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Ryckman TS, McQuaid CF, Cohen T, Menzies NA, Kendall EA. Projected health and economic effects of a pan-tuberculosis treatment regimen: a modelling study. Lancet Glob Health 2024; 12:e1629-e1637. [PMID: 39159654 DOI: 10.1016/s2214-109x(24)00284-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Revised: 06/28/2024] [Accepted: 06/30/2024] [Indexed: 08/21/2024]
Abstract
BACKGROUND A pan-tuberculosis regimen that could be initiated without knowledge of drug susceptibility has been proposed as an objective of tuberculosis regimen development. We modelled the health and economic benefits of such a regimen and analysed which of its features contribute most to impact and savings. METHODS We constructed a mathematical model of tuberculosis treatment parameterised with data from the published literature specific to three countries with a high tuberculosis burden (India, the Philippines, and South Africa). Our model simulated cohorts of newly diagnosed tuberculosis patients, including drug susceptibility testing if performed, regimen assignment, discontinuation, adherence, costs, and resulting outcomes of durable cure (microbiological cure without relapse), need for retreatment, or death. We compared a pan-tuberculosis regimen meeting the WHO 2023 target regimen profile against the standard of care of separate rifampicin-susceptible and rifampicin-resistant regimens. We estimated incremental cures; averted deaths, secondary cases, and costs; and prices below which a pan-tuberculosis regimen would be cost saving. We also assessed scenarios intended to describe which mechanisms of benefit from a pan-tuberculosis regimen (including improved characteristics compared with the current rifampicin-susceptible and rifampicin-resistant regimens and improved regimen assignment and retention in care for patients with rifampicin-resistant tuberculosis) would be most impactful. Results are presented as a range of means across countries with the most extreme 95% uncertainty intervals (UIs) from the three UI ranges. FINDINGS Compared with the standard of care, a pan-tuberculosis regimen could increase the proportion of patients durably cured after an initial treatment attempt from 69-71% (95% UI 57-80) to 75-76% (68-83), preventing 30-32% of the deaths (20-43) and 17-20% of the transmission (9-29) that occur after initial tuberculosis diagnosis. Considering savings to the health system and patients during and after the initial treatment attempt, the regimen could reduce non-drug costs by 32-42% (22-49) and would be cost saving at prices below US$170-340 (130-510). A rifamycin-containing regimen that otherwise met pan-tuberculosis targets yielded only slightly less impact, indicating that most of the benefits from a pan-tuberculosis regimen resulted from its improvements upon the rifampicin-susceptible standard of care. Eliminating non-adherence and treatment discontinuation, for example via a long-acting injectable regimen, increased health impact and savings. INTERPRETATION In countries with a high tuberculosis burden, a shorter, highly efficacious, safe, and tolerable regimen to treat all tuberculosis could yield substantial health improvements and savings. FUNDING Bill & Melinda Gates Foundation.
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Affiliation(s)
- Theresa S Ryckman
- Division of Infectious Diseases, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - C Finn McQuaid
- TB Modelling Group, TB Centre and Centre for Mathematical Modelling of Infectious Diseases, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Ted Cohen
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
| | - Nicolas A Menzies
- Department of Global Health and Population and Center for Health Decision Science, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Emily A Kendall
- Division of Infectious Diseases, Johns Hopkins School of Medicine, Baltimore, MD, USA
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Hoelscher M, Barros-Aguirre D, Dara M, Heinrich N, Sun E, Lange C, Tiberi S, Wells C. Candidate anti-tuberculosis medicines and regimens under clinical evaluation. Clin Microbiol Infect 2024; 30:1131-1138. [PMID: 38909687 DOI: 10.1016/j.cmi.2024.06.016] [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: 04/15/2024] [Revised: 06/14/2024] [Accepted: 06/15/2024] [Indexed: 06/25/2024]
Abstract
BACKGROUND Tuberculosis (TB) is the leading cause of mortality by an infectious disease worldwide. Despite national and international efforts, the world is not on track to end TB by 2030. Antibiotic treatment of TB is longer than for most infectious diseases and is complicated by frequent adverse events. To counter emerging Mycobacterium tuberculosis drug resistance and provide effective, safe drug treatments of shorter duration, novel anti-TB medicines, and treatment regimens are needed. Through a joint global effort, more candidate medicines are in the clinical phases of drug development than ever before. OBJECTIVES To review anti-TB medicines and treatment regimens under clinical evaluation for the future treatment of drug-susceptible and drug-resistant TB. SOURCES Pre-clinical and clinical studies on novel anti-TB drugs. CONTENT Description of novel protein synthesis inhibitors (oxazolidinones and oxaboroles), respiratory chain inhibitors (diarylquinolines and cytochrome bc1 complex inhibitor), cell wall inhibitors (decaprenylphosphoryl-β-d-ribose 2'-epimerase, inhibitors, thioamides, and carbapenems), and cholesterol metabolism inhibitor currently evaluated in clinical trials and novel clinical trial platforms for the evaluation of treatment regimens, rather than single entities. IMPLICATIONS A large number of potential anti-TB candidate medicines and innovations in clinical trial design for the evaluation of regimens, rather than single medicines, provide hope for improvements in the treatment of TB.
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Affiliation(s)
- Michael Hoelscher
- Institute of Infectious Diseases and Tropical Medicine, LMU University Hospital, Munich, Germany; German Centre for Infection Research, Partner Site Munich, Munich, Germany; Fraunhofer Institute ITMP, Immunology, Infection and Pandemic Research, Munich, Germany; Unit Global Health, Helmholtz Zentrum München, German Research Center for Environmental Health (HMGU), Neuherberg, Germany.
| | | | | | - Norbert Heinrich
- Institute of Infectious Diseases and Tropical Medicine, LMU University Hospital, Munich, Germany; German Centre for Infection Research, Partner Site Munich, Munich, Germany; Fraunhofer Institute ITMP, Immunology, Infection and Pandemic Research, Munich, Germany
| | - Eugene Sun
- TB Alliance, New York, NY, United States
| | - Christoph Lange
- Division of Clinical Infectious Diseases, Research Center Borstel, Borstel, Germany; German Center for Infection Research (DZIF), Partner Site Hamburg-Lübeck-Borstel-Riems, Borstel, Germany; Respiratory Medicine and International Health, University of Lübeck, Lübeck, Germany; Baylor College of Medicine and Texas Children Hospital, Global TB Program, Houston, TX, United States
| | - Simon Tiberi
- GSK, Brentford, United Kingdom; Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Charles Wells
- Bill & Melinda Gates Medical Research Institute, Cambridge, MA, United States
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Cevik M, Thompson LC, Upton C, Rolla VC, Malahleha M, Mmbaga B, Ngubane N, Abu Bakar Z, Rassool M, Variava E, Dawson R, Staples S, Lalloo U, Louw C, Conradie F, Eristavi M, Samoilova A, Skornyakov SN, Ntinginya NE, Haraka F, Praygod G, Mayanja-Kizza H, Caoili J, Balanag V, Dalcolmo MP, McHugh T, Hunt R, Solanki P, Bateson A, Crook AM, Fabiane S, Timm J, Sun E, Spigelman M, Sloan DJ, Gillespie SH. Bedaquiline-pretomanid-moxifloxacin-pyrazinamide for drug-sensitive and drug-resistant pulmonary tuberculosis treatment: a phase 2c, open-label, multicentre, partially randomised controlled trial. THE LANCET. INFECTIOUS DISEASES 2024; 24:1003-1014. [PMID: 38768617 DOI: 10.1016/s1473-3099(24)00223-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 03/25/2024] [Accepted: 03/26/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND The current tuberculosis (TB) drug development pipeline is being re-populated with candidates, including nitroimidazoles such as pretomanid, that exhibit a potential to shorten TB therapy by exerting a bactericidal effect on non-replicating bacilli. Based on results from preclinical and early clinical studies, a four-drug combination of bedaquiline, pretomanid, moxifloxacin, and pyrazinamide (BPaMZ) regimen was identified with treatment-shortening potential for both drug-susceptible (DS) and drug-resistant (DR) TB. This trial aimed to determine the safety and efficacy of BPaMZ. We compared 4 months of BPaMZ to the standard 6 months of isoniazid, rifampicin, pyrazinamide, and ethambutol (HRZE) in DS-TB. 6 months of BPaMZ was assessed in DR-TB. METHODS SimpliciTB was a partially randomised, phase 2c, open-label, clinical trial, recruiting participants at 26 sites in eight countries. Participants aged 18 years or older with pulmonary TB who were sputum smear positive for acid-fast bacilli were eligible for enrolment. Participants with DS-TB had Mycobacterium tuberculosis with sensitivity to rifampicin and isoniazid. Participants with DR-TB had M tuberculosis with resistance to rifampicin, isoniazid, or both. Participants with DS-TB were randomly allocated in a 1:1 ratio, stratified by HIV status and cavitation on chest radiograph, using balanced block randomisation with a fixed block size of four. The primary efficacy endpoint was time to sputum culture-negative status by 8 weeks; the key secondary endpoint was unfavourable outcome at week 52. A non-inferiority margin of 12% was chosen for the key secondary outcome. Safety and tolerability outcomes are presented as descriptive analyses. The efficacy analysis population contained patients who received at least one dose of medication and who had efficacy data available and had no major protocol violations. The safety population contained patients who received at least one dose of medication. This study is registered with ClinicalTrials.gov (NCT03338621) and is completed. FINDINGS Between July 30, 2018, and March 2, 2020, 455 participants were enrolled and received at least one dose of study treatment. 324 (71%) participants were male and 131 (29%) participants were female. 303 participants with DS-TB were randomly assigned to 4 months of BPaMZ (n=150) or HRZE (n=153). In a modified intention-to-treat (mITT) analysis, by week 8, 122 (84%) of 145 and 70 (47%) of 148 participants were culture-negative on 4 months of BPaMZ and HRZE, respectively, with a hazard ratio for earlier negative status of 2·93 (95% CI 2·17-3·96; p<0·0001). Median time to negative culture (TTN) was 6 weeks (IQR 4-8) on 4 months of BPaMZ and 11 weeks (6-12) on HRZE. 86% of participants with DR-TB receiving 6 months of BPaMZ (n=152) reached culture-negative status by week 8, with a median TTN of 5 weeks (IQR 3-7). At week 52, 120 (83%) of 144, 134 (93%) of 144, and 111 (83%) of 133 on 4 months of BPaMZ, HRZE, and 6 months of BPaMZ had favourable outcomes, respectively. Despite bacteriological efficacy, 4 months of BPaMZ did not meet the non-inferiority margin for the key secondary endpoint in the pre-defined mITT population due to higher withdrawal rates for adverse hepatic events. Non-inferiority was demonstrated in the per-protocol population confirming the effect of withdrawals with 4 months of BPaMZ. At least one liver-related treatment-emergent adverse effect (TEAE) occurred among 45 (30%) participants on 4 months of BPaMZ, 38 (25%) on HRZE, and 33 (22%) on 6 months of BPaMZ. Serious liver-related TEAEs were reported by 20 participants overall; 11 (7%) among those on 4 months of BPaMZ, one (1%) on HRZE, and eight (5%) on 6 months of BPaMZ. The most common reasons for discontinuation of trial treatment were hepatotoxicity (ten participants [2%]), increased hepatic enzymes (nine participants [2%]), QTcF prolongation (three participants [1%]), and hypersensitivity (two participants [<1%]). INTERPRETATION For DS-TB, BPaMZ successfully met the primary efficacy endpoint of sputum culture conversion. The regimen did not meet the key secondary efficacy endpoint due to adverse events resulting in treatment withdrawal. Our study demonstrated the potential for treatment-shortening efficacy of the BPaMZ regimen for DS-TB and DR-TB, providing clinical validation of a murine model widely used to identify such regimens. It also highlights that novel, treatment-shortening TB treatment regimens require an acceptable toxicity and tolerability profile with minimal monitoring in low-resource and high-burden settings. The increased risk of unpredictable severe hepatic adverse events with 4 months of BPaMZ would be a considerable obstacle to implementation of this regimen in settings with high burdens of TB with limited infrastructure for close surveillance of liver biochemistry. Future research should focus on improving the preclinical and early clinical detection and mitigation of safety issues together and further efforts to optimise shorter treatments. FUNDING TB Alliance.
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Affiliation(s)
- Muge Cevik
- Division of Infection and Global Health Research, School of Medicine, University of St Andrews, St Andrews, UK.
| | | | | | | | | | | | | | | | | | | | - Rodney Dawson
- University of Cape Town Lung Institute, Cape Town, South Africa
| | | | | | - Cheryl Louw
- Madibeng Centre for Research, Brits, South Africa
| | - Francesca Conradie
- Reproductive Health and HIV Research Unit (RHRU), University of the Witwatersrand, Johannesburg, South Africa
| | - Marika Eristavi
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Anastasia Samoilova
- Research Institute of Phthisiopulmonology of IM Sechenov First Moscow State Medical University, Moscow, Russia
| | - Sergey N Skornyakov
- Ural Research Institute for Phthisiopulmonology, National Medical Research Center of Tuberculosis and Infectious Diseases of Ministry of Health of the Russian Federation, Yekaterinburg, Russia
| | | | | | | | | | - Janice Caoili
- Tropical Disease Foundation, Makati City, Manila, Philippines
| | | | | | - Timothy McHugh
- UCL Centre for Clinical Microbiology, University College London, London, UK
| | - Robert Hunt
- UCL Centre for Clinical Microbiology, University College London, London, UK
| | - Priya Solanki
- UCL Centre for Clinical Microbiology, University College London, London, UK
| | - Anna Bateson
- UCL Centre for Clinical Microbiology, University College London, London, UK
| | - Angela M Crook
- MRC Clinical Trials Unit, University College London, London, UK
| | - Stella Fabiane
- MRC Clinical Trials Unit, University College London, London, UK
| | | | | | | | - Derek J Sloan
- Division of Infection and Global Health Research, School of Medicine, University of St Andrews, St Andrews, UK
| | - Stephen H Gillespie
- Division of Infection and Global Health Research, School of Medicine, University of St Andrews, St Andrews, UK
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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 2024; 30:1107-1114. [PMID: 37482332 DOI: 10.1016/j.cmi.2023.07.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [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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Gillespie SH, DiNardo AR, Georghiou SB, Sabiiti W, Kohli M, Panzner U, Kontsevaya I, Hittel N, Stuyver LJ, Tan JB, van Crevel R, Lange C, Thuong TNT, Heyckendorf J, Ruhwald M, Heinrich N. Developing biomarker assays to accelerate tuberculosis drug development: defining target product profiles. THE LANCET. MICROBE 2024; 5:100869. [PMID: 38735303 DOI: 10.1016/s2666-5247(24)00085-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 03/12/2024] [Accepted: 03/20/2024] [Indexed: 05/14/2024]
Abstract
Drug development for tuberculosis is hindered by the methodological limitations in the definitions of patient outcomes, particularly the slow organism growth and difficulty in obtaining suitable and representative samples throughout the treatment. We developed target product profiles for biomarker assays suitable for early-phase and late-phase clinical drug trials by consulting subject-matter experts on the desirable performance and operational characteristics of such assays for monitoring of tuberculosis treatment in drug trials. Minimal and optimal criteria were defined for scope, intended use, pricing, performance, and operational characteristics of the biomarkers. Early-stage trial assays should accurately quantify the number of viable bacilli, whereas late-stage trial assays should match the number, predict relapse-free cure, and replace culture conversion endpoints. The operational criteria reflect the infrastructure and resources available for drug trials. The effective tools should define the sterilising activity of the drug and lower the probability of treatment failure or relapse in people with tuberculosis. The target product profiles outlined in this Review should guide and de-risk the development of biomarker-based assays suitable for phase 2 and 3 clinical drug trials.
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Affiliation(s)
- Stephen H Gillespie
- Division of Infection and Global Health, School of Medicine, University of St Andrews, St Andrews, UK.
| | - Andrew R DiNardo
- Global TB Program, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA; Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, GA Nijmegen, Netherlands
| | | | - Wilber Sabiiti
- Division of Infection and Global Health, School of Medicine, University of St Andrews, St Andrews, UK
| | | | - Ursula Panzner
- Division of Infectious Diseases and Tropical Medicine, University Hospital, Ludwig-Maximilians-Universität München (LMU), Munich, Germany; German Center for Infection Research (DZIF), Partner Site Munich, Munich, Germany
| | - Irina Kontsevaya
- German Center for Infection Research (DZIF), Partner Site Hamburg-Lübeck-Borstel-Riems, Borstel, Germany; Department of Infectious Disease, Faculty of Medicine, Imperial College London, London, UK
| | - Norbert Hittel
- Janssen Global Public Health R&D, Janssen Pharmaceutica NV, Beerse, Belgium
| | | | | | - Reinout van Crevel
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, GA Nijmegen, Netherlands; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Christoph Lange
- Global TB Program, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA; Division of Clinical Infectious Diseases, Research Center Borstel, Borstel, Germany; German Center for Infection Research (DZIF), Clinical Tuberculosis Unit, Borstel, Germany; Respiratory Medicine & International Health, University of Lübeck, Lübeck, Germany
| | | | - Jan Heyckendorf
- Respiratory Medicine & International Health, University of Lübeck, Lübeck, Germany; Clinic for Internal Medicine I, University Hospital Schleswig-Holstein (UKSH) Campus Kiel, Kiel, Germany
| | | | - Norbert Heinrich
- Division of Infectious Diseases and Tropical Medicine, University Hospital, Ludwig-Maximilians-Universität München (LMU), Munich, Germany; German Center for Infection Research (DZIF), Partner Site Munich, Munich, Germany; Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Immunology, Infection and Pandemic Research, Munich, Germany
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Maiwall R, Kulkarni AV, Arab JP, Piano S. Acute liver failure. Lancet 2024; 404:789-802. [PMID: 39098320 DOI: 10.1016/s0140-6736(24)00693-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 03/13/2024] [Accepted: 04/03/2024] [Indexed: 08/06/2024]
Abstract
Acute liver failure (ALF) is a life-threatening disorder characterised by rapid deterioration of liver function, coagulopathy, and hepatic encephalopathy in the absence of pre-existing liver disease. The cause of ALF varies across the world. Common causes of ALF in adults include drug toxicity, hepatotropic and non-hepatotropic viruses, herbal and dietary supplements, antituberculosis drugs, and autoimmune hepatitis. The cause of liver failure affects the management and prognosis, and therefore extensive investigation for cause is strongly suggested. Sepsis with multiorgan failure and cerebral oedema remain the leading causes of death in patients with ALF and early identification and appropriate management can alter the course of ALF. Liver transplantation is the best current therapy, although the role of artificial liver support systems, particularly therapeutic plasma exchange, can be useful for patients with ALF, especially in non-transplant centres. In this Seminar, we discuss the cause, prognostic models, and management of ALF.
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Affiliation(s)
- Rakhi Maiwall
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India.
| | - Anand V Kulkarni
- Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Juan Pablo Arab
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Internal Medicine, Virginia Commonwealth University School of Medicine, Richmond, VA, USA; Departamento de Gastroenterologia, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Salvatore Piano
- Unit of Internal Medicine and Hepatology, Department of Medicine, University and Hospital of Padova, Padova, Italy
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Gao Y, Liao L, Xu Y, Huang J, Gao J, Li L. Bioinformatic Approaches Identify Hybrid Antibiotics against Tuberculosis via d-Amino Acid-Activating Adenylation Domains from Cordyceps militaris. JOURNAL OF NATURAL PRODUCTS 2024; 87:2110-2119. [PMID: 39052090 DOI: 10.1021/acs.jnatprod.4c00718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/27/2024]
Abstract
The development of tuberculosis (TB) therapy has been marked by the discovery of natural-product-derived streptomycin, followed by the introduction of NP-derived rifampicin, representing a significant milestone in the history of TB management. However, TB remains a global challenge, with the emergence of multidrug-resistant Mycobacterium tuberculosis highlighting the need for novel therapeutic agents. In this study, a bioinformatic approach was employed to investigate d-amino acid-activating adenylation domains, leading to the identification of cordysetin A (1), a novel trans-decalin tetramic acid antibiotic from the ascomycete fungi Cordyceps militaris. Cordysetin A (1) exhibits considerable activity against M. tuberculosis in vitro and in vivo while maintaining low cytotoxicity. These results reveal that the d-configuration of the amino acid within this hybrid polyketide-nonribosomal antibiotic is crucial for preserving its anti-tuberculosis efficacy. These findings emphasize the significant translational potential of cordysetin A as a promising candidate for TB treatment, furthering our understanding of bioinformatic approaches in the development of effective anti-tuberculosis agents.
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Affiliation(s)
- Yangle Gao
- Engineering Research Center of Industrial Microbiology, College of Life Sciences, Fujian Normal University, Fuzhou 350117, People's Republic of China
| | - Lijuan Liao
- Key BioAI Synthetica Lab for Natural Product Drug Discovery, College of Bee and Biomedical Sciences, Fujian Agriculture and Forestry University, Fuzhou 350002, People's Republic of China
- State Key Laboratory of Microbial Technology, Shandong University, Qingdao 266237, People's Republic of China
| | - Yuanteng Xu
- Department of Otorhinolaryngology-Head and Neck Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou 350004, People's Republic of China
| | - Jianzhong Huang
- Engineering Research Center of Industrial Microbiology, College of Life Sciences, Fujian Normal University, Fuzhou 350117, People's Republic of China
| | - Jiangtao Gao
- Key BioAI Synthetica Lab for Natural Product Drug Discovery, College of Bee and Biomedical Sciences, Fujian Agriculture and Forestry University, Fuzhou 350002, People's Republic of China
| | - Li Li
- Engineering Research Center of Industrial Microbiology, College of Life Sciences, Fujian Normal University, Fuzhou 350117, People's Republic of China
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Ghanem M, Srivastava R, Ektefaie Y, Hoppes D, Rosenfeld G, Yaniv Z, Grinev A, Xu AY, Yang E, Velásquez GE, Harrison L, Rosenthal A, Savic RM, Jacobson KR, Farhat MR. Percent of lung involved in disease on chest X-ray predicts unfavorable treatment outcome in pulmonary tuberculosis. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.08.19.24311411. [PMID: 39228708 PMCID: PMC11370523 DOI: 10.1101/2024.08.19.24311411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/05/2024]
Abstract
Radiology may better define tuberculosis (TB) severity and guide duration of treatment. We aimed to systematically study baseline chest X-rays (CXR) and their association with TB treatment outcome using real-world data. We used logistic regression to associate TB treatment outcomes with CXR findings, including percent of lung involved in disease (PLI), cavitation, and Timika score, alone or in combination with other clinical characteristics, stratifying by drug resistance status and HIV (n = 2,809). We fine-tuned convolutional neural nets (CNN) to automate PLI measurement from the CXR DICOM images (n = 5,261). PLI is the only CXR finding associated with unfavorable outcome across drug resistance and HIV subgroups [Rifampicin-susceptible disease without HIV, adjusted odds ratio (aOR) 1·11 (1·01, 1·22), P-value 0·025]. The most informed model of baseline characteristics tested predicts outcome with a validation mean area under the curve (AUC) of 0·769. PLI and Timika (AUC 0·656 and 0·655 respectively) predict unfavorable outcomes better than cavitary information (best AUC 0·591). The addition of PLI improves prediction compared to sex and age alone (AUC 0·680 and 0·627, respectively).PLI>25% provides a better separation of favorable and unfavorable outcomes compared to PLI>50%. The best performing ensemble of CNNs has an AUC 0·850 for PLI>25% and mean absolute error of 11·7% for the PLI value. PLI is better than cavitation for predicting unfavorable treatment outcome in pulmonary TB in non-clinical trial settings and it can be accurately and automatically predicted with CNNs. One Sentence Summary The percent of lung involved in disease improves prediction of unfavorable outcomes in pulmonary tuberculosis when added to clinical characteristics.
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9
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Zainabadi K, Vilbrun SC, Mathurin LD, Walsh KF, Pape JW, Fitzgerald DW, Lee MH. A Bedaquiline, Pyrazinamide, Levofloxacin, Linezolid, and Clofazimine Second-line Regimen for Tuberculosis Displays Similar Early Bactericidal Activity as the Standard Rifampin-Based First-line Regimen. J Infect Dis 2024; 230:e447-e456. [PMID: 38060827 PMCID: PMC11326837 DOI: 10.1093/infdis/jiad564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 11/29/2023] [Accepted: 12/04/2023] [Indexed: 05/08/2024] Open
Abstract
BACKGROUND In 2018 the World Health Organization recommended a switch to an all oral bedaquiline-based second-line regimen for treatment of drug-resistant tuberculosis (DR-TB). How these new second-line regimens fare in comparison to first-line regimens for treatment of drug-sensitive tuberculosis (DS-TB) is not well known. METHODS In this study, we contemporaneously enrolled subjects with DS-TB (n = 31) or DR-TB (n = 23) and assessed their response to therapy with first-line (rifampin, isoniazid, ethambutol, pyrazinamide) or second-line (bedaquiline, pyrazinamide, levofloxacin, linezolid, clofazimine) regimens, respectively. RESULTS We found that the early bactericidal activity of first- and second-line regimens was similar during the first 2 weeks of therapy as determined by BACTEC MGIT, colony-forming units, and a liquid limiting dilution assay capable of detecting differentially detectable/culturable Mycobacterium tuberculosis. Furthermore, an identical percentage (77.8%) of subjects from the DS-TB and DR-TB cohorts converted to culture negative after 2 months of therapy. CONCLUSIONS Despite presenting with more advanced disease at time of treatment, subjects with DR-TB receiving an all oral bedaquiline-based second-line treatment regimen displayed a similar microbiological response to therapy as subjects with DS-TB receiving a first-line treatment regimen.
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Affiliation(s)
- Kayvan Zainabadi
- Center for Global Health, Weill Cornell Medicine, NewYork, New York
| | | | | | - Kathleen Frances Walsh
- Center for Global Health, Weill Cornell Medicine, NewYork, New York
- Division of General Internal Medicine, Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Jean William Pape
- Center for Global Health, Weill Cornell Medicine, NewYork, New York
- Les Centres GHESKIO, Port-au-Prince, Haiti
| | | | - Myung Hee Lee
- Center for Global Health, Weill Cornell Medicine, NewYork, New York
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10
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Shaw ES, Stoker NG, Potter JL, Claassen H, Leslie A, Tweed CD, Chiang CY, Conradie F, Esmail H, Lange C, Pinto L, Rucsineanu O, Sloan DJ, Theron G, Tisile P, Voo TC, Warren RM, Lebina L, Lipman M. Bedaquiline: what might the future hold? THE LANCET. MICROBE 2024:100909. [PMID: 39074472 DOI: 10.1016/s2666-5247(24)00149-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 05/27/2024] [Accepted: 05/29/2024] [Indexed: 07/31/2024]
Abstract
Tuberculosis drug development has stagnated for decades, so the recent availability of bedaquiline is welcome. Bedaquiline-containing regimens, now the first-line therapy recommended by WHO, have transformed the treatment of drug-resistant tuberculosis, offering safer and more effective oral treatment options. However, key obstacles need to be overcome to ensure global access and prevent the rapid development of resistance against this promising class of drugs. In this Personal View, building on an international workshop held in 2023, we evaluate the current evidence and suggest possible ways forward, recognising the tension between increasing use and slowing the rise of resistance. We also discuss problems in accessing bedaquiline-containing regimens, the potential widening of their use beyond drug-resistant tuberculosis, and lessons for utilising new drugs as they are developed.
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Affiliation(s)
- Emily S Shaw
- Division of Acute Medical Services, University College London Hospitals NHS Foundation Trust, London, UK.
| | - Neil G Stoker
- Centre for Clinical Microbiology, Royal Free Campus, University College London, London, UK
| | - Jessica L Potter
- Respiratory Medicine, Division of Medicine, University College London, London, UK; Department of Respiratory Medicine, North Middlesex University Hospital, London, UK
| | | | - Alasdair Leslie
- Department of Infection and Immunity, University College London, London, UK; Africa Health Research Institute, Durban, South Africa
| | - Conor D Tweed
- MRC Clinical Trials Unit, University College London, London, UK
| | - Chen-Yuan Chiang
- Division of Pulmonary Medicine, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan; Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; International Union Against Tuberculosis and Lung Disease, Paris, France
| | - Francesca Conradie
- Clinical HIV Research Unit, Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Hanif Esmail
- MRC Clinical Trials Unit, University College London, London, UK; Institute for Global Health, University College London, London, UK; Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Christoph Lange
- Respiratory Medicine & International Health, University of Lübeck, Lübeck, Germany; German Center of Infection Research (DZIF), Borstel, Germany; Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - Lancelot Pinto
- PD Hinduja National Hospital and Medical Research Centre, Mumbai, India
| | - Oxana Rucsineanu
- Moldova National Association of Tuberculosis Patients (SMIT), Bălți, Republic of Moldova
| | - Derek J Sloan
- School of Medicine, University of St Andrews, St Andrews, UK
| | - Grant Theron
- Department of Science and Innovation-National Research Foundation Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | | | | | - Robin M Warren
- Department of Science and Innovation - National Research Foundation Centre of Excellence for Biomedical Tuberculosis Research, Stellenbosch University, Cape Town, South Africa; South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | | | - Marc Lipman
- Respiratory Medicine, Division of Medicine, University College London, London, UK; Royal Free London NHS Foundation Trust, London, UK
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11
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Kamchedzera W, Quaife M, Msukwa-Panje W, Burke RM, Macpherson L, Kumwenda M, Twabi HH, Quartagno M, MacPherson P, Esmail H. Treatment preferences among people at risk of developing tuberculosis: A discrete choice experiment. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0002804. [PMID: 39028696 PMCID: PMC11259259 DOI: 10.1371/journal.pgph.0002804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 05/01/2024] [Indexed: 07/21/2024]
Abstract
Diagnosing and treating people with bacteriologically-negative but radiologically-apparent tuberculosis (TB) may contribute to more effective TB care and reduce transmission. However, optimal treatment approaches for this group are unknown. It is important to understand peoples' preferences of treatment options for effective programmatic implementation of people-centred treatment approaches. We designed and implemented a discrete choice experiment (DCE) to solicit treatment preferences among adults (≥18 years) with TB symptoms attending a primary health clinic in Blantyre, Malawi. Treatment attributes included in the DCE were as follows: duration of treatment; number of tablets per dose; reduction in the risk of being unwell with TB disease; likelihood of infecting others; adverse effects from the treatment; frequency of follow up; and the annual travel cost to access care. Quantitative choice modelling with multinomial logit models estimated through frequentist and Bayesian approaches investigated preferences for the management of bacteriologically-negative, but radiographically-apparent TB. 128 participants were recruited (57% male, 43.8% HIV-positive, 8.6% previously treated for TB). Participants preferred to take any treatment compared to not taking treatment (odds ratio [OR] 5.78; 95% confidence interval [CI]: 2.40, 13.90). Treatments that reduced the relative risk of developing TB disease by 80% were preferred (OR: 2.97; 95% CI: 2.09, 4.21) compared to treatments that lead to a lower reduction in risk of 50%. However, there was no evidence for treatments that are 95% effective being preferred over those that are 80% effective. Participants strongly favoured the treatments that could completely stop transmission (OR: 7.87, 95% CI: 5.71, 10.84), and prioritised avoiding side effects (OR: 0.19, 95% CI: 0.12, 0.29). There was no evidence of an interaction between perceived TB disease risk and treatment preferences. In summary, participants were primarily concerned with the effectiveness of TB treatments and strongly preferred treatments that removed the risk of onward transmission. Person-centred approaches of preferences for treatment should be considered when designing new treatment strategies. Understanding treatment preferences will ensure that any recommended treatment for probable early TB disease is well accepted and utilized by the public.
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Affiliation(s)
- Wala Kamchedzera
- Public Health Research Group, Malawi-Liverpool Wellcome Clinical Research Programme, Blantyre, Malawi
| | - Matthew Quaife
- Faculty of Epidemiology and Population Health, Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, England, United Kingdom
| | - Wezi Msukwa-Panje
- Public Health Research Group, Malawi-Liverpool Wellcome Clinical Research Programme, Blantyre, Malawi
| | - Rachael M. Burke
- Faculty of Infectious and Tropical Disease, Clinical Research Department, London School of Hygiene and Tropical Medicine, London, England, United Kingdom
| | - Liana Macpherson
- MRC Clinical Trials Unit at University College London, London, England, United Kingdom
| | - Moses Kumwenda
- Public Health Research Group, Malawi-Liverpool Wellcome Clinical Research Programme, Blantyre, Malawi
| | - Hussein H. Twabi
- Public Health Research Group, Malawi-Liverpool Wellcome Clinical Research Programme, Blantyre, Malawi
- Helse-Nord Tuberculosis Initiative, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Matteo Quartagno
- MRC Clinical Trials Unit at University College London, London, England, United Kingdom
| | - Peter MacPherson
- Public Health Research Group, Malawi-Liverpool Wellcome Clinical Research Programme, Blantyre, Malawi
- Faculty of Infectious and Tropical Disease, Clinical Research Department, London School of Hygiene and Tropical Medicine, London, England, United Kingdom
- School of Health and Wellbeing, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - Hanif Esmail
- MRC Clinical Trials Unit at University College London, London, England, United Kingdom
- WHO Collaborating Centre on Tuberculosis Research and Innovation, Institute for Global Health, University College London, London, United Kingdom
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12
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Verma R, da Silva KE, Rockwood N, Wasmann RE, Yende N, Song T, Kim E, Denti P, Wilkinson RJ, Andrews JR. A Nanopore Sequencing-based Pharmacogenomic Panel to Personalize Tuberculosis Drug Dosing. Am J Respir Crit Care Med 2024; 209:1486-1496. [PMID: 38647526 PMCID: PMC11208962 DOI: 10.1164/rccm.202309-1583oc] [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: 09/08/2023] [Accepted: 03/04/2024] [Indexed: 04/25/2024] Open
Abstract
Rationale: Standardized dosing of antitubercular drugs leads to variable plasma drug levels, which are associated with adverse drug reactions, delayed treatment response, and relapse. Mutations in genes affecting drug metabolism explain considerable interindividual pharmacokinetic variability; however, pharmacogenomic assays that predict metabolism of antitubercular drugs have been lacking. Objectives: We sought to develop a Nanopore sequencing panel and validate its performance in patients with active tuberculosis (TB) to personalize treatment dosing. Methods: We developed a Nanopore sequencing panel targeting 15 SNPs in five genes affecting the metabolism of antitubercular drugs. For validation, we sequenced DNA samples (n = 48) from the 1,000 Genomes Project and compared the variant calling accuracy with that of Illumina genome sequencing. We then sequenced DNA samples from patients with active TB (n = 100) from South Africa on a MinION Mk1C and evaluated the relationship between genotypes and pharmacokinetic parameters for isoniazid (INH) and rifampin (RIF). Measurements and Main Results: The pharmacogenomic panel achieved 100% concordance with Illumina sequencing in variant identification for the samples from the 1,000 Genomes Project. In the clinical cohort, coverage was more than 100× for 1,498 of 1,500 (99.8%) amplicons across the 100 samples. Thirty-three percent, 47%, and 20% of participants were identified as slow, intermediate, and rapid INH acetylators, respectively. INH clearance was 2.2 times higher among intermediate acetylators and 3.8 times higher among rapid acetylators, compared with slow acetylators (P < 0.0001). RIF clearance was 17.3% (2.50-29.9) lower in individuals with homozygous AADAC rs1803155 G→A substitutions (P = 0.0015). Conclusions: Targeted sequencing can enable the detection of polymorphisms that influence TB drug metabolism on a low-cost, portable instrument to personalize dosing for TB treatment or prevention.
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Affiliation(s)
- Renu Verma
- Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, California
- Manipal Academy of Higher Education, Manipal, India
- Institute of Bioinformatics, International Tech Park, Bangalore, India
| | - Kesia Esther da Silva
- Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, California
| | - Neesha Rockwood
- Wellcome Center for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine and Department Medicine
- Department of Infectious Diseases, Imperial College, London, United Kingdom
- Department of Medical Microbiology and Immunology, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka; and
| | - Roeland E. Wasmann
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Nombuso Yende
- Department of Pathology and Institute of Infectious Disease and Molecular Medicine, and
| | - Taeksun Song
- Department of Pathology and Institute of Infectious Disease and Molecular Medicine, and
| | - Eugene Kim
- Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, California
| | - Paolo Denti
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Robert J. Wilkinson
- Wellcome Center for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine and Department Medicine
- Department of Infectious Diseases, Imperial College, London, United Kingdom
- Francis Crick Institute, London, United Kingdom
| | - Jason R. Andrews
- Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, California
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13
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Ryckman TS, Schumacher SG, Lienhardt C, Sweeney S, Dowdy DW, Mirzayev F, Kendall EA. Economic implications of novel regimens for tuberculosis treatment in three high-burden countries: a modelling analysis. Lancet Glob Health 2024; 12:e995-e1004. [PMID: 38762299 PMCID: PMC11126367 DOI: 10.1016/s2214-109x(24)00088-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 01/24/2024] [Accepted: 02/21/2024] [Indexed: 05/20/2024]
Abstract
BACKGROUND With numerous trials investigating novel drug combinations to treat tuberculosis, we aimed to evaluate the extent to which future improvements in tuberculosis treatment regimens could offset potential increases in drug costs. METHODS In this modelling analysis, we used an ingredients-based approach to estimate prices at which novel regimens for rifampin-susceptible and rifampin-resistant tuberculosis treatment would be cost-neutral or cost-effective compared with standards of care in India, the Philippines, and South Africa. We modelled regimens meeting targets set in the WHO's 2023 Target Regimen Profiles (TRPs). Our decision-analytical model tracked cohorts of adults initiating rifampin-susceptible or rifampin-resistant tuberculosis treatment, simulating their health outcomes and costs accumulated during and following treatment under standard-of-care and novel regimen scenarios. Price thresholds included short-term cost-neutrality (considering only savings accrued during treatment), medium-term cost-neutrality (additionally considering savings from averted retreatments and secondary cases), and cost-effectiveness (incorporating willingness-to-pay for improved health outcomes). FINDINGS Total medium-term costs per person treated using standard-of-care regimens were estimated at US$450 (95% uncertainty interval 310-630) in India, $560 (350-860) in the Philippines, and $730 (530-1090) in South Africa for rifampin-susceptible tuberculosis (current drug costs $46) and $2100 (1590-2810) in India, $2610 (2090-3280) in the Philippines, and $3790 (3090-4630) in South Africa for rifampin-resistant tuberculosis (current drug costs $432). A rifampin-susceptible tuberculosis regimen meeting the optimal targets defined in the TRPs could be cost-neutral in the short term at drug costs of $140 (90-210) per full course in India, $230 (130-380) in the Philippines, and $280 (180-460) in South Africa. For rifampin-resistant tuberculosis, short-term cost-neutral thresholds were higher with $930 (720-1230) in India, $1180 (980-1430) in the Philippines, and $1480 (1230-1780) in South Africa. Medium-term cost-neutral prices were approximately $50-100 higher than short-term cost-neutral prices for rifampin-susceptible tuberculosis and $250-550 higher for rifampin-resistant tuberculosis. Health system cost-neutral prices that excluded patient-borne costs were 45-70% lower (rifampin-susceptible regimens) and 15-50% lower (rifampin-resistant regimens) than the cost-neutral prices that included patient costs. Cost-effective prices were substantially higher. Shorter duration was the most important driver of medium-term savings with novel regimens, followed by ease of adherence. INTERPRETATION Improved tuberculosis regimens, particularly shorter regimens or those that facilitate better adherence, could reduce overall costs, potentially offsetting higher prices. FUNDING WHO.
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Affiliation(s)
- Theresa S Ryckman
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | | | - Christian Lienhardt
- Institut de Recherche pour le Développement, Université de Montpellier, Montpellier, France; Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Sedona Sweeney
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - David W Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Emily A Kendall
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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14
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Ruslami R, Fregonese F, Apriani L, Barss L, Bedingfield N, Chiang V, Cook VJ, Fisher D, Flores E, Fox GJ, Johnston J, Lim RK, Long R, Paulsen C, Nguyen TA, Nhung NV, Gibson D, Valiquette C, Benedetti A, Menzies D. High-dose, short-duration versus standard rifampicin for tuberculosis preventive treatment: a partially blinded, three-arm, non-inferiority, randomised, controlled trial. THE LANCET. RESPIRATORY MEDICINE 2024; 12:433-443. [PMID: 38552659 DOI: 10.1016/s2213-2600(24)00076-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Revised: 02/28/2024] [Accepted: 02/29/2024] [Indexed: 06/02/2024]
Abstract
BACKGROUND Tuberculosis preventive treatment (TPT) is a key component of tuberculosis elimination. To improve completion and reduce the burden for people and health systems, short, safe, and effective TPT regimens are needed. We aimed to compare safety and treatment completion of various doses and durations of rifampicin in people who were recommended to receive TPT. METHODS This partially blinded, parallel-arm, non-inferiority, randomised, controlled, phase 2b trial was done at seven university-affiliated clinics in Canada, Indonesia, and Viet Nam. Participants aged 10 years or older were included if they had an indication for TPT according to WHO guidelines for Indonesia and Viet Nam, or Canadian guidelines for Canadian sites, and a positive tuberculin skin test or interferon-γ release assay. Participants were randomly assigned (1:1:1) to receive oral rifampicin at 10 mg/kg once daily for 4 months (standard-dose group), 20 mg/kg daily for 2 months (20 mg/kg group), or 30 mg/kg daily for 2 months (30 mg/kg group). The randomisation sequence was computer generated with blocks of variable size (three, six, and nine) and stratified by country for Indonesia and Viet Nam, and by city within Canada. Participants and investigators were masked to dose in high-dose groups, but unmasked to duration in all groups. The two co-primary outcomes were safety (in the safety population, in which participants received at least one dose of the study drug) and treatment completion (in the modified intention-to-treat [mITT] population, excluding those ineligible after randomisation). Protocol-defined adverse events were defined as grade 3 or worse, or rash or allergy of any grade, judged by an independent and masked panel as possibly or probably related to the study. A margin of 4% was used to assess non-inferiority. This study is registered with ClinicalTrials.gov, NCT03988933 (active). FINDINGS Between Sept 1, 2019, and Sept 30, 2022, 1692 people were assessed for eligibility, 1376 were randomly assigned, and eight were excluded after randomisation. 1368 participants were included in the mITT population (454 in the standard group, 461 in the 20 mg/kg group, and 453 in the 30 mg/kg group). 589 (43%) participants were male and 779 (57%) were female. 372 (82%) in the standard-dose group, 329 (71%) in the 20 mg/kg group, and 293 (65%) in the 30 mg/kg group completed treatment. No participants in the standard-dose group, one (<1%) of 441 participants in the 20 mg/kg group, and four (1%) of 423 in the 30 mg/kg group developed grade 3 hepatotoxicity. Risk of protocol-defined adverse events was higher in the 30 mg/kg group than in the standard-dose group (adjusted risk difference 4·6% [95% CI 1·8 to 7·4]) or the 20 mg/kg group (5·1% [2·3 to 7·8]). There was no difference in the risk of adverse events between the 20 mg/kg and standard-dose groups (-0·5% [95% CI -2·4 to 1·5]; non-inferiority met). Completion was lower in the 20 mg/kg group (-7·8% [95% CI -13·6 to -2·0]) and the 30 mg/kg group (-15·4% [-21·4 to -9·4]) than in the standard-dose group. INTERPRETATION In this trial, 2 months of 30 mg/kg daily rifampicin had significantly worse safety and completion than 4 months of 10 mg/kg daily and 2 months of 20 mg/kg daily (the latter, a fully blinded comparison); we do not consider 30 mg/kg to be a good option for TPT. Rifampicin at 20 mg/kg daily for 2 months was as safe as standard treatment, but with lower completion. This difference remains unexplained. FUNDING Canadian Institutes of Health Research.
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Affiliation(s)
- Rovina Ruslami
- Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia; Research Center for Care and Control of Infectious Disease, Universitas Padjadjaran, Bandung, Indonesia
| | - Federica Fregonese
- Montreal Chest Institute, Research Institute of the McGill University Health Center, Montreal, QC, Canada; McGill International TB Centre, McGill University, Montreal, QC, Canada
| | - Lika Apriani
- Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia; Research Center for Care and Control of Infectious Disease, Universitas Padjadjaran, Bandung, Indonesia
| | - Leila Barss
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Nancy Bedingfield
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Victor Chiang
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Victoria J Cook
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada; Provincial TB Services, British Columbia Centre for Disease Control, Vancouver, BC, Canada
| | - Dina Fisher
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Eri Flores
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Greg J Fox
- Faculty of Medicine and Health, The University of Sydney, NSW, Australia; Woolcock Institute of Medical Research, Glebe, NSW, Australia
| | - James Johnston
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada; Provincial TB Services, British Columbia Centre for Disease Control, Vancouver, BC, Canada
| | - Rachel K Lim
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Richard Long
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Catherine Paulsen
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Thu Anh Nguyen
- Woolcock Institute of Medical Research, Glebe, NSW, Australia
| | - Nguyen Viet Nhung
- National Lung Hospital, VNU Ha Noi, Viet Nam; University of Medicine and Pharmacy, VNU Ha Noi, Viet Nam
| | - Diana Gibson
- McGill International TB Centre, McGill University, Montreal, QC, Canada
| | - Chantal Valiquette
- Montreal Chest Institute, Research Institute of the McGill University Health Center, Montreal, QC, Canada; McGill International TB Centre, McGill University, Montreal, QC, Canada
| | - Andrea Benedetti
- Montreal Chest Institute, Research Institute of the McGill University Health Center, Montreal, QC, Canada; McGill International TB Centre, McGill University, Montreal, QC, Canada
| | - Dick Menzies
- Montreal Chest Institute, Research Institute of the McGill University Health Center, Montreal, QC, Canada; McGill International TB Centre, McGill University, Montreal, QC, Canada.
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15
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Dheda K, Migliori GB. New framework to define the spectrum of tuberculosis. THE LANCET. RESPIRATORY MEDICINE 2024; 12:426-428. [PMID: 38527483 DOI: 10.1016/s2213-2600(24)00085-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Accepted: 03/12/2024] [Indexed: 03/27/2024]
Affiliation(s)
- Keertan Dheda
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and UCT Lung Institute and South African MRC/UCT Centre for the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, 7700, South Africa; Faculty of Infectious and Tropical Diseases, Department of Immunology and Infection, London School of Hygiene and Tropical Medicine, London, UK.
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16
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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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17
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Singh V. Tuberculosis treatment-shortening. Drug Discov Today 2024; 29:103955. [PMID: 38548262 DOI: 10.1016/j.drudis.2024.103955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Revised: 03/06/2024] [Accepted: 03/21/2024] [Indexed: 04/06/2024]
Abstract
Tuberculosis (TB) presents a significant global health concern, with ∼10 million people developing TB and 1.3 million people dying from the disease each year. The standard treatment regimen for drug-susceptible TB was between 6 and 9 months until recently, presenting a prolonged therapeutic duration compared with other infectious diseases. This is a long time for patients to adhere to the medication, consequently increasing the risk of developing drug-resistant Mycobacterium tuberculosis - a significant challenge in TB management globally. Therefore, the primary objective of contemporary TB drug development research is to shorten the treatment duration. This review comprehensively explores the strategies aimed at shortening TB treatment.
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Affiliation(s)
- Vinayak Singh
- Holistic Drug Discovery and Development (H3D) Centre, University of Cape Town, Rondebosch 7701, South Africa; South African Medical Research Council Drug Discovery and Development Research Unit, University of Cape Town, Rondebosch 7701, South Africa; Institute of Infectious Disease and Molecular Medicine (IDM), University of Cape Town, Observatory 7925, South Africa.
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18
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Dartois V, Dick T. Therapeutic developments for tuberculosis and nontuberculous mycobacterial lung disease. Nat Rev Drug Discov 2024; 23:381-403. [PMID: 38418662 PMCID: PMC11078618 DOI: 10.1038/s41573-024-00897-5] [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] [Accepted: 01/24/2024] [Indexed: 03/02/2024]
Abstract
Tuberculosis (TB) drug discovery and development has undergone nothing short of a revolution over the past 20 years. Successful public-private partnerships and sustained funding have delivered a much-improved understanding of mycobacterial disease biology and pharmacology and a healthy pipeline that can tolerate inevitable attrition. Preclinical and clinical development has evolved from decade-old concepts to adaptive designs that permit rapid evaluation of regimens that might greatly shorten treatment duration over the next decade. But the past 20 years also saw the rise of a fatal and difficult-to-cure lung disease caused by nontuberculous mycobacteria (NTM), for which the drug development pipeline is nearly empty. Here, we discuss the similarities and differences between TB and NTM lung diseases, compare the preclinical and clinical advances, and identify major knowledge gaps and areas of cross-fertilization. We argue that applying paradigms and networks that have proved successful for TB, from basic research to clinical trials, will help to populate the pipeline and accelerate curative regimen development for NTM disease.
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Affiliation(s)
- Véronique Dartois
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, NJ, USA.
- Department of Medical Sciences, Hackensack Meridian School of Medicine, Nutley, NJ, USA.
| | - Thomas Dick
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, NJ, USA
- Department of Medical Sciences, Hackensack Meridian School of Medicine, Nutley, NJ, USA
- Department of Microbiology and Immunology, Georgetown University, Washington, DC, USA
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19
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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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20
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Cross GB, O’ Doherty J, Chang CC, Kelleher AD, Paton NI. Does PET-CT Have a Role in the Evaluation of Tuberculosis Treatment in Phase 2 Clinical Trials? J Infect Dis 2024; 229:1229-1238. [PMID: 37788578 PMCID: PMC11011169 DOI: 10.1093/infdis/jiad425] [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: 06/17/2023] [Revised: 09/10/2023] [Accepted: 10/01/2023] [Indexed: 10/05/2023] Open
Abstract
Positron emission tomography-computed tomography (PET-CT) has the potential to revolutionize research in infectious diseases, as it has done with cancer. There is growing interest in it as a biomarker in the setting of early-phase tuberculosis clinical trials, particularly given the limitations of current biomarkers as adequate predictors of sterilizing cure for tuberculosis. PET-CT is a real-time tool that provides a 3-dimensional view of the spatial distribution of tuberculosis within the lung parenchyma and the nature of lesions with uptake (ie, whether nodular, consolidative, or cavitary). Its ability to provide functional data on changes in metabolism, drug penetration, and immune control of tuberculous lesions has the potential to facilitate drug development and regimen selection for advancement to phase 3 trials in tuberculosis. In this narrative review, we discuss the role that PET-CT may have in evaluating responses to drug therapy in active tuberculosis treatment and the challenges in taking PET-CT forward as predictive biomarker of relapse-free cure in the setting of phase 2 clinical trials.
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Affiliation(s)
- Gail B Cross
- Immunovirology and Pathogenesis Program, The Kirby Institute, UNSW, Sydney
- Burnet Institute, Victoria, Australia
| | - Jim O’ Doherty
- Siemens Medical Solutions, Malvern, PA
- Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC, USA
- Radiography & Diagnostic Imaging, University College Dublin, Dublin, Ireland
| | - Christina C Chang
- Department of Infectious Diseases, Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa
| | - Anthony D Kelleher
- Immunovirology and Pathogenesis Program, The Kirby Institute, UNSW, Sydney
- St Vincent's Hospital, Sydney, Australia
| | - Nicholas I Paton
- Infectious Disease Translational Research Programme, National University of Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- London School of Hygiene and Tropical Medicine, London, UK
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21
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Sangsayunh P, Sanchat T, Chuchottaworn C, Cheewakul K, Rattanawai S. The use of BPaL containing regimen in the MDR/PreXDR TB treatments in Thailand. J Clin Tuberc Other Mycobact Dis 2024; 34:100408. [PMID: 38225943 PMCID: PMC10788258 DOI: 10.1016/j.jctube.2023.100408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2024] Open
Abstract
The primary objective of this study was to evaluate the real-world effectiveness, side effects and challenges associated with the implementing of the groundbreaking BPaL-containing regimen in Thailand. Another aim was to investigate the characteristics and severity of the disease, the presence of abnormal extensive lesions in chest X-Rays and the influence of cavitation on sputum conversion. MATERIAL AND METHOD The case series study included patients at TB clinic of Central chest institute of Thailand between August 2021-April 2023. All 28 Patients fullfilled the diagnostic criterial for MDR-TB by molecular tests and/or sputum culture. Sputum molecular test, utilizing GeneXpert MRB/XDR or Genotype MTBDRsl assay, was conducted. The 8 Pre-XDR patients who exhibited quinolone resistance and the 2 MDR-TB patients who encountered side effected from quinolone drugs were treated with BPaL regimen, while the remainder received BPaLM regimens. RESULTS Among the 28 patients, 23 (82.1 %) successfully completed the treatment with favorable outcomes. However, one patient from the BpaL regimen died due to severe destroy lung lesion, and four patients from the BpalM regimen discontinued treatment. The investigation into the correlation between extension lesion, cavitation lesions, and culture conversion unveiled that the group with extension lesions and cavitation ≥4 cm had a diminished probability of achieving sputum culture conversion within 8 weeks in comparison to the group without attributes. The associated risk ratio was 0.56 (95 % CI, 0.14-2.27), p = 0.14. Although the study report minimal side effects, 6 patients (22.2 %) experienced peripheral neuropathy and a notable adverse reaction identified was optic neuritis, affecting 2 cases (7.1 %). SUMMARY The administration of the BPaL-containing regimen resulted in rapid sputum conversion within 8 weeks and had minimal side effects.
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22
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Nimmo C, Bionghi N, Cummings MJ, Perumal R, Hopson M, Al Jubaer S, Naidoo K, Wolf A, Mathema B, Larsen MH, O'Donnell M. Opportunities and limitations of genomics for diagnosing bedaquiline-resistant tuberculosis: a systematic review and individual isolate meta-analysis. THE LANCET. MICROBE 2024; 5:e164-e172. [PMID: 38215766 PMCID: PMC11072239 DOI: 10.1016/s2666-5247(23)00317-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 08/03/2023] [Accepted: 09/26/2023] [Indexed: 01/14/2024]
Abstract
BACKGROUND Clinical bedaquiline resistance predominantly involves mutations in mmpR5 (Rv0678). However, mmpR5 resistance-associated variants (RAVs) have a variable relationship with phenotypic Mycobacterium tuberculosis resistance. We did a systematic review to assess the maximal sensitivity of sequencing bedaquiline resistance-associated genes and evaluate the association between RAVs and phenotypic resistance, using traditional and machine-based learning techniques. METHODS We screened public databases for articles published from database inception until Oct 31, 2022. Eligible studies performed sequencing of at least mmpR5 and atpE on clinically sourced M tuberculosis isolates and measured bedaquiline minimum inhibitory concentrations (MICs). A bias risk scoring tool was used to identify bias. Individual genetic mutations and corresponding MICs were aggregated, and odds ratios calculated to determine association of mutations with resistance. Machine-based learning methods were used to define test characteristics of parsimonious sets of diagnostic RAVs, and mmpR5 mutations were mapped to the protein structure to highlight mechanisms of resistance. This study was registered in the PROSPERO database (CRD42022346547). FINDINGS 18 eligible studies were identified, comprising 975 M tuberculosis isolates containing at least one potential RAV (mutation in mmpR5, atpE, atpB, or pepQ), with 201 (20·6%) showing phenotypic bedaquiline resistance. 84 (29·5%) of 285 resistant isolates had no candidate gene mutation. Sensitivity and positive predictive value of taking an any mutation approach was 69% and 14%, respectively. 13 mutations, all in mmpR5, had a significant association with a resistant MIC (adjusted p<0·05). Gradient-boosted machine classifier models for predicting intermediate or resistant and resistant phenotypes both had receiver operator characteristic c statistic of 0·73 (95% CI 0·70-0·76). Frameshift mutations clustered in the α1 helix DNA-binding domain, and substitutions in the α2 and α3 helix hinge region and in the α4 helix-binding domain. INTERPRETATION Sequencing candidate genes is insufficiently sensitive to diagnose clinical bedaquiline resistance, but where identified, some mutations should be assumed to be associated with resistance. Genomic tools are most likely to be effective in combination with rapid phenotypic diagnostics. This study was limited by selective sampling in contributing studies and only considering single genetic loci as causative of resistance. FUNDING Francis Crick Institute and National Institute of Allergy and Infectious Diseases at the National Institutes of Health.
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Affiliation(s)
| | - Neda Bionghi
- Department of Medicine, Columbia University Irving Medical Center and New York-Presbyterian Hospital, New York, NY, USA
| | - Matthew J Cummings
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Rubeshan Perumal
- CAPRISA-MRC HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa; Division of Pulmonology and Critical Care, Department of Medicine, Inkosi Albert Luthuli Central Hospital, University of KwaZulu-Natal, Durban, South Africa
| | - Madeleine Hopson
- Department of Medicine, Columbia University Irving Medical Center and New York-Presbyterian Hospital, New York, NY, USA
| | - Shamim Al Jubaer
- Department of Microbiology and Immunology, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Kogieleum Naidoo
- CAPRISA-MRC HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - Allison Wolf
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Barun Mathema
- Department of Epidemiology, Mailman School of Public Health, Columbia University Irving Medical Center, New York, NY, USA
| | - Michelle H Larsen
- Department of Microbiology and Immunology, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Max O'Donnell
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA; CAPRISA-MRC HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa; Division of Pulmonology and Critical Care, Department of Medicine, Inkosi Albert Luthuli Central Hospital, University of KwaZulu-Natal, Durban, South Africa
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23
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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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24
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Ramesh Kumar S, Narendran G, Padmapriyadarsini C. Role for Linezolid in drug sensitive tuberculosis. J Infect Public Health 2024; 17:172-174. [PMID: 38039860 DOI: 10.1016/j.jiph.2023.11.012] [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: 05/08/2023] [Revised: 09/29/2023] [Accepted: 11/08/2023] [Indexed: 12/03/2023] Open
Abstract
Tuberculosis (TB) continues to be a global challenge. Reducing the duration of TB treatment for drug-sensitive TB (DSTB) has direct and distinct advantages. We ventured into the aspect of utilizing linezolid as a pivotal drug in shortening therapy in DSTB. Linezolid has gained prominence as it is faring well in resistant TB management. Only a few studies use the strategy of Linezolid in DS-TB but it seems a lucrative approach, the bactericidal effects have been reported favourably in the studies. There have been concerns about the potential adverse drug effects of Linezolid reported but clinical trials have demonstrated safety and tolerability when administered for shorter periods. If the safety and efficacy of giving Linezolid for a shorter period along with standard drugs for DSTB is established it could lead to newer avenues using Linezolid for shortening the duration of treatment for DSTB as an alternative to treat DSTB.
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Affiliation(s)
- S Ramesh Kumar
- Department of Clinical Research, ICMR-National Institute for Research in Tuberculosis, Madurai unit, Madurai, India.
| | - G Narendran
- Department of Clinical Research,ICMR-National Institute for Research in Tuberculosis, Chennai, India
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25
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Perumal R, Bionghi N, Nimmo C, Letsoalo M, Cummings MJ, Hopson M, Wolf A, Jubaer SA, Padayatchi N, Naidoo K, Larsen MH, O'Donnell M. Baseline and treatment-emergent bedaquiline resistance in drug-resistant tuberculosis: a systematic review and meta-analysis. Eur Respir J 2023; 62:2300639. [PMID: 37945030 PMCID: PMC11035900 DOI: 10.1183/13993003.00639-2023] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Accepted: 10/22/2023] [Indexed: 11/12/2023]
Abstract
Bedaquiline resistance is a major threat to drug-resistant tuberculosis control strategies. This analysis found a pooled prevalence of baseline bedaquiline resistance of 2.4% and a pooled prevalence of treatment-emergent bedaquiline resistance of 2.1%. https://bit.ly/3FC6yio
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Affiliation(s)
- Rubeshan Perumal
- CAPRISA MRC-HIV-TB Pathogenesis and Treatment Research Unit, Centre for the AIDS Programme of Research in South Africa, Durban, South Africa
- Division of Pulmonology and Critical Care, Department of Medicine, University of KwaZulu-Natal, Durban, South Africa
- These authors contributed equally to this work
| | - Neda Bionghi
- Department of Medicine, Columbia University Irving Medical Center and New York-Presbyterian Hospital, New York, NY, USA
- These authors contributed equally to this work
| | | | - Marothi Letsoalo
- CAPRISA MRC-HIV-TB Pathogenesis and Treatment Research Unit, Centre for the AIDS Programme of Research in South Africa, Durban, South Africa
| | - Matthew J Cummings
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Madeleine Hopson
- Department of Medicine, Columbia University Irving Medical Center and New York-Presbyterian Hospital, New York, NY, USA
| | - Allison Wolf
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Shamim Al Jubaer
- Department of Microbiology and Immunology, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Nesri Padayatchi
- CAPRISA MRC-HIV-TB Pathogenesis and Treatment Research Unit, Centre for the AIDS Programme of Research in South Africa, Durban, South Africa
| | - Kogieleum Naidoo
- CAPRISA MRC-HIV-TB Pathogenesis and Treatment Research Unit, Centre for the AIDS Programme of Research in South Africa, Durban, South Africa
| | - Michelle H Larsen
- Department of Microbiology and Immunology, Albert Einstein College of Medicine, Bronx, NY, USA
- These authors contributed equally to this work
| | - Max O'Donnell
- CAPRISA MRC-HIV-TB Pathogenesis and Treatment Research Unit, Centre for the AIDS Programme of Research in South Africa, Durban, South Africa
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University Irving Medical Center, New York, NY, USA
- These authors contributed equally to this work
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26
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Lange C, Vasiliu A, Mandalakas AM. Emerging bedaquiline-resistant tuberculosis. THE LANCET. MICROBE 2023; 4:e964-e965. [PMID: 37931639 DOI: 10.1016/s2666-5247(23)00321-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 10/02/2023] [Indexed: 11/08/2023]
Affiliation(s)
- Christoph Lange
- Research Center Borstel, Clinical Infectious Diseases, Borstel, Germany; German Center for Infection Research Tuberculosis Unit, 23845 Borstel, Germany; Respiratory Medicine & International Health, University of Lübeck, Lübeck, Germany; Global TB Program, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA.
| | - Anca Vasiliu
- Global TB Program, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - Anna M Mandalakas
- Research Center Borstel, Clinical Infectious Diseases, Borstel, Germany; German Center for Infection Research Tuberculosis Unit, 23845 Borstel, Germany; Global TB Program, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
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27
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Fu L, Xiong J, Wang H, Zhang P, Yang Q, Cai Y, Wang W, Sun F, Zhang X, Wang Z, Chen X, Zhang W, Deng G. Study protocol for safety and efficacy of all-oral shortened regimens for multidrug-resistant tuberculosis: a multicenter randomized withdrawal trial and a single-arm trial [SEAL-MDR]. BMC Infect Dis 2023; 23:834. [PMID: 38012543 PMCID: PMC10683225 DOI: 10.1186/s12879-023-08644-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 09/25/2023] [Indexed: 11/29/2023] Open
Abstract
INTRODUCTION The urgent need for new treatments for multidrug-resistant tuberculosis (MDR-TB) and pre-extensively drug-resistant tuberculosis (pre-XDR-TB) is evident. However, the classic randomized controlled trial (RCT) approach faces ethical and practical constraints, making alternative research designs and treatment strategies necessary, such as single-arm trials and host-directed therapies (HDTs). METHODS Our study adopts a randomized withdrawal trial design for MDR-TB to maximize resource allocation and better mimic real-world conditions. Patients' treatment regimens are initially based on drug resistance profiles and patient's preference, and later, treatment-responsive cases are randomized to different treatment durations. Alongside, a single-arm trial is being conducted to evaluate the potential of sulfasalazine (SASP) as an HDT for pre-XDR-TB, as well as another short-course regimen without HDT for pre-XDR-TB. Both approaches account for the limitations in second-line anti-TB drug resistance testing in various regions. DISCUSSION Although our study designs may lack the internal validity commonly associated with RCTs, they offer advantages in external validity, feasibility, and ethical appropriateness. These designs align with real-world clinical settings and also open doors for exploring alternative treatments like SASP for tackling drug-resistant TB forms. Ultimately, our research aims to strike a balance between scientific rigor and practical utility, offering valuable insights into treating MDR-TB and pre-XDR-TB in a challenging global health landscape. In summary, our study employs innovative trial designs and treatment strategies to address the complexities of treating drug-resistant TB, fulfilling a critical gap between ideal clinical trials and the reality of constrained resources and ethical considerations. TRAIL REGISTRATION Chictr.org.cn, ChiCTR2100045930. Registered on April 29, 2021.
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Affiliation(s)
- Liang Fu
- Division Two of Pulmonary Diseases Department, Shenzhen Third People's Hospital, Shenzhen Clinical Research Center for Tuberculosis, National Clinical Research Center for Infectious Disease (Shenzhen), Southern University of Science and Technology, 29 Bulan Rd, Longgang District, Shenzhen, 518112, China
| | - Juan Xiong
- Health Science Center, Shenzhen University, 3688 Nanhai Avenue, Nanshan District, Shenzhen, 518060, China
| | - Haibo Wang
- Peking University Clinical Research Institute, Peking University First Hospital, Xueyuan Rd 38#, Haidian District, Beijing, 100000, 100191, China
| | - Peize Zhang
- Division Two of Pulmonary Diseases Department, Shenzhen Third People's Hospital, Shenzhen Clinical Research Center for Tuberculosis, National Clinical Research Center for Infectious Disease (Shenzhen), Southern University of Science and Technology, 29 Bulan Rd, Longgang District, Shenzhen, 518112, China
| | - Qianting Yang
- Division Two of Pulmonary Diseases Department, Shenzhen Third People's Hospital, Shenzhen Clinical Research Center for Tuberculosis, National Clinical Research Center for Infectious Disease (Shenzhen), Southern University of Science and Technology, 29 Bulan Rd, Longgang District, Shenzhen, 518112, China
| | - Yi Cai
- Department of Pathogen Biology, Guangdong Key Laboratory of Regional Immunity and Diseases, Shenzhen University School of Medicine, 1066 Xueyuan Ave, Nanshan District, Shenzhen, 518060, China
| | - Wenfei Wang
- Division Two of Pulmonary Diseases Department, Shenzhen Third People's Hospital, Shenzhen Clinical Research Center for Tuberculosis, National Clinical Research Center for Infectious Disease (Shenzhen), Southern University of Science and Technology, 29 Bulan Rd, Longgang District, Shenzhen, 518112, China
- Department of Pathogen Biology, Guangdong Key Laboratory of Regional Immunity and Diseases, Shenzhen University School of Medicine, 1066 Xueyuan Ave, Nanshan District, Shenzhen, 518060, 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, Fudan University, 12 Urumqi Middle Road, Jing'an District, Shanghai, 200040, China
| | - Xilin Zhang
- Tuberculosis Prevention and Control Department, The Fourth People's Hospital of Foshan, 106 Jinlannan Rd, Chancheng District, Foshan, 528000, China
| | - Zhaoqin Wang
- Division Two of Pulmonary Diseases Department, Shenzhen Third People's Hospital, Shenzhen Clinical Research Center for Tuberculosis, National Clinical Research Center for Infectious Disease (Shenzhen), Southern University of Science and Technology, 29 Bulan Rd, Longgang District, Shenzhen, 518112, China
| | - Xinchun Chen
- Department of Pathogen Biology, Guangdong Key Laboratory of Regional Immunity and Diseases, Shenzhen University School of Medicine, 1066 Xueyuan Ave, Nanshan District, Shenzhen, 518060, 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, Fudan University, 12 Urumqi Middle Road, Jing'an District, Shanghai, 200040, China.
| | - Guofang Deng
- Division Two of Pulmonary Diseases Department, Shenzhen Third People's Hospital, Shenzhen Clinical Research Center for Tuberculosis, National Clinical Research Center for Infectious Disease (Shenzhen), Southern University of Science and Technology, 29 Bulan Rd, Longgang District, Shenzhen, 518112, China.
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Nath A, Tyagi R. Bedaquiline for rifampicin sensitive tuberculosis: Isn't it too early? Lung India 2023; 40:571-572. [PMID: 37961974 PMCID: PMC10723216 DOI: 10.4103/lungindia.lungindia_334_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 07/10/2023] [Accepted: 07/10/2023] [Indexed: 11/15/2023] Open
Affiliation(s)
- Alok Nath
- Department of Pulmonary Medicine, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India E-mail:
| | - Richa Tyagi
- Department of Pulmonary Medicine, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India E-mail:
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29
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Lee CS, Ho CH, Liao KM, Wu YC, Shu CC. The incidence of tuberculosis recurrence: Impacts of treatment duration of and adherence to standard anti-tuberculous therapy. J Infect Public Health 2023; 16:1778-1783. [PMID: 37738694 DOI: 10.1016/j.jiph.2023.09.005] [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: 06/03/2023] [Revised: 08/28/2023] [Accepted: 09/07/2023] [Indexed: 09/24/2023] Open
Abstract
BACKGROUND We investigated the impacts of the standard treatment durations of and adherence to standard anti-tuberculous therapy (ATT) on recurrence after the successful completion of tuberculosis (TB) treatment. METHODS We recruited patients with TB who had received treatment for six or nine months from the 2008-2017 databases of the Taiwanese National Health Insurance Research Database. Treatment duration and adherence to standard ATT were analyzed for their impacts on recurrence within two years. Complete adherence to standard ATT was defined as daily use of ethambutol, isoniazid, pyrazinamide, and rifampin for the first two months, and daily use of isoniazid and rifampin for the first six months. RESULTS A total of 33,298 TB patients with new-onset TB were identified and classified into two groups by treatment duration: six months (n = 25,849, 77.63%) and nine months (n = 7449). Sex and age distributions varied between the groups. Treatment duration did not affect TB recurrence within two years (adjusted hazard ratio (AHR): 1.18, 95% confidence interval (C.I.) [0.96-1.44], p = 0.1156). Multivariable logistic regression showed that incomplete adherence to standard anti-tuberculous therapy (80-89% and 90-99% standard anti-TB therapy, AHR: 1.57, 95% C.I. [1.26-1.95], and 1.63, 95% C.I. [1.26-2.06], respectively, p < 0.0001) increased TB recurrence. In addition, male sex, older age, and comorbidity with diabetes mellitus or chronic obstructive pulmonary disease were independent risk factors for TB recurrence within two years. CONCLUSIONS TB recurrence was 1.54% within two years under a DOT era. TB treatment durations of six or nine months did not affect TB recurrence within two years after completion of TB treatment, but incomplete adherence to standard anti-tuberculous therapy might increase the TB recurrence rate.
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Affiliation(s)
- Chung-Shu Lee
- Department of Pulmonary and Critical Care Medicine, New Taipei Municipal TuCheng Hospital, New Taipei City, Taiwan; Department of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University, School of Medicine, Taipei, Taiwan
| | - Chung-Han Ho
- Department of Medical Research, Chi Mei Medical Center, Tainan, Taiwan; Department of Information Management, Southern Taiwan University of Science and Technology, Tainan, Taiwan; Cancer Center, Taipei Municipal Wanfang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Kuang-Ming Liao
- Department of Internal Medicine, Chi Mei Medical Center, Chiali, Taiwan
| | - Yu-Cih Wu
- Department of Medical Research, Chi Mei Medical Center, Tainan, Taiwan
| | - Chin-Chung Shu
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan.
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30
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Alvarado-Peña N, Galeana-Cadena D, Gómez-García IA, Mainero XS, Silva-Herzog E. The microbiome and the gut-lung axis in tuberculosis: interplay in the course of disease and treatment. Front Microbiol 2023; 14:1237998. [PMID: 38029121 PMCID: PMC10643882 DOI: 10.3389/fmicb.2023.1237998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Accepted: 10/09/2023] [Indexed: 12/01/2023] Open
Abstract
Tuberculosis is a chronic infectious disease caused by Mycobacterium tuberculosis (MTB) that remains a significant global health challenge. The extensive use of antibiotics in tuberculosis treatment, disrupts the delicate balance of the microbiota in various organs, including the gastrointestinal and respiratory systems. This gut-lung axis involves dynamic interactions among immune cells, microbiota, and signaling molecules from both organs. The alterations of the microbiome resulting from anti-TB treatment can significantly influence the course of tuberculosis, impacting aspects such as complete healing, reinfection, and relapse. This review aims to provide a comprehensive understanding of the gut-lung axis in the context of tuberculosis, with a specific focus on the impact of anti-TB treatment on the microbiome.
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Affiliation(s)
- Néstor Alvarado-Peña
- Clínica de Tuberculosis, Instituto Nacional de Enfermedades Respiratorias “Ismael Cosío Villegas”, México City, Mexico
| | - David Galeana-Cadena
- Laboratorio de Inmunobiología y Genética, Instituto Nacional de Enfermedades Respiratorias, México City, Mexico
| | - Itzel Alejandra Gómez-García
- Laboratorio de Inmunobiología y Genética, Instituto Nacional de Enfermedades Respiratorias, México City, Mexico
- Tecnológico de Monterrey, Escuela de Medicina y Ciencias de la Salud, México City, Mexico
| | - Xavier Soberón Mainero
- Departamento de Ingeniería Celular y Biocatálisis, Instituto de Biotecnología, Universidad Nacional Autónoma de México, Cuernavaca, Mexico
| | - Eugenia Silva-Herzog
- Laboratorio de Vinculación Científica, Facultad de Medicina-Universidad Nacional Autonoma de México-Instituto Nacional de Medicina Genomica, México City, Mexico
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31
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Reid M, Agbassi YJP, Arinaminpathy N, Bercasio A, Bhargava A, Bhargava M, Bloom A, Cattamanchi A, Chaisson R, Chin D, Churchyard G, Cox H, Denkinger CM, Ditiu L, Dowdy D, Dybul M, Fauci A, Fedaku E, Gidado M, Harrington M, Hauser J, Heitkamp P, Herbert N, Herna Sari A, Hopewell P, Kendall E, Khan A, Kim A, Koek I, Kondratyuk S, Krishnan N, Ku CC, Lessem E, McConnell EV, Nahid P, Oliver M, Pai M, Raviglione M, Ryckman T, Schäferhoff M, Silva S, Small P, Stallworthy G, Temesgen Z, van Weezenbeek K, Vassall A, Velásquez GE, Venkatesan N, Yamey G, Zimmerman A, Jamison D, Swaminathan S, Goosby E. Scientific advances and the end of tuberculosis: a report from the Lancet Commission on Tuberculosis. Lancet 2023; 402:1473-1498. [PMID: 37716363 DOI: 10.1016/s0140-6736(23)01379-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 06/14/2023] [Accepted: 06/29/2023] [Indexed: 09/18/2023]
Affiliation(s)
- Michael Reid
- University of California San Francisco Center for Tuberculosis, University of California San Francisco, San Francisco, CA, USA; Institute for Global Health Sciences, University of California San Francisco, San Francisco, CA, USA.
| | - Yvan Jean Patrick Agbassi
- Global TB Community Advisory Board, Abidjan, Côte d'Ivoire, Yenepoya Medical College, Mangalore, India
| | | | - Alyssa Bercasio
- University of California San Francisco Center for Tuberculosis, University of California San Francisco, San Francisco, CA, USA; Institute for Global Health Sciences, University of California San Francisco, San Francisco, CA, USA
| | - Anurag Bhargava
- Department of General Medicine, Yenepoya Medical College, Mangalore, India
| | - Madhavi Bhargava
- Department of Community Medicine, Yenepoya Medical College, Mangalore, India
| | - Amy Bloom
- Division of Tuberculosis, Bureau of Global Health, USAID, Washington, DC, USA
| | | | - Richard Chaisson
- Johns Hopkins School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Daniel Chin
- Bill and Melinda Gates Foundation, Seattle, WA, USA
| | | | - Helen Cox
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Claudia M Denkinger
- Heidelberg University Hospital, German Center of Infection Research, Heidelberg, Germany
| | | | - David Dowdy
- Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Mark Dybul
- Department of Medicine, Center for Global Health Practice and Impact, Georgetown University, Washington, DC, USA
| | - Anthony Fauci
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | | | | | | | | | - Petra Heitkamp
- McGill International TB Centre, McGill University, Montreal, QC, Canada
| | - Nick Herbert
- Global TB Caucus, Houses of Parliament, London, UK
| | | | - Philip Hopewell
- University of California San Francisco Center for Tuberculosis, University of California San Francisco, San Francisco, CA, USA
| | - Emily Kendall
- Johns Hopkins School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Aamir Khan
- Interactive Research & Development, Karachi, Pakistan
| | - Andrew Kim
- University of California San Francisco Center for Tuberculosis, University of California San Francisco, San Francisco, CA, USA
| | | | | | - Nalini Krishnan
- Resource Group for Education and Advocacy for Community Health (REACH), Chennai, India
| | - Chu-Chang Ku
- School of Public Health, Faculty of Medicine, Imperial College London, London, UK
| | - Erica Lessem
- Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | | | - Payam Nahid
- University of California San Francisco Center for Tuberculosis, University of California San Francisco, San Francisco, CA, USA
| | | | - Madhukar Pai
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada; McGill International TB Centre, McGill University, Montreal, QC, Canada
| | - Mario Raviglione
- Centre for Multidisciplinary Research in Health Science, University of Milan, Milan, Italy
| | - Theresa Ryckman
- Johns Hopkins School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | | | - Sachin Silva
- Harvard TH Chan School of Public Health, Harvard University, Cambridge, MA, USA
| | | | | | | | | | - Anna Vassall
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Gustavo E Velásquez
- University of California San Francisco Center for Tuberculosis, University of California San Francisco, San Francisco, CA, USA
| | | | - Gavin Yamey
- Center for Policy Impact in Global Health, Duke Global Health Institute, Duke University, Durham, NC, USA
| | | | - Dean Jamison
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, CA, USA
| | | | - Eric Goosby
- University of California San Francisco Center for Tuberculosis, University of California San Francisco, San Francisco, CA, USA; Institute for Global Health Sciences, University of California San Francisco, San Francisco, CA, USA
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32
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Verma R, da Silva KE, Rockwood N, Wasmann RE, Yende N, Song T, Kim E, Denti P, Wilkinson RJ, Andrews JR. A Nanopore sequencing-based pharmacogenomic panel to personalize tuberculosis drug dosing. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.09.08.23295248. [PMID: 37732197 PMCID: PMC10508808 DOI: 10.1101/2023.09.08.23295248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/22/2023]
Abstract
Rationale Standardized dosing of anti-tubercular (TB) drugs leads to variable plasma drug levels, which are associated with adverse drug reactions, delayed treatment response, and relapse. Mutations in genes affecting drug metabolism explain considerable interindividual pharmacokinetic variability; however, pharmacogenomic (PGx) assays that predict metabolism of anti-TB drugs have been lacking. Objectives To develop a Nanopore sequencing panel and validate its performance in active TB patients to personalize treatment dosing. Measurements and Main Results We developed a Nanopore sequencing panel targeting 15 single nucleotide polymorphisms (SNP) in 5 genes affecting the metabolism of isoniazid (INH), rifampin (RIF), linezolid and bedaquiline. For validation, we sequenced DNA samples (n=48) from the 1000 genomes project and compared variant calling accuracy with Illumina genome sequencing. We then sequenced DNA samples from patients with active TB (n=100) from South Africa on a MinION Mk1C and evaluated the relationship between genotypes and pharmacokinetic parameters for INH and RIF. Results The PGx panel achieved 100% concordance with Illumina sequencing in variant identification for the samples from the 1000 Genomes Project. In the clinical cohort, coverage was >100x for 1498/1500 (99.8%) amplicons across the 100 samples. One third (33%) of participants were identified as slow, 47% were intermediate and 20% were rapid isoniazid acetylators. Isoniazid clearance was significantly impacted by acetylator status (p<0.0001) with median (IQR) clearances of 11.2 L/h (9.3-13.4), 27.2 L/h (22.0-31.7), and 45.1 L/h (34.1-51.1) in slow, intermediate, and rapid acetylators. Rifampin clearance was 17.3% (2.50-29.9) lower in individuals with homozygous AADAC rs1803155 G>A substitutions (p=0.0015). Conclusion Targeted sequencing can enable detection of polymorphisms influencing TB drug metabolism on a low-cost, portable instrument to personalize dosing for TB treatment or prevention.
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Affiliation(s)
- Renu Verma
- Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, California, USA
- Institute of Bioinformatics, International Tech Park, Bangalore, India
- Manipal Academy of Higher Education (MAHE), Manipal, Karnataka, India
| | - Kesia Esther da Silva
- Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, California, USA
| | - Neesha Rockwood
- Center for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine and Dept. Medicine, University of Cape Town, Observatory 7925, South Africa
- Department of Infectious Diseases, Imperial College, London, W12 0NN, United Kingdom
- Department of Medical Microbiology and Immunology, Faculty of Medicine, University of Colombo, Sri Lanka
| | - Roeland E. Wasmann
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Nombuso Yende
- Department of Pathology and Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory 7925, South Africa
| | - Taeksun Song
- Department of Pathology and Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory 7925, South Africa
| | - Eugene Kim
- Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, California, USA
| | - Paolo Denti
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Robert. J. Wilkinson
- Center for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine and Dept. Medicine, University of Cape Town, Observatory 7925, South Africa
- Department of Infectious Diseases, Imperial College, London, W12 0NN, United Kingdom
- Francis Crick Institute, London NW1 1AT, United Kingdom
| | - Jason R. Andrews
- Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, California, USA
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33
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Bloom BR. A half-century of research on tuberculosis: Successes and challenges. J Exp Med 2023; 220:e20230859. [PMID: 37552470 PMCID: PMC10407785 DOI: 10.1084/jem.20230859] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 07/20/2023] [Accepted: 07/21/2023] [Indexed: 08/09/2023] Open
Abstract
Great progress has been made over the past half-century, but TB remains a formidable global health problem, particularly in low- and middle-income countries. Understanding the mechanisms of pathogenesis and necessary and sufficient conditions for protection are critical. The need for inexpensive and sensitive point-of-care diagnostic tests for earlier detection of infection and disease, shorter and less-toxic drug regimens for drug-sensitive and -resistant TB, and a more effective vaccine than BCG is immense. New and better tools, greater support for international research, collaborations, and training will be required to dramatically reduce the burden of this devastating disease which still kills 1.6 million people annually.
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Affiliation(s)
- Barry R. Bloom
- Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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34
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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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35
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Guo X, Zhang J, Wang Y, Zhou F, Li Q, Teng T. Phenotypic Characterization and Comparative Genomic Analyses of Mycobacteriophage WIVsmall as A New Member Assigned to F1 Subcluster. Curr Issues Mol Biol 2023; 45:6432-6448. [PMID: 37623225 PMCID: PMC10453261 DOI: 10.3390/cimb45080406] [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: 06/28/2023] [Revised: 07/28/2023] [Accepted: 07/31/2023] [Indexed: 08/26/2023] Open
Abstract
In this study, we conducted the morphological observation, biological and genomic characterization, evolutionary analysis, comparative genomics description, and proteome identification of a recently isolated mycobacteriophage, WIVsmall. Morphologically, WIVsmall is classified as a member of the Siphoviridae family, characterized by a flexible tail, measuring approximately 212 nm in length. The double-stranded phage genome DNA of WIVsmall spans 53,359 base pairs, and exhibits a G + C content of 61.01%. The genome of WIVsmall comprises 103 protein-coding genes, while no tRNA genes were detected. The genome annotation unveiled the presence of functional gene clusters responsible for mycobacteriophage assembly and maturation, replication, cell lysis, and functional protein synthesis. Based on the analysis of the phylogenetic tree, the genome of WIVsmall was classified as belonging to subgroup F1. A comparative genomics analysis indicated that the WIVsmall genome exhibited the highest similarity to the phage SG4, with a percentage of 64%. The single-step growth curve analysis of WIVsmall revealed a latent period of 120 min, and an outbreak period of 200 min.
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Affiliation(s)
- Xinge Guo
- Institute of Biomedical Informatics, School of Basic Medical Sciences, Henan University, Kaifeng 475004, China
| | - Jing Zhang
- Institute of Biomedical Informatics, School of Basic Medical Sciences, Henan University, Kaifeng 475004, China
| | - Yuhan Wang
- Institute of Biomedical Informatics, School of Basic Medical Sciences, Henan University, Kaifeng 475004, China
| | - Fang Zhou
- Institute of Biomedical Informatics, School of Basic Medical Sciences, Henan University, Kaifeng 475004, China
| | - Qiming Li
- Institute of Biomedical Informatics, School of Basic Medical Sciences, Henan University, Kaifeng 475004, China
| | - Tieshan Teng
- Institute of Biomedical Informatics, School of Basic Medical Sciences, Henan University, Kaifeng 475004, China
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36
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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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Affiliation(s)
- Martin J Boeree
- Radboud University Medical Center, Nijmegen, the Netherlands
| | | | - Rob E Aarnoutse
- Radboud University Medical Center, Nijmegen, the Netherlands
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Brehm TT, Köhler N, Schmiedel S, Terhalle E, Martensen J, Kalsdorf B, Kandulla J, Heyckendorf J, Kuhns M, Friesen I, Lange C. [Treatment of tuberculosis: what is new?]. INNERE MEDIZIN (HEIDELBERG, GERMANY) 2023:10.1007/s00108-023-01523-z. [PMID: 37316702 DOI: 10.1007/s00108-023-01523-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/20/2023] [Indexed: 06/16/2023]
Abstract
Never before have so many people around the world been simultaneously affected by tuberculosis. Tuberculosis is the leading cause of death from a bacterial infectious disease worldwide. The World Health Organization's ambitious goal from 2014 of achieving global elimination of tuberculosis does not seem realistic, but on current trends, tuberculosis could be eliminated in the European Union by 2040. Since the beginning of 2022, there have been more innovations for the treatment of tuberculosis than in no other comparable time period before. One month of rifapentine and isoniazid is effective in treating latent tuberculosis infection. However, rifapentine is licensed in the USA but not in the EU and must be imported for individual cases. The duration of the standard treatment for tuberculosis can be shortened to four months but this treatment regimen is also based on rifapentine, in addition to isoniazid, pyrazinamide, and moxifloxacin. The approval of rifapentine in Europe is a much-needed step towards shortening the treatment of tuberculosis. With new drugs an even shorter standard treatment of only 2 months is possible. The treatment of multidrug-resistant/rifampicin-resistant tuberculosis (MDR-/RR-TB) has been shortened to six months, the same length as the standard treatment available in Germany. The combination of bedaquiline, pretomanid, linezolid ± moxifloxacin, cured around 90% of affected patients were cured in studies with a treatment duration of six months. With 19 drugs in clinical trials, the treatment of tuberculosis is expected to continue to improve rapidly in the coming years.
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Affiliation(s)
- Thomas Theo Brehm
- Sektion Infektiologie, I. Medizinische Klinik und Poliklinik, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
- Deutsches Zentrum für Infektionsforschung (DZIF), Braunschweig, Deutschland
| | - Niklas Köhler
- Forschungszentrum Borstel, Leibniz Lungenzentrum, Parkallee 35, 23845, Borstel, Deutschland
| | - Stefan Schmiedel
- Sektion Infektiologie, I. Medizinische Klinik und Poliklinik, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
- Deutsches Zentrum für Infektionsforschung (DZIF), Braunschweig, Deutschland
| | | | | | - Barbara Kalsdorf
- Forschungszentrum Borstel, Leibniz Lungenzentrum, Parkallee 35, 23845, Borstel, Deutschland
| | | | - Jan Heyckendorf
- Klinik für Innere Medizin I, Universitätsklinikum Schleswig-Holstein, Christian Albrechts-Universität zu Kiel, Kiel, Deutschland
| | - Martin Kuhns
- Nationales Referenzzentrum für Mykobakterien, Forschungszentrum Borstel, Borstel, Deutschland
| | - Inna Friesen
- Nationales Referenzzentrum für Mykobakterien, Forschungszentrum Borstel, Borstel, Deutschland
| | - Christoph Lange
- Deutsches Zentrum für Infektionsforschung (DZIF), Braunschweig, Deutschland.
- Forschungszentrum Borstel, Leibniz Lungenzentrum, Parkallee 35, 23845, Borstel, Deutschland.
- Respiratory Medicine & International Health, Universität zu Lübeck, Lübeck, Deutschland.
- Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA.
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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 PMCID: PMC10301435 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)
| | | | | | - Federico Giannoni
- Department of Infectious Diseases, Istituto Superiore di Sanità, Via Regina Elena 299, 00161 Rome, Italy; (A.L.); (A.I.); (L.F.)
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Nimmo C, Bionghi N, Cummings MJ, Perumal R, Hopson M, Al Jubaer S, Wolf A, Mathema B, Larsen MH, O'Donnell M. Opportunities and limitations of genomics for diagnosing bedaquiline-resistant tuberculosis: an individual isolate metaanalysis. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.05.04.23289023. [PMID: 37205550 PMCID: PMC10187448 DOI: 10.1101/2023.05.04.23289023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
Background Clinical bedaquiline resistance predominantly involves mutations in mmpR5 (Rv0678). However, mmpR5 resistance-associated variants (RAVs) have a variable relationship with phenotypic M. tuberculosis resistance. We performed a systematic review to (1) assess the maximal sensitivity of sequencing bedaquiline resistance-associated genes and (2) evaluate the association between RAVs and phenotypic resistance, using traditional and machine-based learning techniques. Methods We screened public databases for articles published until October 2022. Eligible studies performed sequencing of at least mmpR5 and atpE on clinically-sourced M. tuberculosis isolates and measured bedaquiline minimum inhibitory concentrations (MICs). We performed genetic analysis for identification of phenotypic resistance and determined the association of RAVs with resistance. Machine-based learning methods were employed to define test characteristics of optimised sets of RAVs, and mmpR5 mutations were mapped to the protein structure to highlight mechanisms of resistance. Results Eighteen eligible studies were identified, comprising 975 M. tuberculosis isolates containing ≥1 potential RAV (mutation in mmpR5, atpE, atpB or pepQ), with 201 (20.6%) demonstrating phenotypic bedaquiline resistance. 84/285 (29.5%) resistant isolates had no candidate gene mutation. Sensitivity and positive predictive value of taking an 'any mutation' approach was 69% and 14% respectively. Thirteen mutations, all in mmpR5, had a significant association with a resistant MIC (adjusted p<0.05). Gradient-boosted machine classifier models for predicting intermediate/resistant and resistant phenotypes both had receiver operator characteristic c-statistics of 0.73. Frameshift mutations clustered in the alpha 1 helix DNA binding domain, and substitutions in the alpha 2 and 3 helix hinge region and in the alpha 4 helix binding domain. Discussion Sequencing candidate genes is insufficiently sensitive to diagnose clinical bedaquiline resistance, but where identified a limited number of mutations should be assumed to be associated with resistance. Genomic tools are most likely to be effective in combination with rapid phenotypic diagnostics.
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Affiliation(s)
| | - Neda Bionghi
- Department of Medicine, Columbia University Irving Medical Center and New York-Presbyterian Hospital, New York, NY, USA
| | - Matthew J Cummings
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Rubeshan Perumal
- CAPRISA-MRC HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
- Division of Pulmonology and Critical Care, Department of Medicine, Inkosi Albert Luthuli Central Hospital, University of KwaZulu-Natal, Durban, South Africa
| | - Madeleine Hopson
- Department of Medicine, Columbia University Irving Medical Center and New York-Presbyterian Hospital, New York, NY, USA
| | - Shamim Al Jubaer
- Department of Microbiology and Immunology, Albert Einstein College of Medicine, Bronx, NY
| | - Allison Wolf
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Barun Mathema
- Department of Epidemiology, Mailman School of Public Health, Columbia University Irving Medical Center, New York, NY, USA
| | - Michelle H Larsen
- Department of Microbiology and Immunology, Albert Einstein College of Medicine, Bronx, NY
| | - Max O'Donnell
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
- CAPRISA-MRC HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
- Division of Pulmonology and Critical Care, Department of Medicine, Inkosi Albert Luthuli Central Hospital, University of KwaZulu-Natal, Durban, South Africa
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41
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Reid M, Yamey G, Goosby E, Jamison D, Schäferhoff M. Seizing opportunities to end TB: a call for ambition and optimism on World TB Day. Lancet 2023; 401:1153. [PMID: 36972718 DOI: 10.1016/s0140-6736(23)00622-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 03/22/2023] [Indexed: 03/29/2023]
Affiliation(s)
- Michael Reid
- Institute for Global Health Sciences, University of California, San Francisco, CA 94143, USA.
| | - Gavin Yamey
- Center for Policy Impact in Global Health, Duke University, Durham, NC, USA
| | - Eric Goosby
- Institute for Global Health Sciences, University of California, San Francisco, CA 94143, USA
| | - Dean Jamison
- Institute for Global Health Sciences, University of California, San Francisco, CA 94143, USA
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42
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Affiliation(s)
| | - Eric J Rubin
- From the Center for Discovery and Innovation, Nutley, NJ (V.D.)
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43
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Warner DF, Wood R. New tricks for an old dog: opportunities for better tuberculosis control. J Int AIDS Soc 2023; 26:e26081. [PMID: 36951496 PMCID: PMC10035324 DOI: 10.1002/jia2.26081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 03/03/2023] [Indexed: 03/24/2023] Open
Affiliation(s)
- Digby F. Warner
- Molecular Mycobacteriology Research Unit & DSI/NRF Centre of Excellence for Biomedical TB ResearchDepartment of PathologyFaculty of Health SciencesUniversity of Cape TownCape TownSouth Africa
- Institute of Infectious Disease and Molecular MedicineFaculty of Health SciencesUniversity of Cape TownCape TownSouth Africa
- Wellcome Centre for Infectious Diseases Research in AfricaFaculty of Health SciencesUniversity of Cape TownCape TownSouth Africa
| | - Robin Wood
- Institute of Infectious Disease and Molecular MedicineFaculty of Health SciencesUniversity of Cape TownCape TownSouth Africa
- Desmond Tutu Health FoundationFaculty of Health SciencesUniversity of Cape TownCape TownSouth Africa
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44
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Psomas K, Barber T, Kogilwaimath S, Waters L. Highlights from the 30th Conference on Retroviruses and Opportunist Infections (CROI). J Virus Erad 2023. [DOI: 10.1016/j.jve.2023.100324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023] Open
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