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Rahmasari FV, Asih PBS, Rozi IE, Wangsamuda S, Risandi R, Dewayanti FK, Permana DH, Syahrani L, Prameswari HD, Basri HH, Bustos MDG, Charunwatthana P, Dondorp AM, Imwong M, Syafruddin D. Evolution of genetic markers for drug resistance after the introduction of dihydroartemisinin-piperaquine as first-line anti-malarial treatment for uncomplicated falciparum malaria in Indonesia. Malar J 2023; 22:231. [PMID: 37553646 PMCID: PMC10410932 DOI: 10.1186/s12936-023-04658-4] [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: 03/31/2023] [Accepted: 07/25/2023] [Indexed: 08/10/2023] Open
Abstract
BACKGROUND Dihydroartemisinin-piperaquine has been Indonesia's first-line anti-malarial treatment since 2008. Annual therapeutic efficacy studies (TES) done in the last 12 years showed continued high treatment efficacy in uncomplicated Plasmodium falciparum malaria. Although these studies did not show evidence for artemisinin resistance, a slight increase in Late Treatment Failure was observed over time. It is highlight to explore the evolution of genetic markers for ACT partner drug resistance since adopting DHA-PPQ. METHODS Dry blood spots were identified from a mass blood survey of uncomplicated falciparum malaria patients (N = 50) in Sumba from 2010 to 2018. Analysis of genotypic profile (N = 51) and a Therapeutic Efficacy Study (TES) from Papua (N = 142) from 2020 to 2021, 42-day follow-up. PCR correction using msp1, msp2, and glurp was used to distinguish recrudescence and reinfection. Parasite DNA from DBSs was used for genotyping molecular markers for antimalaria drug resistance, including in Pfk13, pfcrt, and pfmdr1, as well as gene copy number variation in pfpm2/3 and pfmdr1. RESULTS The study revealed the absence of SNPs associated with ART resistance and several novel SNPs such as L396F, I526V, M579I and N537S (4.25%). In Sumba, the mutant haplotype SDD of pfmdr1 was found in one-third of the isolates, while only 8.9% in Papua. None of the pfcrt mutations linked to piperaquine resistance were observed, but 71% of isolates had pfcrt I356L. Amplification of the pfpm2/3 genes was in Sumba (17.02%) and Papua (13.7%), while pfmdr1 copy number prevalence was low (3.8%) in both areas. For the TES study, ten recurrences of infection were observed on days 28, 35, and 42. Late parasitological failure (LPF) was observed in 10/117 (8.5%) subjects by microscopy. PCR correction revealed that all nine cases were re-infections and one was confirmed as recrudescence. CONCLUSION This study revealed that DHA-PPQ is still highly effective against P. falciparum. The genetic architecture of the parasite P. falciparum isolates during 2010-2021 revealed single copy of Pfpm2 and pfmdr1 were highly prevalent. The slight increase in DHA-PPQ LTF alerts researchers to start testing other ACTs as alternatives to DHA-PPQ for baseline data in order to get a chance of achieving malaria elimination wants by 2030.
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Affiliation(s)
- Farindira Vesti Rahmasari
- Graduate Programme in Molecular Medicine, Faculty of Science, Mahidol University, Bangkok, 10400, Thailand
- Department of Molecular Tropical Medicine and Genetics, Faculty of Tropical Medicine, Mahidol University, 420/6 Ratchawithi Road, Ratchathewi, Bangkok, 10400, Thailand
- Department of Parasitology, School of Medicine, Faculty of Medicine and Health Sciences, Universitas Muhammadiyah Yogyakarta, Bantul, Indonesia
| | - Puji Budi Setia Asih
- Eijkman Research Center for Molecular Biology, National Research and Innovation Agency (BRIN), Cibinong, Indonesia
| | - Ismail Ekoprayitno Rozi
- Eijkman Research Center for Molecular Biology, National Research and Innovation Agency (BRIN), Cibinong, Indonesia
| | - Suradi Wangsamuda
- Eijkman Research Center for Molecular Biology, National Research and Innovation Agency (BRIN), Cibinong, Indonesia
| | - Rifqi Risandi
- Eijkman Research Center for Molecular Biology, National Research and Innovation Agency (BRIN), Cibinong, Indonesia
| | - Farahana Kresno Dewayanti
- Eijkman Research Center for Molecular Biology, National Research and Innovation Agency (BRIN), Cibinong, Indonesia
| | - Dendi Hadi Permana
- Eijkman Research Center for Molecular Biology, National Research and Innovation Agency (BRIN), Cibinong, Indonesia
| | - Lepa Syahrani
- Eijkman Research Center for Molecular Biology, National Research and Innovation Agency (BRIN), Cibinong, Indonesia
| | | | - Herdiana H Basri
- World Health Organization, Country Office for Indonesia, Jakarta, Indonesia
| | | | - Prakaykaew Charunwatthana
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Ratchathewi, Bangkok, 10400, Thailand
| | - Arjen M Dondorp
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Mallika Imwong
- Department of Molecular Tropical Medicine and Genetics, Faculty of Tropical Medicine, Mahidol University, 420/6 Ratchawithi Road, Ratchathewi, Bangkok, 10400, Thailand.
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.
| | - Din Syafruddin
- Eijkman Research Center for Molecular Biology, National Research and Innovation Agency (BRIN), Cibinong, Indonesia
- Department of Parasitology, Faculty of Medicine, The University of Hasanuddin, Makassar, Indonesia
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2
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Jacob CG, Thuy-Nhien N, Mayxay M, Maude RJ, Quang HH, Hongvanthong B, Vanisaveth V, Ngo Duc T, Rekol H, van der Pluijm R, von Seidlein L, Fairhurst R, Nosten F, Hossain MA, Park N, Goodwin S, Ringwald P, Chindavongsa K, Newton P, Ashley E, Phalivong S, Maude R, Leang R, Huch C, Dong LT, Nguyen KT, Nhat TM, Hien TT, Nguyen H, Zdrojewski N, Canavati S, Sayeed AA, Uddin D, Buckee C, Fanello CI, Onyamboko M, Peto T, Tripura R, Amaratunga C, Myint Thu A, Delmas G, Landier J, Parker DM, Chau NH, Lek D, Suon S, Callery J, Jittamala P, Hanboonkunupakarn B, Pukrittayakamee S, Phyo AP, Smithuis F, Lin K, Thant M, Hlaing TM, Satpathi P, Satpathi S, Behera PK, Tripura A, Baidya S, Valecha N, Anvikar AR, Ul Islam A, Faiz A, Kunasol C, Drury E, Kekre M, Ali M, Love K, Rajatileka S, Jeffreys AE, Rowlands K, Hubbart CS, Dhorda M, Vongpromek R, Kotanan N, Wongnak P, Almagro Garcia J, Pearson RD, Ariani CV, Chookajorn T, Malangone C, Nguyen T, Stalker J, Jeffery B, Keatley J, Johnson KJ, Muddyman D, Chan XHS, Sillitoe J, Amato R, Simpson V, Gonçalves S, Rockett K, Day NP, Dondorp AM, Kwiatkowski DP, Miotto O. Genetic surveillance in the Greater Mekong subregion and South Asia to support malaria control and elimination. eLife 2021; 10:e62997. [PMID: 34372970 PMCID: PMC8354633 DOI: 10.7554/elife.62997] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 06/30/2021] [Indexed: 02/04/2023] Open
Abstract
Background National Malaria Control Programmes (NMCPs) currently make limited use of parasite genetic data. We have developed GenRe-Mekong, a platform for genetic surveillance of malaria in the Greater Mekong Subregion (GMS) that enables NMCPs to implement large-scale surveillance projects by integrating simple sample collection procedures in routine public health procedures. Methods Samples from symptomatic patients are processed by SpotMalaria, a high-throughput system that produces a comprehensive set of genotypes comprising several drug resistance markers, species markers and a genomic barcode. GenRe-Mekong delivers Genetic Report Cards, a compendium of genotypes and phenotype predictions used to map prevalence of resistance to multiple drugs. Results GenRe-Mekong has worked with NMCPs and research projects in eight countries, processing 9623 samples from clinical cases. Monitoring resistance markers has been valuable for tracking the rapid spread of parasites resistant to the dihydroartemisinin-piperaquine combination therapy. In Vietnam and Laos, GenRe-Mekong data have provided novel knowledge about the spread of these resistant strains into previously unaffected provinces, informing decision-making by NMCPs. Conclusions GenRe-Mekong provides detailed knowledge about drug resistance at a local level, and facilitates data sharing at a regional level, enabling cross-border resistance monitoring and providing the public health community with valuable insights. The project provides a rich open data resource to benefit the entire malaria community. Funding The GenRe-Mekong project is funded by the Bill and Melinda Gates Foundation (OPP11188166, OPP1204268). Genotyping and sequencing were funded by the Wellcome Trust (098051, 206194, 203141, 090770, 204911, 106698/B/14/Z) and Medical Research Council (G0600718). A proportion of samples were collected with the support of the UK Department for International Development (201900, M006212), and Intramural Research Program of the National Institute of Allergy and Infectious Diseases.
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Affiliation(s)
| | | | - Mayfong Mayxay
- Lao-Oxford-Mahosot Hospital-Wellcome Research Unit (LOMWRU), Microbiology Laboratory, Mahosot HospitalVientianeLao People's Democratic Republic
- Institute of Research and Education Development (IRED), University of Health Sciences, Ministry of HealthVientianeLao People's Democratic Republic
- Centre for Tropical Medicine and Global Health, University of OxfordOxfordUnited Kingdom
| | - Richard J Maude
- Centre for Tropical Medicine and Global Health, University of OxfordOxfordUnited Kingdom
- Mahidol-Oxford Tropical Medicine Research Unit, Mahidol UniversityBangkokThailand
- Harvard TH Chan School of Public Health, Harvard UniversityBostonUnited States
| | - Huynh Hong Quang
- Institute of Malariology, Parasitology and Entomology (IMPE-QN)Quy NhonViet Nam
| | - Bouasy Hongvanthong
- Centre of Malariology, Parasitology, and EntomologyVientianeLao People's Democratic Republic
| | - Viengxay Vanisaveth
- Centre of Malariology, Parasitology, and EntomologyVientianeLao People's Democratic Republic
| | - Thang Ngo Duc
- National Institute of Malariology, Parasitology and Entomology (NIMPE)HanoiViet Nam
| | - Huy Rekol
- National Center for Parasitology, Entomology, and Malaria ControlPhnom PenhCambodia
| | - Rob van der Pluijm
- Centre for Tropical Medicine and Global Health, University of OxfordOxfordUnited Kingdom
- Mahidol-Oxford Tropical Medicine Research Unit, Mahidol UniversityBangkokThailand
| | - Lorenz von Seidlein
- Centre for Tropical Medicine and Global Health, University of OxfordOxfordUnited Kingdom
- Mahidol-Oxford Tropical Medicine Research Unit, Mahidol UniversityBangkokThailand
| | - Rick Fairhurst
- National Institute of Allergy and Infectious Diseases, National Institutes of HealthRockvilleUnited States
| | - François Nosten
- Centre for Tropical Medicine and Global Health, University of OxfordOxfordUnited Kingdom
- Shoklo Malaria Research UnitMae SotThailand
| | | | - Naomi Park
- Wellcome Sanger InstituteHinxtonUnited Kingdom
| | | | | | | | - Paul Newton
- Lao-Oxford-Mahosot Hospital-Wellcome Research Unit (LOMWRU), Microbiology Laboratory, Mahosot HospitalVientianeLao People's Democratic Republic
- Centre for Tropical Medicine and Global Health, University of OxfordOxfordUnited Kingdom
- Mahidol-Oxford Tropical Medicine Research Unit, Mahidol UniversityBangkokThailand
| | - Elizabeth Ashley
- Lao-Oxford-Mahosot Hospital-Wellcome Research Unit (LOMWRU), Microbiology Laboratory, Mahosot HospitalVientianeLao People's Democratic Republic
- Centre for Tropical Medicine and Global Health, University of OxfordOxfordUnited Kingdom
| | - Sonexay Phalivong
- Lao-Oxford-Mahosot Hospital-Wellcome Research Unit (LOMWRU), Microbiology Laboratory, Mahosot HospitalVientianeLao People's Democratic Republic
| | - Rapeephan Maude
- Mahidol-Oxford Tropical Medicine Research Unit, Mahidol UniversityBangkokThailand
- Faculty of Medicine, Ramathibodi Hospital, Mahidol UniversityBangkokThailand
| | - Rithea Leang
- National Center for Parasitology, Entomology, and Malaria ControlPhnom PenhCambodia
| | - Cheah Huch
- National Center for Parasitology, Entomology, and Malaria ControlPhnom PenhCambodia
| | - Le Thanh Dong
- Institute of Malariology, Parasitology and Entomology (IMPEHCM)Ho Chi Minh CityViet Nam
| | - Kim-Tuyen Nguyen
- Oxford University Clinical Research UnitHo Chi Minh CityViet Nam
| | - Tran Minh Nhat
- Oxford University Clinical Research UnitHo Chi Minh CityViet Nam
| | - Tran Tinh Hien
- Oxford University Clinical Research UnitHo Chi Minh CityViet Nam
| | | | | | | | | | - Didar Uddin
- Mahidol-Oxford Tropical Medicine Research Unit, Mahidol UniversityBangkokThailand
| | - Caroline Buckee
- Harvard TH Chan School of Public Health, Harvard UniversityBostonUnited States
| | - Caterina I Fanello
- Centre for Tropical Medicine and Global Health, University of OxfordOxfordUnited Kingdom
- Mahidol-Oxford Tropical Medicine Research Unit, Mahidol UniversityBangkokThailand
| | - Marie Onyamboko
- Kinshasa School of Public Health, University of KinshasaKinshasaDemocratic Republic of the Congo
| | - Thomas Peto
- Centre for Tropical Medicine and Global Health, University of OxfordOxfordUnited Kingdom
- Mahidol-Oxford Tropical Medicine Research Unit, Mahidol UniversityBangkokThailand
| | - Rupam Tripura
- Centre for Tropical Medicine and Global Health, University of OxfordOxfordUnited Kingdom
- Mahidol-Oxford Tropical Medicine Research Unit, Mahidol UniversityBangkokThailand
| | - Chanaki Amaratunga
- National Institute of Allergy and Infectious Diseases, National Institutes of HealthRockvilleUnited States
| | - Aung Myint Thu
- Centre for Tropical Medicine and Global Health, University of OxfordOxfordUnited Kingdom
- Shoklo Malaria Research UnitMae SotThailand
| | - Gilles Delmas
- Centre for Tropical Medicine and Global Health, University of OxfordOxfordUnited Kingdom
- Shoklo Malaria Research UnitMae SotThailand
| | - Jordi Landier
- Shoklo Malaria Research UnitMae SotThailand
- Aix-Marseille Université, INSERM, IRD, SESSTIM, Aix Marseille Institute of Public Health, ISSPAMMarseilleFrance
| | - Daniel M Parker
- Shoklo Malaria Research UnitMae SotThailand
- Susan and Henry Samueli College of Health Sciences, University of California, IrvineIrvineUnited States
| | | | - Dysoley Lek
- National Center for Parasitology, Entomology, and Malaria ControlPhnom PenhCambodia
| | - Seila Suon
- National Center for Parasitology, Entomology, and Malaria ControlPhnom PenhCambodia
| | - James Callery
- Centre for Tropical Medicine and Global Health, University of OxfordOxfordUnited Kingdom
- Mahidol-Oxford Tropical Medicine Research Unit, Mahidol UniversityBangkokThailand
| | | | | | - Sasithon Pukrittayakamee
- Faculty of Tropical Medicine, Mahidol UniversityBangkokThailand
- The Royal Society of ThailandBangkokThailand
| | - Aung Pyae Phyo
- Centre for Tropical Medicine and Global Health, University of OxfordOxfordUnited Kingdom
- Myanmar-Oxford Clinical Research UnitYangonMyanmar
| | - Frank Smithuis
- Centre for Tropical Medicine and Global Health, University of OxfordOxfordUnited Kingdom
- Myanmar-Oxford Clinical Research UnitYangonMyanmar
| | - Khin Lin
- Department of Medical ResearchPyin Oo LwinMyanmar
| | - Myo Thant
- Defence Services Medical Research CentreYangonMyanmar
| | | | | | | | | | | | | | - Neena Valecha
- National Institute of Malaria Research, Indian Council of Medical ResearchNew DelhiIndia
| | - Anupkumar R Anvikar
- National Institute of Malaria Research, Indian Council of Medical ResearchNew DelhiIndia
| | | | - Abul Faiz
- Malaria Research Group and Dev Care FoundationDhakaBangladesh
| | - Chanon Kunasol
- Mahidol-Oxford Tropical Medicine Research Unit, Mahidol UniversityBangkokThailand
| | | | - Mihir Kekre
- Wellcome Sanger InstituteHinxtonUnited Kingdom
| | - Mozam Ali
- Wellcome Sanger InstituteHinxtonUnited Kingdom
| | - Katie Love
- Wellcome Sanger InstituteHinxtonUnited Kingdom
| | | | - Anna E Jeffreys
- Wellcome Trust Centre for Human Genetics, University of OxfordOxfordUnited Kingdom
| | - Kate Rowlands
- Wellcome Trust Centre for Human Genetics, University of OxfordOxfordUnited Kingdom
| | - Christina S Hubbart
- Wellcome Trust Centre for Human Genetics, University of OxfordOxfordUnited Kingdom
| | - Mehul Dhorda
- Centre for Tropical Medicine and Global Health, University of OxfordOxfordUnited Kingdom
- Mahidol-Oxford Tropical Medicine Research Unit, Mahidol UniversityBangkokThailand
- Worldwide Antimalarial Resistance Network (WWARN), Asia Regional CentreBangkokThailand
| | - Ranitha Vongpromek
- Mahidol-Oxford Tropical Medicine Research Unit, Mahidol UniversityBangkokThailand
- Worldwide Antimalarial Resistance Network (WWARN), Asia Regional CentreBangkokThailand
| | - Namfon Kotanan
- Faculty of Tropical Medicine, Mahidol UniversityBangkokThailand
| | - Phrutsamon Wongnak
- Mahidol-Oxford Tropical Medicine Research Unit, Mahidol UniversityBangkokThailand
| | - Jacob Almagro Garcia
- MRC Centre for Genomics and Global Health, Big Data Institute, Oxford UniversityOxfordUnited Kingdom
| | - Richard D Pearson
- Wellcome Sanger InstituteHinxtonUnited Kingdom
- MRC Centre for Genomics and Global Health, Big Data Institute, Oxford UniversityOxfordUnited Kingdom
| | | | | | | | - T Nguyen
- Wellcome Sanger InstituteHinxtonUnited Kingdom
| | - Jim Stalker
- Wellcome Sanger InstituteHinxtonUnited Kingdom
| | - Ben Jeffery
- MRC Centre for Genomics and Global Health, Big Data Institute, Oxford UniversityOxfordUnited Kingdom
| | | | - Kimberly J Johnson
- Wellcome Sanger InstituteHinxtonUnited Kingdom
- MRC Centre for Genomics and Global Health, Big Data Institute, Oxford UniversityOxfordUnited Kingdom
| | | | - Xin Hui S Chan
- Centre for Tropical Medicine and Global Health, University of OxfordOxfordUnited Kingdom
- Mahidol-Oxford Tropical Medicine Research Unit, Mahidol UniversityBangkokThailand
| | | | | | - Victoria Simpson
- Wellcome Sanger InstituteHinxtonUnited Kingdom
- MRC Centre for Genomics and Global Health, Big Data Institute, Oxford UniversityOxfordUnited Kingdom
| | | | - Kirk Rockett
- Wellcome Sanger InstituteHinxtonUnited Kingdom
- Wellcome Trust Centre for Human Genetics, University of OxfordOxfordUnited Kingdom
| | - Nicholas P Day
- Centre for Tropical Medicine and Global Health, University of OxfordOxfordUnited Kingdom
- Mahidol-Oxford Tropical Medicine Research Unit, Mahidol UniversityBangkokThailand
| | - Arjen M Dondorp
- Centre for Tropical Medicine and Global Health, University of OxfordOxfordUnited Kingdom
- Mahidol-Oxford Tropical Medicine Research Unit, Mahidol UniversityBangkokThailand
| | - Dominic P Kwiatkowski
- Wellcome Sanger InstituteHinxtonUnited Kingdom
- MRC Centre for Genomics and Global Health, Big Data Institute, Oxford UniversityOxfordUnited Kingdom
| | - Olivo Miotto
- Wellcome Sanger InstituteHinxtonUnited Kingdom
- Mahidol-Oxford Tropical Medicine Research Unit, Mahidol UniversityBangkokThailand
- MRC Centre for Genomics and Global Health, Big Data Institute, Oxford UniversityOxfordUnited Kingdom
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Improved Protocol for Continuous Culture of Plasmodium falciparum Reference Strains. JOURNAL OF PURE AND APPLIED MICROBIOLOGY 2021. [DOI: 10.22207/jpam.15.1.07] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Parasitic biobank of Plasmodium falciparum is almost germinal in Côte d’Ivoire. However, several high-level research topics on this parasite involve the taking into account of nature isolates but also chemo-sensitive or resistant reference strains for a better validation of results. In addition, acquisition of these reference strains is still arduous for laboratories in developing countries due to complexity of administrative procedures. For those reasons, this study aimed in to combine several procedures into a consolidated one in order to enhance the multiplication of P. falciparum reference strains. Continuous culture of plasmodial strains was based on the Trager and Jensen procedures. The CELL culture protocols used are those of the Swiss TPH described by Sergio Wittlin; the “Growing Plasmodium falciparum cultures at high parasitemia” and the “Stockholm sorbitol method” of Methods in Malaria Research-6th edition 2013; and the INV-01 and INV-02 procedures of the Worldwide Antimalarial Resistance Network (WWARN). Reference Plasmodium falciparum strains NF54 sensitive to chloroquine (CQs) and K1 resistant to chloroquine (CQr) were received from the Swiss Tropical Institute and Public Health (Swiss TPH). The CQs NF54 strain reacted more quickly to the protocol unlike the CQr K1 strain. Parasitic densities (DP) obtained with NF54 strain were ranged from 0.4% at day zero (D0) to 11.4% at day eight (D8). Strain K1 finally adapted successfully after one month of follow-up. Related DPs ranged from less than 0.1% to more than 20% in just three growth cycles after adaptation. A joint protocol (from this work) called “CRLP-SwissTPH-Pasteur_001” is available and allows to efficiently multiply reference strains NF54 and K1. It is planned to spread out the tests to other plasmodial strains as well as to wild isolates in order to standardize this procedure.
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Montenegro LM, de Las Salas B, Neal AT, Tobon-Castaño A, Fairhurst RM, Lopera-Mesa TM. State of Artemisinin and Partner Drug Susceptibility in Plasmodium falciparum Clinical Isolates from Colombia. Am J Trop Med Hyg 2021; 104:263-270. [PMID: 33289466 DOI: 10.4269/ajtmh.20-0148] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Delayed parasite clearance time observed in Southeast Asia provided the first evidence of Plasmodium falciparum resistance to artemisinins. The ex vivo ring-stage survival assay (RSA) mimics parasite exposure to pharmacologically relevant artemisinin concentrations. Mutations in the C-terminal propeller domain of the putative kelch protein Pf3D7_1343700 (K13) are associated with artemisinin resistance. Variations in the pfmdr1 gene are associated with reduced susceptibility to the artemisinin partner drugs mefloquine (MQ) and lumefantrine (LF). To clarify the unknown landscape of artemisinin resistance in Colombia, 71 patients with uncomplicated P. falciparum malaria were enrolled in a non-randomized observational study in three endemic localities in 2014-2015. Each patient's parasite isolate was assessed for ex vivo RSA, K13-propeller mutations, pfmdr1 copy number, and pfmdr1 mutations at codons 86, 184, 1034, 1042, and 1246, associated with reduced susceptibility, and 50% inhibitory concentration (IC50) for other antimalarial drugs. Ex vivo RSAs were successful in 56% (40/71) of samples, and nine isolates showed survival rates > 1%. All isolates had wild-type K13-propeller sequences. All isolates harbored either of two pfmdr1 haplotypes, NFSDD (79.3%) and NFSDY (20.7%), and 7.1% of isolates had > 1 pfmdr1 gene. In vitro IC50 assays showed that variable proportions of isolates had decreased susceptibility to chloroquine (52.4%, > 100 nM), amodiaquine (31.2%, > 30 nM), MQ (34.3%, > 30 nM), and LF (3.2%, > 10 nM). In this study, we report ex vivo RSA and K13 data on P. falciparum isolates from Colombia. The identification of isolates with increased ex vivo RSA rates in the absence of K13-propeller mutations and no positivity at day three requires further investigation.
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Affiliation(s)
| | - Briegel de Las Salas
- 1Grupo Malaria, Facultad de Medicina, Universidad de Antioquia, Medellín, Colombia
| | - Aaron T Neal
- 2Laboratory of Malaria and Vector Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, Maryland
| | | | - Rick M Fairhurst
- 2Laboratory of Malaria and Vector Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, Maryland
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Boonyalai N, Vesely BA, Thamnurak C, Praditpol C, Fagnark W, Kirativanich K, Saingam P, Chaisatit C, Lertsethtakarn P, Gosi P, Kuntawunginn W, Vanachayangkul P, Spring MD, Fukuda MM, Lon C, Smith PL, Waters NC, Saunders DL, Wojnarski M. Piperaquine resistant Cambodian Plasmodium falciparum clinical isolates: in vitro genotypic and phenotypic characterization. Malar J 2020; 19:269. [PMID: 32711538 PMCID: PMC7382038 DOI: 10.1186/s12936-020-03339-w] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 07/14/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND High rates of dihydroartemisinin-piperaquine (DHA-PPQ) treatment failures have been documented for uncomplicated Plasmodium falciparum in Cambodia. The genetic markers plasmepsin 2 (pfpm2), exonuclease (pfexo) and chloroquine resistance transporter (pfcrt) genes are associated with PPQ resistance and are used for monitoring the prevalence of drug resistance and guiding malaria drug treatment policy. METHODS To examine the relative contribution of each marker to PPQ resistance, in vitro culture and the PPQ survival assay were performed on seventeen P. falciparum isolates from northern Cambodia, and the presence of E415G-Exo and pfcrt mutations (T93S, H97Y, F145I, I218F, M343L, C350R, and G353V) as well as pfpm2 copy number polymorphisms were determined. Parasites were then cloned by limiting dilution and the cloned parasites were tested for drug susceptibility. Isobolographic analysis of several drug combinations for standard clones and newly cloned P. falciparum Cambodian isolates was also determined. RESULTS The characterization of culture-adapted isolates revealed that the presence of novel pfcrt mutations (T93S, H97Y, F145I, and I218F) with E415G-Exo mutation can confer PPQ-resistance, in the absence of pfpm2 amplification. In vitro testing of PPQ resistant parasites demonstrated a bimodal dose-response, the existence of a swollen digestive vacuole phenotype, and an increased susceptibility to quinine, chloroquine, mefloquine and lumefantrine. To further characterize drug sensitivity, parental parasites were cloned in which a clonal line, 14-B5, was identified as sensitive to artemisinin and piperaquine, but resistant to chloroquine. Assessment of the clone against a panel of drug combinations revealed antagonistic activity for six different drug combinations. However, mefloquine-proguanil and atovaquone-proguanil combinations revealed synergistic antimalarial activity. CONCLUSIONS Surveillance for PPQ resistance in regions relying on DHA-PPQ as the first-line treatment is dependent on the monitoring of molecular markers of drug resistance. P. falciparum harbouring novel pfcrt mutations with E415G-exo mutations displayed PPQ resistant phenotype. The presence of pfpm2 amplification was not required to render parasites PPQ resistant suggesting that the increase in pfpm2 copy number alone is not the sole modulator of PPQ resistance. Genetic background of circulating field isolates appear to play a role in drug susceptibility and biological responses induced by drug combinations. The use of latest field isolates may be necessary for assessment of relevant drug combinations against P. falciparum strains and when down-selecting novel drug candidates.
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Affiliation(s)
- Nonlawat Boonyalai
- Department of Bacterial and Parasitic Diseases, Armed Forces Research Institute of Medical Sciences, 315/6 Rajvithi Road, Bangkok, 10400, Thailand.
| | - Brian A Vesely
- Department of Bacterial and Parasitic Diseases, Armed Forces Research Institute of Medical Sciences, 315/6 Rajvithi Road, Bangkok, 10400, Thailand
| | - Chatchadaporn Thamnurak
- Department of Bacterial and Parasitic Diseases, Armed Forces Research Institute of Medical Sciences, 315/6 Rajvithi Road, Bangkok, 10400, Thailand
| | - Chantida Praditpol
- Department of Bacterial and Parasitic Diseases, Armed Forces Research Institute of Medical Sciences, 315/6 Rajvithi Road, Bangkok, 10400, Thailand
| | - Watcharintorn Fagnark
- Department of Bacterial and Parasitic Diseases, Armed Forces Research Institute of Medical Sciences, 315/6 Rajvithi Road, Bangkok, 10400, Thailand
| | - Kirakarn Kirativanich
- Department of Bacterial and Parasitic Diseases, Armed Forces Research Institute of Medical Sciences, 315/6 Rajvithi Road, Bangkok, 10400, Thailand
| | - Piyaporn Saingam
- Department of Bacterial and Parasitic Diseases, Armed Forces Research Institute of Medical Sciences, 315/6 Rajvithi Road, Bangkok, 10400, Thailand
| | - Chaiyaporn Chaisatit
- Department of Bacterial and Parasitic Diseases, Armed Forces Research Institute of Medical Sciences, 315/6 Rajvithi Road, Bangkok, 10400, Thailand
| | - Paphavee Lertsethtakarn
- Department of Bacterial and Parasitic Diseases, Armed Forces Research Institute of Medical Sciences, 315/6 Rajvithi Road, Bangkok, 10400, Thailand
| | - Panita Gosi
- Department of Bacterial and Parasitic Diseases, Armed Forces Research Institute of Medical Sciences, 315/6 Rajvithi Road, Bangkok, 10400, Thailand
| | - Worachet Kuntawunginn
- Department of Bacterial and Parasitic Diseases, Armed Forces Research Institute of Medical Sciences, 315/6 Rajvithi Road, Bangkok, 10400, Thailand
| | - Pattaraporn Vanachayangkul
- Department of Bacterial and Parasitic Diseases, Armed Forces Research Institute of Medical Sciences, 315/6 Rajvithi Road, Bangkok, 10400, Thailand
| | - Michele D Spring
- Department of Bacterial and Parasitic Diseases, Armed Forces Research Institute of Medical Sciences, 315/6 Rajvithi Road, Bangkok, 10400, Thailand
| | - Mark M Fukuda
- Department of Bacterial and Parasitic Diseases, Armed Forces Research Institute of Medical Sciences, 315/6 Rajvithi Road, Bangkok, 10400, Thailand
| | - Chanthap Lon
- Department of Bacterial and Parasitic Diseases, Armed Forces Research Institute of Medical Sciences, 315/6 Rajvithi Road, Bangkok, 10400, Thailand
| | - Philip L Smith
- Walter Reed Army Institute of Research, Silver Spring, Maryland, 20910, USA
| | - Norman C Waters
- Department of Bacterial and Parasitic Diseases, Armed Forces Research Institute of Medical Sciences, 315/6 Rajvithi Road, Bangkok, 10400, Thailand
| | - David L Saunders
- U.S. Army Research Institute of Infectious Diseases, Frederick, MD, USA
| | - Mariusz Wojnarski
- Department of Bacterial and Parasitic Diseases, Armed Forces Research Institute of Medical Sciences, 315/6 Rajvithi Road, Bangkok, 10400, Thailand
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6
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Ansbro MR, Jacob CG, Amato R, Kekre M, Amaratunga C, Sreng S, Suon S, Miotto O, Fairhurst RM, Wellems TE, Kwiatkowski DP. Development of copy number assays for detection and surveillance of piperaquine resistance associated plasmepsin 2/3 copy number variation in Plasmodium falciparum. Malar J 2020; 19:181. [PMID: 32404110 PMCID: PMC7218657 DOI: 10.1186/s12936-020-03249-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 04/29/2020] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Long regarded as an epicenter of drug-resistant malaria, Southeast Asia continues to provide new challenges to the control of Plasmodium falciparum malaria. Recently, resistance to the artemisinin combination therapy partner drug piperaquine has been observed in multiple locations across Southeast Asia. Genetic studies have identified single nucleotide polymorphisms as well as copy number variations in the plasmepsin 2 and plasmepsin 3 genes, which encode haemoglobin-degrading proteases that associate with clinical and in vitro piperaquine resistance. RESULTS To accurately and quickly determine the presence of copy number variations in the plasmepsin 2/3 genes in field isolates, this study developed a quantitative PCR assay using TaqMan probes. Copy number estimates were validated using a separate SYBR green-based quantitative PCR assay as well as a novel PCR-based breakpoint assay to detect the hybrid gene product. Field samples from 2012 to 2015 across three sites in Cambodia were tested using DNA extracted from dried blood spots and whole blood to monitor the extent of plasmepsin 2/3 gene amplifications, as well as amplifications in the multidrug resistance transporter 1 gene (pfmdr1), a marker of mefloquine resistance. This study found high concordance across all methods of copy number detection. For samples derived from dried blood spots, a success rate greater than 80% was found in each assay, with more recent samples performing better. Evidence of extensive plasmepsin 2/3 copy number amplifications was observed in Pursat (94%, 2015) (Western Cambodia) and Preah Vihear (87%, 2014) (Northern Cambodia), and lower levels in Ratanakiri (16%, 2014) (Eastern Cambodia). A shift was observed from two copies of plasmepsin 2 in Pursat in 2013 to three copies in 2014-2015 (25% to 64%). Pfmdr1 amplifications were absent in all samples from Preah Vihear and Ratanakiri in 2014 and absent in Pursat in 2015. CONCLUSIONS The multiplex TaqMan assay is a robust tool for monitoring both plasmepsin 2/3 and pfmdr1 copy number variations in field isolates, and the SYBR-green and breakpoint assays are useful for monitoring plasmepsin 2/3 amplifications. This study shows increasing levels of plasmepsin 2 copy numbers across Cambodia from 2012 to 2015 and a complete reversion of multicopy pfmdr1 parasites to single copy parasites in all study locations.
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Affiliation(s)
- Megan R Ansbro
- Wellcome Sanger Institute, Hinxton, UK.
- Laboratory of Malaria and Vector Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD, USA.
| | | | | | | | - Chanaki Amaratunga
- Laboratory of Malaria and Vector Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD, USA
| | - Sokunthea Sreng
- National Center for Parasitology, Entomology, and Malaria Control, Phnom Penh, Cambodia
| | - Seila Suon
- National Center for Parasitology, Entomology, and Malaria Control, Phnom Penh, Cambodia
| | - Olivo Miotto
- Wellcome Sanger Institute, Hinxton, UK
- Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
- Centre for Genomics and Global Health, Wellcome Centre for Human Genetics, Oxford, UK
| | - Rick M Fairhurst
- Laboratory of Malaria and Vector Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD, USA
| | - Thomas E Wellems
- Laboratory of Malaria and Vector Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD, USA
| | - Dominic P Kwiatkowski
- Wellcome Sanger Institute, Hinxton, UK
- Centre for Genomics and Global Health, Wellcome Centre for Human Genetics, Oxford, UK
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7
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Breglio KF, Amato R, Eastman R, Lim P, Sa JM, Guha R, Ganesan S, Dorward DW, Klumpp-Thomas C, McKnight C, Fairhurst RM, Roberts D, Thomas C, Simon AK. A single nucleotide polymorphism in the Plasmodium falciparum atg18 gene associates with artemisinin resistance and confers enhanced parasite survival under nutrient deprivation. Malar J 2018; 17:391. [PMID: 30367653 PMCID: PMC6204056 DOI: 10.1186/s12936-018-2532-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Accepted: 10/17/2018] [Indexed: 01/20/2023] Open
Abstract
Background Artemisinin-resistant Plasmodium falciparum has been reported throughout the Greater Mekong subregion and threatens to disrupt current malaria control efforts worldwide. Polymorphisms in kelch13 have been associated with clinical and in vitro resistance phenotypes; however, several studies suggest that the genetic determinants of resistance may involve multiple genes. Current proposed mechanisms of resistance conferred by polymorphisms in kelch13 hint at a connection to an autophagy-like pathway in P. falciparum. Results A SNP in autophagy-related gene 18 (atg18) was associated with long parasite clearance half-life in patients following artemisinin-based combination therapy. This gene encodes PfAtg18, which is shown to be similar to the mammalian/yeast homologue WIPI/Atg18 in terms of structure, binding abilities, and ability to form puncta in response to stress. To investigate the contribution of this polymorphism, the atg18 gene was edited using CRISPR/Cas9 to introduce a T38I mutation into a k13-edited Dd2 parasite. The presence of this SNP confers a fitness advantage by enabling parasites to grow faster in nutrient-limited settings. The mutant and parent parasites were screened against drug libraries of 6349 unique compounds. While the SNP did not modulate the parasite’s susceptibility to any of the anti-malarial compounds using a 72-h drug pulse, it did alter the parasite’s susceptibility to 227 other compounds. Conclusions These results suggest that the atg18 T38I polymorphism may provide additional resistance against artemisinin derivatives, but not partner drugs, even in the absence of kelch13 mutations, and may also be important in parasite survival during nutrient deprivation. Electronic supplementary material The online version of this article (10.1186/s12936-018-2532-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Kimberly F Breglio
- National Center for Advancing Translational Sciences, National Institutes of Health, Bethesda, MD, USA. .,Nuffield Department of Medicine, University of Oxford, Oxford, UK.
| | - Roberto Amato
- Wellcome Sanger Institute, Wellcome Genome Campus, Hinxton, Cambridge, UK
| | - Richard Eastman
- National Center for Advancing Translational Sciences, National Institutes of Health, Bethesda, MD, USA
| | - Pharath Lim
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Juliana M Sa
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Rajarshi Guha
- National Center for Advancing Translational Sciences, National Institutes of Health, Bethesda, MD, USA.,Vertex Pharmaceuticals, Boston, MA, USA
| | - Sundar Ganesan
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - David W Dorward
- Rocky Mountain Laboratories, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Carleen Klumpp-Thomas
- National Center for Advancing Translational Sciences, National Institutes of Health, Bethesda, MD, USA
| | - Crystal McKnight
- National Center for Advancing Translational Sciences, National Institutes of Health, Bethesda, MD, USA
| | - Rick M Fairhurst
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - David Roberts
- Radcliffe Department of Medicine, Medical Sciences Division, University of Oxford, Oxford, UK
| | - Craig Thomas
- National Center for Advancing Translational Sciences, National Institutes of Health, Bethesda, MD, USA
| | - Anna Katharina Simon
- Kennedy Institute of Rheumatology and Medical Research Council Human Immunology Unit, Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, UK
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8
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Hu X, Lim P, Fairhurst RM, Maimone TJ. Synthesis and Study of the Antimalarial Cardamom Peroxide. Tetrahedron 2018; 74:3358-3369. [PMID: 30319159 PMCID: PMC6181145 DOI: 10.1016/j.tet.2018.03.045] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
A full account of our previously disclosed synthesis of the monoterpene dimer cardamom peroxide is reported. Inspired by hypotheses regarding the potential biosynthetic origins of this natural product, several unproductive routes are also reported. The chemical reactivity of this structurally unique metabolite in the presence of iron(II) sources is also reported as is its antimalarial activity against Plasmodium falciparum clinical isolates from several Cambodian provinces.
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Affiliation(s)
- Xirui Hu
- Department of Chemistry, University of California-Berkeley, Berkeley, CA 94720 (USA)
| | - Pharath Lim
- Laboratory of Malaria and Vector Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD (USA)
- National Center for Parasitology, Entomology, and Malaria Control, Phnom Penh, Cambodia
| | - Rick M Fairhurst
- Laboratory of Malaria and Vector Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD (USA)
| | - Thomas J Maimone
- Department of Chemistry, University of California-Berkeley, Berkeley, CA 94720 (USA)
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9
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Bopp S, Magistrado P, Wong W, Schaffner SF, Mukherjee A, Lim P, Dhorda M, Amaratunga C, Woodrow CJ, Ashley EA, White NJ, Dondorp AM, Fairhurst RM, Ariey F, Menard D, Wirth DF, Volkman SK. Plasmepsin II-III copy number accounts for bimodal piperaquine resistance among Cambodian Plasmodium falciparum. Nat Commun 2018; 9:1769. [PMID: 29720620 PMCID: PMC5931971 DOI: 10.1038/s41467-018-04104-z] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2017] [Accepted: 03/30/2018] [Indexed: 12/30/2022] Open
Abstract
Multidrug resistant Plasmodium falciparum in Southeast Asia endangers regional malaria elimination and threatens to spread to other malaria endemic areas. Understanding mechanisms of piperaquine (PPQ) resistance is crucial for tracking its emergence and spread, and to develop effective strategies for overcoming it. Here we analyze a mechanism of PPQ resistance in Cambodian parasites. Isolates exhibit a bimodal dose-response curve when exposed to PPQ, with the area under the curve quantifying their survival in vitro. Increased copy number for plasmepsin II and plasmepsin III appears to explain enhanced survival when exposed to PPQ in most, but not all cases. A panel of isogenic subclones reinforces the importance of plasmepsin II-III copy number to enhanced PPQ survival. We conjecture that factors producing increased parasite survival under PPQ exposure in vitro may drive clinical PPQ failures in the field.
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Affiliation(s)
- Selina Bopp
- Harvard T.H. Chan School of Public Health, Boston, MA, 02115, USA
| | | | - Wesley Wong
- Harvard T.H. Chan School of Public Health, Boston, MA, 02115, USA
| | - Stephen F Schaffner
- Harvard T.H. Chan School of Public Health, Boston, MA, 02115, USA
- The Broad Institute of MIT and Harvard, Cambridge, MA, 02142, USA
| | - Angana Mukherjee
- Harvard T.H. Chan School of Public Health, Boston, MA, 02115, USA
| | - Pharath Lim
- National Institutes of Health, Rockville, MD, 20892, USA
| | - Mehul Dhorda
- Worldwide Antimalarial Resistance Network, Bangkok, 10400, Thailand
- Mahidol-Oxford Tropical Medicine Research Unit, Bangkok, 10400, Thailand
- Myanmar-Oxford Clinical Research Unit, Yangon, Myanmar
| | | | - Charles J Woodrow
- Mahidol-Oxford Tropical Medicine Research Unit, Bangkok, 10400, Thailand
| | - Elizabeth A Ashley
- Myanmar-Oxford Clinical Research Unit, Yangon, Myanmar
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, OX3 7FZ, UK
| | - Nicholas J White
- Mahidol-Oxford Tropical Medicine Research Unit, Bangkok, 10400, Thailand
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, OX3 7FZ, UK
| | - Arjen M Dondorp
- Mahidol-Oxford Tropical Medicine Research Unit, Bangkok, 10400, Thailand
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, OX3 7FZ, UK
| | | | - Frederic Ariey
- Institut Cochin, INSERM U:1016, Parasitology-Mycology Unit, Cochin Hospital Paris Descartes University, Paris, 75014, France
| | - Didier Menard
- Biology of Host-Parasite Interactions Unit, Institut Pasteur, Paris, 75015, France
- CNRS, ERL 9195, Paris, 75794, France
- INSERM, Unit U1201, Paris, 75015, France
| | - Dyann F Wirth
- Harvard T.H. Chan School of Public Health, Boston, MA, 02115, USA
- The Broad Institute of MIT and Harvard, Cambridge, MA, 02142, USA
| | - Sarah K Volkman
- Harvard T.H. Chan School of Public Health, Boston, MA, 02115, USA.
- The Broad Institute of MIT and Harvard, Cambridge, MA, 02142, USA.
- Simmons College, Boston, MA, 02115, USA.
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10
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K13 Propeller Alleles, mdr1 Polymorphism, and Drug Effectiveness at Day 3 after Artemether-Lumefantrine Treatment for Plasmodium falciparum Malaria in Colombia, 2014-2015. Antimicrob Agents Chemother 2017; 61:AAC.01036-17. [PMID: 28947476 DOI: 10.1128/aac.01036-17] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Accepted: 09/11/2017] [Indexed: 12/22/2022] Open
Abstract
High treatment failure rates for Plasmodium falciparum malaria have been reported in Colombia for chloroquine, amodiaquine, and sulfadoxine-pyrimethamine. Artemisinin combination therapies were introduced in 2006 in Colombia, where artemether-lumefantrine (AL) is currently used to treat uncomplicated P. falciparum malaria. Artemisinin (ART) resistance was initially observed in Southeast Asia as an increased parasite clearance time, manifesting as a positive thick-blood smear on day 3 after treatment (D3 positivity). Recently, mutations in the propeller domain of the P. falciparumkelch13 gene (K13 propeller) have been associated with ART resistance. In this study, we surveyed AL effectiveness at D3 and molecular markers of drug resistance among 187 uncomplicated P. falciparum cases in 4 regions of Colombia from June 2014 to July 2015. We found that 3.2% (4/125) of patients showed D3 positivity, 100% (163/163) of isolates carried wild-type K13 propeller alleles, 12.9% (23/178) of isolates had multiple copies of the multidrug resistance 1 gene (mdr1), and 75.8% (113/149) of isolates harbored the double mutant NFSDD mdr1 haplotype (the underlining indicates mutant alleles). These data suggest that ART resistance is not currently suspected in Colombia but that monitoring for lumefantrine resistance and AL failures should continue.
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11
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Mukherjee A, Bopp S, Magistrado P, Wong W, Daniels R, Demas A, Schaffner S, Amaratunga C, Lim P, Dhorda M, Miotto O, Woodrow C, Ashley EA, Dondorp AM, White NJ, Wirth D, Fairhurst R, Volkman SK. Artemisinin resistance without pfkelch13 mutations in Plasmodium falciparum isolates from Cambodia. Malar J 2017; 16:195. [PMID: 28494763 PMCID: PMC5427620 DOI: 10.1186/s12936-017-1845-5] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Accepted: 04/29/2017] [Indexed: 12/31/2022] Open
Abstract
Background Artemisinin resistance is associated with delayed parasite clearance half-life in vivo and correlates with ring-stage survival under dihydroartemisinin in vitro. Both phenotypes are associated with mutations in the PF3D7_1343700 pfkelch13 gene. Recent spread of artemisinin resistance and emerging piperaquine resistance in Southeast Asia show that artemisinin combination therapy, such as dihydroartemisinin–piperaquine, are losing clinical effectiveness, prompting investigation of drug resistance mechanisms and development of strategies to surmount emerging anti-malarial resistance. Methods Sixty-eight parasites isolates with in vivo clearance data were obtained from two Tracking Resistance to Artemisinin Collaboration study sites in Cambodia, culture-adapted, and genotyped for pfkelch13 and other mutations including pfmdr1 copy number; and the RSA0–3h survival rates and response to antimalarial drugs in vitro were measured for 36 of these isolates. Results Among these 36 parasites one isolate demonstrated increased ring-stage survival for a PfKelch13 mutation (D584V, RSA0–3h = 8%), previously associated with slow clearance but not yet tested in vitro. Several parasites exhibited increased ring-stage survival, yet lack pfkelch13 mutations, and one isolate showed evidence for piperaquine resistance. Conclusions This study of 68 culture-adapted Plasmodium falciparum clinical isolates from Cambodia with known clearance values, associated the D584V PfKelch13 mutation with increased ring-stage survival and identified parasites that lack pfkelch13 mutations yet exhibit increased ring-stage survival. These data suggest mutations other than those found in pfkelch13 may be involved in conferring artemisinin resistance in P. falciparum. Piperaquine resistance was also detected among the same Cambodian samples, consistent with reports of emerging piperaquine resistance in the field. These culture-adapted parasites permit further investigation of mechanisms of both artemisinin and piperaquine resistance and development of strategies to prevent or overcome anti-malarial resistance. Electronic supplementary material The online version of this article (doi:10.1186/s12936-017-1845-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Angana Mukherjee
- Department of Immunology and Infectious Disease, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, I-704, Boston, MA, 02115, USA
| | - Selina Bopp
- Department of Immunology and Infectious Disease, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, I-704, Boston, MA, 02115, USA
| | - Pamela Magistrado
- Department of Immunology and Infectious Disease, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, I-704, Boston, MA, 02115, USA
| | - Wesley Wong
- Department of Immunology and Infectious Disease, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, I-704, Boston, MA, 02115, USA
| | - Rachel Daniels
- Department of Immunology and Infectious Disease, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, I-704, Boston, MA, 02115, USA.,Infectious Disease Initiative, The Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Allison Demas
- Department of Immunology and Infectious Disease, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, I-704, Boston, MA, 02115, USA
| | - Stephen Schaffner
- Infectious Disease Initiative, The Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Chanaki Amaratunga
- Laboratory of Malaria and Vector Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD, USA
| | - Pharath Lim
- Laboratory of Malaria and Vector Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD, USA
| | - Mehul Dhorda
- Asia Regional Centre, Worldwide Antimalarial Resistance Network, Bangkok, Thailand.,Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Olivo Miotto
- Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand.,Centre for Genomics and Global Health, Wellcome Trust Centre for Human Genetics, University of Oxford, Oxford, UK.,Wellcome Trust Sanger Institute, Hinxton, UK
| | - Charles Woodrow
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK.,Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
| | - Elizabeth A Ashley
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK.,Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
| | - Arjen M Dondorp
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK.,Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand.,Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Nicholas J White
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK.,Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
| | - Dyann Wirth
- Department of Immunology and Infectious Disease, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, I-704, Boston, MA, 02115, USA.,Infectious Disease Initiative, The Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Rick Fairhurst
- Laboratory of Malaria and Vector Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD, USA
| | - Sarah K Volkman
- Department of Immunology and Infectious Disease, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, I-704, Boston, MA, 02115, USA. .,Infectious Disease Initiative, The Broad Institute of MIT and Harvard, Cambridge, MA, USA. .,School of Nursing and Health Sciences, Simmons College, Boston, MA, USA.
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12
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Gil JP, Krishna S. pfmdr1 (Plasmodium falciparum multidrug drug resistance gene 1): a pivotal factor in malaria resistance to artemisinin combination therapies. Expert Rev Anti Infect Ther 2017; 15:527-543. [DOI: 10.1080/14787210.2017.1313703] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- J. Pedro Gil
- Physiology and Pharmacology Department, Karolinska Institutet, Stockholm, Sweden
| | - S. Krishna
- St George’s University Hospital, Institute for Infection and Immunity, London, United Kingdom
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13
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Mungthin M, Watanatanasup E, Sitthichot N, Suwandittakul N, Khositnithikul R, Ward SA. Influence of the pfmdr1 Gene on In Vitro Sensitivities of Piperaquine in Thai Isolates of Plasmodium falciparum. Am J Trop Med Hyg 2017; 96:624-629. [PMID: 28044042 DOI: 10.4269/ajtmh.16-0668] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Piperaquine combined with dihydroartemisinin is one of the artemisinin derivative combination therapies, which can replace artesunate-mefloquine in treating uncomplicated falciparum malaria in Thailand. The aim of this study was to determine the in vitro sensitivity of Thai Plasmodium falciparum isolates against piperaquine and the influence of the pfmdr1 gene on in vitro response. One hundred and thirty-seven standard laboratory and adapted Thai isolates of P. falciparum were assessed for in vitro piperaquine sensitivity. Polymorphisms of the pfmdr1 gene were determined by polymerase chain reaction methods. The mean and standard deviation of the piperaquine IC50 in Thai isolates of P. falciparum were 16.7 ± 6.3 nM. The parasites exhibiting chloroquine IC50 of ≥ 100 nM were significantly less sensitive to piperaquine compared with the parasite with chloroquine IC50 of < 100 nM. No significant association between the pfmdr1 copy number and piperaquine IC50 values was found. In contrast, the parasites containing the pfmdr1 86Y allele exhibited significantly reduced piperaquine sensitivity. Before nationwide implementation of dihydroartemisinin-piperaquine as the first-line treatment in Thailand, in vitro and in vivo evaluations of this combination should be performed especially in areas where parasites containing the pfmdr1 86Y allele are predominant such as the Thai-Malaysian border.
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Affiliation(s)
- Mathirut Mungthin
- Department of Parasitology, Phramongkutklao College of Medicine, Bangkok, Thailand
| | | | - Naruemon Sitthichot
- Department of Parasitology, Phramongkutklao College of Medicine, Bangkok, Thailand
| | | | | | - Stephen A Ward
- Division of Molecular and Biochemical Parasitology, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
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14
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Srimuang K, Miotto O, Lim P, Fairhurst RM, Kwiatkowski DP, Woodrow CJ, Imwong M. Analysis of anti-malarial resistance markers in pfmdr1 and pfcrt across Southeast Asia in the Tracking Resistance to Artemisinin Collaboration. Malar J 2016; 15:541. [PMID: 27825353 PMCID: PMC5101715 DOI: 10.1186/s12936-016-1598-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2016] [Accepted: 10/31/2016] [Indexed: 01/07/2023] Open
Abstract
Background Declining anti-malarial efficacy of artemisinin-based combination therapy, and reduced Plasmodium falciparum susceptibility to individual anti-malarials are being documented across an expanding area of Southeast Asia (SEA). Genotypic markers complement phenotypic studies in assessing the efficacy of individual anti-malarials. Methods The markers pfmdr1 and pfcrt were genotyped in parasite samples obtained in 2011–2014 at 14 TRAC (Tracking Resistance to Artemisinin Collaboration) sites in mainland Southeast Asia using a combination of PCR and next-generation sequencing methods. Results Pfmdr1 amplification, a marker of mefloquine and lumefantrine resistance, was highly prevalent at Mae Sot on the Thailand–Myanmar border (59.8% of isolates) and common (more than 10%) at sites in central Myanmar, eastern Thailand and western Cambodia; however, its prevalence was lower than previously documented in Pailin, western Cambodia. The pfmdr1 Y184F mutation was common, particularly in and around Cambodia, and the F1226Y mutation was found in about half of samples in Mae Sot. The functional significance of these two mutations remains unclear. Other previously documented pfmdr1 mutations were absent or very rare in the region. The pfcrt mutation K76T associated with chloroquine resistance was found in 98.2% of isolates. The CVIET haplotype made up 95% or more of isolates in western SEA while the CVIDT haplotype was common (30–40% of isolates) in north and northeastern Cambodia, southern Laos, and southern Vietnam. Conclusions These findings generate cause for concern regarding the mid-term efficacy of artemether–lumefantrine in Myanmar, while the absence of resistance-conferring pfmdr1 mutations and SVMNT pfcrt haplotypes suggests that amodiaquine could be an efficacious component of anti-malarial regimens in SEA. Electronic supplementary material The online version of this article (doi:10.1186/s12936-016-1598-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Krongkan Srimuang
- Department of Molecular Tropical Medicine and Genetics, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Olivo Miotto
- Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand.,Wellcome Trust Sanger Institute, Hinxton, UK.,Medical Research Council (MRC) Centre for Genomics and Global Health, University of Oxford, Oxford, UK
| | - Pharath Lim
- Laboratory of Malaria and Vector Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD, 20852, USA
| | - Rick M Fairhurst
- Laboratory of Malaria and Vector Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD, 20852, USA
| | - Dominic P Kwiatkowski
- Wellcome Trust Sanger Institute, Hinxton, UK.,Medical Research Council (MRC) Centre for Genomics and Global Health, University of Oxford, Oxford, UK
| | - Charles J Woodrow
- Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand.,Centre for Tropical Medicine & Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Mallika Imwong
- Department of Molecular Tropical Medicine and Genetics, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. .,Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand.
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15
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Duru V, Witkowski B, Ménard D. Plasmodium falciparum Resistance to Artemisinin Derivatives and Piperaquine: A Major Challenge for Malaria Elimination in Cambodia. Am J Trop Med Hyg 2016; 95:1228-1238. [PMID: 27928074 DOI: 10.4269/ajtmh.16-0234] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Accepted: 09/12/2016] [Indexed: 12/30/2022] Open
Abstract
Artemisinin-based combination therapies (ACTs) are the cornerstone of current strategies for fighting malaria. Over the last decade, ACTs have played a major role in decreasing malaria burden. However, this progress is being jeopardized by the emergence of artemisinin-resistant Plasmodium falciparum parasites. Artemisinin resistance was first detected in western Cambodia in 2008 and has since been observed in neighboring countries in southeast Asia. The problem of antimalarial drug resistance has recently worsened in Cambodia, with reports of parasites resistant to piperaquine, the latest generation of partner drug used in combination with dihydroartemisinin, leading to worrying rates of clinical treatment failure. The monitoring and the comprehension of both types of resistance are crucial to prevent the spread of multidrug-resistant parasites outside southeast Asia, and particularly to Africa, where the public health consequences would be catastrophic. To this end, new tools are required for studying the biological and molecular mechanisms underlying resistance to antimalarial drugs and for monitoring the geographic distribution of the resistant parasites. In this review, we detail the major advances in our understanding of resistance to artemisinin and piperaquine and define the challenges that the malaria community will have to face in the coming years.
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Affiliation(s)
- Valentine Duru
- Malaria Molecular Epidemiology Unit, Institut Pasteur in Cambodia, Phnom Penh, Cambodia
| | - Benoit Witkowski
- Malaria Molecular Epidemiology Unit, Institut Pasteur in Cambodia, Phnom Penh, Cambodia
| | - Didier Ménard
- Malaria Molecular Epidemiology Unit, Institut Pasteur in Cambodia, Phnom Penh, Cambodia.
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16
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[Multiple and successive treatment failures in a patient infected by Plasmodium falciparum in Cambodia and treated by dihydroartemisinin-piperaquine]. ACTA ACUST UNITED AC 2016; 109:87-90. [PMID: 27100863 DOI: 10.1007/s13149-016-0487-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Accepted: 03/09/2016] [Indexed: 10/22/2022]
Abstract
Cases of treatment failures following administration of artemisinin-based combination therapies (ACT) remain rare in malaria endemic areas. In Cambodia, however, failures of these treatments are now commonly observed. Usually, these post-treatment recurrences occur only once and a second course of the same treatment is sufficient to cure patients.We describe here an atypical case of a Plasmodium falciparum-infected patient manifesting several malaria recrudescence episodes following dihydroartemisinin-piperaquine (Eurartesim®) treatment. This case report illustrates the current issue of resistance to the latest generation of antimalarial drugs in Southeast Asia and highlights the difficulty in efficaciously fighting malaria in this region if new therapy remains unimplemented.
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17
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Dihydroartemisinin-piperaquine resistance in Plasmodium falciparum malaria in Cambodia: a multisite prospective cohort study. THE LANCET. INFECTIOUS DISEASES 2016; 16:357-65. [PMID: 26774243 DOI: 10.1016/s1473-3099(15)00487-9] [Citation(s) in RCA: 352] [Impact Index Per Article: 44.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Revised: 11/17/2015] [Accepted: 11/19/2015] [Indexed: 11/22/2022]
Abstract
BACKGROUND Artemisinin resistance in Plasmodium falciparum threatens to reduce the efficacy of artemisinin combination therapies (ACTs), thus compromising global efforts to eliminate malaria. Recent treatment failures with dihydroartemisinin-piperaquine, the current first-line ACT in Cambodia, suggest that piperaquine resistance may be emerging in this country. We explored the relation between artemisinin resistance and dihydroartemisinin-piperaquine failures, and sought to confirm the presence of piperaquine-resistant P falciparum infections in Cambodia. METHODS In this prospective cohort study, we enrolled patients aged 2-65 years with uncomplicated P falciparum malaria in three Cambodian provinces: Pursat, Preah Vihear, and Ratanakiri. Participants were given standard 3-day courses of dihydroartemisinin-piperaquine. Peripheral blood parasite densities were measured until parasites cleared and then weekly to 63 days. The primary outcome was recrudescent P falciparum parasitaemia within 63 days. We measured piperaquine plasma concentrations at baseline, 7 days, and day of recrudescence. We assessed phenotypic and genotypic markers of drug resistance in parasite isolates. The study is registered with ClinicalTrials.gov, number NCT01736319. FINDINGS Between Sept 4, 2012, and Dec 31, 2013, we enrolled 241 participants. In Pursat, where artemisinin resistance is entrenched, 37 (46%) of 81 patients had parasite recrudescence. In Preah Vihear, where artemisinin resistance is emerging, ten (16%) of 63 patients had recrudescence and in Ratanakiri, where artemisinin resistance is rare, one (2%) of 60 patients did. Patients with recrudescent P falciparum infections were more likely to have detectable piperaquine plasma concentrations at baseline compared with non-recrudescent patients, but did not differ significantly in age, initial parasite density, or piperaquine plasma concentrations at 7 days. Recrudescent parasites had a higher prevalence of kelch13 mutations, higher piperaquine 50% inhibitory concentration (IC50) values, and lower mefloquine IC50 values; none had multiple pfmdr1 copies, a genetic marker of mefloquine resistance. INTERPRETATION Dihydroartemisinin-piperaquine failures are caused by both artemisinin and piperaquine resistance, and commonly occur in places where dihydroartemisinin-piperaquine has been used in the private sector. In Cambodia, artesunate plus mefloquine may be a viable option to treat dihydroartemisinin-piperaquine failures, and a more effective first-line ACT in areas where dihydroartemisinin-piperaquine failures are common. The use of single low-dose primaquine to eliminate circulating gametocytes is needed in areas where artemisinin and ACT resistance is prevalent. FUNDING National Institute of Allergy and Infectious Diseases.
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18
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Duru V, Khim N, Leang R, Kim S, Domergue A, Kloeung N, Ke S, Chy S, Eam R, Khean C, Loch K, Ken M, Lek D, Beghain J, Ariey F, Guerin PJ, Huy R, Mercereau-Puijalon O, Witkowski B, Menard D. Plasmodium falciparum dihydroartemisinin-piperaquine failures in Cambodia are associated with mutant K13 parasites presenting high survival rates in novel piperaquine in vitro assays: retrospective and prospective investigations. BMC Med 2015; 13:305. [PMID: 26695060 PMCID: PMC4688949 DOI: 10.1186/s12916-015-0539-5] [Citation(s) in RCA: 127] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2015] [Accepted: 11/30/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The declining efficacy of dihydroartemisinin-piperaquine against Plasmodium falciparum in Cambodia, along with increasing numbers of recrudescent cases, suggests resistance to both artemisinin and piperaquine. Available in vitro piperaquine susceptibility assays do not correlate with treatment outcome. A novel assay using a pharmacologically relevant piperaquine dose/time exposure was designed and its relevance explored in retrospective and prospective studies. METHODS The piperaquine survival assay (PSA) exposed parasites to 200 nM piperaquine for 48 hours and monitored survival 24 hours later. The retrospective study tested 32 culture-adapted, C580Y-K13 mutant parasites collected at enrolment from patients treated with a 3-day course of dihydroartemisinin-piperaquine and having presented or not with a recrudescence at day 42 (registered ACTRN12615000793516). The prospective study assessed ex vivo PSA survival rate alongside K13 polymorphism of isolates collected from patients enrolled in an open-label study with dihydroartemisinin-piperaquine for uncomplicated P. falciparum malaria in Cambodia (registered ACTRN12615000696594). RESULTS All parasites from recrudescent cases had in vitro or ex vivo PSA survival rates ≥10%, a relevant cut-off value for piperaquine-resistance. Ex vivo PSA survival rates were higher for recrudescent than non-recrudescent cases (39.2% vs. 0.17%, P <1 × 10(-7)). Artemisinin-resistant K13 mutants with ex vivo PSA survival rates ≥10% were associated with 32-fold higher risk of recrudescence (95% CI, 4.5-224; P = 0.0005). CONCLUSION PSA adequately captures the piperaquine resistance/recrudescence phenotype, a mainstay to identify molecular marker(s) and evaluate efficacy of alternative drugs. Combined ex vivo PSA and K13 genotyping provides a convenient monitor for both artemisinin and piperaquine resistance where dihydroartemisinin-piperaquine is used.
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Affiliation(s)
- Valentine Duru
- Malaria Molecular Epidemiology Unit, Institut Pasteur du Cambodge, 5 Boulevard Monivong, BP 983, Phnom Penh, Cambodia.
| | - Nimol Khim
- Malaria Molecular Epidemiology Unit, Institut Pasteur du Cambodge, 5 Boulevard Monivong, BP 983, Phnom Penh, Cambodia.
| | - Rithea Leang
- National Center for Parasitology, Entomology and Malaria Control, Phnom Penh, Cambodia.
| | - Saorin Kim
- Malaria Molecular Epidemiology Unit, Institut Pasteur du Cambodge, 5 Boulevard Monivong, BP 983, Phnom Penh, Cambodia.
| | - Anais Domergue
- Malaria Molecular Epidemiology Unit, Institut Pasteur du Cambodge, 5 Boulevard Monivong, BP 983, Phnom Penh, Cambodia.
| | - Nimol Kloeung
- Malaria Molecular Epidemiology Unit, Institut Pasteur du Cambodge, 5 Boulevard Monivong, BP 983, Phnom Penh, Cambodia.
| | - Sopheakvatey Ke
- Malaria Molecular Epidemiology Unit, Institut Pasteur du Cambodge, 5 Boulevard Monivong, BP 983, Phnom Penh, Cambodia.
| | - Sophy Chy
- Malaria Molecular Epidemiology Unit, Institut Pasteur du Cambodge, 5 Boulevard Monivong, BP 983, Phnom Penh, Cambodia.
| | - Rotha Eam
- Malaria Molecular Epidemiology Unit, Institut Pasteur du Cambodge, 5 Boulevard Monivong, BP 983, Phnom Penh, Cambodia.
| | - Chanra Khean
- Malaria Molecular Epidemiology Unit, Institut Pasteur du Cambodge, 5 Boulevard Monivong, BP 983, Phnom Penh, Cambodia.
| | - Kaknika Loch
- Malaria Molecular Epidemiology Unit, Institut Pasteur du Cambodge, 5 Boulevard Monivong, BP 983, Phnom Penh, Cambodia.
| | - Malen Ken
- Malaria Molecular Epidemiology Unit, Institut Pasteur du Cambodge, 5 Boulevard Monivong, BP 983, Phnom Penh, Cambodia.
| | - Dysoley Lek
- National Center for Parasitology, Entomology and Malaria Control, Phnom Penh, Cambodia.
| | - Johann Beghain
- Department of Parasites and Insect Vectors, Institut Pasteur, Paris, France.
| | - Frédéric Ariey
- Department of Parasites and Insect Vectors, Institut Pasteur, Paris, France.
| | - Philippe J Guerin
- WorldWide Antimalarial Resistance Network, Oxford, UK. .,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Oxford University, Oxford, UK.
| | - Rekol Huy
- National Center for Parasitology, Entomology and Malaria Control, Phnom Penh, Cambodia.
| | | | - Benoit Witkowski
- Malaria Molecular Epidemiology Unit, Institut Pasteur du Cambodge, 5 Boulevard Monivong, BP 983, Phnom Penh, Cambodia.
| | - Didier Menard
- Malaria Molecular Epidemiology Unit, Institut Pasteur du Cambodge, 5 Boulevard Monivong, BP 983, Phnom Penh, Cambodia.
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19
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Chaorattanakawee S, Lanteri CA, Sundrakes S, Yingyuen K, Gosi P, Chanarat N, Wongarunkochakorn S, Buathong N, Chann S, Kuntawunginn W, Arsanok M, Lin JT, Juliano JJ, Tyner SD, Char M, Lon C, Saunders DL. Attenuation of Plasmodium falciparum in vitro drug resistance phenotype following culture adaptation compared to fresh clinical isolates in Cambodia. Malar J 2015; 14:486. [PMID: 26626127 PMCID: PMC4667454 DOI: 10.1186/s12936-015-1021-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2015] [Accepted: 11/26/2015] [Indexed: 01/03/2023] Open
Abstract
Background There is currently no standardized approach for assessing in vitro anti-malarial drug susceptibility. Potential alterations in drug susceptibility results between fresh immediate ex vivo (IEV) and cryopreserved culture-adapted (CCA) Plasmodium falciparum isolates, as well as changes in parasite genotype during culture adaptation were investigated. Methods The 50 % inhibitory concentration (IC50) of 12 P. falciparum isolates from Cambodia against a panel of commonly used drugs were compared using both IEV and CCA. Results were compared using both histidine-rich protein-2 ELISA (HRP-2) and SYBR-Green I fluorescence methods. Molecular genotyping and amplicon deep sequencing were also used to compare multiplicity of infection and genetic polymophisms in fresh versus culture-adapted isolates. Results IC50 for culture-adapted specimens were significantly lower compared to the original fresh isolates for both HRP-2 and SYBR-Green I assays, with greater than a 50 % decline for the majority of drug-assay combinations. There were correlations between IC50s from IEV and CCA for most drugs assays. Infections were nearly all monoclonal, with little or no change in merozoite surface protein 1 (MSP1), MSP2, glutamate-rich protein (GLURP) or apical membrane antigen 1 (AMA1) polymorphisms, nor differences in P. falciparum multidrug resistance 1 gene (PfMDR1) copy number or single nucleotide polymorphisms following culture adaptation. Conclusions The overall IC50 reduction combined with the correlation between fresh isolates and culture-adapted drug susceptibility assays suggests the utility of both approaches, as long as there is consistency of method, and remaining mindful of possible attenuation of resistance phenotype occurring in culture. Further study should be done in higher transmission settings where polyclonal infections are prevalent. Electronic supplementary material The online version of this article (doi:10.1186/s12936-015-1021-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Suwanna Chaorattanakawee
- Department of Immunology and Medicine, Armed Forces Research Institute of Medical Science, Bangkok, Thailand.
| | - Charlotte A Lanteri
- Department of Immunology and Medicine, Armed Forces Research Institute of Medical Science, Bangkok, Thailand. .,Microbiology Section, Department of Pathology and Area Laboratory Services, Brooke Army Medical Center, San Antonio, TX, USA.
| | - Siratchana Sundrakes
- Department of Immunology and Medicine, Armed Forces Research Institute of Medical Science, Bangkok, Thailand.
| | - Kritsanai Yingyuen
- Department of Immunology and Medicine, Armed Forces Research Institute of Medical Science, Bangkok, Thailand.
| | - Panita Gosi
- Department of Immunology and Medicine, Armed Forces Research Institute of Medical Science, Bangkok, Thailand.
| | - Nitima Chanarat
- Department of Immunology and Medicine, Armed Forces Research Institute of Medical Science, Bangkok, Thailand.
| | - Saowaluk Wongarunkochakorn
- Department of Immunology and Medicine, Armed Forces Research Institute of Medical Science, Bangkok, Thailand.
| | - Nillawan Buathong
- Department of Immunology and Medicine, Armed Forces Research Institute of Medical Science, Bangkok, Thailand.
| | - Soklyda Chann
- Department of Immunology and Medicine, Armed Forces Research Institute of Medical Science, Bangkok, Thailand.
| | - Worachet Kuntawunginn
- Department of Immunology and Medicine, Armed Forces Research Institute of Medical Science, Bangkok, Thailand.
| | - Montri Arsanok
- Department of Immunology and Medicine, Armed Forces Research Institute of Medical Science, Bangkok, Thailand.
| | - Jessica T Lin
- Division of Infectious Diseases, School of Medicine, University of North Carolina, Chapel Hill, NC, USA.
| | - Jonathan J Juliano
- Division of Infectious Diseases, School of Medicine, University of North Carolina, Chapel Hill, NC, USA.
| | - Stuart D Tyner
- Department of Immunology and Medicine, Armed Forces Research Institute of Medical Science, Bangkok, Thailand. .,US Army Institute of Surgical Research, Joint Base San Antonio-Fort Sam Houston, San Antonio, TX, USA.
| | - Mengchuor Char
- National Centre for Parasitology, Entomology and Malaria Control, Phnom Penh, Cambodia.
| | - Chanthap Lon
- Department of Immunology and Medicine, Armed Forces Research Institute of Medical Science, Bangkok, Thailand.
| | - David L Saunders
- Department of Immunology and Medicine, Armed Forces Research Institute of Medical Science, Bangkok, Thailand.
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20
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Altering Antimalarial Drug Regimens May Dramatically Enhance and Restore Drug Effectiveness. Antimicrob Agents Chemother 2015; 59:6419-27. [PMID: 26239993 DOI: 10.1128/aac.00482-15] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Accepted: 07/22/2015] [Indexed: 01/16/2023] Open
Abstract
There is considerable concern that malaria parasites are starting to evolve resistance to the current generation of antimalarial drugs, the artemisinin-based combination therapies (ACTs). We use pharmacological modeling to investigate changes in ACT effectiveness likely to occur if current regimens are extended from 3 to 5 days or, alternatively, given twice daily over 3 days. We show that the pharmacology of artemisinins allows both regimen changes to substantially increase the artemisinin killing rate. Malaria patients rarely contain more than 10(12) parasites, while the standard dosing regimens allow approximately 1 in 10(10) parasites to survive artemisinin treatment. Parasite survival falls dramatically, to around 1 in 10(17) parasites if the dose is extended or split; theoretically, this increase in drug killing appears to be more than sufficient to restore failing ACT efficacy. One of the most widely used dosing regimens, artemether-lumefantrine, already successfully employs a twice-daily dosing regimen, and we argue that twice-daily dosing should be incorporated into all ACT regimen design considerations as a simple and effective way of ensuring the continued long-term effectiveness of ACTs.
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21
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Djimde AA, Makanga M, Kuhen K, Hamed K. The emerging threat of artemisinin resistance in malaria: focus on artemether-lumefantrine. Expert Rev Anti Infect Ther 2015; 13:1031-45. [PMID: 26081265 DOI: 10.1586/14787210.2015.1052793] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The development of artemisinin resistance in the Greater Mekong Subregion poses a significant threat to malaria elimination. Artemisinin-based combination therapies including artemether-lumefantrine (AL) are recommended by WHO as first-line treatment for uncomplicated Plasmodium falciparum malaria. This article provides a comprehensive review of the existing and latest data as a basis for interpretation of observed variability in parasite sensitivity to AL over the last 5 years. Clinical efficacy and preclinical data from a range of endemic countries are summarized, including potential molecular markers of resistance. Overall, AL remains effective in the treatment of uncomplicated P. falciparum malaria in most regions. Establishing validated molecular markers for resistance and strict efficacy monitoring will reinforce timely updates of treatment policies.
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Affiliation(s)
- Abdoulaye A Djimde
- Malaria Research and Training Center, University of Science, Techniques and Technologies of Bamako, Bamako, Mali
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22
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Ex Vivo Drug Susceptibility Testing and Molecular Profiling of Clinical Plasmodium falciparum Isolates from Cambodia from 2008 to 2013 Suggest Emerging Piperaquine Resistance. Antimicrob Agents Chemother 2015; 59:4631-43. [PMID: 26014942 DOI: 10.1128/aac.00366-15] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Accepted: 05/18/2015] [Indexed: 12/26/2022] Open
Abstract
Cambodia's first-line artemisinin combination therapy, dihydroartemisinin-piperaquine (DHA-PPQ), is no longer sufficiently curative against multidrug-resistant Plasmodium falciparum malaria at some Thai-Cambodian border regions. We report recent (2008 to 2013) drug resistance trends in 753 isolates from northern, western, and southern Cambodia by surveying for ex vivo drug susceptibility and molecular drug resistance markers to guide the selection of an effective alternative to DHA-PPQ. Over the last 3 study years, PPQ susceptibility declined dramatically (geomean 50% inhibitory concentration [IC50] increased from 12.8 to 29.6 nM), while mefloquine (MQ) sensitivity doubled (67.1 to 26 nM) in northern Cambodia. These changes in drug susceptibility were significantly associated with a decreased prevalence of P. falciparum multidrug resistance 1 gene (Pfmdr1) multiple copy isolates and coincided with the timing of replacing artesunate-mefloquine (AS-MQ) with DHA-PPQ as the first-line therapy. Widespread chloroquine resistance was suggested by all isolates being of the P. falciparum chloroquine resistance transporter gene CVIET haplotype. Nearly all isolates collected from the most recent years had P. falciparum kelch13 mutations, indicative of artemisinin resistance. Ex vivo bioassay measurements of antimalarial activity in plasma indicated 20% of patients recently took antimalarials, and their plasma had activity (median of 49.8 nM DHA equivalents) suggestive of substantial in vivo drug pressure. Overall, our findings suggest DHA-PPQ failures are associated with emerging PPQ resistance in a background of artemisinin resistance. The observed connection between drug policy changes and significant reduction in PPQ susceptibility with mitigation of MQ resistance supports reintroduction of AS-MQ, in conjunction with monitoring of the P. falciparum mdr1 copy number, as a stop-gap measure in areas of DHA-PPQ failure.
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23
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Evidence of Plasmodium falciparum Malaria Multidrug Resistance to Artemisinin and Piperaquine in Western Cambodia: Dihydroartemisinin-Piperaquine Open-Label Multicenter Clinical Assessment. Antimicrob Agents Chemother 2015; 59:4719-26. [PMID: 26014949 DOI: 10.1128/aac.00835-15] [Citation(s) in RCA: 214] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Accepted: 05/20/2015] [Indexed: 01/18/2023] Open
Abstract
Western Cambodia is recognized as the epicenter of Plasmodium falciparum multidrug resistance. Recent reports of the efficacy of dihydroartemisinin (DHA)-piperaquine (PP), the latest of the artemisinin-based combination therapies (ACTs) recommended by the WHO, have prompted further investigations. The clinical efficacy of dihydroartemisinin-piperaquine in uncomplicated falciparum malaria was assessed in western and eastern Cambodia over 42 days. Day 7 plasma piperaquine concentrations were measured and day 0 isolates tested for in vitro susceptibilities to piperaquine and mefloquine, polymorphisms in the K13 gene, and the copy number of the Pfmdr-1 gene. A total of 425 patients were recruited in 2011 to 2013. The proportion of patients with recrudescent infections was significantly higher in western (15.4%) than in eastern (2.5%) Cambodia (P <10(-3)). Day 7 plasma PP concentrations and median 50% inhibitory concentrations (IC50) of PP were independent of treatment outcomes, in contrast to median mefloquine IC50, which were found to be lower for isolates from patients with recrudescent infections (18.7 versus 39.7 nM; P = 0.005). The most significant risk factor associated with DHA-PP treatment failure was infection by parasites carrying the K13 mutant allele (odds ratio [OR], 17.5; 95% confidence interval [CI], 1 to 308; P = 0.04). Our data show evidence of P. falciparum resistance to PP in western Cambodia, an area of widespread artemisinin resistance. New therapeutic strategies, such as the use of triple ACTs, are urgently needed and must be tested. (This study has been registered at the Australian New Zealand Clinical Trials Registry under registration no. ACTRN12614000344695.).
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24
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Spring MD, Lin JT, Manning JE, Vanachayangkul P, Somethy S, Bun R, Se Y, Chann S, Ittiverakul M, Sia-ngam P, Kuntawunginn W, Arsanok M, Buathong N, Chaorattanakawee S, Gosi P, Ta-aksorn W, Chanarat N, Sundrakes S, Kong N, Heng TK, Nou S, Teja-isavadharm P, Pichyangkul S, Phann ST, Balasubramanian S, Juliano JJ, Meshnick SR, Chour CM, Prom S, Lanteri CA, Lon C, Saunders DL. Dihydroartemisinin-piperaquine failure associated with a triple mutant including kelch13 C580Y in Cambodia: an observational cohort study. THE LANCET. INFECTIOUS DISEASES 2015; 15:683-91. [PMID: 25877962 DOI: 10.1016/s1473-3099(15)70049-6] [Citation(s) in RCA: 192] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Dihydroartemisinin-piperaquine has been adopted as first-line artemisinin combination therapy (ACT) for multidrug-resistant Plasmodium falciparum malaria in Cambodia because of few remaining alternatives. We aimed to assess the efficacy of standard 3 day dihydroartemisinin-piperaquine treatment of uncomplicated P falciparum malaria, with and without the addition of primaquine, focusing on the factors involved in drug resistance. METHODS In this observational cohort study, we assessed 107 adults aged 18-65 years presenting to Anlong Veng District Hospital, Oddar Meanchey Province, Cambodia, with uncomplicated P falciparum or mixed P falciparum/Plasmodium vivax infection of between 1000 and 200,000 parasites per μL of blood, and participating in a randomised clinical trial in which all had received dihydroartemisinin-piperaquine for 3 days, after which they had been randomly allocated to receive either primaquine or no primaquine. The trial was halted early due to poor dihydroartemisinin-piperaquine efficacy, and we assessed day 42 PCR-corrected therapeutic efficacy (proportion of patients with recurrence at 42 days) and evidence of drug resistance from the initial cohort. We did analyses on both the intention to treat (ITT), modified ITT (withdrawals, losses to follow-up, and those with secondary outcomes [eg, new non-recrudescent malaria infection] were censored on the last day of follow-up), and per-protocol populations of the original trial. The original trial was registered with ClinicalTrials.gov, number NCT01280162. FINDINGS Between Dec 10, 2012, and Feb 18, 2014, we had enrolled 107 patients in the original trial. Enrolment was voluntarily halted on Feb 16, 2014, before reaching planned enrolment (n=150) because of poor efficacy. We had randomly allocated 50 patients to primaquine and 51 patients to no primaquine groups. PCR-adjusted Kaplan-Meier risk of P falciparum 42 day recrudescence was 54% (95% CI 45-63) in the modified ITT analysis population. We found two kelch13 propeller gene mutations associated with artemisinin resistance--a non-synonymous Cys580Tyr substitution in 70 (65%) of 107 participants, an Arg539Thr substitution in 33 (31%), and a wild-type parasite in four (4%). Unlike Arg539Thr, Cys580Tyr was accompanied by two other mutations associated with extended parasite clearance (MAL10:688956 and MAL13:1718319). This combination triple mutation was associated with a 5·4 times greater risk of treatment failure (hazard ratio 5·4 [95% CI 2·4-12]; p<0·0001) and higher piperaquine 50% inhibitory concentration (triple mutant 34 nM [28-41]; non-triple mutant 24 nM [1-27]; p=0·003) than other infections had. The drug was well tolerated, with gastrointestinal symptoms being the most common complaints. INTERPRETATION The dramatic decline in efficacy of dihydroartemisinin-piperaquine compared with what was observed in a study at the same location in 2010 was strongly associated with a new triple mutation including the kelch13 Cys580Tyr substitution. 3 days of artemisinin as part of an artemisinin combination therapy regimen might be insufficient. Strict regulation and monitoring of antimalarial use, along with non-pharmacological approaches to malaria resistance containment, must be integral parts of the public health response to rapidly accelerating drug resistance in the region. FUNDING Armed Forces Health Surveillance Center/Global Emerging Infections Surveillance and Response System, Military Infectious Disease Research Program, National Institute of Allergy and Infectious Diseases, and American Society of Tropical Medicine and Hygiene/Burroughs Wellcome Fund.
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Affiliation(s)
- Michele D Spring
- Armed Forces Research Institute of Medical Sciences, Department of Immunology and Medicine, Bangkok, Thailand
| | | | - Jessica E Manning
- Armed Forces Research Institute of Medical Sciences, Department of Immunology and Medicine, Bangkok, Thailand
| | - Pattaraporn Vanachayangkul
- Armed Forces Research Institute of Medical Sciences, Department of Immunology and Medicine, Bangkok, Thailand
| | - Sok Somethy
- Royal Cambodian Armed Forces, Phnom Penh, Cambodia
| | - Rathvicheth Bun
- National Center for Parasitology, Entomology and Malaria Control, Phnom Penh, Cambodia
| | - Youry Se
- Armed Forces Research Institute of Medical Sciences, Department of Immunology and Medicine, Bangkok, Thailand; Armed Forces Research Institute of Medical Sciences, Phnom Penh, Cambodia
| | - Soklyda Chann
- Armed Forces Research Institute of Medical Sciences, Phnom Penh, Cambodia
| | - Mali Ittiverakul
- Armed Forces Research Institute of Medical Sciences, Department of Immunology and Medicine, Bangkok, Thailand
| | - Piyaporn Sia-ngam
- Armed Forces Research Institute of Medical Sciences, Department of Immunology and Medicine, Bangkok, Thailand
| | - Worachet Kuntawunginn
- Armed Forces Research Institute of Medical Sciences, Department of Immunology and Medicine, Bangkok, Thailand
| | - Montri Arsanok
- Armed Forces Research Institute of Medical Sciences, Department of Immunology and Medicine, Bangkok, Thailand
| | - Nillawan Buathong
- Armed Forces Research Institute of Medical Sciences, Department of Immunology and Medicine, Bangkok, Thailand
| | - Suwanna Chaorattanakawee
- Armed Forces Research Institute of Medical Sciences, Department of Immunology and Medicine, Bangkok, Thailand
| | - Panita Gosi
- Armed Forces Research Institute of Medical Sciences, Department of Immunology and Medicine, Bangkok, Thailand
| | - Winita Ta-aksorn
- Armed Forces Research Institute of Medical Sciences, Department of Immunology and Medicine, Bangkok, Thailand
| | - Nitima Chanarat
- Armed Forces Research Institute of Medical Sciences, Department of Immunology and Medicine, Bangkok, Thailand
| | - Siratchana Sundrakes
- Armed Forces Research Institute of Medical Sciences, Department of Immunology and Medicine, Bangkok, Thailand
| | - Nareth Kong
- National Center for Parasitology, Entomology and Malaria Control, Phnom Penh, Cambodia
| | - Thay Kheang Heng
- National Center for Parasitology, Entomology and Malaria Control, Phnom Penh, Cambodia
| | - Samon Nou
- Armed Forces Research Institute of Medical Sciences, Phnom Penh, Cambodia
| | - Paktiya Teja-isavadharm
- Armed Forces Research Institute of Medical Sciences, Department of Immunology and Medicine, Bangkok, Thailand
| | - Sathit Pichyangkul
- Armed Forces Research Institute of Medical Sciences, Department of Immunology and Medicine, Bangkok, Thailand
| | - Sut Thang Phann
- National Center for Parasitology, Entomology and Malaria Control, Phnom Penh, Cambodia
| | | | | | | | - Char Meng Chour
- National Center for Parasitology, Entomology and Malaria Control, Phnom Penh, Cambodia
| | | | - Charlotte A Lanteri
- Armed Forces Research Institute of Medical Sciences, Department of Immunology and Medicine, Bangkok, Thailand
| | - Chanthap Lon
- Armed Forces Research Institute of Medical Sciences, Department of Immunology and Medicine, Bangkok, Thailand; Armed Forces Research Institute of Medical Sciences, Phnom Penh, Cambodia
| | - David L Saunders
- Armed Forces Research Institute of Medical Sciences, Department of Immunology and Medicine, Bangkok, Thailand.
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25
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Decreasing pfmdr1 copy number suggests that Plasmodium falciparum in Western Cambodia is regaining in vitro susceptibility to mefloquine. Antimicrob Agents Chemother 2015; 59:2934-7. [PMID: 25712365 DOI: 10.1128/aac.05163-14] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Accepted: 02/18/2015] [Indexed: 11/20/2022] Open
Abstract
Dihydroartemisinin-piperaquine is the current frontline artemisinin combination therapy (ACT) for Plasmodium falciparum malaria in Cambodia but is now failing in several western provinces. To investigate artesunate plus mefloquine (AS+MQ) as a replacement ACT, we measured the prevalence of multiple pfmdr1 copies--a molecular marker for MQ resistance--in 844 P. falciparum clinical isolates collected in 2008 to 2013. The pfmdr1 copy number is decreasing in Western Cambodia, suggesting that P. falciparum is regaining in vitro susceptibility to MQ.
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Pascual A, Madamet M, Briolant S, Gaillard T, Amalvict R, Benoit N, Travers D, Pradines B. Multinormal in vitro distribution of Plasmodium falciparum susceptibility to piperaquine and pyronaridine. Malar J 2015; 14:49. [PMID: 25848972 PMCID: PMC4323025 DOI: 10.1186/s12936-015-0586-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Accepted: 01/26/2015] [Indexed: 12/27/2022] Open
Abstract
Background In 2002, the World Health Organization recommended that artemisinin-based combination therapy (ACT) be used to treat uncomplicated malaria. Dihydroartemisinin-piperaquine and artesunate-pyronaridine are two of these new combinations. The aim of the present work was to assess the distribution of the in vitro values of pyronaridine (PND) and piperaquine (PPQ) and to define a cut-off for reduced susceptibility for the two anti-malarial drugs. Methods The distribution and range of the 50% inhibitory concentration values (IC50) of PND and PPQ were determined for 313 isolates obtained between 2008 and 2012 from patients hospitalized in France for imported malaria. The statistical Bayesian analysis was designed to answer the specific question of whether Plasmodium falciparum has different phenotypes of susceptibility to PND and PPQ. Results The PND IC50 values ranged from 0.6 to 84.6 nM, with a geometric mean of 21.1 ± 16.0 nM (standard deviation). These values were classified into three components. The PPQ IC50 values ranged from 9.8 to 217.3 nM, and the geometric mean was 58.0 ± 34.5 nM. All 313 PPQ values were classified into four components. Isolates with IC50 values greater than 60 nM or four-fold greater than 3D7 IC50 are considered isolates that have reduced susceptibility to PND and those with IC50 values greater than 135 nM or 2.3-fold greater than 3D7 IC50 are considered isolates that have reduced susceptibility to PPQ. Conclusion The existence of at least three phenotypes for PND and four phenotypes for PPQ was demonstrated. Based on the cut-off values, 18 isolates (5.8%) and 13 isolates (4.2%) demonstrated reduced susceptibility to PND and PPQ, respectively.
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27
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Ex vivo activity of endoperoxide antimalarials, including artemisone and arterolane, against multidrug-resistant Plasmodium falciparum isolates from Cambodia. Antimicrob Agents Chemother 2014; 58:5831-40. [PMID: 25049252 DOI: 10.1128/aac.02462-14] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Novel synthetic endoperoxides are being evaluated as new components of artemisinin combination therapies (ACTs) to treat artemisinin-resistant Plasmodium falciparum malaria. We conducted blinded ex vivo activity testing of fully synthetic (OZ78 and OZ277) and semisynthetic (artemisone, artemiside, artesunate, and dihydroartemisinin) endoperoxides in the histidine-rich protein 2 enzyme-linked immunosorbent assay against 200 P. falciparum isolates from areas of artemisinin-resistant malaria in western and northern Cambodia in 2009 and 2010. The order of potency and geometric mean (GM) 50% inhibitory concentrations (IC50s) were as follows: artemisone (2.40 nM) > artesunate (8.49 nM) > dihydroartemisinin (11.26 nM) > artemiside (15.28 nM) > OZ277 (31.25 nM) > OZ78 (755.27 nM). Ex vivo activities of test endoperoxides positively correlated with dihydroartemisinin and artesunate. The isolates were over 2-fold less susceptible to dihydroartemisinin than the artemisinin-sensitive P. falciparum W2 clone and showed sensitivity comparable to those with test endoperoxides and artesunate, with isolate/W2 IC50 susceptibility ratios of <2.0. All isolates had P. falciparum chloroquine resistance transporter mutations, with negative correlations in sensitivity to endoperoxides and chloroquine. The activities of endoperoxides (artesunate, dihydroartemisinin, OZ277, and artemisone) significantly correlated with that of the ACT partner drug, mefloquine. Isolates had mutations associated with clinical resistance to mefloquine, with 35% prevalence of P. falciparum multidrug resistance gene 1 (pfmdr1) amplification and 84.5% occurrence of the pfmdr1 Y184F mutation. GM IC50s for mefloquine, lumefantrine, and endoperoxides (artesunate, dihydroartemisinin, OZ277, OZ78, and artemisone) correlated with pfmdr1 copy number. Given that current ACTs are failing potentially from reduced sensitivity to artemisinins and partner drugs, newly identified mutations associated with artemisinin resistance reported in the literature and pfmdr1 mutations should be examined for their combined contributions to emerging ACT resistance.
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28
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Dormoi J, Savini H, Amalvict R, Baret E, Pradines B. In vitro interaction of lumefantrine and piperaquine by atorvastatin against Plasmodium falciparum. Malar J 2014; 13:189. [PMID: 24886347 PMCID: PMC4045961 DOI: 10.1186/1475-2875-13-189] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2013] [Accepted: 05/20/2014] [Indexed: 12/25/2022] Open
Abstract
Background There is an urgent need for the discovery of new anti-malarial drugs and combination therapy. A combinatorial approach protects each drug from the development of resistance and reduces generally the overall transmission rate of malaria. Statins, the inhibitors of 3-hydroxy-3-methylglutaryl-Coenzyme A reductase and a family of lipid-lowering drugs, have in vitro anti-malarial properties, and more specially atorvastatin. However, atorvastatin has a short elimination half-life (14 hours) and an efficient combination of anti-malarial drugs must associate a drug with a short elimination half-life and a drug with a long elimination half-life. The objective of the present work was to identify new potential partners among standard new anti-malarial drugs with long elimination half-life, such as lumefantrine, piperaquine, pyronaridine and atovaquone, to improve the in vitro activity of atorvastatin against different Plasmodium falciparum strains to treat uncomplicated malaria. Methods In vitro interaction of atorvastatin in combination with lumefantrine, piperaquine, pyronaridine and atovaquone was assessed against 13 P. falciparum strains by isotopic test. Results Atorvastatin showed additive effects with pyronaridine, piperaquine and lumefantrine. Atorvastatin increased the in vitro activity of lumefantrine and piperaquine at concentrations expected in clinical observations. The average IC50 values of lumefantrine decreased significantly from 31.9 nM to 20.5 nM (a decrease of 35.7%) in combination with 1 μM of atorvastatin. Conclusions Even though in vitro data indicate that atorvastatin improved the activity of lumefantrine and piperaquine, the same may not necessarily be true in vivo. Piperaquine, a new drug with long terminal elimination half-life, is currently a very promising anti-malarial drug.
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Affiliation(s)
| | | | | | | | - Bruno Pradines
- Unité de Parasitologie et d'Entomologie, Département de Microbiologie, Institut de Recherche Biomédicale des Armées, Brétigny sur Orge, France.
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29
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Conrad MD, LeClair N, Arinaitwe E, Wanzira H, Kakuru A, Bigira V, Muhindo M, Kamya MR, Tappero JW, Greenhouse B, Dorsey G, Rosenthal PJ. Comparative impacts over 5 years of artemisinin-based combination therapies on Plasmodium falciparum polymorphisms that modulate drug sensitivity in Ugandan children. J Infect Dis 2014; 210:344-53. [PMID: 24610872 DOI: 10.1093/infdis/jiu141] [Citation(s) in RCA: 82] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Artemisinin-based combination therapies, including artemether-lumefantrine (AL) and dihydroartemisinin-piperaquine (DP), are recommended to treat uncomplicated falciparum malaria. Sensitivities to components of AL and DP are impacted by polymorphisms in pfmdr1 and pfcrt. We monitored changes in prevalences of polymorphisms in Tororo, Uganda, from 2008 to 2012. METHODS Polymorphic loci in pfmdr1 and pfcrt were characterized in samples from 312 children randomized to AL or DP for each episode of uncomplicated malaria (50 samples per arm for each 3-month interval) utilizing a fluorescent microsphere assay. Treatment outcomes and impacts of prior therapies were also characterized. RESULTS Prevalence increased significantly over time for pfmdr1 N86 (AL: odds ratio [OR], 2.08 [95% confidence interval {CI}, 1.83-2.38]; DP: 1.41 [95% CI, 1.25-1.57]), pfmdr1 D1246 (AL: 1.46 [95% CI, 1.29-1.64]; DP: 1.36 [95% CI, 1.23-1.50]), and pfcrt K76 (AL: 3.37 [95% CI, 1.85-6.16]; DP: 5.84 [95% CI, 1.94-17.53], and decreased for pfmdr1 Y184 (AL: 0.78 [95% CI, .70-.86]; DP: 0.84 [95% CI, .76-1.50]); changes were consistently greater in the AL arm. Recent AL treatment selected for pfmdr1 N86, D1246, and 184F in subsequent episodes; DP selected for the opposite alleles. CONCLUSIONS Genotypes with decreased sensitivity to AL components increased over time. This increase was greater in children receiving AL, suggesting that the choice of treatment regimen can profoundly influence parasite genetics and drug sensitivity. CLINICAL TRIALS REGISTRATION NCT00527800.
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Affiliation(s)
| | - Norbert LeClair
- Department of Medicine, University of California, San Francisco
| | | | | | | | | | | | - Moses R Kamya
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Jordan W Tappero
- Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | - Grant Dorsey
- Department of Medicine, University of California, San Francisco
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