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Schaaf HS, Hughes J. Current Treatment of Drug-Resistant Tuberculosis in Children. Indian J Pediatr 2024; 91:806-816. [PMID: 37995068 PMCID: PMC11249413 DOI: 10.1007/s12098-023-04888-z] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 09/29/2023] [Indexed: 11/24/2023]
Abstract
Optimal diagnosis and management of children aged <15 y with rifampicin- or multidrug-resistant tuberculosis (RR/MDR-TB) relies on identification of adults with the disease and pro-active screening of their close contacts. Children may be diagnosed with RR/MDR-TB based on microbiological confirmation from clinical specimens (sputum, gastric washings, stool), but usually the diagnosis is presumptive, with a history of exposure to RR/MDR-TB and clinical/radiological signs and symptoms suggestive of TB disease. RR/MDR-TB should also be considered in children where first-line TB treatment fails despite good adherence to therapy. Composition and duration of all-oral RR/MDR-TB treatment regimens in children are based on site and severity of TB disease, drug resistance profile of the Mycobacterium tuberculosis strain (isolated from the child or from the most likely source patient), inclusion of at least four drugs considered to be effective (with priority given to World Health Organization Group A and B drugs), toxicity and tolerability of medications (and feasibility of adverse effect monitoring in the child's setting), and availability of child-friendly formulations of TB medications. Individualized RR/MDR-TB regimens are preferable to the standardised 9-12-mo regimen for children, and injectable agents must not be used. Optimal adherence to treatment relies on education, training and support for caregivers and others who are responsible for administering medications to children, as well as close clinical monitoring and early management of adverse effects. Children who are initiated on adequate RR/MDR-TB regimens have high treatment success rates, but efforts to find and treat more children with undiagnosed RR/MDR-TB are crucial to reduce childhood TB mortality.
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Affiliation(s)
- H Simon Schaaf
- Desmond Tutu TB Centre, Department of Pediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.
| | - Jennifer Hughes
- Desmond Tutu TB Centre, Department of Pediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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Gopalaswamy R, Palani N, Viswanathan D, Preysingh B, Rajendran S, Vijayaraghavan V, Thangavel K, Vadivel SD, Stanley H, Thiruvengadam K, Jayabal L, Murugesan K, Rathinam S, Frederick A, Sivaramakrishnan G, Padmapriyadarsini C, Shanmugam S. Resistance Profiles to Second-Line Anti-Tuberculosis Drugs and Their Treatment Outcomes: A Three-Year Retrospective Analysis from South India. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1005. [PMID: 37374209 DOI: 10.3390/medicina59061005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 05/12/2023] [Accepted: 05/19/2023] [Indexed: 06/29/2023]
Abstract
Background: Patients with first-line drug resistance (DR) to rifampicin (RIF) or isoniazid (INH) as a first-line (FL) line probe assay (LPA) were subjected to genotypic DST using second-line (SL) LPA to identify SL-DR (including pre-XDR) under the National TB Elimination Program (NTEP), India. SL-DR patients were initiated on different DR-TB treatment regimens and monitored for their outcomes. The objective of this retrospective analysis was to understand the mutation profile and treatment outcomes of SL-DR patients. Materials and Methods: A retrospective analysis of mutation profile, treatment regimen, and treatment outcome was performed for SL-DR patients who were tested at ICMR-NIRT, Supra-National Reference Laboratory, Chennai between the years 2018 and 2020. All information, including patient demographics and treatment outcomes, was extracted from the NTEP Ni-kshay database. Results: Between 2018 and 2020, 217 patients out of 2557 samples tested were identified with SL-DR by SL-LPA. Among them, 158/217 were FQ-resistant, 34/217 were SLID-resistant, and 25/217 were resistant to both. D94G (Mut3C) of gyrA and a1401g of rrs were the most predominant mutations in the FQ and SLID resistance types, respectively. Favorable (cured and treatment complete) and unfavorable outcomes (died, lost to follow up, treatment failed, and treatment regimen changed) were recorded in a total of 82/217 and 68/217 patients in the NTEP Ni-kshay database. Conclusions: As per the testing algorithm, SL- LPA is used for genotypic DST following identification of first-line resistance, for early detection of SL-DR in India. The fluoroquinolone resistance pattern seen in this study population corelates with the global trend. Early detection of fluoroquinolone resistance and monitoring of treatment outcome can help achieve better patient management.
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Affiliation(s)
- Radha Gopalaswamy
- ICMR-National Institute for Research in Tuberculosis, Chennai 600031, India
| | - Nandhini Palani
- ICMR-National Institute for Research in Tuberculosis, Chennai 600031, India
| | - Dinesh Viswanathan
- ICMR-National Institute for Research in Tuberculosis, Chennai 600031, India
| | - Bershila Preysingh
- ICMR-National Institute for Research in Tuberculosis, Chennai 600031, India
| | | | | | | | | | - Hannah Stanley
- ICMR-National Institute for Research in Tuberculosis, Chennai 600031, India
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Rana V, Singh N, Nikam C, Kambli P, Singh PK, Singh U, Jain A, Rodrigues C, Sharma C. Molecular Epidemiology and Polymorphism Analysis in Drug-Resistant Genes in M. tuberculosis Clinical Isolates from Western and Northern India. Infect Drug Resist 2022; 15:1717-1732. [PMID: 35422638 PMCID: PMC9005233 DOI: 10.2147/idr.s345855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 03/02/2022] [Indexed: 11/23/2022] Open
Abstract
Introduction The mechanistic details of first line drug (FLD) resistance have been thoroughly explored but the genetic resistance mechanisms of second line injectables, which form the backbone of the combinatorial drug resistant tuberculosis therapy, are partially identified. This study aims to highlight the genetic and spoligotypic differences in the second line drug (SLD) resistant and sensitive Mycobacterium tuberculosis (Mtb) clinical isolates from Mumbai (Western India) and Lucknow (Northern India). Methods The rrs, eis, whiB7, tlyA, gyrA and gyrB target loci were screened in 126 isolates and spoligotyped. Results The novel mutations were observed in whiB7 loci (A43T, C44A, C47A, G48T, G59A and T152G in 5’-UTR; A42C, C253T and T270G in gene), tlyA (+CG200, G165A, C415G, and +G543) and gyrB (+G1359 and +A1429). Altogether, the rrs, eis, and whiB7 loci harbored mutations in ~86% and ~47% kanamycin resistant isolates from Mumbai and Lucknow, respectively. Mumbai strains displayed higher prevalence of mutations in gyrA (~85%) and gyrB loci (~13%) as compared to those from Lucknow (~69% and ~3.0%, respectively). Further, spoligotyping revealed that Beijing lineage is distributed equally amongst the drug resistant strains of Mumbai and Lucknow, but EAI-5 is existed at a higher level only in Mumbai. The lineages Manu2, CAS1-Delhi and T1 are more prevalent in Lucknow. Conclusion Besides identifying novel mutations in whiB7, tlyA and gyrB target loci, our analyses unveiled a potential polymorphic and phylogeographical demarcation among two distinct regions.
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Affiliation(s)
- Vibhuti Rana
- CSIR- Institute of Microbial Technology, Chandigarh, 160036, India
| | - Nittu Singh
- CSIR- Institute of Microbial Technology, Chandigarh, 160036, India
| | - Chaitali Nikam
- Department of Microbiology, P. D. Hinduja National Hospital and Medical Research Centre, Mumbai, 400016, Maharashtra, India
| | - Priti Kambli
- Department of Microbiology, P. D. Hinduja National Hospital and Medical Research Centre, Mumbai, 400016, Maharashtra, India
| | - Pravin K Singh
- Department of Microbiology, King George Medical University, Lucknow, 226003, Uttar Pradesh, India
| | - Urmila Singh
- Department of Microbiology, King George Medical University, Lucknow, 226003, Uttar Pradesh, India
| | - Amita Jain
- Department of Microbiology, King George Medical University, Lucknow, 226003, Uttar Pradesh, India
| | - Camilla Rodrigues
- Department of Microbiology, P. D. Hinduja National Hospital and Medical Research Centre, Mumbai, 400016, Maharashtra, India
| | - Charu Sharma
- CSIR- Institute of Microbial Technology, Chandigarh, 160036, India
- Correspondence: Charu Sharma, CSIR-Institute of Microbial Technology, Sector 39-A, Chandigarh, 160036, India, Tel +911722880309/310, Fax +911722690585, Email
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Chaiyachat P, Chaiprasert A, Nonghanphithak D, Smithtikarn S, Kamolwat P, Pungrassami P, Reechaipichitkul W, Ong RTH, Teo YY, Faksri K. Whole-genome analysis of drug-resistant Mycobacterium tuberculosis reveals novel mutations associated with fluoroquinolone resistance. Int J Antimicrob Agents 2021; 58:106385. [PMID: 34161790 DOI: 10.1016/j.ijantimicag.2021.106385] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 04/19/2021] [Accepted: 06/05/2021] [Indexed: 12/13/2022]
Abstract
Multidrug-resistant and extensively drug-resistant tuberculosis (M/XDR-TB) remains a global public-health challenge. Known mutations in quinolone resistance-determination regions cannot fully explain phenotypic fluoroquinolone (FQ) resistance in Mycobacterium tuberculosis (Mtb). The aim of this study was to look for novel mutations in Mtb associated with resistance to FQ drugs using whole-genome sequencing analysis. Whole-genome sequences of 659 Mtb strains, including 214 with phenotypic FQ resistance and 445 pan-susceptible isolates, were explored for mutations associated with FQ resistance overall and with resistance to individual FQ drugs (ofloxacin, levofloxacin, moxifloxacin and gatifloxacin). Three novel genes (recC, Rv2005c and PPE59) associated with FQ resistance were identified (P < 0.00001 based on screening analysis and absence of relevant mutations in a pan-susceptible validation set of 360 strains). Nine novel single nucleotide polymorphisms (SNPs), including in gyrB (G5383A and G6773A), gyrA (G7892A), recC (G725900C and G726857T/C), Rv2005c (C2251373G, G2251420C and C2251725T) and PPE59 (C3847269T), were used for diagnostic performance analysis. Enhancing the known SNP set with five of these novel SNPs, including gyrA [G7892A (Leu247Leu)], recC [G725900C (Leu893Leu) and G726857T/C (Arg484Arg)], Rv2005c [G2251420C (Pro205Arg)] and PPE59 [C3847269T (Asn35Asn)] increased the sensitivity of detection of FQ-resistant Mtb from 83.2% (178/214) to 86.9% (186/214) while maintaining 100% specificity (360/360). No specific mutation associated with resistance to only a single drug (ofloxacin, levofloxacin, moxifloxacin or gatifloxacin) was found. In conclusion, this study reports possible additional mutations associated with FQ resistance in Mtb.
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Affiliation(s)
- Pratchakan Chaiyachat
- Department of Microbiology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand; Research and Diagnostic Center for Emerging Infectious Diseases (RCEID), Khon Kaen University, Khon Kaen, Thailand
| | - Angkana Chaiprasert
- Office for Research and Development, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Ditthawat Nonghanphithak
- Department of Microbiology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand; Research and Diagnostic Center for Emerging Infectious Diseases (RCEID), Khon Kaen University, Khon Kaen, Thailand
| | - Saijai Smithtikarn
- Bureau of Tuberculosis, Department of Disease Control, Ministry of Public Health, Thailand
| | - Phalin Kamolwat
- Bureau of Tuberculosis, Department of Disease Control, Ministry of Public Health, Thailand
| | - Petchawan Pungrassami
- Bureau of Tuberculosis, Department of Disease Control, Ministry of Public Health, Thailand
| | - Wipa Reechaipichitkul
- Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Rick Twee-Hee Ong
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore
| | - Yik-Ying Teo
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore; Genome Institute of Singapore, Singapore; Department of Statistics and Applied Probability, National University of Singapore, Singapore; Life Sciences Institute, National University of Singapore, Singapore
| | - Kiatichai Faksri
- Department of Microbiology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand; Research and Diagnostic Center for Emerging Infectious Diseases (RCEID), Khon Kaen University, Khon Kaen, Thailand.
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