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Mukherjee A, Gowtham L, Kabra SK, Lodha R, Velpandian T. Pharmacokinetic-Pharmacodynamic (PK-PD) Analysis of Second-Line Anti-Tubercular Drugs in Indian Children with Multi-Drug Resistance. Indian J Pediatr 2024:10.1007/s12098-024-05135-9. [PMID: 38802673 DOI: 10.1007/s12098-024-05135-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 04/12/2024] [Indexed: 05/29/2024]
Abstract
OBJECTIVES To conduct a thorough pharmacokinetic (PK) - pharmacodynamic (PD) analysis of second-line anti-tubercular therapy (ATT) in children diagnosed with multi-drug resistant tuberculosis (MDR-TB). METHODS Twenty-seven children undergoing second-line ATT, including kanamycin (KM, n = 13), fluoroquinolones (FQs, n = 26), ethionamide (ETH, n = 20), para amino salicylic acid (PASA, n = 4), and cycloserine (CS, n = 15), were sampled at 0 (pre-dose), 1, 2, 3, and 4 h post-drug administration. Plasma drug levels were determined using a mass spectrometer and the collected dataset underwent non-compartmental PK analysis using PK solver ver2.0. PK/PD assessments involved individual drug simulation studies on 1000 subjects using Modviz Pop ver 1.0 in R-software. RESULTS A total of 22 and 5 children were considered as responders and non-responders, respectively. Non-compartmental PK analysis revealed mean plasma drug levels of this study cohort attained the targeted maximum drug plasma concentration (Cmax). The ratio of Cmax /minimum inhibitory concentration (MIC) or the area under the curve (AUC)/MIC of the studied drugs had not shown a significant difference between responders and non-responders. Non-responders of ETH and ofloxacin had shown deviation from the derived dose-response profile for the simulated population. CONCLUSIONS The management of MDR-TB with second-line ATT following national guidelines had cured the majority of the children (> 80%) who participated in the study. Inter-individual variability in few children from the targeted Cmax range suggests the need for future investigations on pharmacogenomic aspects of drug metabolism.
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Affiliation(s)
- Aparna Mukherjee
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Lakshminarayanan Gowtham
- Ocular Pharmacology and Pharmacy Division, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Sushil Kumar Kabra
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Rakesh Lodha
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Thirumurthy Velpandian
- Ocular Pharmacology and Pharmacy Division, All India Institute of Medical Sciences, New Delhi, 110029, India.
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2
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Maitre T, Baulard A, Aubry A, Veziris N. Optimizing the use of current antituberculosis drugs to overcome drug resistance in Mycobacterium tuberculosis. Infect Dis Now 2024; 54:104807. [PMID: 37839674 DOI: 10.1016/j.idnow.2023.104807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 10/10/2023] [Indexed: 10/17/2023]
Abstract
Antibiotic-resistant tuberculosis continues to be one of the major threats to global tuberculosis control. After a hiatus of over 40 years in antituberculosis drug development, the last decade has seen a resurgence of research, yielding a number of promising compounds in the tuberculosis drug pipeline, with some that are now game changers in the treatment of MDRTB. Despite this progress, there are still obstacles restricting the use of these molecules as first-line drugs. The quick appearance of bacteria resistant to these new treatments highlights a continuing need to fuel the discovery and development of new molecules. With this in mind, alternative strategies aimed at optimizing the utilization of existing antituberculosis agents are currently under evaluation. They are focused on enhancing the efficacy of antibiotics against their bacterial targets, primarily by augmenting the quantity of antibiotic that engages with these targets. This objective can be achieved through two primary approaches: (1) Provided that toxicity concerns are not a limiting factor, increased dosing is a viable avenue, as demonstrated by rifampicin, isoniazid, and fluoroquinolones, for which escalated dosing has been effective; and (2) Employing enhancers such as drug activator boosters (ethionamide), efflux pump inhibitors, or hydrolytic enzyme inhibitors (kanamycin) can elevate the concentration of antibiotics in bacterial cells. These strategies offer the potential to mitigate antibiotic obsolescence and complement the discovery of new antibiotics.
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Affiliation(s)
- Thomas Maitre
- Sorbonne Université, Centre d'Immunologie et des Maladies Infectieuses (Cimi-Paris), UMR 1135, Paris, France; Service de Pneumologie et d'Oncologie Thoracique, Centre constitutif maladies rares, Hôpital Tenon, AP-HP, Sorbonne-Université, Paris, France.
| | - Alain Baulard
- Univ. Lille, CNRS, Inserm, CHU Lille, Institut Pasteur Lille, U1019 - UMR 9017 - CIIL - Center for Infection and Immunity of Lille, F-59000 Lille, France
| | - Alexandra Aubry
- Sorbonne Université, Centre d'Immunologie et des Maladies Infectieuses (Cimi-Paris), UMR 1135, Paris, France; AP-HP, Sorbonne-Universite, Hôpital Pitié Salpêtrière, Laboratoire de Bactériologie-Hygiene, Centre National de Référence des Mycobactéries, Paris France
| | - Nicolas Veziris
- Sorbonne Université, Centre d'Immunologie et des Maladies Infectieuses (Cimi-Paris), UMR 1135, Paris, France; AP-HP, Sorbonne-Université, Hôpital Saint-Antoine, Département de Bactériologie, Centre National de Référence des Mycobactéries et de la Résistance des Mycobactéries aux Antituberculeux, Hôpital Pitié-Salpêtrière, Paris, France
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Xavier RM, Sharumathi SM, Kanniyappan Parthasarathy A, Mani D, Mohanasundaram T. Limited sampling strategies for therapeutic drug monitoring of anti-tuberculosis medications: A systematic review of their feasibility and clinical utility. Tuberculosis (Edinb) 2023; 141:102367. [PMID: 37429151 DOI: 10.1016/j.tube.2023.102367] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 06/13/2023] [Accepted: 06/22/2023] [Indexed: 07/12/2023]
Abstract
Therapeutic drug monitoring (TDM) is recommended for medications with high inter-individual variability, narrow therapeutic index drugs, possible drug-drug interactions, drug toxicity, and subtherapeutic concentrations, as well as to assess noncompliance. The area under the plasma concentration-time curve (AUC) is a significant pharmacokinetic parameter since it calculates the drug's total systematic exposure in the body. However, multiple blood samples from the patient are required to calculate the area under the curve, which is inconvenient for both the patient and the healthcare professional. To alleviate the issue, the limited sampling strategy (LSS) was devised, in which sampling is minimized while obtaining complete and precise findings to anticipate the area under the curve. One can reduce costs, labor, and discomfort for patients and healthcare workers by applying this limited sampling strategy. This article examines a systematic evaluation of all the limited sampling done in anti-tuberculosis (anti-TB) medications resulting from the literature search of several research papers. This article also briefly describes the two methodologies: Multiple regression analysis (MRA) and the Bayesian approach used to develop a limited sampling strategy model. Anti-TB medications have been found to have considerable inter-individual variability, and isoniazid has a narrow therapeutic index, both of which are criteria for therapeutic drug monitoring. To avoid multi-drug resistance and therapy failure, it is proposed that limited sampling strategy-based therapeutic drug monitoring of anti-TB medications be undertaken to generate an individualized dose regimen, particularly for individuals at high risk of treatment failure or delayed response.
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Affiliation(s)
- Rinu Mary Xavier
- Department of Pharmacy Practice, JSS College of Pharmacy, JSS Academy of Higher Education & Research, Ooty, Nilgiris, Tamil Nadu, 643001, India.
| | - S M Sharumathi
- Department of Pharmacy Practice, JSS College of Pharmacy, JSS Academy of Higher Education & Research, Ooty, Nilgiris, Tamil Nadu, 643001, India.
| | - Arun Kanniyappan Parthasarathy
- Department of Pharmacy Practice, JSS College of Pharmacy, JSS Academy of Higher Education & Research, Ooty, Nilgiris, Tamil Nadu, 643001, India.
| | - Deepalakshmi Mani
- Department of Pharmacy Practice, JSS College of Pharmacy, JSS Academy of Higher Education & Research, Ooty, Nilgiris, Tamil Nadu, 643001, India.
| | - Tharani Mohanasundaram
- Department of Pharmacology, JSS College of Pharmacy, JSS Academy of Higher Education & Research, Ooty, Nilgiris, Tamil Nadu, 643001, India.
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Mohamed S, Mvungi HC, Sariko M, Rao P, Mbelele P, Jongedijk EM, van Winkel CAJ, Touw DJ, Stroup S, Alffenaar JWC, Mpagama S, Heysell SK. Levofloxacin pharmacokinetics in saliva as measured by a mobile microvolume UV spectrophotometer among people treated for rifampicin-resistant TB in Tanzania. J Antimicrob Chemother 2021; 76:1547-1552. [PMID: 33675664 PMCID: PMC8120342 DOI: 10.1093/jac/dkab057] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 02/05/2021] [Indexed: 12/25/2022] Open
Abstract
Background Early detection and correction of low fluoroquinolone exposure may improve treatment of MDR-TB. Objectives To explore a recently developed portable, battery-powered, UV spectrophotometer for measuring levofloxacin in saliva of people treated for MDR-TB. Methods Patients treated with levofloxacin as part of a regimen for MDR-TB in Northern Tanzania had serum and saliva collected concurrently at 1 and 4 h after 2 weeks of observed levofloxacin administration. Saliva levofloxacin concentrations were quantified in the field via spectrophotometry, while serum was analysed at a regional laboratory using HPLC. A Bayesian population pharmacokinetics model was used to estimate the area under the concentration–time curve (AUC0–24). Subtarget exposures of levofloxacin were defined by serum AUC0–24 <80 mg·h/L. The study was registered at Clinicaltrials.gov with clinical trial identifier NCT04124055. Results Among 45 patients, 11 (25.6%) were women and 16 (37.2%) were living with HIV. Median AUC0–24 in serum was 140 (IQR = 102.4–179.09) mg·h/L and median AUC0–24 in saliva was 97.10 (IQR = 74.80–121.10) mg·h/L. A positive linear correlation was observed with serum and saliva AUC0–24, and a receiver operating characteristic curve constructed to detect serum AUC0–24 below 80 mg·h/L demonstrated excellent prediction [AUC 0.80 (95% CI = 0.62–0.94)]. Utilizing a saliva AUC0–24 cut-off of 91.6 mg·h/L, the assay was 88.9% sensitive and 69.4% specific in detecting subtarget serum AUC0–24 values, including identifying eight of nine patients below target. Conclusions Portable UV spectrophotometry as a point-of-care screen for subtarget levofloxacin exposure was feasible. Use for triage to other investigation or personalized dosing strategy should be tested in a randomized study.
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Affiliation(s)
- Sagal Mohamed
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, VA, USA
| | | | | | - Prakruti Rao
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, VA, USA
| | - Peter Mbelele
- Kibong'oto Infectious Diseases Hospital, Sanya Juu, Tanzania
| | - Erwin M Jongedijk
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Claudia A J van Winkel
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Daan J Touw
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Suzanne Stroup
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, VA, USA
| | - Jan-Willem C Alffenaar
- School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, Australia.,Westmead Hospital, Sydney, Australia.,Marie Bashir Institute for Infectious Diseases and Biosecurity, University of Sydney, Sydney, Australia
| | | | - Scott K Heysell
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, VA, USA
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Alffenaar JWC, Jongedijk EM, van Winkel CAJ, Sariko M, Heysell SK, Mpagama S, Touw DJ. A mobile microvolume UV/visible light spectrophotometer for the measurement of levofloxacin in saliva. J Antimicrob Chemother 2021; 76:423-429. [PMID: 33089322 PMCID: PMC7816168 DOI: 10.1093/jac/dkaa420] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 09/10/2020] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Therapeutic drug monitoring (TDM) for personalized dosing of fluoroquinolones has been recommended to optimize efficacy and reduce acquired drug resistance in the treatment of MDR TB. Therefore, the aim of this study was to develop a simple, low-cost, robust assay for TDM using mobile UV/visible light (UV/VIS) spectrophotometry to quantify levofloxacin in human saliva at the point of care for TB endemic settings. METHODS All experiments were performed on a mobile UV/VIS spectrophotometer. The levofloxacin concentration was quantified by using the amplitude of the second-order spectrum between 300 and 400 nm of seven calibrators. The concentration of spiked samples was calculated from the spectrum amplitude using linear regression. The method was validated for selectivity, specificity, linearity, accuracy and precision. Drugs frequently co-administered were tested for interference. RESULTS The calibration curve was linear over a range of 2.5-50.0 mg/L for levofloxacin, with a correlation coefficient of 0.997. Calculated accuracy ranged from -5.2% to 2.4%. Overall precision ranged from 2.1% to 16.1%. Application of the Savitsky-Golay method reduced the effect of interferents on the quantitation of levofloxacin. Although rifampicin and pyrazinamide showed analytical interference at the lower limit of quantitation of levofloxacin concentrations, this interference had no implication on decisions regarding the levofloxacin dose. CONCLUSIONS A simple UV/VIS spectrophotometric method to quantify levofloxacin in saliva using a mobile nanophotometer has been validated. This method can be evaluated in programmatic settings to identify patients with low levofloxacin drug exposure to trigger personalized dose adjustment.
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Affiliation(s)
- Jan-Willem C Alffenaar
- University of Sydney, Faculty of Medicine and Health, School of Pharmacy, Sydney, Australia.,Westmead Hospital, Sydney, Australia.,Marie Bashir Institute for Infectious Diseases and Biosecurity, University of Sydney, Sydney, NSW, Australia.,University of Groningen, University Medical Center Groningen, Department of Clinical Pharmacy and Pharmacology, Groningen, The Netherlands
| | - Erwin M Jongedijk
- University of Groningen, University Medical Center Groningen, Department of Clinical Pharmacy and Pharmacology, Groningen, The Netherlands
| | - Claudia A J van Winkel
- University of Groningen, University Medical Center Groningen, Department of Clinical Pharmacy and Pharmacology, Groningen, The Netherlands
| | | | - Scott K Heysell
- University of Virginia, Division of Infectious Diseases and International Health, Charlottesville, VA, USA
| | - Stellah Mpagama
- Kibong'oto Infectious Diseases Hospital, Kilimanjaro, Tanzania
| | - Daan J Touw
- University of Groningen, University Medical Center Groningen, Department of Clinical Pharmacy and Pharmacology, Groningen, The Netherlands
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6
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Boonpeng A, Jaruratanasirikul S, Wattanavijitkul T, Nawakitrangsan M, Samaeng M. Population pharmacokinetics of oral levofloxacin in healthy volunteers and dosing optimization for multidrug-resistant tuberculosis therapy. Biopharm Drug Dispos 2021; 42:329-337. [PMID: 34117648 DOI: 10.1002/bdd.2294] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 05/30/2021] [Accepted: 06/01/2021] [Indexed: 12/22/2022]
Abstract
Levofloxacin is considered a key component of a multidrug-resistant tuberculosis (MDR-TB) regimen. However, there is considerable concern regarding the subtherapeutic concentrations of the currently used doses and the development of drug resistance. Therefore, this study aimed to describe the population pharmacokinetics (PPK) of oral levofloxacin in healthy volunteers and to evaluate the probability of target attainment (PTA) in an attempt to optimize the dosing regimens for MDR-TB therapy. Data of levofloxacin in healthy volunteers from a previous study were used to construct a PPK model. Monte Carlo simulations were performed to derive the PTAs of various regimens. A two-compartment model with linear elimination and transit absorption compartments best described the pharmacokinetics (PK) of levofloxacin. The estimated PK parameters (interindividual variability, %) were: apparent clearance 8.32 L h-1 (22.6%), apparent central volume of distribution 35.8 L (45.2%), apparent peripheral volume of distribution 39.7 L, intercompartmental clearance 40.6 L h-1 (43.8%), absorption rate constant 7.45 h-1 (150%), mean absorption transit time 0.355 h (52.4%), and total number of transit compartments 6.01 (131.9%). Monte Carlo simulations using levofloxacin 750-1000 mg yielded a probability of achieving a target free area under the concentration-time curve/minimum inhibitory concentration (MIC) of 100 at greater than 90% for Mycobacterium tuberculosis with an MIC < 0.5 mg L-1 , while a dose of 1500 mg was required for strains with an MIC of 1 mg L-1 . A higher dose of levofloxacin might be needed to treat tuberculosis. However, further studies on the efficacy and safety of this dose are needed to confirm our findings.
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Affiliation(s)
- Apinya Boonpeng
- Division of Pharmacy Practice, Department of Pharmaceutical Care, School of Pharmaceutical Sciences, University of Phayao, Muang, Thailand
| | - Sutep Jaruratanasirikul
- Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Thailand
| | - Thitima Wattanavijitkul
- Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Chulalongkorn University, Bangkok, Thailand
| | - Monchana Nawakitrangsan
- Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Thailand
| | - Maseetoh Samaeng
- Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Thailand
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7
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Ghimire S, Karki S, Maharjan B, Kosterink JGW, Touw DJ, van der Werf TS, Shrestha B, Alffenaar JW. Treatment outcomes of patients with MDR-TB in Nepal on a current programmatic standardised regimen: retrospective single-centre study. BMJ Open Respir Res 2021; 7:7/1/e000606. [PMID: 32796020 PMCID: PMC7430340 DOI: 10.1136/bmjresp-2020-000606] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 07/16/2020] [Accepted: 07/16/2020] [Indexed: 01/20/2023] Open
Abstract
Objectives The objectives of this study were to evaluate treatment in patients on current programmatic multidrug-resistant tuberculosis (MDR-TB) regimen and verify eligibility for the 9-month regimen and therapeutic drug monitoring (TDM). Methods We performed a retrospective chart review of patients with MDR-TB receiving standardised regimen at the German Nepal TB Project Clinic, Nepal, between 2014 and 2016. Eligibility for the 9-month regimen and indications for TDM were evaluated. Results Out of 107 available patients’ medical records, 98 were included. In this centre, the MDR-TB treatment success rates were 69.0% in 2015, 86.6% in 2016 and 86.5% in 2017. The median time to sputum smear conversion was 60 days (60–90 IQR) and culture conversion was 60 days (60–90 IQR). Observed side effects did not impact treatment outcomes. No difference in treatment success rates was observed between patients with predisposing risk factors and those without. Only 49% (36/74) of patients were eligible for the 9-month regimen and 23 patients for TDM according to American Thoracic Society guideline criteria. Conclusions Nepalese patients with MDR-TB on ambulatory care had good treatment outcome after programmatic treatment. Implementation of the new WHO oral MDR-TB treatment regimen may further improve treatment results. The 9-month regimen and TDM should be considered as part of programmatic care.
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Affiliation(s)
- Samiksha Ghimire
- Clinical Pharmacy and Pharmacology, University of Groningen Faculty of Medical Sciences, Groningen, The Netherlands
| | - Samriddhi Karki
- Tuberculosis Unit, Nepal Anti-Tuberculosis Association/German Nepal TB Project, Kathmandu, Nepal
| | - Bhagwan Maharjan
- Tuberculosis Unit, Nepal Anti-Tuberculosis Association/German Nepal TB Project, Kathmandu, Nepal
| | - Jos G W Kosterink
- Clinical Pharmacy and Pharmacology, University of Groningen Faculty of Medical Sciences, Groningen, The Netherlands
| | - Daan J Touw
- Clinical Pharmacy and Pharmacology, University of Groningen Faculty of Medical Sciences, Groningen, The Netherlands.,Groningen Research Institute of Pharmacy, Department of Pharmaceutical Analysis, University of Groningen, Groningen, Groningen, the Netherlands
| | - Tjip S van der Werf
- Infectious Diseases Service and Tuberculosis Unit, University of Groningen Faculty of Medical Sciences, Groningen, The Netherlands
| | - Bhabana Shrestha
- Tuberculosis Unit, Nepal Anti-Tuberculosis Association/German Nepal TB Project, Kathmandu, Nepal
| | - Jan-Willem Alffenaar
- Clinical Pharmacy and Pharmacology, University of Groningen Faculty of Medical Sciences, Groningen, The Netherlands.,Faculty of Medicine and Health, School of Pharmacy and Westmead hospital, University of Sydney, Sydney, New South Wales, Australia
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A Review of Clinical Pharmacokinetic and Pharmacodynamic Relationships and Clinical Implications for Drugs Used to Treat Multi-drug Resistant Tuberculosis. Eur J Drug Metab Pharmacokinet 2021; 45:305-313. [PMID: 31925745 DOI: 10.1007/s13318-019-00604-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Multidrug-resistant tuberculosis (MDR-TB) is becoming a global health crisis. The World Health Organization has released new guidelines for the use of tuberculosis-active drugs for the treatment of patients with MDR-TB. Despite documented activity against tuberculosis isolates, doses and exposure targets are yet to be optimized. Our objective was therefore to review the clinical pharmacokinetic and pharmacodynamic literature pertaining to drugs recommended to treat MDR-TB and to identify target areas for future research. To date, published research is limited but studies were identified that evaluated the pharmacokinetics and pharmacodynamics of these drugs. Exposure targets were assessed and summarized for each drug. Exposure-based targets (e.g., area under the concentration curve/minimum inhibitory concentration) appear to be most commonly associated with predicting drug efficacy. Dose variation studies based on these targets were largely inconclusive. Future research should focus on determining the risks and benefits of dose optimization to meet exposure targets and improve patient outcomes. The role of therapeutic drug monitoring also remains yet to be confirmed, both from a clinical perspective as well as a resource allocation perspective in regions where MDR-TB is active.
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Szipszky C, Van Aartsen D, Criddle S, Rao P, Zentner I, Justine M, Mduma E, Mpagama S, Al-Shaer MH, Peloquin C, Thomas TA, Vinnard C, Heysell SK. Determination of Rifampin Concentrations by Urine Colorimetry and Mobile Phone Readout for Personalized Dosing in Tuberculosis Treatment. J Pediatric Infect Dis Soc 2021; 10:104-111. [PMID: 32170944 PMCID: PMC7996640 DOI: 10.1093/jpids/piaa024] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 03/01/2020] [Indexed: 01/26/2023]
Abstract
BACKGROUND Individual pharmacokinetic variability is a driver of poor tuberculosis (TB) treatment outcomes. We developed a method for measurement of rifampin concentrations by urine colorimetry and a mobile phone photographic application to predict clinically important serum rifampin pharmacokinetic measurements in children treated for TB. METHODS Among spiked urine samples, colorimetric assay performance was tested with conventional spectrophotometric and the mobile phone/light box methods under various environmental and biologic conditions. Urine rifampin absorbance (Abs) was then determined from timed specimens from children treated for TB in Tanzania, and compared to serum pharmacokinetic measurements collected throughout the dosing interval. RESULTS Both the mobile phone/light box and spectrophotometry demonstrated excellent correlation across a wide range of urine rifampin concentrations (7.8-1000 mg/L) in intra- and interday trials, 24-hour exposure to ambient light or darkness, and varying urinalysis profiles (all r ≥ 0.98). In 12 Tanzanian children, the urine mobile phone/light box measurement and serum peak concentration (Cmax) were significantly correlated (P = .004). Using a Cmax target of 8 mg/L, the area under the receiver operating characteristic curve was 80.1% (range, 47.2%-100%). A urine mobile phone/light box threshold of 50 Abs correctly classified all patients (n = 6) with serum measurements below target. CONCLUSIONS The urine colorimetry with mobile phone/light box assay accurately measured rifampin absorbance in varying environmental and biological conditions that may be observed clinically. Among children treated for TB, the assay was sensitive for detection of low rifampin serum concentrations. Future work will identify the optimal timing for urine collection, and operationalize use in TB-endemic settings.
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Affiliation(s)
- Claire Szipszky
- Departments of Biology and Public Health Sciences, University of Virginia, Charlottesville, Virginia, USA
| | - Daniel Van Aartsen
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA
| | - Sarah Criddle
- School of Medicine, University of Virginia, Charlottesville, Virginia, USA
| | - Prakruti Rao
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA
| | - Isaac Zentner
- Public Health Research Institute, Rutgers State University of New Jersey, Newark, New Jersey, USA
| | | | | | - Stellah Mpagama
- Kibong’oto Infectious Diseases Hospital, Sanya Juu, Kilimanjaro, Tanzania
| | - Mohammad H Al-Shaer
- Infectious Disease Pharmacokinetics Laboratory, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Charles Peloquin
- Infectious Disease Pharmacokinetics Laboratory, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Tania A Thomas
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA
| | - Christopher Vinnard
- Public Health Research Institute, Rutgers State University of New Jersey, Newark, New Jersey, USA
| | - Scott K Heysell
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA
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10
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Busse D, Schaeftlein A, Solms A, Ilia L, Michelet R, Zeitlinger M, Huisinga W, Kloft C. Which Analysis Approach Is Adequate to Leverage Clinical Microdialysis Data? A Quantitative Comparison to Investigate Exposure and Reponse Exemplified by Levofloxacin. Pharm Res 2021; 38:381-395. [PMID: 33723793 PMCID: PMC7994214 DOI: 10.1007/s11095-021-02994-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 11/05/2020] [Indexed: 01/22/2023]
Abstract
Purpose Systematic comparison of analysis methods of clinical microdialysis data for impact on target-site drug exposure and response. Methods 39 individuals received a 500 mg levofloxacin short-term infusion followed by 24-h dense sampling in plasma and microdialysate collection in interstitial space fluid (ISF). ISF concentrations were leveraged using non-compartmental (NCA) and compartmental analysis (CA) via (ii) relative recovery correction at midpoint of the collection interval (midpoint-NCA, midpoint-CA) and (ii) dialysate-based integrals of time (integral-CA). Exposure and adequacy of community-acquired pneumonia (CAP) therapy via pharmacokinetic/pharmacodynamic target-attainment (PTA) analysis were compared between approaches. Results Individual AUCISF estimates strongly varied for midpoint-NCA and midpoint-CA (≥52.3%CV) versus integral-CA (≤32.9%CV) owing to separation of variability in PK parameters (midpoint-CA = 46.5%–143%CVPK, integral-CA = 26.4%–72.6%CVPK) from recovery-related variability only in integral-CA (41.0%–50.3%CVrecovery). This also led to increased variability of AUCplasma for midpoint-CA (56.0%CV) versus midpoint-NCA and integral-CA (≤33.0%CV), and inaccuracy of predictive model performance of midpoint-CA in plasma (visual predictive check). PTA analysis translated into 33% of evaluated patient cases being at risk of incorrectly rejecting recommended dosing regimens at CAP-related epidemiological cut-off values. Conclusions Integral-CA proved most appropriate to characterise clinical pharmacokinetics- and microdialysis-related variability. Employing this knowledge will improve the understanding of drug target-site PK for therapeutic decision-making. Supplementary Information The online version contains supplementary material available at 10.1007/s11095-021-02994-1.
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Affiliation(s)
- David Busse
- Institute of Pharmacy, Department of Clinical Pharmacy and Biochemistry, Freie Universitaet Berlin, Berlin, Germany.,Graduate Research Training program PharMetrX, Berlin/Potsdam, Germany
| | | | - Alexander Solms
- Institute of Mathematics, University of Potsdam, Potsdam, Germany.,Clinical Pharmacometrics, Bayer AG, Berlin, Germany
| | - Luis Ilia
- Institute of Pharmacy, Department of Clinical Pharmacy and Biochemistry, Freie Universitaet Berlin, Berlin, Germany
| | - Robin Michelet
- Institute of Pharmacy, Department of Clinical Pharmacy and Biochemistry, Freie Universitaet Berlin, Berlin, Germany
| | - Markus Zeitlinger
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Wilhelm Huisinga
- Institute of Mathematics, University of Potsdam, Potsdam, Germany
| | - Charlotte Kloft
- Institute of Pharmacy, Department of Clinical Pharmacy and Biochemistry, Freie Universitaet Berlin, Berlin, Germany.
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11
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Kong S, Chen H, Huang K, Jin D, Zhang G, Ye F. Antibiotic susceptibility guided reuse of levofloxacin-based therapy in a penicillin-allergic patient for Helicobacter pylori infection: A case report. Medicine (Baltimore) 2021; 100:e24915. [PMID: 33725850 PMCID: PMC7969298 DOI: 10.1097/md.0000000000024915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 02/04/2021] [Indexed: 01/05/2023] Open
Abstract
RATIONALE Antibiotic resistance poses a challenge for Helicobacter pylori eradication treatment. Current guidelines strongly recommend avoiding repeated treatments with the same antibiotic to prevent the emergence of drug resistance. However, for penicillin-allergic patients with recurrent H. pylori eradication failures, avoiding repeated treatments with the same antibiotic severely limits the choice of treatment. PATIENT CONCERNS A 47-year-old woman with a penicillin allergy for whom 2 previous levofloxacin and bismuth-based therapies had failed. DIAGNOSIS H. pylori infection. INTERVENTIONS Agar dilution susceptibility testing and gene sequence analysis was performed to confirm levofloxacin susceptibility again. Therefore, we treated her with a 14-day regimen consisting of levofloxacin (500 mg once daily), furazolidone (100 mg twice daily), colloidal bismuth pectin (220 mg twice daily), and esomeprazole (20 mg twice daily). OUTCOMES The patient was successfully treated with a third levofloxacin and bismuth-based regimen. LESSONS Antibiotics included in previous failed therapies need not be eliminated if no antibiotic resistance is found on antimicrobial susceptibility testing.
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Affiliation(s)
- Siya Kong
- Department of Gastroenterology, The First Affiliated Hospital of Nanjing Medical University
- First Clinical Medical College of Nanjing Medical University, Nanjing, PR China
| | - Han Chen
- Department of Gastroenterology, The First Affiliated Hospital of Nanjing Medical University
| | - Keting Huang
- Department of Gastroenterology, The First Affiliated Hospital of Nanjing Medical University
- First Clinical Medical College of Nanjing Medical University, Nanjing, PR China
| | - Duochen Jin
- Department of Gastroenterology, The First Affiliated Hospital of Nanjing Medical University
- First Clinical Medical College of Nanjing Medical University, Nanjing, PR China
| | - Guoxin Zhang
- Department of Gastroenterology, The First Affiliated Hospital of Nanjing Medical University
- First Clinical Medical College of Nanjing Medical University, Nanjing, PR China
| | - Feng Ye
- Department of Gastroenterology, The First Affiliated Hospital of Nanjing Medical University
- First Clinical Medical College of Nanjing Medical University, Nanjing, PR China
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12
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Forsman LD, Jonsson J, Wagrell C, Werngren J, Mansjö M, Wijkander M, Groenheit R, Hammar U, Giske CG, Schön T, Bruchfeld J. Minimum Inhibitory Concentrations of Fluoroquinolones and Pyrazinamide Susceptibility Correlate to Clinical Improvement in Multidrug-resistant Tuberculosis Patients: A Nationwide Swedish Cohort Study Over 2 Decades. Clin Infect Dis 2020; 69:1394-1402. [PMID: 30561569 DOI: 10.1093/cid/ciy1068] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 12/13/2018] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Minimum inhibitory concentration (MIC) testing, unlike routine drug susceptibility testing (DST) at a single critical concentration, quantifies drug resistance. The association of MICs and treatment outcome in multidrug-resistant (MDR)-tuberculosis patients is unclear. Therefore, we correlated MICs of first- and second-line tuberculosis drugs with time to sputum culture conversion (tSCC) and treatment outcome in MDR-tuberculosis patients. METHODS Clinical and demographic data of MDR-tuberculosis patients in Sweden, including DST results, were retrieved from medical records from 1992 to 2014. MIC determinations were performed retrospectively for the stored individual Mycobacterium tuberculosis (Mtb) isolates using broth microdilution in Middlebrook 7H9. We fitted Cox proportional hazard models correlating MICs, DST results, and clinical variables to tSCC and treatment outcome. RESULTS Successful treatment outcome was observed in 83.5% (132/158) of MDR-tuberculosis patients. Increasing MICs of fluoroquinolones, diabetes, and age >40 years were significantly associated with unsuccessful treatment outcome. Patients treated with pyrazinamide (PZA) had a significantly shorter tSCC compared to patients who were not (median difference, 27 days). CONCLUSIONS Increasing MICs of fluoroquinolones were correlated with unsuccessful treatment outcome in MDR-tuberculosis patients. Further studies, including MIC testing and clinical outcome data to define clinical Mtb breakpoints, are warranted. PZA treatment was associated with shorter tSCC, highlighting the importance of PZA DST.
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Affiliation(s)
- Lina Davies Forsman
- Division of Infectious Diseases, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.,Department of Infectious Diseases, Karolinska University Hospital Solna, Stockholm, Sweden
| | - Jerker Jonsson
- Division of Infectious Diseases, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.,Department of Public Health Analysis and Data Management, Stockholm, Sweden
| | - Charlotta Wagrell
- Division of Infectious Diseases, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Jim Werngren
- Department of Microbiology, Public Health Agency of Sweden, Stockholm, Sweden
| | - Mikael Mansjö
- Department of Microbiology, Public Health Agency of Sweden, Stockholm, Sweden
| | - Maria Wijkander
- Department of Microbiology, Public Health Agency of Sweden, Stockholm, Sweden
| | - Ramona Groenheit
- Department of Microbiology, Public Health Agency of Sweden, Stockholm, Sweden
| | - Ulf Hammar
- Unit of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Christian G Giske
- Department of Laboratory Medicine, Division of Clinical Microbiology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Thomas Schön
- Department of Clinical and Experimental Medicine, Linköping University, Sweden.,Department of Clinical Microbiology and Infectious Diseases, Kalmar County Hospital, Sweden
| | - Judith Bruchfeld
- Division of Infectious Diseases, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.,Department of Infectious Diseases, Karolinska University Hospital Solna, Stockholm, Sweden
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13
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van den Elsen SH, Sturkenboom MG, Akkerman O, Barkane L, Bruchfeld J, Eather G, Heysell SK, Hurevich H, Kuksa L, Kunst H, Kuhlin J, Manika K, Moschos C, Mpagama SG, Muñoz Torrico M, Skrahina A, Sotgiu G, Tadolini M, Tiberi S, Volpato F, van der Werf TS, Wilson MR, Zúñiga J, Touw DJ, Migliori GB, Alffenaar JW. Prospective evaluation of improving fluoroquinolone exposure using centralised therapeutic drug monitoring (TDM) in patients with tuberculosis (PERFECT): a study protocol of a prospective multicentre cohort study. BMJ Open 2020; 10:e035350. [PMID: 32554740 PMCID: PMC7304807 DOI: 10.1136/bmjopen-2019-035350] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
INTRODUCTION Global multidrug-resistant tuberculosis (MDR-TB) treatment success rates remain suboptimal. Highly active WHO group A drugs moxifloxacin and levofloxacin show intraindividual and interindividual pharmacokinetic variability which can cause low drug exposure. Therefore, therapeutic drug monitoring (TDM) of fluoroquinolones is recommended to personalise the drug dosage, aiming to prevent the development of drug resistance and optimise treatment. However, TDM is considered laborious and expensive, and the clinical benefit in MDR-TB has not been extensively studied. This observational multicentre study aims to determine the feasibility of centralised TDM and to investigate the impact of fluoroquinolone TDM on sputum conversion rates in patients with MDR-TB compared with historical controls. METHODS AND ANALYSIS Patients aged 18 years or older with sputum smear and culture-positive pulmonary MDR-TB will be eligible for inclusion. Patients receiving TDM using a limited sampling strategy (t=0 and t=5 hours) will be matched to historical controls without TDM in a 1:2 ratio. Sample analysis and dosing advice will be performed in a centralised laboratory. Centralised TDM will be considered feasible if >80% of the dosing recommendations are returned within 7 days after sampling and 100% within 14 days. The number of patients who are sputum smear and culture-negative after 2 months of treatment will be determined in the prospective TDM group and will be compared with the control group without TDM to determine the impact of TDM. ETHICS AND DISSEMINATION Ethical clearance was obtained by the ethical review committees of the 10 participating hospitals according to local procedures or is pending (online supplementary file 1). Patients will be included after obtaining written informed consent. We aim to publish the study results in a peer-reviewed journal. TRIAL REGISTRATION NUMBER ClinicalTrials.gov Registry (NCT03409315).
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Affiliation(s)
- Simone Hj van den Elsen
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Marieke Gg Sturkenboom
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Onno Akkerman
- Department of Pulmonary Diseases and Tuberculosis, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Tuberculosis Center Beatrixoord, University of Groningen, University Medical Center Groningen, Haren, The Netherlands
| | - Linda Barkane
- Department of Multidrug Resistant Tuberculosis, Riga East University Hospital TB and Lung Disease Clinic, Riga, Latvia
| | - Judith Bruchfeld
- Division of Infectious Diseases, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Geoffrey Eather
- Department of Respiratory Medicine and Metro South Clinical Tuberculosis Service, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
| | - Scott K Heysell
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA
| | - Henadz Hurevich
- The Republican Scientific and Practical Center for Pulmonology and Tuberculosis, Minsk, Belarus
| | - Liga Kuksa
- Department of Multidrug Resistant Tuberculosis, Riga East University Hospital TB and Lung Disease Clinic, Riga, Latvia
| | - Heinke Kunst
- Department of Respiratory Medicine, Blizard Institute, Queen Mary University of London, Barts Health NHS Trust, London, UK
| | - Johanna Kuhlin
- Division of Infectious Diseases, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Katerina Manika
- Pulmonary Department, Respiratory Infections Unit, G. Papanikolaou Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Charalampos Moschos
- Drug-Resistant Tuberculosis Unit, 'Sotiria' Hospital for Chest Diseases, Athens, Greece
| | - Stellah G Mpagama
- Kibong'oto Infectious Diseases Hospital, Kilimanjaro, United Republic of Tanzania
| | - Marcela Muñoz Torrico
- Clínica de Tuberculosis, Instituto Nacional de Enfermedades Respiratorias, Mexico City, Mexico
| | - Alena Skrahina
- The Republican Scientific and Practical Center for Pulmonology and Tuberculosis, Minsk, Belarus
| | - Giovanni Sotgiu
- Department of Medical, Surgical and Experimental Sciences, Clinical Epidemiology and Medical Statistics Unit, University of Sassari, Sassari, Italy
| | - Marina Tadolini
- Department of Medical and Surgical Sciences, Unit of Infectious Diseases, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Simon Tiberi
- Department of Infection, Blizard Institute, Queen Mary University of London, Barts Health NHS Trust, London, UK
| | - Francesca Volpato
- Department of Medical and Surgical Sciences, Unit of Infectious Diseases, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Tjip S van der Werf
- Department of Pulmonary Diseases and Tuberculosis, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Department of Internal Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Malcolm R Wilson
- Department of Respiratory Medicine and Metro South Clinical Tuberculosis Service, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
| | - Joaquin Zúñiga
- Laboratory of Immunobiology and Genetics, Instituto Nacional de Enfermedades Respiratorias, Mexico City, Mexico
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de Salud, Mexico City, Mexico
| | - Daan J Touw
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Giovanni B Migliori
- Servizio di Epidemiologia Clinica delle Malattie Respiratorie, Istituti Clinici Scientifici Maugeri IRCCS, Tradate, Italy
| | - Jan-Willem Alffenaar
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
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14
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Potential anti-TB investigational compounds and drugs with repurposing potential in TB therapy: a conspectus. Appl Microbiol Biotechnol 2020; 104:5633-5662. [PMID: 32372202 DOI: 10.1007/s00253-020-10606-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 03/27/2020] [Accepted: 04/05/2020] [Indexed: 02/07/2023]
Abstract
The latest WHO report estimates about 1.6 million global deaths annually from TB, which is further exacerbated by drug-resistant (DR) TB and comorbidities with diabetes and HIV. Exiguous dosing, incomplete treatment course, and the ability of the tuberculosis bacilli to tolerate and survive current first-line and second-line anti-TB drugs, in either their latent state or active state, has resulted in an increased prevalence of multidrug-resistant (MDR), extensively drug-resistant (XDR), and totally drug-resistant TB (TDR-TB). Although a better understanding of the TB microanatomy, genome, transcriptome, proteome, and metabolome, has resulted in the discovery of a few novel promising anti-TB drug targets and diagnostic biomarkers of late, no new anti-TB drug candidates have been approved for routine therapy in over 50 years, with only bedaquiline, delamanid, and pretomanid recently receiving tentative regulatory approval. Considering this, alternative approaches for identifying possible new anti-TB drug candidates, for effectively eradicating both replicating and non-replicating Mycobacterium tuberculosis, are still urgently required. Subsequently, several antibiotic and non-antibiotic drugs with known treatment indications (TB targeted and non-TB targeted) are now being repurposed and/or derivatized as novel antibiotics for possible use in TB therapy. Insights gathered here reveal that more studies focused on drug-drug interactions between licensed and potential lead anti-TB drug candidates need to be prioritized. This write-up encapsulates the most recent findings regarding investigational compounds with promising anti-TB potential and drugs with repurposing potential in TB therapy.
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15
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Potential Genes Related to Levofloxacin Resistance in Mycobacterium tuberculosis Based on Transcriptome and Methylome Overlap Analysis. J Mol Evol 2020; 88:202-209. [PMID: 31919584 PMCID: PMC6989609 DOI: 10.1007/s00239-019-09926-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 12/18/2019] [Indexed: 01/07/2023]
Abstract
Drug-resistant Mycobacterium tuberculosis (M. tuberculosis) has become an increasingly serious public health problem and has complicated tuberculosis (TB) treatment. Levofloxacin (LOF) is an ideal anti-tuberculosis drug in clinical applications. However, the detailed molecular mechanisms of LOF-resistant M. tuberculosis in TB treatment have not been revealed. Our study performed transcriptome and methylome sequencing to investigate the potential biological characteristics of LOF resistance in M. tuberculosis H37Rv. In the transcriptome analysis, 953 differentially expressed genes (DEGs) were identified; 514 and 439 DEGs were significantly downregulated and upregulated in the LOF-resistant group and control group, respectively. The KEGG pathway analysis revealed that 97 pathways were enriched in this study. In the methylome analysis, 239 differentially methylated genes (DMGs) were identified; 150 and 89 DMGs were hypomethylated and hypermethylated in the LOF-resistant group and control group, respectively. The KEGG pathway analysis revealed that 74 pathways were enriched in this study. The overlap study suggested that 25 genes were obtained. It was notable that nine genes expressed downregulated mRNA and upregulated methylated levels, including pgi, fadE4, php, cyp132, pckA, rpmB1, pfkB, acg, and ctpF, especially cyp132, pckA, and pfkB, which were vital in LOF-resistant M. tuberculosis H37Rv. The overlapping genes between transcriptome and methylome could be essential for studying the molecular mechanisms of LOF-resistant M. tuberculosis H37Rv. These results may provide informative evidence for TB treatment with LOF.
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16
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Seifert M, Capparelli E, Catanzaro DG, Rodwell TC. Using Mycobacterium tuberculosis Single-Nucleotide Polymorphisms To Predict Fluoroquinolone Treatment Response. Antimicrob Agents Chemother 2019; 63:e00076-19. [PMID: 31085512 PMCID: PMC6591594 DOI: 10.1128/aac.00076-19] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 05/03/2019] [Indexed: 12/22/2022] Open
Abstract
Clinical phenotypic fluoroquinolone susceptibility testing of Mycobacterium tuberculosis is currently based on M. tuberculosis growth at a single critical concentration, which provides limited information for a nuanced clinical response. We propose using specific resistance-conferring M. tuberculosis mutations in gyrA together with population pharmacokinetic and pharmacodynamic modeling as a novel tool to better inform fluoroquinolone treatment decisions. We sequenced the gyrA resistance-determining region of 138 clinical M. tuberculosis isolates collected from India, Moldova, Philippines, and South Africa and then determined each strain's MIC against ofloxacin, moxifloxacin, levofloxacin, and gatifloxacin. Strains with specific gyrA single-nucleotide polymorphisms (SNPs) were grouped into high or low drug-specific resistance categories based on their empirically measured MICs. Published population pharmacokinetic models were then used to explore the pharmacokinetics and pharmacodynamics of each fluoroquinolone relative to the empirical MIC distribution for each resistance category to make predictions about the likelihood of patients achieving defined therapeutic targets. In patients infected with M. tuberculosis isolates containing SNPs associated with a fluoroquinolone-specific low-level increase in MIC, models suggest increased fluoroquinolone dosing improved the probability of achieving therapeutic targets for gatifloxacin and moxifloxacin but not for levofloxacin and ofloxacin. In contrast, among patients with isolates harboring SNPs associated with a high-level increase in MIC, increased dosing of levofloxacin, moxifloxacin, gatifloxacin, or ofloxacin did not meaningfully improve the probability of therapeutic target attainment. We demonstrated that quantifiable fluoroquinolone drug resistance phenotypes could be predicted from rapidly detectable gyrA SNPs and used to support dosing decisions based on the likelihood of patients reaching therapeutic targets. Our findings provide further supporting evidence for the moxifloxacin clinical breakpoint recently established by the World Health Organization.
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Affiliation(s)
- Marva Seifert
- Department of Medicine, University of California San Diego, La Jolla, California, USA
| | - Edmund Capparelli
- Department of Pediatrics, University of California San Diego, La Jolla, California, USA
| | - Donald G Catanzaro
- Department of Biological Sciences, University of Arkansas, Fayetteville, Arkansas, USA
| | - Timothy C Rodwell
- Department of Medicine, University of California San Diego, La Jolla, California, USA
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17
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Fluoroquinolones in Drug-Resistant Tuberculosis: Culture Conversion and Pharmacokinetic/Pharmacodynamic Target Attainment To Guide Dose Selection. Antimicrob Agents Chemother 2019; 63:AAC.00279-19. [PMID: 31061152 PMCID: PMC6591615 DOI: 10.1128/aac.00279-19] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 04/25/2019] [Indexed: 12/15/2022] Open
Abstract
Fluoroquinolones are group A drugs in tuberculosis guidelines. We aim to compare the culture conversion between new-generation (levofloxacin and moxifloxacin) and old-generation (ciprofloxacin and ofloxacin) fluoroquinolones, develop pharmacokinetic models, and calculate target attainment for levofloxacin and moxifloxacin. We included three U.S. tuberculosis centers. Fluoroquinolones are group A drugs in tuberculosis guidelines. We aim to compare the culture conversion between new-generation (levofloxacin and moxifloxacin) and old-generation (ciprofloxacin and ofloxacin) fluoroquinolones, develop pharmacokinetic models, and calculate target attainment for levofloxacin and moxifloxacin. We included three U.S. tuberculosis centers. Patients admitted between 1984 and 2015, infected with drug-resistant tuberculosis, and who had received fluoroquinolones for ≥28 days were included. Demographics, sputum cultures and susceptibility, treatment regimens, and serum concentrations were collected. A time-to-event analysis was conducted, and Cox proportional hazards model was used to compare the time to culture conversion. Using additional data from ongoing studies, pharmacokinetic modelling and Monte Carlo simulations were performed to assess target attainment for different doses. Overall, 124 patients received fluoroquinolones. The median age was 40 years, and the median weight was 60 kg. Fifty-six patients (45%) received old-generation fluoroquinolones. New-generation fluoroquinolones showed a faster time to culture conversion (median 16 versus 40 weeks, P = 0.012). After adjusting for isoniazid and clofazimine treatment, patients treated with new-generation fluoroquinolones were more likely to have culture conversion (adjusted hazards ratio, 2.16 [95% confidence interval, 1.28 to 3.64]). We included 178 patients in the pharmacokinetic models. Levofloxacin and moxifloxacin were best described by a one-compartment model with first-order absorption and elimination. At least 1,500 to 1,750 mg levofloxacin and 800 mg moxifloxacin may be needed for maximum kill at the current epidemiologic cutoff values. In summary, new-generation fluoroquinolones showed faster time to culture conversion compared to the old generation. For optimal target attainment at the current MIC values, higher doses of levofloxacin and moxifloxacin may be needed.
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18
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Collin SM, Wurie F, Muzyamba MC, de Vries G, Lönnroth K, Migliori GB, Abubakar I, Anderson SR, Zenner D. Effectiveness of interventions for reducing TB incidence in countries with low TB incidence: a systematic review of reviews. Eur Respir Rev 2019; 28:28/152/180107. [PMID: 31142548 DOI: 10.1183/16000617.0107-2018] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 03/22/2019] [Indexed: 12/18/2022] Open
Abstract
AIMS What is the evidence base for the effectiveness of interventions to reduce tuberculosis (TB) incidence in countries which have low TB incidence? METHODS We conducted a systematic review of interventions for TB control and prevention relevant to low TB incidence settings (<10 cases per 100 000 population). Our analysis was stratified according to "direct" or "indirect" effects on TB incidence. Review quality was assessed using AMSTAR2 criteria. We summarised the strength of review level evidence for interventions as "sufficient", "tentative", "insufficient" or "no" using a framework based on the consistency of evidence within and between reviews. RESULTS We found sufficient review level evidence for direct effects on TB incidence/case prevention of vaccination and treatment of latent TB infection. We also found sufficient evidence of beneficial indirect effects attributable to drug susceptibility testing and adverse indirect effects (measured as sub-optimal treatment outcomes) in relation to use of standardised first-line drug regimens for isoniazid-resistant TB and intermittent dosing regimens. We found insufficient review level evidence for direct or indirect effects of interventions in other areas, including screening, adherence, multidrug-resistant TB, and healthcare-associated infection. DISCUSSION Our review has shown a need for stronger evidence to support expert opinion and country experience when formulating TB control policy.
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Affiliation(s)
- Simon M Collin
- TB Unit, National Infection Service, Public Health England, London, UK
| | - Fatima Wurie
- TB Unit, National Infection Service, Public Health England, London, UK
| | - Morris C Muzyamba
- TB Unit, National Infection Service, Public Health England, London, UK
| | | | | | | | | | - Sarah R Anderson
- TB Unit, National Infection Service, Public Health England, London, UK
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19
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Ghimire S, Maharjan B, Jongedijk EM, Kosterink JGW, Ghimire GR, Touw DJ, van der Werf TS, Shrestha B, Alffenaar JWC. Levofloxacin pharmacokinetics, pharmacodynamics and outcome in multidrug-resistant tuberculosis patients. Eur Respir J 2019; 53:13993003.02107-2018. [PMID: 30655280 DOI: 10.1183/13993003.02107-2018] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Accepted: 12/28/2018] [Indexed: 12/16/2022]
Affiliation(s)
- Samiksha Ghimire
- University of Groningen, University Medical Center Groningen, Dept of Clinical Pharmacy and Pharmacology, Groningen, The Netherlands
| | - Bhagwan Maharjan
- German Nepal TB Project, Nepal Anti-Tuberculosis Association, Kathmandu, Nepal
| | - Erwin M Jongedijk
- University of Groningen, University Medical Center Groningen, Dept of Clinical Pharmacy and Pharmacology, Groningen, The Netherlands
| | - Jos G W Kosterink
- University of Groningen, University Medical Center Groningen, Dept of Clinical Pharmacy and Pharmacology, Groningen, The Netherlands
| | - Gokarna R Ghimire
- Government of Nepal, Ministry of Health and Population, Dept of Health Services, National Tuberculosis Center, Kathmandu, Nepal
| | - Daan J Touw
- University of Groningen, University Medical Center Groningen, Dept of Clinical Pharmacy and Pharmacology, Groningen, The Netherlands
| | - Tjip S van der Werf
- University of Groningen, Groningen Research Institute of Pharmacy, Dept of Pharmacokinetics, Toxicology and Targeting, Groningen, The Netherlands.,University of Groningen, University Medical Center Groningen, Infectious Diseases Service and Tuberculosis Unit, Groningen, The Netherlands
| | - Bhabana Shrestha
- German Nepal TB Project, Nepal Anti-Tuberculosis Association, Kathmandu, Nepal
| | - Jan-Willem C Alffenaar
- University of Groningen, University Medical Center Groningen, Dept of Clinical Pharmacy and Pharmacology, Groningen, The Netherlands
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Cristinacce A, Wright JG, Stone GG, Hammond J, McFadyen L, Raber S. A Retrospective Analysis of Probability of Target Attainment in Community-Acquired Pneumonia: Ceftaroline Fosamil Versus Comparators. Infect Dis Ther 2019; 8:185-198. [PMID: 30963520 PMCID: PMC6522587 DOI: 10.1007/s40121-019-0243-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Indexed: 02/07/2023] Open
Abstract
Introduction This retrospective analysis compares the probability of target attainment (PTA) for ceftriaxone, levofloxacin and ceftaroline fosamil against Staphylococcus aureus, Streptococcus pneumoniae and Haemophilus influenzae in a representative patient population with moderate-to-severe community-acquired pneumonia (CAP). Methods Published pharmacokinetic (PK) models for levofloxacin and ceftriaxone, and an existing model for ceftaroline, were used with standard dosage regimens for simulating individual PK data with covariates representative of patients with CAP (5000 patients/drug regimen). PTA for clinically relevant pharmacokinetic/pharmacodynamic (PK/PD) targets was calculated from steady state PK profiles for a range of minimum inhibitory concentrations (MICs). Cumulative fractions of response (CFRs) were also calculated using MIC distributions from 2012 to 2017 global surveillance data. Results Ceftaroline fosamil (600 mg q12 h) achieved > 90% PTA at all exposure targets for each pathogen at European Committee on Antimicrobial Susceptibility Testing (EUCAST)/Clinical and Laboratory Standards Institute (CLSI) susceptibility breakpoints, and CFRs were > 99%. Ceftriaxone, but not levofloxacin, achieved 100% PTA and > 90% CFR against S. pneumoniae. Both levofloxacin and ceftriaxone achieved high PTA and CFR against H. influenzae. Levofloxacin achieved PTAs < 90% at EUCAST/CLSI breakpoints and ceftriaxone achieved PTAs < 90% at MICs up to 2 mg/L against S. aureus; both agents produced generally low CFRs against S. aureus (except levofloxacin against methicillin-sensitive S. aureus), reflecting the lack of activity of these agents against methicillin-resistant S. aureus. Conclusion Ceftaroline fosamil demonstrated higher overall PTA rates than levofloxacin and ceftriaxone, in particular against S. aureus. These results provide insight regarding the potential comparative efficacy of the described antibiotics for moderate-to-severe CAP. Funding Pfizer.
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21
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van den Elsen SHJ, Sturkenboom MGG, Van't Boveneind-Vrubleuskaya N, Skrahina A, van der Werf TS, Heysell SK, Mpagama S, Migliori GB, Peloquin CA, Touw DJ, Alffenaar JWC. Population Pharmacokinetic Model and Limited Sampling Strategies for Personalized Dosing of Levofloxacin in Tuberculosis Patients. Antimicrob Agents Chemother 2018; 62:e01092-18. [PMID: 30373800 PMCID: PMC6256746 DOI: 10.1128/aac.01092-18] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Accepted: 09/18/2018] [Indexed: 12/20/2022] Open
Abstract
Levofloxacin is an antituberculosis drug with substantial interindividual pharmacokinetic variability; therapeutic drug monitoring (TDM) could therefore be helpful to improve treatment results. TDM would be more feasible with limited sampling strategies (LSSs), a method to estimate the area under the concentration curve for the 24-h dosing interval (AUC0-24) by using a limited number of samples. This study aimed to develop a population pharmacokinetic (popPK) model of levofloxacin in tuberculosis patients, along with LSSs using a Bayesian and multiple linear regression approach. The popPK model and Bayesian LSS were developed using data from 30 patients and externally validated with 20 patients. The LSS based on multiple linear regression was internally validated using jackknife analysis. Only clinically suitable LSSs (maximum time span, 8 h; minimum interval, 1 h; 1 to 3 samples) were tested. Performance criteria were root-mean-square error (RMSE) of <15%, mean prediction error (MPE) of <5%, and r2 value of >0.95. A one-compartment model with lag time best described the data while only slightly underestimating the AUC0-24 (mean, -7.9%; standard error [SE], 1.7%). The Bayesian LSS using 0- and 5-h postdose samples (RMSE, 8.8%; MPE, 0.42%; r2 = 0.957) adequately estimated the AUC0-24, with a mean underestimation of -4.4% (SE, 2.7%). The multiple linear regression LSS using 0- and 4-h postdose samples (RMSE, 7.0%; MPE, 5.5%; r2 = 0.977) was internally validated, with a mean underestimation of -0.46% (SE, 2.0%). In this study, we successfully developed a popPK model and two LSSs that could be implemented in clinical practice to assist TDM of levofloxacin. (This study has been registered at ClinicalTrials.gov under identifier NCT01918397.).
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Affiliation(s)
- Simone H J van den Elsen
- University of Groningen, University Medical Center Groningen, Department of Clinical Pharmacy and Pharmacology, Groningen, The Netherlands
| | - Marieke G G Sturkenboom
- University of Groningen, University Medical Center Groningen, Department of Clinical Pharmacy and Pharmacology, Groningen, The Netherlands
| | - Natasha Van't Boveneind-Vrubleuskaya
- University of Groningen, University Medical Center Groningen, Department of Clinical Pharmacy and Pharmacology, Groningen, The Netherlands
- Department of Public Health TB Control, Metropolitan Public Health Service Haaglanden, The Hague, The Netherlands
| | - Alena Skrahina
- The Republic Scientific and Practical Center for Pulmonology and Tuberculosis, Minsk, Belarus
| | - Tjip S van der Werf
- University of Groningen, University Medical Center Groningen, Department of Internal Diseases, Groningen, The Netherlands
- University of Groningen, University Medical Center Groningen, Department of Pulmonary Diseases and Tuberculosis, Groningen, The Netherlands
| | - Scott K Heysell
- Division of Infectious Diseases and International Health, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Stellah Mpagama
- Kibong'oto National Tuberculosis Hospital, Sanya Juu, Tanzania
| | | | - Charles A Peloquin
- Infectious Disease Pharmacokinetics Laboratory, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Daan J Touw
- University of Groningen, University Medical Center Groningen, Department of Clinical Pharmacy and Pharmacology, Groningen, The Netherlands
| | - Jan-Willem C Alffenaar
- University of Groningen, University Medical Center Groningen, Department of Clinical Pharmacy and Pharmacology, Groningen, The Netherlands
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22
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Davies Forsman L, Niward K, Hu Y, Zheng R, Zheng X, Ke R, Cai W, Hong C, Li Y, Gao Y, Werngren J, Paues J, Kuhlin J, Simonsson USH, Eliasson E, Alffenaar JW, Mansjö M, Hoffner S, Xu B, Schön T, Bruchfeld J. Plasma concentrations of second-line antituberculosis drugs in relation to minimum inhibitory concentrations in multidrug-resistant tuberculosis patients in China: a study protocol of a prospective observational cohort study. BMJ Open 2018; 8:e023899. [PMID: 30287613 PMCID: PMC6173237 DOI: 10.1136/bmjopen-2018-023899] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Revised: 06/21/2018] [Accepted: 08/06/2018] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION Individualised treatment through therapeutic drug monitoring (TDM) may improve tuberculosis (TB) treatment outcomes but is not routinely implemented. Prospective clinical studies of drug exposure and minimum inhibitory concentrations (MICs) in multidrug-resistant TB (MDR-TB) are scarce. This translational study aims to characterise the area under the concentration-time curve of individual MDR-TB drugs, divided by the MIC for Mycobacterium tuberculosis isolates, to explore associations with markers of treatment progress and to develop useful strategies for clinical implementation of TDM in MDR-TB. METHODS AND ANALYSIS Adult patients with pulmonary MDR-TB treated in Xiamen, China, are included. Plasma samples for measure of drug exposure are obtained at 0, 1, 2, 4, 6, 8 and 10 hours after drug intake at week 2 and at 0, 4 and 6 hours during weeks 4 and 8. Sputum samples for evaluating time to culture positivity and MIC determination are collected at days 0, 2 and 7 and at weeks 2, 4, 8 and 12 after treatment initiation. Disease severity are assessed with a clinical scoring tool (TBscore II) and quality of life evaluated using EQ-5D-5L. Drug concentrations of pyrazinamide, ethambutol, levofloxacin, moxifloxacin, cycloserine, prothionamide and para-aminosalicylate are measured by liquid chromatography tandem-mass spectrometry and the levels of amikacin measured by immunoassay. Dried blood spot on filter paper, to facilitate blood sampling for analysis of drug concentrations, is also evaluated. The MICs of the drugs listed above are determined using custom-made broth microdilution plates and MYCOTB plates with Middlebrook 7H9 media. MIC determination of pyrazinamide is performed in BACTEC MGIT 960. ETHICS AND DISSEMINATION This study has been approved by the ethical review boards of Karolinska Institutet, Sweden and Fudan University, China. Informed written consent is given by participants. The study results will be submitted to a peer-reviewed journal. TRIAL REGISTRATION NUMBER NCT02816931; Pre-results.
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Affiliation(s)
- Lina Davies Forsman
- Division of Infectious Diseases, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Infectious Disease, Karolinska University Hospital, Stockholm, Sweden
| | - Katarina Niward
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
- Department of Infectious Diseases, Linköping University, Linkoping, Sweden
| | - Yi Hu
- Department of Epidemiology, School of Public Health and Key Laboratory of Public Health Safety, Fudan University, Shanghai, China
| | - Rongrong Zheng
- Department of Tuberculosis and AIDS prevention, Xiamen City Centre for Disease Control, Xiamen, China
| | - Xubin Zheng
- Department of Epidemiology, School of Public Health and Key Laboratory of Public Health Safety, Fudan University, Shanghai, China
| | - Ran Ke
- Department of Tuberculosis and AIDS prevention, Xiamen City Centre for Disease Control, Xiamen, China
| | - Weiping Cai
- Department of Tuberculosis and AIDS prevention, Xiamen City Centre for Disease Control, Xiamen, China
| | - Chao Hong
- Department of Tuberculosis and AIDS prevention, Xiamen City Centre for Disease Control, Xiamen, China
| | - Yang Li
- Department of Epidemiology, School of Public Health and Key Laboratory of Public Health Safety, Fudan University, Shanghai, China
| | - Yazhou Gao
- Department of Epidemiology, School of Public Health and Key Laboratory of Public Health Safety, Fudan University, Shanghai, China
| | - Jim Werngren
- Department of Microbiology, The Public Health Agency of Sweden, Stockholm, Sweden
| | - Jakob Paues
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
- Department of Infectious Diseases, Linköping University, Linkoping, Sweden
| | - Johanna Kuhlin
- Division of Infectious Diseases, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Infectious Disease, Karolinska University Hospital, Stockholm, Sweden
| | | | - Erik Eliasson
- Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Jan-Willem Alffenaar
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Mikael Mansjö
- Department of Microbiology, The Public Health Agency of Sweden, Stockholm, Sweden
| | - Sven Hoffner
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Biao Xu
- Department of Epidemiology, School of Public Health and Key Laboratory of Public Health Safety, Fudan University, Shanghai, China
| | - Thomas Schön
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
- Department of Clinical Microbiology and Infectious Diseases, Kalmar County Hospital, Kalmar, Sweden
| | - Judith Bruchfeld
- Division of Infectious Diseases, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Infectious Disease, Karolinska University Hospital, Stockholm, Sweden
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23
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Lange C, Alghamdi WA, Al-Shaer MH, Brighenti S, Diacon AH, DiNardo AR, Grobbel HP, Gröschel MI, von Groote-Bidlingmaier F, Hauptmann M, Heyckendorf J, Köhler N, Kohl TA, Merker M, Niemann S, Peloquin CA, Reimann M, Schaible UE, Schaub D, Schleusener V, Thye T, Schön T. Perspectives for personalized therapy for patients with multidrug-resistant tuberculosis. J Intern Med 2018; 284:163-188. [PMID: 29806961 DOI: 10.1111/joim.12780] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
According to the World Health Organization (WHO), tuberculosis is the leading cause of death attributed to a single microbial pathogen worldwide. In addition to the large number of patients affected by tuberculosis, the emergence of Mycobacterium tuberculosis drug-resistance is complicating tuberculosis control in many high-burden countries. During the past 5 years, the global number of patients identified with multidrug-resistant tuberculosis (MDR-TB), defined as bacillary resistance at least against rifampicin and isoniazid, the two most active drugs in a treatment regimen, has increased by more than 20% annually. Today we experience a historical peak in the number of patients affected by MDR-TB. The management of MDR-TB is characterized by delayed diagnosis, uncertainty of the extent of bacillary drug-resistance, imprecise standardized drug regimens and dosages, very long duration of therapy and high frequency of adverse events which all translate into a poor prognosis for many of the affected patients. Major scientific and technological advances in recent years provide new perspectives through treatment regimens tailor-made to individual needs. Where available, such personalized treatment has major implications on the treatment outcomes of patients with MDR-TB. The challenge now is to bring these adances to those patients that need them most.
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Affiliation(s)
- C Lange
- Clinical Infectious Diseases, Research Center Borstel, Borstel, Germany
- Tuberculosis Unit, German Center for Infection Research (DZIF), Borstel, Germany
- International Health/Infectious Diseases, University of Lübeck, Lübeck, Germany
- Department of Medicine, Karolinska Institute, Stockholm, Sweden
| | - W A Alghamdi
- Department of Pharmacotherapy and Translational Research, Infectious Disease Pharmacokinetics Laboratory, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - M H Al-Shaer
- Department of Pharmacotherapy and Translational Research, Infectious Disease Pharmacokinetics Laboratory, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - S Brighenti
- Department of Medicine, Center for Infectious Medicine (CIM), Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - A H Diacon
- Task Applied Science, Bellville, South Africa
- Division of Physiology, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - A R DiNardo
- Section of Global and Immigrant Health, Baylor College of Medicine, Houston, TX, USA
| | - H P Grobbel
- Clinical Infectious Diseases, Research Center Borstel, Borstel, Germany
- Tuberculosis Unit, German Center for Infection Research (DZIF), Borstel, Germany
- International Health/Infectious Diseases, University of Lübeck, Lübeck, Germany
| | - M I Gröschel
- Department of Pumonary Diseases & Tuberculosis, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Molecular and Experimental Mycobacteriology, National Reference Center for Mycobacteria, Research Center Borstel, Borstel, Germany
| | | | - M Hauptmann
- Tuberculosis Unit, German Center for Infection Research (DZIF), Borstel, Germany
- Cellular Microbiology, Research Center Borstel, Borstel, Germany
| | - J Heyckendorf
- Clinical Infectious Diseases, Research Center Borstel, Borstel, Germany
- Tuberculosis Unit, German Center for Infection Research (DZIF), Borstel, Germany
- International Health/Infectious Diseases, University of Lübeck, Lübeck, Germany
| | - N Köhler
- Clinical Infectious Diseases, Research Center Borstel, Borstel, Germany
- Tuberculosis Unit, German Center for Infection Research (DZIF), Borstel, Germany
- International Health/Infectious Diseases, University of Lübeck, Lübeck, Germany
| | - T A Kohl
- Molecular and Experimental Mycobacteriology, National Reference Center for Mycobacteria, Research Center Borstel, Borstel, Germany
| | - M Merker
- Molecular and Experimental Mycobacteriology, National Reference Center for Mycobacteria, Research Center Borstel, Borstel, Germany
| | - S Niemann
- Tuberculosis Unit, German Center for Infection Research (DZIF), Borstel, Germany
- Molecular and Experimental Mycobacteriology, National Reference Center for Mycobacteria, Research Center Borstel, Borstel, Germany
| | - C A Peloquin
- Department of Pharmacotherapy and Translational Research, Infectious Disease Pharmacokinetics Laboratory, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - M Reimann
- Clinical Infectious Diseases, Research Center Borstel, Borstel, Germany
- Tuberculosis Unit, German Center for Infection Research (DZIF), Borstel, Germany
- International Health/Infectious Diseases, University of Lübeck, Lübeck, Germany
| | - U E Schaible
- Tuberculosis Unit, German Center for Infection Research (DZIF), Borstel, Germany
- Cellular Microbiology, Research Center Borstel, Borstel, Germany
- Biochemical Microbiology & Immunochemistry, University of Lübeck, Lübeck, Germany
- LRA INFECTIONS'21, Borstel, Germany
| | - D Schaub
- Clinical Infectious Diseases, Research Center Borstel, Borstel, Germany
- Tuberculosis Unit, German Center for Infection Research (DZIF), Borstel, Germany
- International Health/Infectious Diseases, University of Lübeck, Lübeck, Germany
| | - V Schleusener
- Molecular and Experimental Mycobacteriology, National Reference Center for Mycobacteria, Research Center Borstel, Borstel, Germany
| | - T Thye
- Department of Infectious Disease Epidemiology, Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany
| | - T Schön
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
- Department of Clinical Microbiology and Infectious Diseases, Kalmar County Hospital, Linköping University, Linköping, Sweden
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24
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Lange C, Chesov D, Heyckendorf J, Leung CC, Udwadia Z, Dheda K. Drug-resistant tuberculosis: An update on disease burden, diagnosis and treatment. Respirology 2018; 23:656-673. [PMID: 29641838 DOI: 10.1111/resp.13304] [Citation(s) in RCA: 133] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 03/14/2018] [Accepted: 03/14/2018] [Indexed: 01/02/2023]
Abstract
The emergence of antimicrobial resistance against Mycobacterium tuberculosis, the leading cause of mortality due to a single microbial pathogen worldwide, represents a growing threat to public health and economic growth. The global burden of multidrug-resistant tuberculosis (MDR-TB) has recently increased by an annual rate of more than 20%. According to the World Health Organization approximately only half of all patients treated for MDR-TB achieved a successful outcome. For many years, patients with drug-resistant tuberculosis (TB) have received standardized treatment regimens, thereby accelerating the development of MDR-TB through drug-specific resistance amplification. Comprehensive drug susceptibility testing (phenotypic and/or genotypic) is necessary to inform physicians about the best drugs to treat individual patients with tailor-made treatment regimens. Phenotypic drug resistance can now often, but with variable sensitivity, be predicted by molecular drug susceptibility testing based on whole genome sequencing, which in the future could become an affordable method for the guidance of treatment decisions, especially in high-burden/resource-limited settings. More recently, MDR-TB treatment outcomes have dramatically improved with the use of bedaquiline-based regimens. Ongoing clinical trials with novel and repurposed drugs will potentially further improve cure-rates, and may substantially decrease the duration of MDR-TB treatment necessary to achieve relapse-free cure.
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Affiliation(s)
- Christoph Lange
- Division of Clinical Infectious Diseases, Research Center Borstel, Borstel, Germany.,German Center for Infection Research (DZIF), TTU-TB, Borstel, Germany.,International Health/Infectious Diseases, University of Lübeck, Lübeck, Germany.,Department of Medicine, Karolinska Institute, Stockholm, Sweden
| | - Dumitru Chesov
- Division of Clinical Infectious Diseases, Research Center Borstel, Borstel, Germany.,Department of Pneumology and Allergology, State University of Medicine and Pharmacy "Nicolae Testemitanu", Chisinau, Republic of Moldova
| | - Jan Heyckendorf
- Division of Clinical Infectious Diseases, Research Center Borstel, Borstel, Germany.,German Center for Infection Research (DZIF), TTU-TB, Borstel, Germany.,International Health/Infectious Diseases, University of Lübeck, Lübeck, Germany
| | - Chi C Leung
- Department of Health, Tuberculosis and Chest Service, Centre for Health Protection, Hong Kong, China
| | - Zarir Udwadia
- Department of Pulmonology, Hinduja Hospital and Research Centre, Mumbai, India
| | - Keertan Dheda
- Lung Infection and Immunity Unit, Division of Pulmonology and UCT Lung Institute, Department of Medicine, University of Cape Town, Cape Town, South Africa
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25
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Pharmacokinetics of Levofloxacin in Multidrug- and Extensively Drug-Resistant Tuberculosis Patients. Antimicrob Agents Chemother 2017; 61:AAC.00343-17. [PMID: 28507117 DOI: 10.1128/aac.00343-17] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 05/10/2017] [Indexed: 12/17/2022] Open
Abstract
Pharmacodynamics are especially important in the treatment of multidrug- and extensively drug-resistant tuberculosis (M/XDR-TB). The free area under the concentration time curve in relation to MIC (fAUC/MIC) is the most relevant pharmacokinetic (PK)-pharmacodynamic (PD) parameter for predicting the efficacy of levofloxacin (LFX). The objective of our study was to assess LFX PK variability in M/XDR-TB patients and its potential consequence for fAUC/MIC ratios. Patients with pulmonary M/XDR-TB received LFX as part of the treatment regimen at a dose of 15 mg/kg administered once daily. Blood samples obtained at steady state before and 1, 2, 3, 4, 7, and 12 h after drug administration were measured by validated liquid chromatography-tandem mass spectrometry. The MIC values of LFX were determined by the agar dilution method on Middlebrook 7H10 and the MGIT960 system. Twenty patients with a mean age of 31 years (interquartile range [IQR] = 27 to 35 years) were enrolled in this study. The median AUC0-24 was 98.8 mg/h/liter (IQR = 84.8 to 159.6 mg/h/liter). The MIC median value for LFX was 0.5 mg/liter with a range of 0.25 to 2.0 mg/liter, and the median fAUC0-24/MIC ratio was 109.5 (IQR = 48.5 to 399.4). In 4 of the 20 patients, the value was below the target value of ≥100. When MICs of 0.25, 0.5, 1.0, and 2.0 mg/liter were applicable, 19, 18, 3, and no patients, respectively, had an fAUC/MIC ratio that exceeded 100. We observed a large variability in AUC. An fAUC0-24/MIC of ≥100 was only observed when the MIC values for LFX were 0.25 to 0.5 mg/liter. Dosages exceeding 15 mg/kg should be considered for target attainment if exposures are assumed to be safe. (This study has been registered at ClinicalTrials.gov under registration no. NCT02169141.).
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26
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Davies Forsman L, Bruchfeld J, Alffenaar JWC. Therapeutic drug monitoring to prevent acquired drug resistance of fluoroquinolones in the treatment of tuberculosis. Eur Respir J 2017; 49:49/4/1700173. [PMID: 28446561 DOI: 10.1183/13993003.00173-2017] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 02/15/2017] [Indexed: 12/11/2022]
Affiliation(s)
- Lina Davies Forsman
- Karolinska Institutet, Dept of Medicine, Unit of Infectious Disease, Stockholm, Sweden.,Karolinska University Hospital, Dept of Infectious Disease, Stockholm, Sweden
| | - Judith Bruchfeld
- Karolinska Institutet, Dept of Medicine, Unit of Infectious Disease, Stockholm, Sweden.,Karolinska University Hospital, Dept of Infectious Disease, Stockholm, Sweden
| | - Jan-Willem C Alffenaar
- University of Groningen, University Medical Center Groningen, Dept of Clinical Pharmacy and Pharmacology, Groningen, The Netherlands
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