scale.
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Affiliation(s)
- Sadia Shakoor
- Department of Pathology, Section of Microbiology, Aga Khan University, Supariwala Building, PO Box 3500, Karachi, Pakistan
| | - Fatima Mir
- Department of Pediatrics and Child Health, The Aga Khan University, Faculty Office Building, PO Box 3500, Stadium Road, Karachi 74800, Pakistan.
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50
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Moore DP, Hesseling AC, Marx FM. Prolonged-course tuberculosis treatment or secondary prevention for those at high risk of recurrence? Clin Microbiol Infect 2022; 28:631-633. [DOI: 10.1016/j.cmi.2022.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 01/13/2022] [Accepted: 01/17/2022] [Indexed: 11/03/2022]
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