Studies in Chemotherapy

Laboratory Selection of Trypanosomatid Pathogens for Drug Resistance

The selection of parasites for drug resistance in the laboratory is an approach frequently used to investigate the mode of drug action, estimate the risk of emergence of drug resistance, or develop molecular markers for drug resistance. Here, we focused on the How rather than the Why of laboratory selection, discussing different experimental set-ups based on research examples with Trypanosoma brucei, Trypanosoma cruzi, and Leishmania spp. The trypanosomatids are particularly well-suited to illustrate different strategies of selecting for drug resistance, since it was with African trypanosomes that Paul Ehrlich performed such an experiment for the first time, more than a century ago. While breakthroughs in reverse genetics and genome editing have greatly facilitated the identification and validation of candidate resistance mutations in the trypanosomatids, the forward selection of drug-resistant mutants still relies on standard in vivo models and in vitro culture systems. Critical questions are: is selection for drug resistance performed in vivo or in vitro? With the mammalian or with the insect stages of the parasites? Under steady pressure or by sudden shock? Is a mutagen used? While there is no bona fide best approach, we think that a methodical consideration of these questions provides a helpful framework for selection of parasites for drug resistance in the laboratory.

Immunity in trypanosomiasis

Antibody-resistant strains are less sensitive to suramin and antrycide than antibody-sensitive strains. When living trypanosomes were exposed to suramin and antrycide in vitro, antibody-resistant strains needed 50 times more drugs than antibody-sensitive trypanosomes in order to make them non-infectious to mice. In therapeutic experiments in mice the minimal therapeutic dose of drugs for antibody-sensitive strains was 0·1 mg. but for resistant strains it was 0·3 mg./20 g. mice. Rabbits treated prophylactically with suramin resisted infection with the antibody-sensitive strain for a period of 4 months, but failed to resist infection with the antibody-resistant strain after 2 months.

Rabbits treated prophylactically with antrycide pro-salt, resisted infection with antibody-sensitive strains for a period of 2 months, but failed to resist infection with the antibody-resistant strain even 1 month after injection with the drug. Although trypanosomes can become drug resistant without being antibody resistant it is suggested that, under natural conditions, drug-resistant strains in animals and man develop from antibody-resistant strains, particularly when trypanostatic drugs are used. It is suggested in conclusion from these experiments that strains of trypanosomes which are exposed for some time to antibodies and become antibody resistant after passage through animals like rabbits, as well as those strains frequently passaged through mice, should be used in all tests for the efficiency of chemotherapeutic drugs.

Drug-resistance in Plasmodium gallinaceum, and the persistence of paludrine-resistance after mosquito transmission

1. Attempts, made over a period of more than 6 months, to produce a strain of Plasmodium gallinaceum resistant to mepacrine failed.

2. A strain of P. gallinaceum resistant to daily doses of 0·08 mg./20 g. of pamaquin was obtained after approximately 8 months' treatment with the drug.

3. A strain of P. gallinaceum resistant to the maximum dose of paludrine which the chicks would tolerate (1·0 mg./20 g. twice daily) was obtained after 4½ months' treatment with gradually increasing doses of the drug.

4. The exo-erythrocytic parasites of P. gallinaceum formed in chicks infected with a paludrine-resistant strain are themselves resistant to the drug. It is not, however, considered probable that the development of resistance is due to the action of the drugs upon the exo-erythrocytic parasites, as the technique used was one which reduced their number to a minimum.

5. A strain of P. gallinaceum resistant to paludrine showed a normal sensitivity to mepacrine and pamaquin, but was resistant to 4430, the methyl homologue of paludrine.

6. Chicks carrying a latent infection of the normal strain of P. gallinaceum were immune to infection with the paludrine-resistant strain; and conversely chicks carrying a latent infection of the paludrine-resistant strain were immune to infection with the normal parasite.

7. A paludrine-resistant strain of P. gallinaceum retained its resistance to this drug after five cyclical passages through mosquitoes without intervening drug treatment.

Drug resistance in trapanososmes: cross-resitance analyses

Eight strains of Trypanosoma rhodesiense, made resistant respectively to atoxyl, butarsen, acriflavine, stilbamidine, Surfen C, suramin, and pontamine sky blue 5BX, have been examined for cross-resistance to representatives of nine structurally dissimilar groups of trypanocide. On the basis of their predominant ionic form at blood pH, these groups are considered in three main classes: (a) feebly ionized (neutral aromatic arsenicals), (b) ionized as cations (melaminyl arsenicals and antimonials, acridine derivatives, diguanidines and diamidines, 6-aminoquinoline and 6-aminocinnoline derivatives, phenanthridinium derivatives, triphenylmethane dyes), and (c) ionized as anions (carboxylated aromatic arsenicals and sulphonated naphthylamine derivatives). The results are discussed in relation to those of other workers and to possible modes of trypanocidal drug action. Cross-resistance behaviour is not wholly explicable on an ionic basis; the results suggest that stereospecific structural changes associated with initial drug uptake occur in resistant trypanosomes.

Induction of resistance to melarsenoxide cysteamine (Mel Cy) in Trypanosoma brucei brucei

A population of Trypanosoma brucei brucei with reduced sensitivity to melarsenoxide cysteamine (Mel Cy) was produced in immunosuppresed mice using subcurative drug treatment. Melarsenoxide cysteamine resistance was stable after cyclical transmission through Glossina morsitans centralis. In vitro, the blood-stream forms showed 15-fold higher values for the minimal inhibitory concentration as compared with the parental clone. Cross-resistance could be determined with another arsenical drug, melarsoprol (14-fold) and to two different diamidines (diminazene aceturate: 47-fold; pentamidine methanesulphonate: 34-fold), but not to suramin. When cells were transformed to procyclic forms and tested in vitro, the sensitivity of the resistant population to melarsenoxide cysteamine was only 6-fold lower than that of the parent, but comparatively high cross-resistance could be shown to other drugs (melarsoprol; 85-fold; pentamidine methanesulphonate: 17-fold; quinapyramine sulphate: 40-fold). Selection of the resistant trypanosomes from non-resistant ones was possible under pentamidine methanesulphonate pressure in cell culture.

The rapid development of drug-resistance by Trypanosoma evansi in immunosuppressed mice

The effect of immunosuppression on the development of drug resistance by trypanosomes was investigated in mice infected with Trypanosoma evansi. As a result of frequent passage in immunosuppressed mice given subcurative drug treatments clones of T. evansi rapidly developed high levels of resistance to mel Cy, diminazene aceturate and isometamidium chloride. Similar protocols in normal immunocompetent mice infected with the same parent clones did not lead to the development of drug-resistance. The resistant populations developed in immunosuppressed mice maintained their high levels of resistance when tested in normal mice. The mel Cy resistant clone was tested for cross-resistance to other trypanocides and was found to be also highly resistant to diminazene and pentamidine. The results indicate that impairment of the host immune system may lead to the rapid development of drug-resistance by T. evansi under experimental conditions in mice and may possibly play a role in the development of drug resistance by trypanosomes in the field.

Trypanosoma congolense: drug resistance during cyclical transmissions in tsetse flies and syringe passages in mice

A drug-resistant Trypanosoma congolense strain with predetermined curative doses (CD50 and CD90) of samorin at 13.9 +/- 1.02 and 20.3 +/- 1.13 mg/kg body weight, respectively, was cyclically transmitted through tsetse flies and by syringe passages in mice in the absence of drug pressure. The changing levels of drug sensitivity were determined after every 3rd cyclic and 5th syringe passage intervals. It was noted that when the strain was maintained in tsetse flies through 12 cyclical transmissions, the CD50 and CD90 dropped slightly from 13.9 to 11.9 +/- 1.06 and from 20.3 to 18.0 +/- 1.08 mg/kg body weight, respectively. This decrease in the level of resistance was not significant (P greater than 0.05). However, when the trypanosomes were maintained by syringe passages in mice, there was a significant reduction (P less than 0.05) in the degree of resistance (CD50 from 13.9 to 11.4 +/- 1.07 and CD90 from 20.3 to 16.7 +/- 1.16 mg/kg), by the 15th syringe passage.

Resistance to primaquine in Plasmodium gallinaceum, and the problem of resistance to quinoline compounds in malaria parasites

A tenfold enhancement of resistance to primaquine was obtained by maintaining a strain of Plasmodium gallinaceum in a state of acute infection by serial passage of infected blood through young chicks treated with gradually increasing doses of the drug.

No loss in resistance to primaquine was observed when the resistant strain was transmitted through mosquitoes, though there was some loss in resistance to the maximum tolerated dose, but not to lower doses, when the strain was maintained in a state of acute infection through untreated chicks for 41 weeks.

The primaquine-resistant strain was cross-resistant to lower effective doses of pamaquin, and slightly less sensitive to quinine than the parent strain but the loss in sensitivity to chloroquine was only marginal. Sensitivity to proguanil, dihydrotriazine and pyrimethamine was normal.

Attempts were made to produce a chloroquine-resistant strain of P. gallinaceum using different doses of the drug but no change in sensitivity was observed though the experiments were continued for more than a year. An attempt to produce a chloroquine-resistant strain by treatment of a proguanil-resistant strain with chloroquine also failed.

The problem of resistance to quinoline compounds in different species of Plasmodium is discussed.