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Yates PJ, Mehta N, Watson HA, Peppercorn AF. Lessons from resistance analysis in clinical trials of IV zanamivir. Virus Res 2023; 325:199039. [PMID: 36610656 DOI: 10.1016/j.virusres.2023.199039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 12/14/2022] [Accepted: 01/03/2023] [Indexed: 01/05/2023]
Abstract
Influenza infection causes substantial morbidity and mortality during seasonal epidemics and pandemics. Antivirals, including neuraminidase inhibitors, play an important role in the treatment of severely ill patients infected with influenza. Resistance is a key factor that can affect the efficacy of neuraminidase inhibitors (NAIs). It is a recommendation by regulatory authorities to monitor for resistance during the development of anti-influenza medications. An additional requirement by regulators is to examine amino acid sequences for minority species harbouring resistance substitutions. In a Phase III study of intravenous (IV) zanamivir respiratory samples were analysed for the presence of resistant quasi species using Next Generation Sequencing (NGS). In this study ten resistance substitutions, two of which were treatment emergent, were detected by NGS that otherwise would not have been detectable by Sanger sequencing. None of the substitutions were present at any other timepoints analysed. The effect these mutations have on clinical response is difficult to characterize; in fact, all patients from which these variants were isolated had a successful clinical outcome and the effect on clinical response was therefore likely minimal. Although NGS is becoming a routine method for nucleic acid sequencing and will detect substitutions previously undetected by Sanger sequencing, the value of this technique in identifying minority species with resistance substitutions that are clinically meaningful remains to be demonstrated, particularly with acute infections such as influenza.
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Pawestri HA, Eggink D, Isfandari S, Thanh TT, Rogier van Doorn H, Setiawaty V, de Jong MD. Viral Factors Associated With the High Mortality Related to Human Infections With Clade 2.1 Influenza A/H5N1 Virus in Indonesia. Clin Infect Dis 2021; 70:1139-1146. [PMID: 31321436 PMCID: PMC7052542 DOI: 10.1093/cid/ciz328] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Accepted: 04/24/2019] [Indexed: 01/26/2023] Open
Abstract
Background Since their emergence in Indonesia in 2005, 200 human infections with clade 2.1 highly pathogenic avian influenza A/H5N1 virus have been reported, associated with exceptionally high mortality (84%) compared to regions affected by other genetic clades of this virus. To provide potential clues towards understanding this high mortality, detailed clinical virological analyses were performed in specimens from 180 H5N1 patients, representing 90% of all Indonesian patients and 20% of reported H5N1-infected patients globally. Methods H5N1 RNA was quantified in available upper- and lower-respiratory tract specimens as well as fecal and blood samples from 180 patients with confirmed infection between 2005 and 2017. Mutations in the neuraminidase and M2 genes that confer resistance to oseltamivir and adamantanes were assessed. Fatal and nonfatal cases were compared. Results High viral RNA loads in nasal and pharyngeal specimens were associated with fatal outcome. Mortality increased over time during the study period, which correlated with increasing viral RNA loads on admission. Furthermore, the prevalence of amantadine resistance–conferring M2 mutations increased over time, and viral loads were higher in patients infected with viruses that harbored these mutations. Compared to observations from other regions, viral RNA was detected more frequently in feces (80%) and particularly in blood (85%), and antiviral responses to oseltamivir appeared less pronounced. Conclusions These observations confirm the association of viral load with outcome of human H5N1 infections and suggest potential differences in virulence and antiviral responses to oseltamivir that may explain the exceptionally high mortality related to clade 2.1 H5N1 infections in Indonesia.
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Affiliation(s)
- Hana A Pawestri
- National Institute of Health Research and Development, Ministry of Health, Jakarta, Indonesia
| | - Dirk Eggink
- Department of Medical Microbiology, Amsterdam University Medical Center, University of Amsterdam, The Netherlands
| | - Siti Isfandari
- National Institute of Health Research and Development, Ministry of Health, Jakarta, Indonesia
| | - Tran Tan Thanh
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.,Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - H Rogier van Doorn
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, United Kingdom
| | - Vivi Setiawaty
- National Institute of Health Research and Development, Ministry of Health, Jakarta, Indonesia
| | - Menno D de Jong
- Department of Medical Microbiology, Amsterdam University Medical Center, University of Amsterdam, The Netherlands
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Mandal RS, Panda S, Das S. In silico prediction of drug resistance due to S247R mutation of Influenza H1N1 neuraminidase protein. J Biomol Struct Dyn 2017; 36:966-980. [DOI: 10.1080/07391102.2017.1305295] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Rahul Shubhra Mandal
- Biomedical Informatics Centre, National Institute of Cholera and Enteric Diseases, P-33, C.I.T. Road, Scheme XM, Beleghata, Kolkata 700 010, India
| | - Samiran Panda
- Division of Epidemiology, National Institute of Cholera and Enteric Diseases, P-33, C.I.T. Road, Scheme XM, Beliaghata, Kolkata 700 010, India
| | - Santasabuj Das
- Biomedical Informatics Centre, National Institute of Cholera and Enteric Diseases, P-33, C.I.T. Road, Scheme XM, Beleghata, Kolkata 700 010, India
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Kossyvakis A, Mentis AFA, Tryfinopoulou K, Pogka V, Kalliaropoulos A, Antalis E, Lytras T, Meijer A, Tsiodras S, Karakitsos P, Mentis AF. Antiviral susceptibility profile of influenza A viruses; keep an eye on immunocompromised patients under prolonged treatment. Eur J Clin Microbiol Infect Dis 2016; 36:361-371. [PMID: 27848039 DOI: 10.1007/s10096-016-2809-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 10/03/2016] [Indexed: 11/24/2022]
Abstract
There was an increase in severe and fatal influenza cases in Greece during the 2011-2015 post-pandemic period. To investigate causality, we determined neuraminidase (NA) inhibitor susceptibility and resistance-conferring NA and hemagglutinin (HA) mutations in circulating influenza type A viruses during the pandemic (2009-2010) and post-pandemic periods in Greece. One hundred thirty-four influenza A(H1N1)pdm09 and 95 influenza A(H3N2) viruses submitted to the National Influenza Reference Laboratory of Southern Greece were tested for susceptibility to oseltamivir and zanamivir. Antiviral resistance was assessed by neuraminidase sequence analysis, as well as the fluorescence-based 50 % inhibitory concentration (IC50) method. Five influenza A(H1N1)pdm09 viruses (2.2 %) showed significantly reduced inhibition by oseltamivir (average IC50 300.60nM vs. 1.19nM) by Gaussian kernel density plot analysis. These viruses were isolated from immunocompromised patients and harbored the H275Y oseltamivir resistance-conferring NA substitution. All A(H1N1)pdm09 viruses were zanamivir-susceptible, and all A(H3N2) viruses were susceptible to both drugs. Oseltamivir-resistant viruses did not form a distinct cluster by phylogenetic analysis. Permissive mutations were detected in immunogenic and non immunogenic NA regions of both oseltamivir- resistant and susceptible viruses in the post-pandemic seasons. Several amino acid substitutions in the HA1 domain of the HA gene of post-pandemic viruses were identified. This study indicated low resistance to NAIs among tested influenza viruses. Antiviral resistance emerged only in immunocompromised patients under long-term oseltamivir treatment. Sequential sample testing in this vulnerable group of patients is recommended to characterise resistance or reinfection and viral evolution.
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Affiliation(s)
- A Kossyvakis
- National Influenza Reference Laboratory of Southern Greece, Hellenic Pasteur Institute, 127, Vas. Sofias Ave., 11521, Athens, Greece
| | - A-F A Mentis
- National Influenza Reference Laboratory of Southern Greece, Hellenic Pasteur Institute, 127, Vas. Sofias Ave., 11521, Athens, Greece.,Johns Hopkins University, AAP, Baltimore, MD, USA
| | - K Tryfinopoulou
- European Programme for Public Health Microbiology Training (EUPHEM), European Centre for Disease Prevention and Control, Stockholm, Sweden.,Antimicrobial Resistance and Healthcare-associated Infections Laboratory, National School of Public Health, Athens, Greece.,Hellenic Central Public Health Laboratory, Hellenic Centre for Disease Control and Prevention, Athens, Greece
| | - V Pogka
- National Influenza Reference Laboratory of Southern Greece, Hellenic Pasteur Institute, 127, Vas. Sofias Ave., 11521, Athens, Greece
| | - A Kalliaropoulos
- National Influenza Reference Laboratory of Southern Greece, Hellenic Pasteur Institute, 127, Vas. Sofias Ave., 11521, Athens, Greece
| | - E Antalis
- 4th Academic Department of Internal Medicine and Infectious Diseases, Attikon University Hospital, University of Athens Medical School, Athens, Greece
| | - T Lytras
- Department of Epidemiological Surveillance and Intervention, Hellenic Centre for Disease Control and Prevention, Athens, Greece.,Centre for Research in Environmental Epidemiology (CREAL), Barcelona, Spain.,Department of Experimental and Health Sciences, Universitat Pompeu Fabra (UPF), Barcelona, Spain
| | - A Meijer
- National Institute for Public Health and the Environment, Centre for Infectious Disease Control, Bilthoven, Netherlands
| | - S Tsiodras
- 4th Academic Department of Internal Medicine and Infectious Diseases, Attikon University Hospital, University of Athens Medical School, Athens, Greece
| | - P Karakitsos
- Department of Cytopathology, Attikon University Hospital, University of Athens Medical School, Athens, Greece
| | - A F Mentis
- National Influenza Reference Laboratory of Southern Greece, Hellenic Pasteur Institute, 127, Vas. Sofias Ave., 11521, Athens, Greece.
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