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Gaensbauer JT, Dash N, Verma S, Hall DJ, Adler-Shohet FC, Li G, Lee G, Dinnes L, Wendorf K. Multidrug-resistant tuberculosis in children: A practical update on epidemiology, diagnosis, treatment and prevention. J Clin Tuberc Other Mycobact Dis 2024; 36:100449. [PMID: 38757115 PMCID: PMC11096739 DOI: 10.1016/j.jctube.2024.100449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2024] Open
Abstract
Pediatric multidrug-resistant tuberculosis (MDR-TB) remains a significant global problem, and there are numerous barriers preventing children with MDR-TB from being identified, confirmed with microbiologic tests, and treated with a safe, practical, and effective regimen. However, several recent advances in diagnostics and treatment regimens have the promise to improve outcomes for children with MDR-TB. We introduce this review with two cases that exemplify both the challenges in management of MDR-TB in children, but also the potential to achieve a positive outcome. More than 30,000 cases of MDR-TB per year are believed to occur in children but less than 5% are confirmed microbiologically, contributing to poorer outcomes and excess mortality. Rapid molecular-based testing that provides information on rifampin susceptibility is increasingly globally available and recommended for all children suspected of TB disease--but remains limited by challenges obtaining appropriate samples and the paucibacillary nature of most pediatric TB. More complex assays allowing better characterization of drug-resistant isolates are emerging. For children diagnosed with MDR-TB, treatment regimens have traditionally been long and utilize multiple drugs associated with significant side effects, particularly injectable agents. Several new or repurposed drugs including bedaquiline, delamanid, clofazimine and linezolid now allow most treatment regimens to be shorter and all-oral. Yet data to support short, all-oral, novel regimens for young children containing pretomanid remain insufficient at present, and there is a compelling need to conduct pediatric trials of promising therapeutics and MDR-TB treatment regimens.
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Affiliation(s)
- James T. Gaensbauer
- Mayo Clinic Center for Tuberculosis, Mayo Clinic, Rochester, MN, USA
- Division of Pediatric Infectious Diseases, Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, MN, USA
| | - Nabaneeta Dash
- Department of Telemedicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sanjay Verma
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - DJ Hall
- Division of Pediatric Hospital Medicine, Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, MN, USA
| | - Felice C. Adler-Shohet
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Guyu Li
- Division of Pediatric Infectious Diseases, Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, MN, USA
| | - Grace Lee
- Department of Pharmacy, Mayo Clinic, Rochester, MN, USA
| | - Laura Dinnes
- Department of Pharmacy, Mayo Clinic, Rochester, MN, USA
| | - Kristen Wendorf
- Department of Pediatrics, University of California San Francisco Benioff Children’s Hospital, Oakland, CA, USA
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2
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Calcagno A, Coppola N, Sarmati L, Tadolini M, Parrella R, Matteelli A, Riccardi N, Trezzi M, Di Biagio A, Pirriatore V, Russo A, Gualano G, Pontali E, Surace L, Falbo E, Mencarini J, Palmieri F, Gori A, Schiuma M, Lapadula G, Goletti D. Drugs for treating infections caused by non-tubercular mycobacteria: a narrative review from the study group on mycobacteria of the Italian Society of Infectious Diseases and Tropical Medicine. Infection 2024; 52:737-765. [PMID: 38329686 PMCID: PMC11142973 DOI: 10.1007/s15010-024-02183-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 01/12/2024] [Indexed: 02/09/2024]
Abstract
BACKGROUND Non-tuberculous mycobacteria (NTM) are generally free-living organism, widely distributed in the environment, with sporadic potential to infect. In recent years, there has been a significant increase in the global incidence of NTM-related disease, spanning across all continents and an increased mortality after the diagnosis has been reported. The decisions on whether to treat or not and which drugs to use are complex and require a multidisciplinary approach as well as patients' involvement in the decision process. METHODS AND RESULTS This review aims at describing the drugs used for treating NTM-associated diseases emphasizing the efficacy, tolerability, optimization strategies as well as possible drugs that might be used in case of intolerance or resistance. We also reviewed data on newer compounds highlighting the lack of randomised clinical trials for many drugs but also encouraging preliminary data for others. We also focused on non-pharmacological interventions that need to be adopted during care of individuals with NTM-associated diseases CONCLUSIONS: Despite insufficient efficacy and poor tolerability this review emphasizes the improvement in patients' care and the needs for future studies in the field of anti-NTM treatments.
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Affiliation(s)
- A Calcagno
- Unit of Infectious Diseases, Department of Medical Sciences, University of Turin, Turin, Italy.
- Stop TB Italy, Milan, Italy.
| | - N Coppola
- Infectious Diseases Unit, Section of Infectious Diseases, Department of Mental Health and Public Medicine, University of Campania Luigi Vanvitelli, Naples, Italy
| | - L Sarmati
- Department of System Medicine, Tor Vergata University and Infectious Disease Clinic, Policlinico Tor Vergata, Rome, Italy
| | - M Tadolini
- Stop TB Italy, Milan, Italy
- Infectious Diseases Unit, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - R Parrella
- Stop TB Italy, Milan, Italy
- Respiratory Infectious Diseases Unit, Cotugno Hospital, A. O. R. N. dei Colli, Naples, Italy
| | - A Matteelli
- Institute of Infectious and Tropical Diseases, WHO Collaborating Centre for TB Prevention, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - N Riccardi
- Stop TB Italy, Milan, Italy
- Infectious Diseases Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
| | - M Trezzi
- Stop TB Italy, Milan, Italy
- Infectious and Tropical Diseases Unit, Department of Medical Sciences, Azienda Ospedaliero-Universitaria Senese, Siena, Italy
| | - A Di Biagio
- Infectious Diseases Unit, San Martino Policlinico Hospital-IRCCS for Oncology and Neurosciences, Genoa, Italy
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
| | - V Pirriatore
- Stop TB Italy, Milan, Italy
- Unit of Infectious Diseases, "DivisioneA", Ospedale Amedeo di Savoia, ASL CIttà di Torino, Turin, Italy
| | - A Russo
- Infectious Diseases Unit, Section of Infectious Diseases, Department of Mental Health and Public Medicine, University of Campania Luigi Vanvitelli, Naples, Italy
| | - G Gualano
- Stop TB Italy, Milan, Italy
- Respiratory Infectious Diseases Unit, National Institute for Infectious Diseases Lazzaro Spallanzani-IRCCS, Rome, Italy
| | - E Pontali
- Department of Infectious Diseases, Galliera Hospital, Genoa, Italy
| | - L Surace
- Stop TB Italy, Milan, Italy
- Dipartimento Di Prevenzione, Azienda Sanitaria Provinciale di Catanzaro, Centro di Medicina del Viaggiatore e delle Migrazioni, P. O. Giovanni Paolo II, Lamezia Terme, CZ, Italy
| | - E Falbo
- Stop TB Italy, Milan, Italy
- Dipartimento Di Prevenzione, Azienda Sanitaria Provinciale di Catanzaro, Centro di Medicina del Viaggiatore e delle Migrazioni, P. O. Giovanni Paolo II, Lamezia Terme, CZ, Italy
| | - J Mencarini
- Infectious and Tropical Diseases Unit, Careggi University Hospital, Florence, Italy
| | - F Palmieri
- Respiratory Infectious Diseases Unit, National Institute for Infectious Diseases Lazzaro Spallanzani-IRCCS, Rome, Italy
| | - A Gori
- Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, ASST Fatebenefratelli Sacco-Ospedale Luigi Sacco-Polo Universitario and Università Degli Studi di Milano, Milano, Italy
| | - M Schiuma
- Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, ASST Fatebenefratelli Sacco-Ospedale Luigi Sacco-Polo Universitario and Università Degli Studi di Milano, Milano, Italy
| | - G Lapadula
- Infectious Diseases Unit, Fondazione IRCCS San Gerardo dei Tintori, University of Milano-Bicocca, Monza, Italy
| | - D Goletti
- Stop TB Italy, Milan, Italy
- Translational Research Unit, Epidemiology Department, National Institute for Infectious Diseases-IRCCS L. Spallanzani, Rome, Italy
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3
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Ali AM, P. Solans B, Hesseling AC, Winckler J, Schaaf HS, Draper HR, van der Laan L, Hughes J, Fourie B, Nielsen J, Wiesner L, Garcia-Prats AJ, Savic RM. Pharmacokinetics and cardiac safety of clofazimine in children with rifampicin-resistant tuberculosis. Antimicrob Agents Chemother 2024; 68:e0079423. [PMID: 38112526 PMCID: PMC10777824 DOI: 10.1128/aac.00794-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 10/18/2023] [Indexed: 12/21/2023] Open
Abstract
Clofazimine is recommended for the treatment of rifampicin-resistant tuberculosis (RR-TB), but there is currently no verified dosing guideline for its use in children. There is only limited safety and no pharmacokinetic (PK) data available for children. We aimed to characterize clofazimine PK and its relationship with QT-interval prolongation in children. An observational cohort study of South African children <18 years old routinely treated for RR-TB with a clofazimine-containing regimen was analyzed. Clofazimine 100 mg gelatin capsules were given orally once daily (≥20 kg body weight), every second day (10 to <20 kg), or thrice weekly (<10 kg). PK sampling and electrocardiograms were completed pre-dose and at 1, 4, and 10 hours post-dose, and the population PK and Fridericia-corrected QT (QTcF) interval prolongation were characterized. Fifty-four children contributed both PK and QTcF data, with a median age (2.5th-97.5th centiles) of 3.3 (0.5-15.6) years; five children were living with HIV. Weekly area under the time-concentration curve at steady state was 79.1 (15.0-271) mg.h/L compared to an adult target of 60.9 (56.0-66.6) mg.h/L. Children living with HIV had four times higher clearance compared to those without. No child had a QTcF ≥500 ms. A linear concentration-QTcF relationship was found, with a drug effect of 0.05 (0.027, 0.075) ms/µg/L. In some of the first PK data in children, we found clofazimine exposure using an off-label dosing strategy was higher in children versus adults. Clofazimine concentrations were associated with an increase in QTcF, but severe prolongation was not observed. More data are required to inform dosing strategies in children.
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Affiliation(s)
- Ali Mohamed Ali
- Department of Bioengineering and Therapeutic Sciences, University of California San Francisco, San Francisco, California, USA
- Department of Interventions and Clinical Trials, Bagamoyo Research and Training Center, Ifakara Health Institute, Bagamoyo, Tanzania
| | - Belén P. Solans
- Department of Bioengineering and Therapeutic Sciences, University of California San Francisco, San Francisco, California, USA
| | - Anneke C. Hesseling
- Department of Paediatrics and Child Health, Desmond Tutu TB Centre, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Jana Winckler
- Department of Paediatrics and Child Health, Desmond Tutu TB Centre, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - H. Simon Schaaf
- Department of Paediatrics and Child Health, Desmond Tutu TB Centre, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Heather R. Draper
- Department of Paediatrics and Child Health, Desmond Tutu TB Centre, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Louvina van der Laan
- Department of Paediatrics and Child Health, Desmond Tutu TB Centre, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Jennifer Hughes
- Department of Paediatrics and Child Health, Desmond Tutu TB Centre, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Barend Fourie
- Department of Paediatrics and Child Health, Desmond Tutu TB Centre, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - James Nielsen
- Department of Pediatrics, New York University School of Medicine, New York, New York, USA
| | - Lubbe Wiesner
- Department of Medicine, Division of Clinical Pharmacology, University of Cape Town, Cape Town, South Africa
| | - Anthony J. Garcia-Prats
- Department of Paediatrics and Child Health, Desmond Tutu TB Centre, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Department of Pediatrics, University of Wisconsin-Madison, School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Radojka M. Savic
- Department of Bioengineering and Therapeutic Sciences, University of California San Francisco, San Francisco, California, USA
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4
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Chaudhry KA, Jacobi JJ, Gillard BM, Karasik E, Martin JC, da Silva Fernandes T, Hurley E, Feltri ML, Attwood KM, Twist CJ, Smiraglia DJ, Long MD, Bianchi-Smiraglia A. Aryl hydrocarbon receptor is a tumor promoter in MYCN-amplified neuroblastoma cells through suppression of differentiation. iScience 2023; 26:108303. [PMID: 38026169 PMCID: PMC10654598 DOI: 10.1016/j.isci.2023.108303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 09/25/2023] [Accepted: 10/20/2023] [Indexed: 12/01/2023] Open
Abstract
Neuroblastoma is the most common extracranial solid tumor in children. MYCN amplification is detected in almost half of high-risk cases and is associated with poorly differentiated tumors, poor patient prognosis and poor response to therapy, including retinoids. We identify the aryl hydrocarbon receptor (AhR) as a transcription factor promoting the growth and suppressing the differentiation of MYCN-amplified neuroblastoma. A neuroblastoma specific AhR transcriptional signature reveals an inverse correlation of AhR activity with patients' outcome, suggesting AhR activity is critical for disease progression. AhR modulates chromatin structures, reducing accessibility to regions responsive to retinoic acid. Genetic and pharmacological inhibition of AhR results in induction of differentiation. Importantly, AhR antagonism with clofazimine synergizes with retinoic acid in inducing differentiation both in vitro and in vivo. Thus, we propose AhR as a target for MYCN-amplified neuroblastoma and that its antagonism, combined with current standard-of-care, may result in a more durable response in patients.
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Affiliation(s)
- Kanita A. Chaudhry
- Department of Cell Stress Biology, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Justine J. Jacobi
- Department of Cell Stress Biology, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Bryan M. Gillard
- Department of Pharmacology and Therapeutics, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Ellen Karasik
- Department of Pharmacology and Therapeutics, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Jeffrey C. Martin
- Department of Cell Stress Biology, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | | | - Edward Hurley
- Department of Biochemistry and Neurology, Institute for Myelin and Glia Exploration, State University of New York at Buffalo, Buffalo, NY, USA
| | - Maria Laura Feltri
- Department of Biochemistry and Neurology, Institute for Myelin and Glia Exploration, State University of New York at Buffalo, Buffalo, NY, USA
- Department of Medical Biotechnology and Translational Medicine, University of Milan, Foundation I.R.C.C.S. Carlo Besta Neurological Institute Milan, Italy
| | - Kristopher M. Attwood
- Department of Biostatistics and Bioinformatics, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Clare J. Twist
- Department of Pediatric Oncology, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Dominic J. Smiraglia
- Department of Cell Stress Biology, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Mark D. Long
- Department of Pharmacology and Therapeutics, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
- Department of Biostatistics and Bioinformatics, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Anna Bianchi-Smiraglia
- Department of Cell Stress Biology, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
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5
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Ali AM, Radtke KK, Hesseling AC, Winckler J, Schaaf HS, Draper HR, Solans BP, van der Laan L, Hughes J, Fourie B, Nielsen J, Garcia-Prats AJ, Savic RM. QT Interval Prolongation with One or More QT-Prolonging Agents Used as Part of a Multidrug Regimen for Rifampicin-Resistant Tuberculosis Treatment: Findings from Two Pediatric Studies. Antimicrob Agents Chemother 2023; 67:e0144822. [PMID: 37358463 PMCID: PMC10353402 DOI: 10.1128/aac.01448-22] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 05/22/2023] [Indexed: 06/27/2023] Open
Abstract
Rifampicin-resistant tuberculosis (RR-TB) involves treatment with many drugs that can prolong the QT interval; this risk may increase when multiple QT-prolonging drugs are used together. We assessed QT interval prolongation in children with RR-TB receiving one or more QT-prolonging drugs. Data were obtained from two prospective observational studies in Cape Town, South Africa. Electrocardiograms were performed before and after drug administration of clofazimine (CFZ), levofloxacin (LFX), moxifloxacin (MFX), bedaquiline (BDQ), and delamanid. The change in Fridericia-corrected QT (QTcF) was modeled. Drug and other covariate effects were quantified. A total of 88 children with a median (2.5th-to-97.5th range) age of 3.9 (0.5 to 15.7) years were included, of whom 55 (62.5%) were under 5 years of age. A QTcF interval of >450 ms was observed in 7 patient-visits: regimens were CFZ+MFX (n = 3), CFZ+BDQ+LFX (n = 2), CFZ alone (n = 1), and MFX alone (n = 1). There were no events with a QTcF interval of >500 ms. In a multivariate analysis, CFZ+MFX was associated with a 13.0-ms increase in change in QTcF (P < 0.001) and in maximum QTcF (P = 0.0166) compared to those when other MFX- or LFX-based regimens were used. In conclusion, we found a low risk of QTcF interval prolongation in children with RR-TB who received at least one QT-prolonging drug. Greater increases in maximum QTcF and ΔQTcF were observed when MFX and CFZ were used together. Future studies characterizing exposure-QTcF responses in children will be helpful to ensure safety with higher doses if required for effective treatment of RR-TB.
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Affiliation(s)
- Ali Mohamed Ali
- Department of Bioengineering and Therapeutic Sciences, University of California San Francisco, San Francisco, California, USA
- Bagamoyo Research and Training Center, Ifakara Health Institute, Bagamoyo, Tanzania
| | - Kendra K. Radtke
- Department of Bioengineering and Therapeutic Sciences, University of California San Francisco, San Francisco, California, USA
| | - Anneke C. Hesseling
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
| | - Jana Winckler
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
| | - H. Simon Schaaf
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
| | - Heather R. Draper
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
| | - Belén P. Solans
- Department of Bioengineering and Therapeutic Sciences, University of California San Francisco, San Francisco, California, USA
| | - Louvina van der Laan
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
| | - Jennifer Hughes
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
| | - Barend Fourie
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
| | - James Nielsen
- Department of Pediatrics, New York University School of Medicine, New York, New York, USA
| | - Anthony J. Garcia-Prats
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
- Department of Pediatrics, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Rada M. Savic
- Department of Bioengineering and Therapeutic Sciences, University of California San Francisco, San Francisco, California, USA
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Warnken Z, Trementozzi A, Martins PP, Parkeh J, Koleng JJ, Smyth HDC, Brunaugh A. Development of Low-Cost, Weight-Adjustable Clofazimine Mini-Tablets for Treatment of Tuberculosis in Pediatrics. Eur J Pharm Sci 2023; 187:106470. [PMID: 37207942 DOI: 10.1016/j.ejps.2023.106470] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 05/16/2023] [Accepted: 05/16/2023] [Indexed: 05/21/2023]
Abstract
Clofazimine (CFZ) is an important component of the World Health Organization's (WHO) recommended all-oral drug regimen for treatment of multi-drug resistant tuberculosis (MDR-TB). However, the lack of a dividable oral dosage form has limited the use of the drug in pediatric populations, who may require lowering of the dose to reduce the likelihood of adverse drug events. In this study, pediatric-friendly CFZ mini-tablets were prepared from micronized powder via direct compression. Rapid disintegration and maximized dissolution in GI fluids was achieved using an iterative formulation design process. Pharmacokinetic (PK) parameters of the optimized mini-tablets were obtained in Sprague-Dawley rats and compared against an oral suspension of micronized CFZ particles to examine the effect of processing and formulation on the oral absorption of the drug. Differences in maximum concentration and area under the curve between the two formulations were non-significant at the highest dosing level tested. Variability between rats prevented bioequivalence from being determined according to guidelines outlined by the Food and Drug Administration (FDA). These studies provide an important proof-of-concept for an alternative, low-cost formulation and processing approach for the oral delivery of CFZ in manner that is suitable for children as young as 6 months of age.
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Affiliation(s)
- Zachary Warnken
- Via Therapeutics, 2409 University Ave, Austin, TX, USA, 78712
| | | | | | - Jagruti Parkeh
- Via Therapeutics, 2409 University Ave, Austin, TX, USA, 78712
| | - John J Koleng
- Via Therapeutics, 2409 University Ave, Austin, TX, USA, 78712
| | - Hugh D C Smyth
- Via Therapeutics, 2409 University Ave, Austin, TX, USA, 78712; University of Texas at Austin, College of Pharmacy, Division of Molecular Pharmaceutics and Drug Delivery, 2409 University Ave, Austin, TX, USA, 78712
| | - Ashlee Brunaugh
- Via Therapeutics, 2409 University Ave, Austin, TX, USA, 78712; University of Michigan, College of Pharmacy, Department of Pharmaceutical Sciences, 428 Church St, Ann Arbor, MI, USA, 48109.
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7
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Haubrich K, Mammen C, Sekirov I, Mitchell H. Mycobacterium fortuitum peritoneal dialysis-related peritonitis in a child: A case report and review of the literature. JOURNAL OF THE ASSOCIATION OF MEDICAL MICROBIOLOGY AND INFECTIOUS DISEASE CANADA = JOURNAL OFFICIEL DE L'ASSOCIATION POUR LA MICROBIOLOGIE MEDICALE ET L'INFECTIOLOGIE CANADA 2022; 7:125-130. [PMID: 36337360 PMCID: PMC9608115 DOI: 10.3138/jammi-2021-0029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 11/19/2021] [Accepted: 11/25/2021] [Indexed: 06/16/2023]
Abstract
BACKGROUND Non-tuberculous mycobacteria (NTM) are an uncommon but serious cause of peritoneal dialysis (PD)-related infections. NTM peritonitis typically necessitates PD catheter removal, PD withdrawal, and aggressive, prolonged antimicrobial treatment. Few reported cases of NTM peritonitis in the pediatric population exist. METHODS We describe a case of a 9-year-old boy on PD after kidney allograft failure who developed Mycobacterium fortuitum peritonitis, and we summarize the available literature on M. fortuitum peritonitis in pediatric patients receiving PD. RESULTS AND CONCLUSION Therapeutic options were limited by adverse medication effects and risk of drug-drug interactions in a patient with complex mental health comorbidities. Clofazimine presented an acceptable oral treatment option for long-term therapy in combination with ciprofloxacin and was well tolerated by this patient. Prompt PD catheter removal followed by 6 months of dual antimicrobial therapy resulted in a full recovery and successful re-transplantation with no infection relapse.
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Affiliation(s)
- Kathryn Haubrich
- Department of Pharmacy, BC Children’s Hospital, Vancouver, British Columbia, Canada
| | - Cherry Mammen
- Division of Nephrology, BC Children’s Hospital, Vancouver, British Columbia, Canada
| | - Inna Sekirov
- BC Center for Disease Control Public Health Laboratory, Vancouver, British Columbia, Canada
| | - Hana Mitchell
- Division of Infectious Diseases, BC Children’s Hospital, Vancouver, British Columbia, Canada
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8
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Radtke KK, Hesseling AC, Winckler JL, Draper HR, Solans BP, Thee S, Wiesner L, van der Laan LE, Fourie B, Nielsen J, Schaaf HS, Savic RM, Garcia-Prats AJ. Moxifloxacin Pharmacokinetics, Cardiac Safety, and Dosing for the Treatment of Rifampicin-Resistant Tuberculosis in Children. Clin Infect Dis 2022; 74:1372-1381. [PMID: 34286843 PMCID: PMC9049278 DOI: 10.1093/cid/ciab641] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Moxifloxacin is a recommended drug for rifampin-resistant tuberculosis (RR-TB) treatment, but there is limited pediatric pharmacokinetic and safety data, especially in young children. We characterize moxifloxacin population pharmacokinetics and QT interval prolongation and evaluate optimal dosing in children with RR-TB. METHODS Pharmacokinetic data were pooled from 2 observational studies in South African children with RR-TB routinely treated with oral moxifloxacin once daily. The population pharmacokinetics and Fridericia-corrected QT (QTcF)-interval prolongation were characterized in NONMEM. Pharmacokinetic simulations were performed to predict expected exposure and optimal weight-banded dosing. RESULTS Eighty-five children contributed pharmacokinetic data (median [range] age of 4.6 [0.8-15] years); 16 (19%) were aged <2 years, and 8 (9%) were living with human immunodeficiency virus (HIV). The median (range) moxifloxacin dose on pharmacokinetic sampling days was 11 mg/kg (6.1 to 17). Apparent clearance was 6.95 L/h for a typical 16-kg child. Stunting and HIV increased apparent clearance. Crushed or suspended tablets had faster absorption. The median (range) maximum change in QTcF after moxifloxacin administration was 16.3 (-27.7 to 61.3) ms. No child had QTcF ≥500 ms. The concentration-QTcF relationship was nonlinear, with a maximum drug effect (Emax) of 8.80 ms (interindividual variability = 9.75 ms). Clofazimine use increased Emax by 3.3-fold. Model-based simulations of moxifloxacin pharmacokinetics predicted that current dosing recommendations are too low in children. CONCLUSIONS Moxifloxacin doses above 10-15 mg/kg are likely required in young children to match adult exposures but require further safety assessment, especially when coadministered with other QT-prolonging agents.
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Affiliation(s)
- Kendra K Radtke
- Department of Bioengineering and Therapeutic Sciences, University of California–San Francisco, San Francisco, California, USA
| | - Anneke C Hesseling
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - J L Winckler
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - Heather R Draper
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - Belen P Solans
- Department of Bioengineering and Therapeutic Sciences, University of California–San Francisco, San Francisco, California, USA
| | - Stephanie Thee
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine, Charité—Universitätsmedizin Berlin, Berlin, Germany
| | - Lubbe Wiesner
- Department of Medicine, Division of Clinical Pharmacology, University of Cape Town, Cape Town, South Africa
| | - Louvina E van der Laan
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - Barend Fourie
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - James Nielsen
- Department of Pediatrics, New York University School of Medicine, New York, New York, USA
| | - H Simon Schaaf
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - Radojka M Savic
- Department of Bioengineering and Therapeutic Sciences, University of California–San Francisco, San Francisco, California, USA
| | - Anthony J Garcia-Prats
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
- University of Wisconsin, Department of Pediatrics, Madison, Wisconsin, USA
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9
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Singh J, O'Donnell K, Nieves DJ, Adler-Shohet FC, Arrieta AC, Ashouri N, Ahuja G, Cheung M, Holmes WN, Huoh K, Tran L, Tran MT, Pham N, Zahn M. Invasive Mycobacterium abscessus Outbreak at a Pediatric Dental Clinic. Open Forum Infect Dis 2021; 8:ofab165. [PMID: 34113683 PMCID: PMC8186244 DOI: 10.1093/ofid/ofab165] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 03/26/2021] [Indexed: 11/25/2022] Open
Abstract
Background Mycobacterium species, specifically M. abscessus and M. chelonae (MABs), are known to contaminate water systems and are uncommon causes of health care–associated infection, but morbidity can be significant and treatment complex. Methods Odontogenic MAB infections occurred in patients following pulpotomy procedures at dental clinic A from 1 January to 6 September 2016. We identified confirmed and probable cases using culture data, imaging, pathology results, and surgical findings. Epidemiologic and clinical data including demographics, symptoms, laboratory findings, treatment regimens, and outcomes were extracted. Results Of 1082 at-risk patients, 71 case patients (22 confirmed; 49 probable) were identified. Median age was 6 years. Median symptom onset was 85 days postpulpotomy. Pain and/or swelling on admission occurred in 79%. On imaging, 49 of 70 had abnormalities of the mandible or maxilla, 13 of 70 had lymphadenopathy, and 19 of 68 had pulmonary nodules. Seventy were hospitalized (average of 8.5 days). Intravenous antibiotics were administered to 32 cases for a median length of 137 days. Clofazimine was administered to 29 patients as part of their multidrug regimen. Antibiotic treatment was associated with many adverse effects. Treated children showed evidence of jaw healing with resolved/improving pulmonary nodules at 1-year follow-up. Conclusions This is the largest outbreak of invasive MAB infections associated with a pediatric dental practice. While infections were indolent, patients suffered medical and surgical consequences of treatment, including permanent tooth loss. Identification of this outbreak led to a change in water standards for pediatric dental procedures in California. Enhanced national dental water quality standards are needed to prevent future outbreaks.
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Affiliation(s)
- Jasjit Singh
- Department of Pediatric Infectious Diseases, Children's Hospital of Orange County, Orange, California, USA
| | - Kathleen O'Donnell
- Disease Control and Epidemiology, Orange County Health Care Agency, Santa Ana, California, USA
| | - Delma J Nieves
- Department of Pediatric Infectious Diseases, Children's Hospital of Orange County, Orange, California, USA
| | - Felice C Adler-Shohet
- Department of Pediatric Infectious Diseases, Children's Hospital of Orange County, Orange, California, USA
| | - Antonio C Arrieta
- Department of Pediatric Infectious Diseases, Children's Hospital of Orange County, Orange, California, USA
| | - Negar Ashouri
- Department of Pediatric Infectious Diseases, Children's Hospital of Orange County, Orange, California, USA
| | - Gurpreet Ahuja
- Department of Pediatric Otolaryngology, Children's Hospital of Orange County, Orange, California, USA.,University of California, Irvine School of Medicine, Irvine, California, USA
| | - Michele Cheung
- Disease Control and Epidemiology, Orange County Health Care Agency, Santa Ana, California, USA
| | - W Nathan Holmes
- Department of Pediatric Radiology, Children's Hospital of Orange County, Orange, California, USA
| | - Kevin Huoh
- Department of Pediatric Otolaryngology, Children's Hospital of Orange County, Orange, California, USA.,University of California, Irvine School of Medicine, Irvine, California, USA
| | - Lisa Tran
- Department of Surgery, Children's Hospital of Orange County, Orange, California, USA
| | - M Tuan Tran
- Department of Pediatric Infectious Diseases, Children's Hospital of Orange County, Orange, California, USA
| | - Nguyen Pham
- Department of Pediatric Otolaryngology, Children's Hospital of Orange County, Orange, California, USA.,University of California, Irvine School of Medicine, Irvine, California, USA
| | - Matthew Zahn
- Disease Control and Epidemiology, Orange County Health Care Agency, Santa Ana, California, USA
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10
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Riccardi N, Giacomelli A, Canetti D, Comelli A, Intini E, Gaiera G, Diaw MM, Udwadia Z, Besozzi G, Codecasa L, Biagio AD. Clofazimine: an old drug for never-ending diseases. Future Microbiol 2020; 15:557-566. [PMID: 32476494 DOI: 10.2217/fmb-2019-0231] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Clofazimine (CFZ), an old hydrophobic riminophenazine, has a wide range of antimycobacterial activity ranging from leprosy to nontuberculous mycobacterial diseases. CFZ has several advantages such as a favorable pharmacokinetic profile, dose-dependent side effects as well as low price. In this narrative review, we have assessed the clinical development of CFZ, starting from the potential in vitro mechanism of actions, to the spectrum of side effects and potential drug-drug interactions, highlighting its current place in therapy and future possible use in leprosy, nontuberculous mycobacterial diseases and drug-resistant tuberculosis.
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Affiliation(s)
- Niccolò Riccardi
- Department of Infectious, Tropical Diseases & Microbiology, IRCCS Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, Verona, Italy.,StopTB Italia Onlus, Milan, Italy
| | - Andrea Giacomelli
- StopTB Italia Onlus, Milan, Italy.,III Infectious Diseases Unit, ASST Fatebenefratelli Sacco, Milano, Italy.,Department of Biomedical & Clinical Sciences "Luigi Sacco", Università degli Studi di Milano, Italy
| | - Diana Canetti
- StopTB Italia Onlus, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy.,Clinic of Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Agnese Comelli
- Department of Infectious & Tropical Diseases, Spedali Civili, Brescia, Italy
| | - Enrica Intini
- StopTB Italia Onlus, Milan, Italy.,Division of Respiratory Medicine, A. Gemelli University Hospital, Catholic University of the Sacred Heart, Rome, Italy
| | - Giovanni Gaiera
- Clinic of Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Mama M Diaw
- StopTB Italia Onlus, Milan, Italy.,Médecin coordonnateur lutte contre la TB, Région médicale de Thiès, Thiès, Sénégal
| | - Zarir Udwadia
- Department of Pulmonary Medicine, PD. Hinduja National Hospital & Medical Research Centre, Mumbai, Maharashtra, India
| | | | - Luigi Codecasa
- StopTB Italia Onlus, Milan, Italy.,Regional TB Reference Centre & Laboratory, Villa Marelli Institute/ASST Niguarda Ca' Granda, Milan, Italy
| | - Antonio Di Biagio
- StopTB Italia Onlus, Milan, Italy.,Clinic of Infectious Diseases, IRCCS AOU San Martino-IST, Genoa, Italy
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