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Pieterman ED, Keutzer L, van der Meijden A, van den Berg S, Wang H, Zimmerman MD, Simonsson USH, Bax HI, de Steenwinkel JEM. Superior efficacy of a bedaquiline, delamanid and linezolid combination regimen in a mouse-TB model. J Infect Dis 2021; 224:1039-1047. [PMID: 33502537 DOI: 10.1093/infdis/jiab043] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 01/21/2021] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND The treatment success rate of drug-resistant tuberculosis (DR-TB) is alarmingly low. Therefore, more effective and less complex regimens are urgently required. METHODS We compared the efficacy of an all oral DR-TB drug regimen consisting of bedaquiline (25 mg/kg), delamanid (2.5 mg/kg) and linezolid (100 mg/kg) (BDL) on the mycobacterial load in the lungs and spleen of TB infected mice during a treatment period of 24 weeks. This treatment was compared to the standard regimen of isoniazid, rifampicin, pyrazinamide and ethambutol (HRZE). Relapse was assessed 12 weeks post-treatment. Two logistic regression models were developed to compare the efficacy of both regimens. RESULTS Culture negativity in the lungs was achieved at 8 and 20 weeks of treatment with BDL and HRZE, respectively. After 14 weeks of treatment only one mouse relapsed in the BDL group, while in the HRZE group relapse was still observed at 24 weeks of treatment. Predictions from the final mathematical models showed that a 95% cure rate was reached after 20.5 and 28.5 weeks of treatment with BDL and HRZE, respectively. CONCLUSION The BDL regimen was observed to be more effective than HRZE and could be a valuable option for the treatment of DR-TB.
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Affiliation(s)
- Elise D Pieterman
- Department of Medical Microbiology and Infectious Diseases, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Lina Keutzer
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | - Aart van der Meijden
- Department of Medical Microbiology and Infectious Diseases, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Sanne van den Berg
- Department of Medical Microbiology and Infectious Diseases, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Han Wang
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, NJ, USA
| | - Matthew D Zimmerman
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, NJ, USA
| | | | - Hannelore I Bax
- Department of Medical Microbiology and Infectious Diseases, Erasmus University Medical Center, Rotterdam, the Netherlands.,Department of Internal Medicine, Section of Infectious Diseases, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Jurriaan E M de Steenwinkel
- Department of Medical Microbiology and Infectious Diseases, Erasmus University Medical Center, Rotterdam, the Netherlands
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2
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Lee H, Sohn JW, Sim YS, Shin TR, Kim DG, Choi H. Outcomes of extended duration therapy for drug-susceptible cavitary pulmonary tuberculosis. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:346. [PMID: 32355790 PMCID: PMC7186603 DOI: 10.21037/atm.2020.02.104] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Background Extending the continuation phase treatment duration is recommended to improve outcomes of drug-susceptible cavitary pulmonary tuberculosis (TB), but limited data are available on extended treatment outcomes. Methods We evaluated outcomes of 67 patients with drug-susceptible cavitary pulmonary TB who had received extended therapy. The primary endpoint of our study was the rate of a favorable outcome (cured or treatment completion without recurrence). Results Of the 67 patients, 40 (59.7%) were culture negative and 27 (40.3%) were culture positive two months after treatment initiation. The median treatment duration was 275 days. Extended duration therapy resulted in a 100% treatment success rate and 2.5% recurrence rate in patients with a negative culture at month 2. However, patients with a positive culture at month 2, showed a 74.1% treatment success rate and 8.0% recurrence rate (P<0.001 and P=0.554, respectively). In multivariable analyses, positive culture at month 2 was associated with greater odds of unfavorable outcomes (adjusted OR, 17.04, 95% CI, 1.68–177.92). Conclusions While extending the continuation phase was associated with favorable outcomes in pulmonary TB patients with negative culture at month 2, the same could not be achieved in those with positive culture at month 2, suggesting that this condition might not be overcome by merely extending the continuation phase.
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Affiliation(s)
- Hyun Lee
- Division of Pulmonary Medicine and Allergy, Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Jang Won Sohn
- Division of Pulmonary Medicine and Allergy, Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Yun Su Sim
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Hallym University Kangnam Sacred Heart Hospital, Seoul, Korea.,Lung Research Institute, Hallym University College of Medicine, Chuncheon, Korea
| | - Tae Rim Shin
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Hallym University Kangnam Sacred Heart Hospital, Seoul, Korea.,Lung Research Institute, Hallym University College of Medicine, Chuncheon, Korea
| | - Dong-Gyu Kim
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Hallym University Kangnam Sacred Heart Hospital, Seoul, Korea.,Lung Research Institute, Hallym University College of Medicine, Chuncheon, Korea
| | - Hayoung Choi
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Hallym University Kangnam Sacred Heart Hospital, Seoul, Korea.,Lung Research Institute, Hallym University College of Medicine, Chuncheon, Korea
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3
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Mourik BC, de Steenwinkel JEM, de Knegt GJ, Huizinga R, Verbon A, Ottenhoff THM, van Soolingen D, Leenen PJM. Mycobacterium tuberculosis clinical isolates of the Beijing and East-African Indian lineage induce fundamentally different host responses in mice compared to H37Rv. Sci Rep 2019; 9:19922. [PMID: 31882653 PMCID: PMC6934500 DOI: 10.1038/s41598-019-56300-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 11/14/2019] [Indexed: 11/15/2022] Open
Abstract
Substantial differences exist in virulence among Mycobacterium tuberculosis strains in preclinical TB models. In this study we show how virulence affects host responses in mice during the first four weeks of infection with a mycobacterial strain belonging to the Beijing, East-African-Indian or Euro-American lineage. BALB/c mice were infected with clinical isolates of the Beijing-1585 strain or the East-African Indian (EAI)-1627 strain and host responses were compared to mice infected with the non-clinical H37Rv strain of the Euro-American lineage. We found that H37Rv induced a ‘classical’ T-cell influx with high IFN-γ levels, while Beijing-1585 and EAI-1627 induced an influx of B-cells into the lungs together with elevated pulmonary IL-4 protein levels. Myeloid cells in the lungs appeared functionally impaired upon infection with Beijing-1585 and EAI-1627 with reduced iNOS and IL-12 expression levels compared to H37Rv infection. This impairment might be related to significantly reduced expression in the bone marrow of IFN-γ, TNF-α and IFN-β in mice infected with Beijing-1585 and EAI-1627, which could be detected from the third day post infection onwards. Our findings suggest that increased virulence of two clinical isolates compared to H37Rv is associated with a fundamentally different systemic immune response, which already can be detected early during infection.
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Affiliation(s)
- Bas C Mourik
- Department Medical Microbiology & Infectious Diseases, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Jurriaan E M de Steenwinkel
- Department Medical Microbiology & Infectious Diseases, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Gerjo J de Knegt
- Department Medical Microbiology & Infectious Diseases, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Ruth Huizinga
- Department of Immunology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Annelies Verbon
- Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Tom H M Ottenhoff
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, The Netherlands
| | - Dick van Soolingen
- National Tuberculosis Reference Laboratory, National Institute of Public Health and the Environment (RIVM), Bilthoven, The Netherlands
| | - Pieter J M Leenen
- Department of Immunology, Erasmus University Medical Center, Rotterdam, The Netherlands.
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McKay B, Castellanos M, Ebell M, Whalen CC, Handel A. An attempt to reproduce a previous meta-analysis and a new analysis regarding the impact of directly observed therapy on tuberculosis treatment outcomes. PLoS One 2019; 14:e0217219. [PMID: 31120965 PMCID: PMC6532908 DOI: 10.1371/journal.pone.0217219] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 05/02/2019] [Indexed: 11/18/2022] Open
Abstract
Directly observed therapy (DOT) is almost universally used for the treatment of TB. Several meta-analyses using different methods have assessed the effectiveness of DOT compared to self-administered therapy (SAT). The results of these meta-analyses often conflict with some concluding DOT is superior and others that there is little or no difference. Meta-analyses can guide policymaking, but such analyses must be reliable. To assess the validity of a previous meta-analysis, we tried to reproduce it. We encountered problems with the previous analysis that did not allow for a meaningful reproduction. We describe the issues we encountered here. We then performed a new meta-analysis comparing the treatment outcomes of adults given treatment with SAT versus DOT. Outcomes in the new analysis are loss to follow-up, treatment failure, cure, treatment completed, and all-cause mortality. All data, documentation, and code used to generate our results is provided. Our new analysis included four randomized and three observational studies with 1603 and 1626 individuals respectively. The pooled relative risks (RR) are as follows: Lost to follow-up (RR = 1.2, 95% CI 0.9, 1.7), Treatment Failure (RR = 1.1, 95% CI 0.6, 2), Cure (RR = 0.9, 95% CI 0.8, 1.1), Treatment Completion (RR = 1, 95% CI 0.9, 1.1), Mortality (RR = 0.9, 95% CI 0.6, 1.3). Based on data from our new meta-analysis, the magnitude of the difference between DOT and SAT for all reported outcomes is small, and none of the differences are statistically significant.
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Affiliation(s)
- Brian McKay
- Department of Epidemiology and Biostatistics, The University of Georgia, Athens, Georgia, United States of America
- * E-mail: (BM); (AH)
| | - Maria Castellanos
- Department of Epidemiology and Biostatistics, The University of Georgia, Athens, Georgia, United States of America
| | - Mark Ebell
- Department of Epidemiology and Biostatistics, The University of Georgia, Athens, Georgia, United States of America
| | - Christopher C. Whalen
- Department of Epidemiology and Biostatistics, The University of Georgia, Athens, Georgia, United States of America
| | - Andreas Handel
- Department of Epidemiology and Biostatistics, The University of Georgia, Athens, Georgia, United States of America
- * E-mail: (BM); (AH)
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Seijger C, Hoefsloot W, Bergsma-de Guchteneire I, te Brake L, van Ingen J, Kuipers S, van Crevel R, Aarnoutse R, Boeree M, Magis-Escurra C. High-dose rifampicin in tuberculosis: Experiences from a Dutch tuberculosis centre. PLoS One 2019; 14:e0213718. [PMID: 30870476 PMCID: PMC6417786 DOI: 10.1371/journal.pone.0213718] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 02/27/2019] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Recent evidence suggests that higher rifampicin doses may improve tuberculosis (TB) treatment outcome. METHODS In this observational cohort study we evaluated all TB patients who were treated with high-dose rifampicin (> 10 mg/kg daily) in our reference centre, from January 2008 to May 2018. Indications, achieved plasma rifampicin exposures, safety and tolerability were evaluated. RESULTS Eighty-eight patients were included. The main indications were low plasma concentrations (64.7%) and severe illness (29.5%), including central nervous system TB. Adjusted rifampicin dosages ranged from 900 mg to a maximum of 2400 mg (corresponding to 32 mg/kg) per day. Patients with severe illness received high-dose rifampicin immediately, the others had a higher dosage guided by therapeutic drug monitoring. Four patients developed hepatotoxicity, of which two were proven due to isoniazid. Re-introduction of high-dose rifampicin was successful in all four. Eighty-seven patients tolerated high-dose rifampicin well throughout treatment. Only one patient required a dose reduction due to gastro-intestinal disturbance. CONCLUSION High-dose rifampicin, used in specific groups of patients in our clinical setting, is safe and well-tolerated for the whole treatment duration. Measurement of drug exposures could be used as a tool/guide to increase rifampicin dosage if a reduced medication absorption or a poor treatment outcome is suspected. We suggest to administer high-dose rifampicin to patients with severe manifestations of TB or low rifampicin exposure to improve treatment outcome.
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Affiliation(s)
- Charlotte Seijger
- Department of Pulmonary Diseases, Radboud University Medical Center-Dekkerswald, Nijmegen, The Netherlands
| | - Wouter Hoefsloot
- Department of Pulmonary Diseases, Radboud University Medical Center-Dekkerswald, Nijmegen, The Netherlands
| | | | - Lindsey te Brake
- Department of Pharmacy, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jakko van Ingen
- Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Saskia Kuipers
- Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Reinout van Crevel
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Rob Aarnoutse
- Department of Pharmacy, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Martin Boeree
- Department of Pulmonary Diseases, Radboud University Medical Center-Dekkerswald, Nijmegen, The Netherlands
| | - Cecile Magis-Escurra
- Department of Pulmonary Diseases, Radboud University Medical Center-Dekkerswald, Nijmegen, The Netherlands
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Colangeli R, Jedrey H, Kim S, Connell R, Ma S, Chippada Venkata UD, Chakravorty S, Gupta A, Sizemore EE, Diem L, Sherman DR, Okwera A, Dietze R, Boom WH, Johnson JL, Mac Kenzie WR, Alland D. Bacterial Factors That Predict Relapse after Tuberculosis Therapy. N Engl J Med 2018; 379:823-833. [PMID: 30157391 PMCID: PMC6317071 DOI: 10.1056/nejmoa1715849] [Citation(s) in RCA: 84] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Approximately 5% of patients with drug-susceptible tuberculosis have a relapse after 6 months of first-line therapy, as do approximately 20% of patients after 4 months of short-course therapy. We postulated that by analyzing pretreatment isolates of Mycobacterium tuberculosis obtained from patients who subsequently had a relapse or were cured, we could determine any correlations between the minimum inhibitory concentration (MIC) of a drug below the standard resistance breakpoint and the relapse risk after treatment. METHODS Using data from the Tuberculosis Trials Consortium Study 22 (development cohort), we assessed relapse and cure isolates to determine the MIC values of isoniazid and rifampin that were below the standard resistance breakpoint (0.1 μg per milliliter for isoniazid and 1.0 μg per milliliter for rifampin). We combined this analysis with clinical, radiologic, and laboratory data to generate predictive relapse models, which we validated by analyzing data from the DMID 01-009 study (validation cohort). RESULTS In the development cohort, the mean (±SD) MIC of isoniazid below the breakpoint was 0.0334±0.0085 μg per milliliter in the relapse group and 0.0286±0.0092 μg per milliliter in the cure group, which represented a higher value in the relapse group by a factor of 1.17 (P=0.02). The corresponding MIC values of rifampin were 0.0695±0.0276 and 0.0453±0.0223 μg per milliliter, respectively, which represented a higher value in the relapse group by a factor of 1.53 (P<0.001). Higher MIC values remained associated with relapse in a multivariable analysis that included other significant between-group differences. In an analysis of receiver-operating-characteristic curves of relapse based on these MIC values, the area under the curve (AUC) was 0.779. In the development cohort, the AUC in a multivariable model that included MIC values was 0.875. In the validation cohort, the MIC values either alone or combined with other patient characteristics were also predictive of relapse, with AUC values of 0.964 and 0.929, respectively. The use of a model score for the MIC values of isoniazid and rifampin to achieve 75.0% sensitivity in cross-validation analysis predicted relapse with a specificity of 76.5% in the development cohort and a sensitivity of 70.0% and a specificity of 100% in the validation cohort. CONCLUSIONS In pretreatment isolates of M. tuberculosis with decrements of MIC values of isoniazid or rifampin below standard resistance breakpoints, higher MIC values were associated with a greater risk of relapse than lower MIC values. (Funded by the National Institute of Allergy and Infectious Diseases.).
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Affiliation(s)
- Roberto Colangeli
- From the Department of Medicine, Rutgers-New Jersey Medical School (R. Colangeli, H.J., U.D.C.V., S.C., A.G., D.A.), and the Department of Biostatistics, Rutgers School of Public Health (S.K., R. Connell), Newark; the Center for Infectious Disease Research, Seattle (S.M., D.R.S.); the Centers for Disease Control and Prevention, Atlanta (E.E.S., L.D., W.R.M.K.); Uganda-Case Western Reserve University Research Collaboration, Kampala, Uganda (A.O.); Nucleo de Doencas Infecciosas, Centro de Ciencias da Saude, Universidade Federal do Espirito Santo, Vitoria, Brazil (R.D.); and the Tuberculosis Research Unit, Department of Medicine, Case Western Reserve University School of Medicine and University Hospitals Cleveland Medical Center, Cleveland (W.H.B., J.L.J.)
| | - Hannah Jedrey
- From the Department of Medicine, Rutgers-New Jersey Medical School (R. Colangeli, H.J., U.D.C.V., S.C., A.G., D.A.), and the Department of Biostatistics, Rutgers School of Public Health (S.K., R. Connell), Newark; the Center for Infectious Disease Research, Seattle (S.M., D.R.S.); the Centers for Disease Control and Prevention, Atlanta (E.E.S., L.D., W.R.M.K.); Uganda-Case Western Reserve University Research Collaboration, Kampala, Uganda (A.O.); Nucleo de Doencas Infecciosas, Centro de Ciencias da Saude, Universidade Federal do Espirito Santo, Vitoria, Brazil (R.D.); and the Tuberculosis Research Unit, Department of Medicine, Case Western Reserve University School of Medicine and University Hospitals Cleveland Medical Center, Cleveland (W.H.B., J.L.J.)
| | - Soyeon Kim
- From the Department of Medicine, Rutgers-New Jersey Medical School (R. Colangeli, H.J., U.D.C.V., S.C., A.G., D.A.), and the Department of Biostatistics, Rutgers School of Public Health (S.K., R. Connell), Newark; the Center for Infectious Disease Research, Seattle (S.M., D.R.S.); the Centers for Disease Control and Prevention, Atlanta (E.E.S., L.D., W.R.M.K.); Uganda-Case Western Reserve University Research Collaboration, Kampala, Uganda (A.O.); Nucleo de Doencas Infecciosas, Centro de Ciencias da Saude, Universidade Federal do Espirito Santo, Vitoria, Brazil (R.D.); and the Tuberculosis Research Unit, Department of Medicine, Case Western Reserve University School of Medicine and University Hospitals Cleveland Medical Center, Cleveland (W.H.B., J.L.J.)
| | - Roy Connell
- From the Department of Medicine, Rutgers-New Jersey Medical School (R. Colangeli, H.J., U.D.C.V., S.C., A.G., D.A.), and the Department of Biostatistics, Rutgers School of Public Health (S.K., R. Connell), Newark; the Center for Infectious Disease Research, Seattle (S.M., D.R.S.); the Centers for Disease Control and Prevention, Atlanta (E.E.S., L.D., W.R.M.K.); Uganda-Case Western Reserve University Research Collaboration, Kampala, Uganda (A.O.); Nucleo de Doencas Infecciosas, Centro de Ciencias da Saude, Universidade Federal do Espirito Santo, Vitoria, Brazil (R.D.); and the Tuberculosis Research Unit, Department of Medicine, Case Western Reserve University School of Medicine and University Hospitals Cleveland Medical Center, Cleveland (W.H.B., J.L.J.)
| | - Shuyi Ma
- From the Department of Medicine, Rutgers-New Jersey Medical School (R. Colangeli, H.J., U.D.C.V., S.C., A.G., D.A.), and the Department of Biostatistics, Rutgers School of Public Health (S.K., R. Connell), Newark; the Center for Infectious Disease Research, Seattle (S.M., D.R.S.); the Centers for Disease Control and Prevention, Atlanta (E.E.S., L.D., W.R.M.K.); Uganda-Case Western Reserve University Research Collaboration, Kampala, Uganda (A.O.); Nucleo de Doencas Infecciosas, Centro de Ciencias da Saude, Universidade Federal do Espirito Santo, Vitoria, Brazil (R.D.); and the Tuberculosis Research Unit, Department of Medicine, Case Western Reserve University School of Medicine and University Hospitals Cleveland Medical Center, Cleveland (W.H.B., J.L.J.)
| | - Uma D Chippada Venkata
- From the Department of Medicine, Rutgers-New Jersey Medical School (R. Colangeli, H.J., U.D.C.V., S.C., A.G., D.A.), and the Department of Biostatistics, Rutgers School of Public Health (S.K., R. Connell), Newark; the Center for Infectious Disease Research, Seattle (S.M., D.R.S.); the Centers for Disease Control and Prevention, Atlanta (E.E.S., L.D., W.R.M.K.); Uganda-Case Western Reserve University Research Collaboration, Kampala, Uganda (A.O.); Nucleo de Doencas Infecciosas, Centro de Ciencias da Saude, Universidade Federal do Espirito Santo, Vitoria, Brazil (R.D.); and the Tuberculosis Research Unit, Department of Medicine, Case Western Reserve University School of Medicine and University Hospitals Cleveland Medical Center, Cleveland (W.H.B., J.L.J.)
| | - Soumitesh Chakravorty
- From the Department of Medicine, Rutgers-New Jersey Medical School (R. Colangeli, H.J., U.D.C.V., S.C., A.G., D.A.), and the Department of Biostatistics, Rutgers School of Public Health (S.K., R. Connell), Newark; the Center for Infectious Disease Research, Seattle (S.M., D.R.S.); the Centers for Disease Control and Prevention, Atlanta (E.E.S., L.D., W.R.M.K.); Uganda-Case Western Reserve University Research Collaboration, Kampala, Uganda (A.O.); Nucleo de Doencas Infecciosas, Centro de Ciencias da Saude, Universidade Federal do Espirito Santo, Vitoria, Brazil (R.D.); and the Tuberculosis Research Unit, Department of Medicine, Case Western Reserve University School of Medicine and University Hospitals Cleveland Medical Center, Cleveland (W.H.B., J.L.J.)
| | - Aditi Gupta
- From the Department of Medicine, Rutgers-New Jersey Medical School (R. Colangeli, H.J., U.D.C.V., S.C., A.G., D.A.), and the Department of Biostatistics, Rutgers School of Public Health (S.K., R. Connell), Newark; the Center for Infectious Disease Research, Seattle (S.M., D.R.S.); the Centers for Disease Control and Prevention, Atlanta (E.E.S., L.D., W.R.M.K.); Uganda-Case Western Reserve University Research Collaboration, Kampala, Uganda (A.O.); Nucleo de Doencas Infecciosas, Centro de Ciencias da Saude, Universidade Federal do Espirito Santo, Vitoria, Brazil (R.D.); and the Tuberculosis Research Unit, Department of Medicine, Case Western Reserve University School of Medicine and University Hospitals Cleveland Medical Center, Cleveland (W.H.B., J.L.J.)
| | - Erin E Sizemore
- From the Department of Medicine, Rutgers-New Jersey Medical School (R. Colangeli, H.J., U.D.C.V., S.C., A.G., D.A.), and the Department of Biostatistics, Rutgers School of Public Health (S.K., R. Connell), Newark; the Center for Infectious Disease Research, Seattle (S.M., D.R.S.); the Centers for Disease Control and Prevention, Atlanta (E.E.S., L.D., W.R.M.K.); Uganda-Case Western Reserve University Research Collaboration, Kampala, Uganda (A.O.); Nucleo de Doencas Infecciosas, Centro de Ciencias da Saude, Universidade Federal do Espirito Santo, Vitoria, Brazil (R.D.); and the Tuberculosis Research Unit, Department of Medicine, Case Western Reserve University School of Medicine and University Hospitals Cleveland Medical Center, Cleveland (W.H.B., J.L.J.)
| | - Lois Diem
- From the Department of Medicine, Rutgers-New Jersey Medical School (R. Colangeli, H.J., U.D.C.V., S.C., A.G., D.A.), and the Department of Biostatistics, Rutgers School of Public Health (S.K., R. Connell), Newark; the Center for Infectious Disease Research, Seattle (S.M., D.R.S.); the Centers for Disease Control and Prevention, Atlanta (E.E.S., L.D., W.R.M.K.); Uganda-Case Western Reserve University Research Collaboration, Kampala, Uganda (A.O.); Nucleo de Doencas Infecciosas, Centro de Ciencias da Saude, Universidade Federal do Espirito Santo, Vitoria, Brazil (R.D.); and the Tuberculosis Research Unit, Department of Medicine, Case Western Reserve University School of Medicine and University Hospitals Cleveland Medical Center, Cleveland (W.H.B., J.L.J.)
| | - David R Sherman
- From the Department of Medicine, Rutgers-New Jersey Medical School (R. Colangeli, H.J., U.D.C.V., S.C., A.G., D.A.), and the Department of Biostatistics, Rutgers School of Public Health (S.K., R. Connell), Newark; the Center for Infectious Disease Research, Seattle (S.M., D.R.S.); the Centers for Disease Control and Prevention, Atlanta (E.E.S., L.D., W.R.M.K.); Uganda-Case Western Reserve University Research Collaboration, Kampala, Uganda (A.O.); Nucleo de Doencas Infecciosas, Centro de Ciencias da Saude, Universidade Federal do Espirito Santo, Vitoria, Brazil (R.D.); and the Tuberculosis Research Unit, Department of Medicine, Case Western Reserve University School of Medicine and University Hospitals Cleveland Medical Center, Cleveland (W.H.B., J.L.J.)
| | - Alphonse Okwera
- From the Department of Medicine, Rutgers-New Jersey Medical School (R. Colangeli, H.J., U.D.C.V., S.C., A.G., D.A.), and the Department of Biostatistics, Rutgers School of Public Health (S.K., R. Connell), Newark; the Center for Infectious Disease Research, Seattle (S.M., D.R.S.); the Centers for Disease Control and Prevention, Atlanta (E.E.S., L.D., W.R.M.K.); Uganda-Case Western Reserve University Research Collaboration, Kampala, Uganda (A.O.); Nucleo de Doencas Infecciosas, Centro de Ciencias da Saude, Universidade Federal do Espirito Santo, Vitoria, Brazil (R.D.); and the Tuberculosis Research Unit, Department of Medicine, Case Western Reserve University School of Medicine and University Hospitals Cleveland Medical Center, Cleveland (W.H.B., J.L.J.)
| | - Reynaldo Dietze
- From the Department of Medicine, Rutgers-New Jersey Medical School (R. Colangeli, H.J., U.D.C.V., S.C., A.G., D.A.), and the Department of Biostatistics, Rutgers School of Public Health (S.K., R. Connell), Newark; the Center for Infectious Disease Research, Seattle (S.M., D.R.S.); the Centers for Disease Control and Prevention, Atlanta (E.E.S., L.D., W.R.M.K.); Uganda-Case Western Reserve University Research Collaboration, Kampala, Uganda (A.O.); Nucleo de Doencas Infecciosas, Centro de Ciencias da Saude, Universidade Federal do Espirito Santo, Vitoria, Brazil (R.D.); and the Tuberculosis Research Unit, Department of Medicine, Case Western Reserve University School of Medicine and University Hospitals Cleveland Medical Center, Cleveland (W.H.B., J.L.J.)
| | - W Henry Boom
- From the Department of Medicine, Rutgers-New Jersey Medical School (R. Colangeli, H.J., U.D.C.V., S.C., A.G., D.A.), and the Department of Biostatistics, Rutgers School of Public Health (S.K., R. Connell), Newark; the Center for Infectious Disease Research, Seattle (S.M., D.R.S.); the Centers for Disease Control and Prevention, Atlanta (E.E.S., L.D., W.R.M.K.); Uganda-Case Western Reserve University Research Collaboration, Kampala, Uganda (A.O.); Nucleo de Doencas Infecciosas, Centro de Ciencias da Saude, Universidade Federal do Espirito Santo, Vitoria, Brazil (R.D.); and the Tuberculosis Research Unit, Department of Medicine, Case Western Reserve University School of Medicine and University Hospitals Cleveland Medical Center, Cleveland (W.H.B., J.L.J.)
| | - John L Johnson
- From the Department of Medicine, Rutgers-New Jersey Medical School (R. Colangeli, H.J., U.D.C.V., S.C., A.G., D.A.), and the Department of Biostatistics, Rutgers School of Public Health (S.K., R. Connell), Newark; the Center for Infectious Disease Research, Seattle (S.M., D.R.S.); the Centers for Disease Control and Prevention, Atlanta (E.E.S., L.D., W.R.M.K.); Uganda-Case Western Reserve University Research Collaboration, Kampala, Uganda (A.O.); Nucleo de Doencas Infecciosas, Centro de Ciencias da Saude, Universidade Federal do Espirito Santo, Vitoria, Brazil (R.D.); and the Tuberculosis Research Unit, Department of Medicine, Case Western Reserve University School of Medicine and University Hospitals Cleveland Medical Center, Cleveland (W.H.B., J.L.J.)
| | - William R Mac Kenzie
- From the Department of Medicine, Rutgers-New Jersey Medical School (R. Colangeli, H.J., U.D.C.V., S.C., A.G., D.A.), and the Department of Biostatistics, Rutgers School of Public Health (S.K., R. Connell), Newark; the Center for Infectious Disease Research, Seattle (S.M., D.R.S.); the Centers for Disease Control and Prevention, Atlanta (E.E.S., L.D., W.R.M.K.); Uganda-Case Western Reserve University Research Collaboration, Kampala, Uganda (A.O.); Nucleo de Doencas Infecciosas, Centro de Ciencias da Saude, Universidade Federal do Espirito Santo, Vitoria, Brazil (R.D.); and the Tuberculosis Research Unit, Department of Medicine, Case Western Reserve University School of Medicine and University Hospitals Cleveland Medical Center, Cleveland (W.H.B., J.L.J.)
| | - David Alland
- From the Department of Medicine, Rutgers-New Jersey Medical School (R. Colangeli, H.J., U.D.C.V., S.C., A.G., D.A.), and the Department of Biostatistics, Rutgers School of Public Health (S.K., R. Connell), Newark; the Center for Infectious Disease Research, Seattle (S.M., D.R.S.); the Centers for Disease Control and Prevention, Atlanta (E.E.S., L.D., W.R.M.K.); Uganda-Case Western Reserve University Research Collaboration, Kampala, Uganda (A.O.); Nucleo de Doencas Infecciosas, Centro de Ciencias da Saude, Universidade Federal do Espirito Santo, Vitoria, Brazil (R.D.); and the Tuberculosis Research Unit, Department of Medicine, Case Western Reserve University School of Medicine and University Hospitals Cleveland Medical Center, Cleveland (W.H.B., J.L.J.)
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7
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Assessment of the Additional Value of Verapamil to a Moxifloxacin and Linezolid Combination Regimen in a Murine Tuberculosis Model. Antimicrob Agents Chemother 2018; 62:AAC.01354-18. [PMID: 29987154 DOI: 10.1128/aac.01354-18] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 06/26/2018] [Indexed: 01/24/2023] Open
Abstract
The favorable treatment outcome rate for multidrug-resistant tuberculosis (MDR-TB) is only 54%, and therefore new drug regimens are urgently needed. In this study, we evaluated the activity of the combination of moxifloxacin and linezolid as a possible new MDR-TB regimen in a murine TB model and the value of the addition of the efflux pump inhibitor verapamil to this backbone. BALB/c mice were infected with drug-sensitive Mycobacterium tuberculosis and were treated with human-equivalent doses of moxifloxacin (200 mg/kg of body weight) and linezolid (100 mg/kg) with or without verapamil (12.5 mg/kg) for 12 weeks. Pharmacokinetic parameters were collected during treatment at the steady state. After 12 weeks of treatment, a statistically significant decline in mycobacterial load in the lungs was observed with the moxifloxacin-linezolid regimen with and without verapamil (5.9 and 5.0 log CFU, respectively), but sterilization was not achieved yet. The spleens of all mice were culture negative after 12 weeks of treatment with both treatment modalities, and the addition of verapamil caused a significant reduction in relapse (14/14 positive spleens without versus 9/15 with verapamil, P = 0.017). In conclusion, treatment with a combination regimen of moxifloxacin and linezolid showed a strong decline in mycobacterial load in the mice. The addition of verapamil to this backbone had a modest additional effect in terms of reducing mycobacterial load in the lung as well as reducing the spleen relapse rate. These results warrant further studies on the role of efflux pump inhibition in improving the efficacy of MDR-TB backbone regimens.
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8
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Assessment of Bactericidal Drug Activity and Treatment Outcome in a Mouse Tuberculosis Model Using a Clinical Beijing Strain. Antimicrob Agents Chemother 2017; 61:AAC.00696-17. [PMID: 28739784 DOI: 10.1128/aac.00696-17] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Accepted: 07/13/2017] [Indexed: 11/20/2022] Open
Abstract
Mycobacterium tuberculosis Beijing strains are associated with lower treatment success rates in tuberculosis (TB) patients. In contrast, laboratory strains such as H37Rv are often used in preclinical tuberculosis models. Therefore, we explored the impact of using a clinical Beijing strain on treatment outcome in our mouse tuberculosis model. Additionally, the predictive value of bactericidal activity on treatment outcome was assessed. BALB/c mice were infected with a Beijing strain and treated with one of 10 different combinations of conventional anti-TB drugs. Bactericidal activity was assessed by determining reductions in mycobacterial load after 7, 14, and 28 days and after 2, 3, and 6 months of treatment. Treatment outcome was evaluated after a 6-month treatment course and was based on lung culture status 3 months posttreatment. None of the anti-TB drug regimens tested could achieve 100% treatment success. Treatment outcome depended critically on rifampin. Four non-rifampin-containing regimens showed 0% treatment success compared to success rates between 81 and 95% for six rifampin-containing regimens. Bactericidal activity was predictive only for treatment outcome after 3 months of treatment. Our data advocate the use of multiple mycobacterial strains, including a Beijing strain, to increase the translational value of mouse TB models evaluating treatment outcome. Additionally, our findings support the notion that bactericidal activity in the first 2 months of treatment, as measured in clinical phase IIa/b trials, has limited predictive value for tuberculosis treatment outcome, thus emphasizing the need for better parameters to guide future phase IIII trials.
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9
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Espindola AL, Varughese M, Laskowski M, Shoukat A, Heffernan JM, Moghadas SM. Strategies for halting the rise of multidrug resistant TB epidemics: assessing the effect of early case detection and isolation. Int Health 2017; 9:80-90. [PMID: 28338827 DOI: 10.1093/inthealth/ihw059] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Accepted: 12/21/2016] [Indexed: 11/14/2022] Open
Abstract
Background The increasing rates of multidrug resistant TB (MDR-TB) have posed the question of whether control programs under enhanced directly observed treatment, short-course (DOTS-Plus) are sufficient or implemented optimally. Despite enhanced efforts on early case detection and improved treatment regimens, direct transmission of MDR-TB remains a major hurdle for global TB control. Methods We developed an agent-based simulation model of TB dynamics to evaluate the effect of transmission reduction measures on the incidence of MDR-TB. We implemented a 15-day isolation period following the start of treatment in active TB cases. The model was parameterized with the latest estimates derived from the published literature. Results We found that if high rates (over 90%) of TB case identification are achieved within 4 weeks of developing active TB, then a 15-day patient isolation strategy with 50% effectiveness in interrupting disease transmission leads to 10% reduction in the incidence of MDR-TB over 10 years. If transmission is fully prevented, the rise of MDR-TB can be halted within 10 years, but the temporal reduction of MDR-TB incidence remains below 20% in this period. Conclusions The impact of transmission reduction measures on the TB incidence depends critically on the rates and timelines of case identification. The high costs and adverse effects associated with MDR-TB treatment warrant increased efforts and investments on measures that can interrupt direct transmission through early case detection.
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Affiliation(s)
- Aquino L Espindola
- Departamento de Física, Instituto de Ciéncias Exatas-ICEx, Universidade Federal Fluminense, Volta Redonda, RJ, 27.213-145Brazil
| | - Marie Varughese
- Department of Mathematical and Statistical Sciences and Department of Public Health Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Marek Laskowski
- Agent-Based Modelling Laboratory, York University, 4700 Keele St., Toronto, Ontario, M3J 1P3, Canada
| | - Affan Shoukat
- Agent-Based Modelling Laboratory, York University, 4700 Keele St., Toronto, Ontario, M3J 1P3, Canada
| | - Jane M Heffernan
- Centre for Disease Modelling, Department of Mathematics and Statistics, York University, Toronto, ON, M3J 1P3, Canada
| | - Seyed M Moghadas
- Agent-Based Modelling Laboratory, York University, 4700 Keele St., Toronto, Ontario, M3J 1P3, Canada
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10
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Dheda K, Gumbo T, Maartens G, Dooley KE, McNerney R, Murray M, Furin J, Nardell EA, London L, Lessem E, Theron G, van Helden P, Niemann S, Merker M, Dowdy D, Van Rie A, Siu GKH, Pasipanodya JG, Rodrigues C, Clark TG, Sirgel FA, Esmail A, Lin HH, Atre SR, Schaaf HS, Chang KC, Lange C, Nahid P, Udwadia ZF, Horsburgh CR, Churchyard GJ, Menzies D, Hesseling AC, Nuermberger E, McIlleron H, Fennelly KP, Goemaere E, Jaramillo E, Low M, Jara CM, Padayatchi N, Warren RM. The epidemiology, pathogenesis, transmission, diagnosis, and management of multidrug-resistant, extensively drug-resistant, and incurable tuberculosis. THE LANCET. RESPIRATORY MEDICINE 2017; 5:S2213-2600(17)30079-6. [PMID: 28344011 DOI: 10.1016/s2213-2600(17)30079-6] [Citation(s) in RCA: 382] [Impact Index Per Article: 54.6] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 10/24/2016] [Accepted: 12/08/2016] [Indexed: 12/25/2022]
Abstract
Global tuberculosis incidence has declined marginally over the past decade, and tuberculosis remains out of control in several parts of the world including Africa and Asia. Although tuberculosis control has been effective in some regions of the world, these gains are threatened by the increasing burden of multidrug-resistant (MDR) and extensively drug-resistant (XDR) tuberculosis. XDR tuberculosis has evolved in several tuberculosis-endemic countries to drug-incurable or programmatically incurable tuberculosis (totally drug-resistant tuberculosis). This poses several challenges similar to those encountered in the pre-chemotherapy era, including the inability to cure tuberculosis, high mortality, and the need for alternative methods to prevent disease transmission. This phenomenon mirrors the worldwide increase in antimicrobial resistance and the emergence of other MDR pathogens, such as malaria, HIV, and Gram-negative bacteria. MDR and XDR tuberculosis are associated with high morbidity and substantial mortality, are a threat to health-care workers, prohibitively expensive to treat, and are therefore a serious public health problem. In this Commission, we examine several aspects of drug-resistant tuberculosis. The traditional view that acquired resistance to antituberculous drugs is driven by poor compliance and programmatic failure is now being questioned, and several lines of evidence suggest that alternative mechanisms-including pharmacokinetic variability, induction of efflux pumps that transport the drug out of cells, and suboptimal drug penetration into tuberculosis lesions-are likely crucial to the pathogenesis of drug-resistant tuberculosis. These factors have implications for the design of new interventions, drug delivery and dosing mechanisms, and public health policy. We discuss epidemiology and transmission dynamics, including new insights into the fundamental biology of transmission, and we review the utility of newer diagnostic tools, including molecular tests and next-generation whole-genome sequencing, and their potential for clinical effectiveness. Relevant research priorities are highlighted, including optimal medical and surgical management, the role of newer and repurposed drugs (including bedaquiline, delamanid, and linezolid), pharmacokinetic and pharmacodynamic considerations, preventive strategies (such as prophylaxis in MDR and XDR contacts), palliative and patient-orientated care aspects, and medicolegal and ethical issues.
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Affiliation(s)
- Keertan Dheda
- Lung Infection and Immunity Unit, Department of Medicine, Division of Pulmonology and UCT Lung Institute, University of Cape Town, Groote Schuur Hospital, Cape Town, South Africa.
| | - Tawanda Gumbo
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Kelly E Dooley
- Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ruth McNerney
- Lung Infection and Immunity Unit, Department of Medicine, Division of Pulmonology and UCT Lung Institute, University of Cape Town, Groote Schuur Hospital, Cape Town, South Africa
| | - Megan Murray
- Department of Global Health and Social Medicine, Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Jennifer Furin
- Department of Global Health and Social Medicine, Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Edward A Nardell
- TH Chan School of Public Health, Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Leslie London
- School of Public Health and Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Grant Theron
- SA MRC Centre for Tuberculosis Research/DST/NRF Centre of Excellence for Biomedical Tuberculosis Research, Division of Molecular Biology and Human Genetics, Stellenbosch University, Tygerberg, South Africa
| | - Paul van Helden
- SA MRC Centre for Tuberculosis Research/DST/NRF Centre of Excellence for Biomedical Tuberculosis Research, Division of Molecular Biology and Human Genetics, Stellenbosch University, Tygerberg, South Africa
| | - Stefan Niemann
- Molecular and Experimental Mycobacteriology, Research Center Borstel, Borstel, Schleswig-Holstein, Germany; German Centre for Infection Research (DZIF), Partner Site Borstel, Borstel, Schleswig-Holstein, Germany
| | - Matthias Merker
- Molecular and Experimental Mycobacteriology, Research Center Borstel, Borstel, Schleswig-Holstein, Germany
| | - David Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Annelies Van Rie
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; International Health Unit, Epidemiology and Social Medicine, Faculty of Medicine, University of Antwerp, Antwerp, Belgium
| | - Gilman K H Siu
- Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Hung Hom, Hong Kong SAR, China
| | - Jotam G Pasipanodya
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Camilla Rodrigues
- Department of Microbiology, P.D. Hinduja National Hospital & Medical Research Centre, Mumbai, India
| | - Taane G Clark
- Faculty of Infectious and Tropical Diseases and Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Frik A Sirgel
- SA MRC Centre for Tuberculosis Research/DST/NRF Centre of Excellence for Biomedical Tuberculosis Research, Division of Molecular Biology and Human Genetics, Stellenbosch University, Tygerberg, South Africa
| | - Aliasgar Esmail
- Lung Infection and Immunity Unit, Department of Medicine, Division of Pulmonology and UCT Lung Institute, University of Cape Town, Groote Schuur Hospital, Cape Town, South Africa
| | - Hsien-Ho Lin
- Institute of Epidemiology and Preventive Medicine, National Taiwan University, Taipei, Taiwan
| | - Sachin R Atre
- Center for Clinical Global Health Education (CCGHE), Johns Hopkins University, Baltimore, MD, USA; Medical College, Hospital and Research Centre, Pimpri, Pune, India
| | - H Simon Schaaf
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Kwok Chiu Chang
- Tuberculosis and Chest Service, Centre for Health Protection, Department of Health, Hong Kong SAR, China
| | - Christoph Lange
- Division of Clinical Infectious Diseases, German Center for Infection Research, Research Center Borstel, Borstel, Schleswig-Holstein, Germany; International Health/Infectious Diseases, University of Lübeck, Lübeck, Germany; Department of Medicine, Karolinska Institute, Stockholm, Sweden; Department of Medicine, University of Namibia School of Medicine, Windhoek, Namibia
| | - Payam Nahid
- Division of Pulmonary and Critical Care, San Francisco General Hospital, University of California, San Francisco, CA, USA
| | - Zarir F Udwadia
- Pulmonary Department, Hinduja Hospital & Research Center, Mumbai, India
| | | | - Gavin J Churchyard
- Aurum Institute, Johannesburg, South Africa; School of Public Health, University of Witwatersrand, Johannesburg, South Africa; Advancing Treatment and Care for TB/HIV, South African Medical Research Council, Johannesburg, South Africa
| | - Dick Menzies
- Montreal Chest Institute, McGill University, Montreal, QC, Canada
| | - Anneke C Hesseling
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Eric Nuermberger
- Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Helen McIlleron
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Kevin P Fennelly
- Pulmonary Clinical Medicine Section, Division of Intramural Research, National Heart, Lung, and Blood Institute (NHLBI), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Eric Goemaere
- MSF South Africa, Cape Town, South Africa; School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Marcus Low
- Treatment Action Campaign, Johannesburg, South Africa
| | | | - Nesri Padayatchi
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), MRC HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - Robin M Warren
- SA MRC Centre for Tuberculosis Research/DST/NRF Centre of Excellence for Biomedical Tuberculosis Research, Division of Molecular Biology and Human Genetics, Stellenbosch University, Tygerberg, South Africa
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11
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de Knegt GJ, van der Meijden A, de Vogel CP, Aarnoutse RE, de Steenwinkel JEM. Activity of moxifloxacin and linezolid against Mycobacterium tuberculosis in combination with potentiator drugs verapamil, timcodar, colistin and SQ109. Int J Antimicrob Agents 2017; 49:302-307. [PMID: 28162983 DOI: 10.1016/j.ijantimicag.2016.11.027] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Revised: 11/03/2016] [Accepted: 11/25/2016] [Indexed: 01/17/2023]
Abstract
Current treatment for tuberculosis (TB) is complicated by the emergence of multidrug resistant TB (MDR-TB). As a result, there is an urgent need for new powerful anti-TB regimens and novel strategies. In this study, we aimed to potentiate a moxifloxacin + linezolid backbone as treatment for MDR-TB with the efflux pump inhibitors verapamil and timcodar as well as with drugs that act on mycobacterial cell wall stability such as colistin and SQ109. Using a time-kill kinetics assay, the activities of moxifloxacin, linezolid, verapamil, timcodar, colistin and SQ109 as single drugs against Mycobacterium tuberculosis were evaluated. In addition, the activity of the moxifloxacin + linezolid backbone in combination with one of the potentiator drugs was assessed. As little as 0.125 mg/L moxifloxacin achieved 99% killing of M. tuberculosis after 6 days of exposure. Linezolid showed moderate killing but 99% killing was not achieved. Verapamil, timcodar and colistin only resulted in killing with the highest concentrations tested but 99% killing was not achieved. SQ109 resulted in complete elimination after 1 day of exposure to 256 mg/L and in 99% elimination after 6 days of exposure to 1 mg/L. Furthermore, colistin added to the moxifloxacin + linezolid backbone resulted in increased elimination, whereas verapamil, timcodar and SQ109 showed no added value to the backbone. This finding that colistin potentiates the activity of the moxifloxacin + linezolid backbone against M. tuberculosis suggests its potential role in further studies on the applicability of a moxifloxacin + linezolid treatment of MDR-TB.
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Affiliation(s)
- Gerjo J de Knegt
- Department of Medical Microbiology & Infectious Diseases, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands.
| | - Aart van der Meijden
- Department of Medical Microbiology & Infectious Diseases, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Corné P de Vogel
- Department of Medical Microbiology & Infectious Diseases, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Rob E Aarnoutse
- Department of Pharmacy, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Jurriaan E M de Steenwinkel
- Department of Medical Microbiology & Infectious Diseases, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
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12
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Muralikrishnan B, Dan VM, Vinodh JS, Jamsheena V, Ramachandran R, Thomas S, Dastager SG, Kumar KS, Lankalapalli RS, Kumar RA. Anti-microbial activity of chrysomycin A produced by Streptomyces sp. against Mycobacterium tuberculosis. RSC Adv 2017. [DOI: 10.1039/c7ra05576e] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Chrysomycin A isolated fromStreptomycessp. OA161 is bactericidal toMycobacterium tuberculosis, methicillin resistantStaphylococcus aureusand vancomycin resistantEnterococcus faecalis.
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Affiliation(s)
- Balaji Muralikrishnan
- Mycobacterium Research Laboratory
- Rajiv Gandhi Centre for Biotechnology
- Trivandrum
- India
| | - Vipin Mohan Dan
- Mycobacterium Research Laboratory
- Rajiv Gandhi Centre for Biotechnology
- Trivandrum
- India
| | - J. S. Vinodh
- Mycobacterium Research Laboratory
- Rajiv Gandhi Centre for Biotechnology
- Trivandrum
- India
| | - Vellekkatt Jamsheena
- Chemical Sciences and Technology Division
- National Institute for Interdisciplinary Science and Technology
- CSIR
- Trivandrum
- India
| | - Ranjit Ramachandran
- Mycobacterium Research Laboratory
- Rajiv Gandhi Centre for Biotechnology
- Trivandrum
- India
| | - Sabu Thomas
- Cholera and Biofilm Research Laboratory
- Rajiv Gandhi Centre for Biotechnology
- Trivandrum
- India
| | | | - K. Santhosh Kumar
- Chemical and Environmental Biology
- Rajiv Gandhi Centre for Biotechnology
- Trivandrum
- India
| | - Ravi Shankar Lankalapalli
- Chemical Sciences and Technology Division
- National Institute for Interdisciplinary Science and Technology
- CSIR
- Trivandrum
- India
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13
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Cadosch D, Abel zur Wiesch P, Kouyos R, Bonhoeffer S. The Role of Adherence and Retreatment in De Novo Emergence of MDR-TB. PLoS Comput Biol 2016; 12:e1004749. [PMID: 26967493 PMCID: PMC4788301 DOI: 10.1371/journal.pcbi.1004749] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Accepted: 01/12/2016] [Indexed: 11/19/2022] Open
Abstract
Treatment failure after therapy of pulmonary tuberculosis (TB) infections is an important challenge, especially when it coincides with de novo emergence of multi-drug-resistant TB (MDR-TB). We seek to explore possible causes why MDR-TB has been found to occur much more often in patients with a history of previous treatment. We develop a mathematical model of the replication of Mycobacterium tuberculosis within a patient reflecting the compartments of macrophages, granulomas, and open cavities as well as parameterizing the effects of drugs on the pathogen dynamics in these compartments. We use this model to study the influence of patient adherence to therapy and of common retreatment regimens on treatment outcome. As expected, the simulations show that treatment success increases with increasing adherence. However, treatment occasionally fails even under perfect adherence due to interpatient variability in pharmacological parameters. The risk of generating MDR de novo is highest between 40% and 80% adherence. Importantly, our simulations highlight the double-edged effect of retreatment: On the one hand, the recommended retreatment regimen increases the overall success rate compared to re-treating with the initial regimen. On the other hand, it increases the probability to accumulate more resistant genotypes. We conclude that treatment adherence is a key factor for a positive outcome, and that screening for resistant strains is advisable after treatment failure or relapse.
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Affiliation(s)
| | - Pia Abel zur Wiesch
- Division of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, United States of America
- Department of Pharmacy, Faculty of Health Sciences, Norwegian Arctic University (UiT), Tromsø, Norway
| | - Roger Kouyos
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Switzerland & Institute of Medical Virology, Swiss National Center for Retroviruses, University of Zurich, Zurich, Switzerland
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14
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Prevalence of Tuberculosis, Drug Susceptibility Testing, and Genotyping of Mycobacterial Isolates from Pulmonary Tuberculosis Patients in Dessie, Ethiopia. Tuberc Res Treat 2015; 2015:215015. [PMID: 26180642 PMCID: PMC4477223 DOI: 10.1155/2015/215015] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Revised: 05/14/2015] [Accepted: 05/18/2015] [Indexed: 01/13/2023] Open
Abstract
Due to their initially seemingly high cost, timely diagnosis and effective treatment of tuberculosis (TB) are usually hampered by lack or shortage of resources in many high TB burden countries. However, the benefits of effective treatment can eventually outweigh those of empirical treatment. Here, a cross-sectional study was conducted on samples from smear-positive new and retreatment TB patients. Data on sociodemographic and HIV status were collected. Samples were cultured for identification, conventional drug sensitivity testing, and molecular typing by deletion typing and spoligotyping. The results showed the youth were disproportionately affected. New cases were being treated following general treatment guidelines only. Monoresistance or multiple drug resistance was found in 16.5% of new patients. Spoligotyping showed that there were 44 patterns with families H3 and T1 (lineage 4) and CAS-Delhi (lineage 3) being dominant. Some rare patterns from lineage 7 were also found. Spoligotype pattern, HIV positivity, and previous treatment were not associated with drug resistance. That the vast majority of the patients were new cases and young and the large number of these patients with mono- or multiple drug resistance indicate that most TB cases are due to recent transmissions and that urgent actions are needed to curb the transmissions.
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15
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16
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Differential expression of efflux pump genes of Mycobacterium tuberculosis in response to varied subinhibitory concentrations of antituberculosis agents. Tuberculosis (Edinb) 2015; 95:155-61. [PMID: 25680943 DOI: 10.1016/j.tube.2015.01.005] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2014] [Accepted: 01/13/2015] [Indexed: 12/15/2022]
Abstract
Several reports have elaborated on the role of efflux pumps in drug resistance in Mycobacterium tuberculosis by analysing the mRNA expression profiles. However, there is no uniformity in the subinhibitory concentrations of drugs chosen in these studies. Some investigators studied the expression of efflux pumps under a drug concentration of 1/2 minimum inhibitory concentration (MIC), while others used 1/3, 1/4 or 1/8MIC. The present study was planned to understand the effect of different concentrations of antituberculosis drugs on the expression of efflux pump genes. Log phase culture of the laboratory strain M. tuberculosis H37Rv was exposed to rifampicin (RIF), isoniazid (INH), streptomycin (SM) and ethambutol (EMB) at different drug concentrations (1/2MIC, 1/3MIC and 1/4MIC). The expression of 10 putative efflux pump genes was studied using quantitative Real Time-Polymerase Chain Reaction (qRT-PCR). We observed an optimal expression of efflux pumps at higher concentrations of INH; and at lower concentrations of RIF and EMB. However, in the presence of SM, a decreased expression of efflux genes with increasing concentrations of the drug was confounded by a significant reduction in Colony Forming Units (CFU).
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de Knegt GJ, Ten Kate MT, van Soolingen D, Aarnoutse R, Boeree MJ, Bakker-Woudenberg IAJM, de Steenwinkel JEM. Enhancement of in vitro activity of tuberculosis drugs by addition of thioridazine is not reflected by improved in vivo therapeutic efficacy. Tuberculosis (Edinb) 2014; 94:S1472-9792(14)20507-5. [PMID: 25423883 DOI: 10.1016/j.tube.2014.09.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2014] [Revised: 08/21/2014] [Accepted: 09/01/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVES Assessment of the activity of thioridazine towards Mycobacterium tuberculosis (Mtb), in vitro and in vivo as a single drug and in combination with tuberculosis (TB) drugs. METHODS The in vitro activity of thioridazine as single drug or in combination with TB drugs was assessed in terms of MIC and by use of the time-kill kinetics assay. Various Mtb strains among which the Beijing genotype strain BE-1585 were included. In vivo, mice with TB induced by BE-1585 were treated with a TB drug regimen with thioridazine during 13 weeks. Therapeutic efficacy was assessed by the change in mycobacterial load in the lung, spleen and liver during treatment and 13 weeks post-treatment. RESULTS In vitro, thioridazine showed a concentration-dependent and time-dependent bactericidal activity towards both actively-replicating and slowly-replicating Mtb. Thioridazine at high concentrations could enhance the activity of isoniazid and rifampicin, and in case of isoniazid resulted in elimination of mycobacteria and prevention of isoniazid-resistant mutants. Thioridazine had no added value in combination with moxifloxacin or amikacin. In mice with TB, thioridazine was poorly tolerated, limiting the maximum tolerated dose (MTD). The addition of thioridazine at the MTD to an isoniazid-rifampicin-pyrazinamide regimen for 13 weeks did not result in enhanced therapeutic efficacy. CONCLUSIONS Thioridazine is bactericidal towards Mtb in vitro, irrespective the mycobacterial growth rate and results in enhanced activity of the standard regimen. The in vitro activity of thioridazine in potentiating isoniazid and rifampicin is not reflected by improved therapeutic efficacy in a murine TB-model.
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Affiliation(s)
- Gerjo J de Knegt
- Erasmus MC, University Medical Centre Rotterdam, Department of Medical Microbiology & Infectious Diseases, Rotterdam, The Netherlands.
| | - Marian T Ten Kate
- Erasmus MC, University Medical Centre Rotterdam, Department of Medical Microbiology & Infectious Diseases, Rotterdam, The Netherlands
| | - Dick van Soolingen
- National Institute for Public Health and the Environment (RIVM), National Mycobacteria Reference Laboratory, Bilthoven, The Netherlands
| | - Rob Aarnoutse
- Radboud University Medical Centre, Department of Pharmacy, Nijmegen, The Netherlands
| | - Martin J Boeree
- Radboud University Nijmegen Medical Centre, University Centre for Chronic Diseases Dekkerswald, Nijmegen, The Netherlands
| | - Irma A J M Bakker-Woudenberg
- Erasmus MC, University Medical Centre Rotterdam, Department of Medical Microbiology & Infectious Diseases, Rotterdam, The Netherlands
| | - Jurriaan E M de Steenwinkel
- Erasmus MC, University Medical Centre Rotterdam, Department of Medical Microbiology & Infectious Diseases, Rotterdam, The Netherlands
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Dheda K, Gumbo T, Gandhi NR, Murray M, Theron G, Udwadia Z, Migliori GB, Warren R. Global control of tuberculosis: from extensively drug-resistant to untreatable tuberculosis. THE LANCET RESPIRATORY MEDICINE 2014; 2:321-38. [PMID: 24717628 DOI: 10.1016/s2213-2600(14)70031-1] [Citation(s) in RCA: 200] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Extensively drug-resistant tuberculosis is a burgeoning global health crisis mainly affecting economically active young adults, and has high mortality irrespective of HIV status. In some countries such as South Africa, drug-resistant tuberculosis represents less than 3% of all cases but consumes more than a third of the total national budget for tuberculosis, which is unsustainable and threatens to destabilise national tuberculosis programmes. However, concern about drug-resistant tuberculosis has been eclipsed by that of totally and extremely drug-resistant tuberculosis--ie, resistance to all or nearly all conventional first-line and second-line antituberculosis drugs. In this Review, we discuss the epidemiology, pathogenesis, diagnosis, management, implications for health-care workers, and ethical and medicolegal aspects of extensively drug-resistant tuberculosis and other resistant strains. Finally, we discuss the emerging problem of functionally untreatable tuberculosis, and the issues and challenges that it poses to public health and clinical practice. The emergence and growth of highly resistant strains of tuberculosis make the development of new drugs and rapid diagnostics for tuberculosis--and increased funding to strengthen global control efforts, research, and advocacy--even more pressing.
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Affiliation(s)
- 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; Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa.
| | - Tawanda Gumbo
- Office of Global Health and Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Neel R Gandhi
- Departments of Epidemiology, Global Health, and Infectious Diseases, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Megan Murray
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - Grant Theron
- Lung Infection and Immunity Unit, Division of Pulmonology and UCT Lung Institute, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | | | - G B Migliori
- WHO Collaborating Centre for TB and Lung Diseases, Fondazione S Maugeri, Care and Research Institute, Tradate, Italy
| | - Robin Warren
- DST/NRF Centre of Excellence for Biomedical Tuberculosis Research, MRC Centre for Molecular and Cellular Biology, Division of Molecular Biology and Human Genetics, Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
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Adane AA, Alene KA, Koye DN, Zeleke BM. Non-adherence to anti-tuberculosis treatment and determinant factors among patients with tuberculosis in northwest Ethiopia. PLoS One 2013; 8:e78791. [PMID: 24244364 PMCID: PMC3823971 DOI: 10.1371/journal.pone.0078791] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2013] [Accepted: 09/21/2013] [Indexed: 11/18/2022] Open
Abstract
Background Non-adherence to anti tuberculosis treatment is one of the crucial challenges in improving tuberculosis cure-rates and reducing further healthcare costs. The poor adherence to anti-tuberculosis treatment among patients with tuberculosis is a major problem in Ethiopia. Hence, this study assessed level of non-adherence to anti-tuberculosis therapy and associated factors among patients with tuberculosis in northwest Ethiopia. Methods An institution based cross-sectional survey was conducted among tuberculosis patients who were following anti-tuberculosis treatment in North Gondar zone from February 20 – March 30, 2013. Data were collected by trained data collectors using a structured and pre-tested questionnaire. Data were entered to EPI INFO version 3.5.3 and analyzed using statistical package for social sciences (SPSS) version 20. Multiple logistic regressions were fitted to identify associations and to control potential confounding variables. Odds ratio (OR) with 95% confidence interval was calculated and p-values<0.05 were considered statistically significant. Results A total of 280 tuberculosis patients were interviewed; 55.7% were males and nearly three quarters (72.5%) were urban dwellers. The overall non-adherence for the last one month and the last four days before the survey were 10% and 13.6% respectively. Non-adherence was high if the patients had forgetfulness (AOR 7.04, 95% CI 1.40–35.13), is on the continuation phase of chemotherapy (AOR: 6.95, 95% CI 1.81–26.73), had symptoms of tuberculosis during the interview (AOR: 4.29, 95% CI 1.53–12.03), and had co-infection with HIV (AOR: 4.06, 95% CI 1.70–9.70). Conclusions Non-adherence to anti-tuberculosis treatment was high. Forgetfulness, being in the continuation phases of chemotherapy, having symptoms of tuberculosis during the interview, and co-infected with HIV were significantly associated with non-adherence to anti-tuberculosis therapy. Special attention on adherence counseling should be given to symptomatic patients, TB/HIV co-infected patients, and those in the continuation phase of the tuberculosis therapy.
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Affiliation(s)
- Akilew Awoke Adane
- Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
- * E-mail:
| | - Kefyalew Addis Alene
- Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Digsu Negese Koye
- Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Berihun Megabiaw Zeleke
- Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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McGrath M, Gey van Pittius NC, van Helden PD, Warren RM, Warner DF. Mutation rate and the emergence of drug resistance in Mycobacterium tuberculosis. J Antimicrob Chemother 2013; 69:292-302. [DOI: 10.1093/jac/dkt364] [Citation(s) in RCA: 99] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
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de Steenwinkel JEM, Aarnoutse RE, de Knegt GJ, ten Kate MT, Teulen M, Verbrugh HA, Boeree MJ, van Soolingen D, Bakker-Woudenberg IAJM. Optimization of the rifampin dosage to improve the therapeutic efficacy in tuberculosis treatment using a murine model. Am J Respir Crit Care Med 2013; 187:1127-34. [PMID: 23525933 DOI: 10.1164/rccm.201207-1210oc] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE The dosage of 10 mg/kg/d rifampin, as currently used in the treatment of tuberculosis (TB), is not an optimal dose. Shortening of treatment duration might be achievable using an increased rifampin dose. OBJECTIVES Determination of optimal rifampin dosage in mice, resulting in maximum therapeutic effect and without adverse effects. Assessment of associated pharmacokinetic parameters and pharmacokinetic/pharmacodynamic indices. METHODS A murine TB infection using a Beijing genotype Mycobacterium tuberculosis strain was established by intratracheal bacterial instillation followed by proper inhalation, while keeping mice in a vertical position. We assessed dose-dependent activity of rifampin in single-drug treatment during 3 weeks. The maximum tolerated dosage, pharmacokinetic parameters, and pharmacokinetic/pharmacodynamic index were determined. Therapeutic efficacy of a range of rifampin (R) dosages added to a regimen of isoniazid (H) and pyrazinamide (Z) was assessed. MEASUREMENTS AND MAIN RESULTS Maximum tolerated dosage of rifampin in the murine TB was 160 mg/kg/d. Pharmacokinetic measurement in HR(10)Z and HR(160)Z therapy regimens showed for rifampin a C(max) of 16.2 and 157.3 mg/L, an AUC(0-24h) of 132 and 1,782 h·mg/L, and AUC(0-24h)/minimum inhibitory concentration ratios of 528 and 7129, respectively. A clear dose-effect correlation was observed for rifampin after 3-week single-drug treatment. Administration of HR(80)Z allowed 9-week treatment duration to be effective without relapse of infection. CONCLUSIONS Our findings indicate that the currently used rifampin dosage in the therapy of TB is too low. In our murine TB model a rifampin dosage of 80 mg/kg/d enabled a significant reduction in therapy duration without adverse effects.
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Affiliation(s)
- Jurriaan E M de Steenwinkel
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands.
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Pasipanodya JG, Gumbo T. Reply to Moonan and Weis, Seaworth et al, and Nunn and Phillips. Clin Infect Dis 2013; 57:1065-6. [PMID: 23811417 DOI: 10.1093/cid/cit434] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Jotam G Pasipanodya
- Office of Global Health and Department of Medicine, The University of Texas Southwestern Medical Center, Dallas
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