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Surarak T, Chumnumwat S, Nosoongnoen W, Tragulpiankit P. Efficacy, safety, and pharmacokinetics of isoniazid affected by NAT2 polymorphisms in patients with tuberculosis: A systematic review. Clin Transl Sci 2024; 17:e13795. [PMID: 38629592 PMCID: PMC11022300 DOI: 10.1111/cts.13795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 03/22/2024] [Accepted: 03/30/2024] [Indexed: 04/19/2024] Open
Abstract
N-acetyltransferase 2 (NAT2) genetic polymorphisms might alter isoniazid metabolism leading to toxicity. We reviewed the impact of NAT2 genotype status on the pharmacokinetics, efficacy, and safety of isoniazid, a treatment for tuberculosis (TB). A systematic search for research articles published in Scopus, PubMed, and Embase until August 31, 2023, was conducted without filters or limits on the following search terms and Boolean operators: "isoniazid" AND "NAT2." Studies were selected if NAT2 phenotypes with pharmacokinetics or efficacy or safety of isoniazid in patients with TB were reported. Patient characteristics, NAT2 status, isoniazid pharmacokinetic parameters, early treatment failure, and the prevalence of drug-induced liver injury were extracted. If the data were given as a median, these values were standardized to the mean. Forty-one pharmacokinetics and 53 safety studies were included, but only one efficacy study was identified. The average maximum concentrations of isoniazid were expressed as supratherapeutic concentrations in adults (7.16 ± 4.85 μg/mL) and children (6.43 ± 3.87 μg/mL) in slow acetylators. The mean prevalence of drug-induced liver injury was 36.23 ± 19.84 in slow acetylators, which was significantly different from the intermediate (19.49 ± 18.20) and rapid (20.47 ± 20.68) acetylators. Subgroup analysis by continent showed that the highest mean drug-induced liver injury prevalence was in Asian slow acetylators (42.83 ± 27.61). The incidence of early treatment failure was decreased by genotype-guided isoniazid dosing in one study. Traditional weight-based dosing of isoniazid in most children and adults yielded therapeutic isoniazid levels (except for slow acetylators). Drug-induced liver injury was more commonly observed in slow acetylators. Genotype-guided dosing may prevent early treatment failure.
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Combrinck J, Tshavhungwe P, Rohlwink U, Enslin N, Thango N, Lazarus J, Kriegler K, Castel S, Abdelgawad N, Mcilleron H, Denti P, Wiesner L, Figaji A. Rifampicin and protein concentrations in paired spinal versus ventricular cerebrospinal fluid samples of children with tuberculous meningitis. J Antimicrob Chemother 2024; 79:280-286. [PMID: 38101948 PMCID: PMC10832594 DOI: 10.1093/jac/dkad371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 11/18/2023] [Indexed: 12/17/2023] Open
Abstract
BACKGROUND Tuberculous meningitis (TBM) is the most lethal form of TB. To study the disease, drug concentrations in samples obtained from the spinal CSF are usually used to reflect brain concentrations. Emerging data suggest that transport of substances across capillaries in the brain (ventricular CSF) and spinal cord may differ. METHODS We examined paired, time-linked samples of ventricular CSF (VCSF) and lumbar CSF (LCSF) of 28 patients with TBM and analysed these for rifampicin and total protein concentrations. Clinically indicated samples from procedures to determine the level of CSF block were collected from children being treated for TBM and hydrocephalus. Total protein concentrations were determined using the bicinchoninic acid (BCA) or turbidimetry assay, and rifampicin concentrations were determined using a validated LC coupled with tandem MS method. A paired Wilcoxon signed-rank test was used to determine significance. RESULTS TBM was confirmed in 19 cases (68%) using TB culture or GeneXpert Mtb/Rifampicin assay. All other cases were classified as probable. The median total protein concentration in LCSF was 6.0 g/L and in VCSF was 1.3 g/L. The median rifampicin concentration in LCSF was 299 ng/mL and 133 ng/mL in VCSF. The median ratio of LCSF/VSCF for protein was 4.23 and 1.57 for rifampicin. CONCLUSIONS Total protein and rifampicin concentrations differed significantly between the two compartments, both being higher in LCSF than in VCSF samples (P < 0.0001 for total protein and P = 0.0046 for rifampicin). Further studies are required to explore the causative reasons for the observed differences.
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Affiliation(s)
- Jill Combrinck
- Division of Paediatric Neurosurgery, Department of Surgery, University of Cape Town, Cape Town, South Africa
- Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Phophi Tshavhungwe
- Division of Paediatric Neurosurgery, Department of Surgery, University of Cape Town, Cape Town, South Africa
| | - Ursula Rohlwink
- Division of Paediatric Neurosurgery, Department of Surgery, University of Cape Town, Cape Town, South Africa
- Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Nico Enslin
- Division of Paediatric Neurosurgery, Department of Surgery, University of Cape Town, Cape Town, South Africa
- Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Nqobile Thango
- Division of Paediatric Neurosurgery, Department of Surgery, University of Cape Town, Cape Town, South Africa
- Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Jed Lazarus
- Division of Paediatric Neurosurgery, Department of Surgery, University of Cape Town, Cape Town, South Africa
| | - Katie Kriegler
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Sandra Castel
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Noha Abdelgawad
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Helen Mcilleron
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Paolo Denti
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Anthony Figaji
- Division of Paediatric Neurosurgery, Department of Surgery, University of Cape Town, Cape Town, South Africa
- Neuroscience Institute, University of Cape Town, Cape Town, South Africa
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Tamaki R, Noshiro K, Furugen A, Nishimura A, Asano H, Watari H, Kobayashi M, Umazume T. Breast milk concentrations of acetaminophen and diclofenac - unexpectedly high mammary transfer of the general-purpose drug acetaminophen. BMC Pregnancy Childbirth 2024; 24:90. [PMID: 38287321 PMCID: PMC10826108 DOI: 10.1186/s12884-024-06287-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 01/22/2024] [Indexed: 01/31/2024] Open
Abstract
BACKGROUND Breastfeeding is considered to be the most effective way of ensuring the health and survival of newborns. However, mammary transfer of drugs administered to mothers to breastfeeding infants remains a pressing concern. Acetaminophen and diclofenac sodium are widely prescribed analgesics for postpartum pain relief, but there have been few recent reports on the mammary transfer of these drugs, despite advances in analytic techniques. METHODS We conducted a study on 20 postpartum mothers from August 2019-March 2020. Blood and milk samples from participants were analyzed using liquid chromatography-electrospray ionization tandem mass spectrometry within 24 hours after oral administration of acetaminophen and diclofenac sodium. The area under the concentration-time curve (AUC) was calculated from the concentration curve obtained by a naive pooled-data approach. RESULTS For acetaminophen, AUC was 36,053 ng/mL.h and 37,768 ng/mL.h in plasma and breast milk, respectively, with a milk-to-plasma drug concentration ratio of 1.048. For diclofenac, the AUC was 0.227 ng/mL.h and 0.021 ng/mL.h, in plasma and breast milk, respectively, with a milk-to-plasma drug concentration ratio of 0.093. CONCLUSIONS While diclofenac sodium showed low mammary transfer, acetaminophen showed a relatively high milk-to-plasma drug concentration ratio. Given recent studies suggesting potential connections between acetaminophen use during pregnancy and risks to developmental prognosis in children, we believe that adequate information regarding the fact that acetaminophen is easily transferred to breast milk should be provided to mothers.
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Affiliation(s)
- Ryo Tamaki
- Department of Obstetrics, Hokkaido University Hospital, Kita-ku N15 W7, Sapporo, 060-8638, Japan
| | - Kiwamu Noshiro
- Department of Obstetrics, Hokkaido University Hospital, Kita-ku N15 W7, Sapporo, 060-8638, Japan
| | - Ayako Furugen
- Laboratory of Clinical Pharmaceutics & Therapeutics, Division of Pharmasciences, Faculty of Pharmaceutical Sciences, Hokkaido University, Sapporo, Japan
| | - Ayako Nishimura
- Department of Pharmacy, Hokkaido University Hospital, Sapporo, Japan
| | - Hiroshi Asano
- Department of Obstetrics, Hokkaido University Hospital, Kita-ku N15 W7, Sapporo, 060-8638, Japan
| | - Hidemichi Watari
- Department of Obstetrics, Hokkaido University Hospital, Kita-ku N15 W7, Sapporo, 060-8638, Japan
| | - Masaki Kobayashi
- Laboratory of Clinical Pharmaceutics & Therapeutics, Division of Pharmasciences, Faculty of Pharmaceutical Sciences, Hokkaido University, Sapporo, Japan
- Education Research Center for Clinical Pharmacy, Faculty of Pharmaceutical Sciences, Hokkaido University, Sapporo, Japan
| | - Takeshi Umazume
- Department of Obstetrics, Hokkaido University Hospital, Kita-ku N15 W7, Sapporo, 060-8638, Japan.
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Chen RH, Michael T, Kuhlin J, Schön T, Stocker S, Alffenaar JWC. Is there a need to optimise pyrazinamide doses in patients with tuberculosis? A systematic review. Int J Antimicrob Agents 2023; 62:106914. [PMID: 37419292 DOI: 10.1016/j.ijantimicag.2023.106914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 06/09/2023] [Accepted: 06/30/2023] [Indexed: 07/09/2023]
Abstract
Pyrazinamide (PZA) is a first-line antituberculosis drug with potent sterilising activity. Variability in drug exposure may translate into suboptimal treatment responses. This systematic review, conducted according to PRISMA guidelines, aimed to evaluate the concentration-effect relationship. In vitro/in vivo studies had to contain information on the infection model, PZA dose and concentration, and microbiological outcome. Human studies had to present information on PZA dose, measures of drug exposure and maximum concentration, and microbiological response parameter or overall treatment outcome. A total of 34 studies were assessed, including in vitro (n = 2), in vivo (n = 3) and clinical studies (n = 29). Intracellular and extracellular models demonstrated a direct correlation between PZA dose of 15-50 mg/kg/day and reduction in bacterial count between 0.50-27.7 log10 CFU/mL. Consistent with this, higher PZA doses (>150 mg/kg) were associated with a greater reduction in bacterial burden in BALB/c mice models. Human pharmacokinetic studies displayed a linear positive correlation between PZA dose (i.e. 21.4-35.7 mg/kg/day) and drug exposure (AUC range 220.6-514.5 mg·h/L). Additionally, human studies confirmed a dose-effect relationship, with an increased 2-month sputum culture conversion rate at AUC/MIC targets of 8.4-11.3 with higher exposure/susceptibility ratios leading to greater efficacy. A 5-fold variability in AUC was observed at PZA dose of 25 mg/kg. A direct concentration-effect relationship and increased treatment efficacy with higher PZA exposure to susceptibility ratios was observed. Taking into account variability in drug exposure and treatment response, further studies on dose optimisation are justified.
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Affiliation(s)
- Ricky Hao Chen
- School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Toni Michael
- School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Johanna Kuhlin
- Karolinska Institutet, Department of Medicine Solna, Division of Infectious Diseases, Stockholm, Sweden; Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Thomas Schön
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden; Department of Infectious Diseases, Linköping University Hospital, Linköping, Sweden; Department of Infectious Diseases, Kalmar County Hospital, Linköping University, Kalmar, Sweden
| | - Sophie Stocker
- School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia; Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital, Sydney, NSW, Australia; School of Clinical Medicine, St Vincent's Healthcare Clinical Campus, Faculty of Medicine and Health, The University of New South Wales, Sydney, NSW, Australia; Sydney Institute for Infectious Diseases, University of Sydney, Sydney, NSW, Australia
| | - Jan-Willem C Alffenaar
- School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia; Westmead Hospital, Sydney, NSW, Australia; Sydney Institute for Infectious Diseases, University of Sydney, Sydney, NSW, Australia.
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Gafar F, Wasmann RE, McIlleron HM, Aarnoutse RE, Schaaf HS, Marais BJ, Agarwal D, Antwi S, Bang ND, Bekker A, Bell DJ, Chabala C, Choo L, Davies GR, Day JN, Dayal R, Denti P, Donald PR, Engidawork E, Garcia-Prats AJ, Gibb D, Graham SM, Hesseling AC, Heysell SK, Idris MI, Kabra SK, Kinikar A, Kumar AKH, Kwara A, Lodha R, Magis-Escurra C, Martinez N, Mathew BS, Mave V, Mduma E, Mlotha-Mitole R, Mpagama SG, Mukherjee A, Nataprawira HM, Peloquin CA, Pouplin T, Ramachandran G, Ranjalkar J, Roy V, Ruslami R, Shah I, Singh Y, Sturkenboom MGG, Svensson EM, Swaminathan S, Thatte U, Thee S, Thomas TA, Tikiso T, Touw DJ, Turkova A, Velpandian T, Verhagen LM, Winckler JL, Yang H, Yunivita V, Taxis K, Stevens J, Alffenaar JWC. Global estimates and determinants of antituberculosis drug pharmacokinetics in children and adolescents: a systematic review and individual patient data meta-analysis. Eur Respir J 2023; 61:2201596. [PMID: 36328357 PMCID: PMC9996834 DOI: 10.1183/13993003.01596-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 10/10/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Suboptimal exposure to antituberculosis (anti-TB) drugs has been associated with unfavourable treatment outcomes. We aimed to investigate estimates and determinants of first-line anti-TB drug pharmacokinetics in children and adolescents at a global level. METHODS We systematically searched MEDLINE, Embase and Web of Science (1990-2021) for pharmacokinetic studies of first-line anti-TB drugs in children and adolescents. Individual patient data were obtained from authors of eligible studies. Summary estimates of total/extrapolated area under the plasma concentration-time curve from 0 to 24 h post-dose (AUC0-24) and peak plasma concentration (C max) were assessed with random-effects models, normalised with current World Health Organization-recommended paediatric doses. Determinants of AUC0-24 and C max were assessed with linear mixed-effects models. RESULTS Of 55 eligible studies, individual patient data were available for 39 (71%), including 1628 participants from 12 countries. Geometric means of steady-state AUC0-24 were summarised for isoniazid (18.7 (95% CI 15.5-22.6) h·mg·L-1), rifampicin (34.4 (95% CI 29.4-40.3) h·mg·L-1), pyrazinamide (375.0 (95% CI 339.9-413.7) h·mg·L-1) and ethambutol (8.0 (95% CI 6.4-10.0) h·mg·L-1). Our multivariate models indicated that younger age (especially <2 years) and HIV-positive status were associated with lower AUC0-24 for all first-line anti-TB drugs, while severe malnutrition was associated with lower AUC0-24 for isoniazid and pyrazinamide. N-acetyltransferase 2 rapid acetylators had lower isoniazid AUC0-24 and slow acetylators had higher isoniazid AUC0-24 than intermediate acetylators. Determinants of C max were generally similar to those for AUC0-24. CONCLUSIONS This study provides the most comprehensive estimates of plasma exposures to first-line anti-TB drugs in children and adolescents. Key determinants of drug exposures were identified. These may be relevant for population-specific dose adjustment or individualised therapeutic drug monitoring.
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Affiliation(s)
- Fajri Gafar
- University of Groningen, Groningen Research Institute of Pharmacy, Unit of PharmacoTherapy, -Epidemiology and -Economics, Groningen, The Netherlands
| | - Roeland E Wasmann
- University of Cape Town, Department of Medicine, Division of Clinical Pharmacology, Cape Town, South Africa
| | - Helen M McIlleron
- University of Cape Town, Department of Medicine, Division of Clinical Pharmacology, Cape Town, South Africa
- University of Cape Town, Institute of Infectious Disease and Molecular Medicine, Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Cape Town, South Africa
| | - Rob E Aarnoutse
- Radboud University Medical Center, Radboud Institute of Health Sciences, Department of Pharmacy, Nijmegen, The Netherlands
| | - H Simon Schaaf
- Stellenbosch University, Faculty of Medicine and Health Sciences, Department of Paediatrics and Child Health, Desmond Tutu Tuberculosis Centre, Tygerberg, South Africa
| | - Ben J Marais
- The Children's Hospital at Westmead, Sydney, Australia
- The University of Sydney, Sydney Institute for Infectious Diseases, Sydney, Australia
| | - Dipti Agarwal
- Ram Manohar Lohia Institute of Medical Sciences, Department of Paediatrics, Lucknow, India
| | - Sampson Antwi
- Komfo Anokye Teaching Hospital, Department of Child Health, Kumasi, Ghana
- Kwame Nkrumah University of Science and Technology, School of Medical Sciences, Department of Child Health, Kumasi, Ghana
| | | | - Adrie Bekker
- Stellenbosch University, Faculty of Medicine and Health Sciences, Department of Paediatrics and Child Health, Desmond Tutu Tuberculosis Centre, Tygerberg, South Africa
| | - David J Bell
- NHS Greater Glasgow and Clyde, Infectious Diseases Unit, Glasgow, UK
| | - Chishala Chabala
- University of Cape Town, Department of Medicine, Division of Clinical Pharmacology, Cape Town, South Africa
- University of Zambia, School of Medicine, Department of Paediatrics, Lusaka, Zambia
- University Teaching Hospitals - Children's Hospital, Lusaka, Zambia
| | - Louise Choo
- University College London, Medical Research Council Clinical Trials Unit, London, UK
| | - Geraint R Davies
- Malawi Liverpool Wellcome Clinical Research Programme, Clinical Department, Blantyre, Malawi
- University of Liverpool, Institute of Infection, Veterinary and Ecological Sciences, Liverpool, UK
| | - Jeremy N Day
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
- University of Oxford, Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, Oxford, UK
| | - Rajeshwar Dayal
- Sarojini Naidu Medical College, Department of Pediatrics, Agra, India
| | - Paolo Denti
- University of Cape Town, Department of Medicine, Division of Clinical Pharmacology, Cape Town, South Africa
| | - Peter R Donald
- Stellenbosch University, Faculty of Medicine and Health Sciences, Department of Paediatrics and Child Health, Desmond Tutu Tuberculosis Centre, Tygerberg, South Africa
| | - Ephrem Engidawork
- Addis Ababa University, College of Health Sciences, School of Pharmacy, Department of Pharmacology and Clinical Pharmacy, Addis Ababa, Ethiopia
| | - Anthony J Garcia-Prats
- Stellenbosch University, Faculty of Medicine and Health Sciences, Department of Paediatrics and Child Health, Desmond Tutu Tuberculosis Centre, Tygerberg, South Africa
- University of Wisconsin-Madison, School of Medicine and Public Health, Department of Pediatrics, Madison, WI, USA
| | - Diana Gibb
- University College London, Medical Research Council Clinical Trials Unit, London, UK
| | - Stephen M Graham
- University of Melbourne, Department of Paediatrics and Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, Australia
- International Union Against Tuberculosis and Lung Disease, Paris, France
| | - Anneke C Hesseling
- Stellenbosch University, Faculty of Medicine and Health Sciences, Department of Paediatrics and Child Health, Desmond Tutu Tuberculosis Centre, Tygerberg, South Africa
| | - Scott K Heysell
- University of Virginia, Division of Infectious Diseases and International Health, Charlottesville, VA, USA
| | - Misgana I Idris
- University of Alabama at Birmingham, Department of Biology, Birmingham, AL, USA
| | - Sushil K Kabra
- All India Institute of Medical Sciences, Departments of Pediatrics, New Delhi, India
| | - Aarti Kinikar
- Byramjee Jeejeebhoy Government Medical College - Johns Hopkins University Clinical Research Site, Pune, India
| | - Agibothu K Hemanth Kumar
- Indian Council of Medical Research, National Institute for Research in Tuberculosis, Chennai, India
| | - Awewura Kwara
- University of Florida, Emerging Pathogens Institute, College of Medicine, Gainesville, FL, USA
| | - Rakesh Lodha
- All India Institute of Medical Sciences, Departments of Pediatrics, New Delhi, India
| | | | - Nilza Martinez
- Instituto Nacional de Enfermedades Respiratorias y Del Ambiente, Asunción, Paraguay
| | - Binu S Mathew
- Christian Medical College and Hospital, Department of Pharmacology and Clinical Pharmacology, Vellore, India
| | - Vidya Mave
- Byramjee Jeejeebhoy Government Medical College - Johns Hopkins University Clinical Research Site, Pune, India
- Johns Hopkins University, Department of Medicine and Infectious Diseases, Baltimore, MD, USA
| | - Estomih Mduma
- Haydom Lutheran Hospital, Center for Global Health Research, Haydom, Tanzania
| | | | | | - Aparna Mukherjee
- All India Institute of Medical Sciences, Departments of Pediatrics, New Delhi, India
| | - Heda M Nataprawira
- Universitas Padjadjaran, Hasan Sadikin Hospital, Faculty of Medicine, Department of Child Health, Division of Paediatric Respirology, Bandung, Indonesia
| | | | - Thomas Pouplin
- Mahidol University, Faculty of Tropical Medicine, Mahidol-Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | - Geetha Ramachandran
- Indian Council of Medical Research, National Institute for Research in Tuberculosis, Chennai, India
| | - Jaya Ranjalkar
- Christian Medical College and Hospital, Department of Pharmacology and Clinical Pharmacology, Vellore, India
| | - Vandana Roy
- Maulana Azad Medical College, Department of Pharmacology, New Delhi, India
| | - Rovina Ruslami
- Universitas Padjadjaran, Faculty of Medicine, Department of Biomedical Sciences, Division of Pharmacology and Therapy, Bandung, Indonesia
| | - Ira Shah
- Bai Jerbai Wadia Hospital for Children, Department of Pediatric Infectious Diseases, Pediatric TB Clinic, Mumbai, India
| | - Yatish Singh
- Sarojini Naidu Medical College, Department of Pediatrics, Agra, India
| | - Marieke G G Sturkenboom
- University of Groningen, University Medical Center Groningen, Department of Clinical Pharmacy and Pharmacology, Groningen, The Netherlands
| | - Elin M Svensson
- Radboud University Medical Center, Radboud Institute of Health Sciences, Department of Pharmacy, Nijmegen, The Netherlands
- Uppsala University, Department of Pharmacy, Uppsala, Sweden
| | - Soumya Swaminathan
- Indian Council of Medical Research, National Institute for Research in Tuberculosis, Chennai, India
- World Health Organization, Public Health Division, Geneva, Switzerland
| | - Urmila Thatte
- Seth Gordhandas Sunderdas Medical College and King Edward Memorial Hospital, Department of Clinical Pharmacology, Mumbai, India
| | - Stephanie Thee
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine, Berlin, Germany
| | - Tania A Thomas
- University of Virginia, Division of Infectious Diseases and International Health, Charlottesville, VA, USA
| | - Tjokosela Tikiso
- University of Cape Town, Department of Medicine, Division of Clinical Pharmacology, Cape Town, South Africa
| | - Daan J Touw
- University of Groningen, University Medical Center Groningen, Department of Clinical Pharmacy and Pharmacology, Groningen, The Netherlands
| | - Anna Turkova
- University College London, Medical Research Council Clinical Trials Unit, London, UK
| | - Thirumurthy Velpandian
- All India Institute of Medical Sciences, Ocular Pharmacology and Pharmacy Division, Dr R.P. Centre, New Delhi, India
| | - Lilly M Verhagen
- Radboud University Medical Center, Radboud Center for Infectious Diseases, Laboratory of Medical Immunology, Section of Pediatric Infectious Diseases, Nijmegen, The Netherlands
- Radboud University Medical Center, Amalia Children's Hospital, Department of Paediatric Infectious Diseases and Immunology, Nijmegen, The Netherlands
- Stellenbosch University, Family Centre for Research with UBUNTU, Department of Paediatrics and Child Health, Cape Town, South Africa
| | - Jana L Winckler
- Stellenbosch University, Faculty of Medicine and Health Sciences, Department of Paediatrics and Child Health, Desmond Tutu Tuberculosis Centre, Tygerberg, South Africa
| | - Hongmei Yang
- University of Rochester, School of Medicine and Dentistry, Department of Biostatistics and Computational Biology, Rochester, NY, USA
| | - Vycke Yunivita
- Universitas Padjadjaran, Faculty of Medicine, Department of Biomedical Sciences, Division of Pharmacology and Therapy, Bandung, Indonesia
| | - Katja Taxis
- University of Groningen, Groningen Research Institute of Pharmacy, Unit of PharmacoTherapy, -Epidemiology and -Economics, Groningen, The Netherlands
| | - Jasper Stevens
- University of Groningen, University Medical Center Groningen, Department of Clinical Pharmacy and Pharmacology, Groningen, The Netherlands
- Both authors contributed equally and shared senior authorship
| | - Jan-Willem C Alffenaar
- The University of Sydney, Sydney Institute for Infectious Diseases, Sydney, Australia
- The University of Sydney, Faculty of Medicine and Health, School of Pharmacy, Sydney, Australia
- Westmead Hospital, Sydney, Australia
- Both authors contributed equally and shared senior authorship
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6
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Viaggi B, Cangialosi A, Langer M, Olivieri C, Gori A, Corona A, Finazzi S, Di Paolo A. Tissue Penetration of Antimicrobials in Intensive Care Unit Patients: A Systematic Review-Part II. Antibiotics (Basel) 2022; 11:antibiotics11091193. [PMID: 36139972 PMCID: PMC9495066 DOI: 10.3390/antibiotics11091193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Revised: 08/28/2022] [Accepted: 09/01/2022] [Indexed: 11/18/2022] Open
Abstract
In patients that are admitted to intensive care units (ICUs), the clinical outcome of severe infections depends on several factors, as well as the early administration of chemotherapies and comorbidities. Antimicrobials may be used in off-label regimens to maximize the probability of therapeutic concentrations within infected tissues and to prevent the selection of resistant clones. Interestingly, the literature clearly shows that the rate of tissue penetration is variable among antibacterial drugs, and the correlation between plasma and tissue concentrations may be inconstant. The present review harvests data about tissue penetration of antibacterial drugs in ICU patients, limiting the search to those drugs that mainly act as protein synthesis inhibitors and disrupting DNA structure and function. As expected, fluoroquinolones, macrolides, linezolid, and tigecycline have an excellent diffusion into epithelial lining fluid. That high penetration is fundamental for the therapy of ventilator and healthcare-associated pneumonia. Some drugs also display a high penetration rate within cerebrospinal fluid, while other agents diffuse into the skin and soft tissues. Further studies are needed to improve our knowledge about drug tissue penetration, especially in the presence of factors that may affect drug pharmacokinetics.
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Affiliation(s)
- Bruno Viaggi
- Department of Anesthesiology, Neuro-Intensive Care Unit, Careggi University Hospital, 50139 Florence, Italy
- Associazione GiViTI, c/o Istituto di Ricerche Farmacologiche Mario Negri IRCCS, 20156 Milan, Italy
| | - Alice Cangialosi
- Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy
| | - Martin Langer
- Associazione GiViTI, c/o Istituto di Ricerche Farmacologiche Mario Negri IRCCS, 20156 Milan, Italy
| | - Carlo Olivieri
- Anesthesia and Intensive Care, Sant’Andrea Hospital, ASL VC, 13100 Vercelli, Italy
| | - Andrea Gori
- Infectious Diseases Unit, Foundation Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Alberto Corona
- ICU and Accident & Emergency Department, ASST Valcamonica, 25043 Breno, Italy
| | - Stefano Finazzi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, 24020 Ranica, Italy
| | - Antonello Di Paolo
- Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy
- Correspondence:
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7
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Radtke KK, Svensson EM, van der Laan LE, Hesseling AC, Savic RM, Garcia-Prats AJ. Emerging data on rifampicin pharmacokinetics and approaches to optimal dosing in children with tuberculosis. Expert Rev Clin Pharmacol 2022; 15:161-174. [PMID: 35285351 DOI: 10.1080/17512433.2022.2053110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Despite its longstanding role in tuberculosis (TB) treatment, there continues to be emerging rifampicin research that has important implications for pediatric TB treatment and outstanding questions about its pharmacokinetics and optimal dose in children. AREAS COVERED This review aims to summarize and discuss emerging data on the use of rifampicin for: 1) routine treatment of drug-susceptible TB; 2) special subpopulations such as children with malnutrition, HIV, or TB meningitis; 3) treatment shortening. We also highlight the implications of these new data for child-friendly rifampicin formulations and identify future research priorities. EXPERT OPINION New data consistently show low rifampicin exposures across all pediatric populations with 10-20 mg/kg dosing. Although clinical outcomes in children are generally good, rifampicin dose optimization is needed, especially given a continued push to shorten treatment durations and for specific high-risk populations of children who have worse outcomes. A pooled analysis of existing data using applied pharmacometrics would answer many of the important questions remaining about rifampicin pharmacokinetics needed to optimize doses, especially in special populations. Targeted clinical studies in children with TB meningitis and treatment shortening with high-dose rifampicin are also priorities.
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Affiliation(s)
- Kendra K Radtke
- Bioengineering and Therapeutic Sciences, University of California San Francisco, San Francisco, CA, USA
| | - Elin M Svensson
- Department of Pharmacy, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Pharmacy, Uppsala University, Uppsala, Sweden
| | - Louvina E van der Laan
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg, South Africa
| | - Anneke C Hesseling
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg, South Africa
| | - Radojka M Savic
- Bioengineering and Therapeutic Sciences, University of California San Francisco, San Francisco, CA, USA
| | - Anthony J Garcia-Prats
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg, South Africa.,Department of Pediatrics, University of Wisconsin, Madison, WI, USA
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8
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Ruslami R, Gafar F, Yunivita V, Parwati I, Ganiem AR, Aarnoutse RE, Wilffert B, Alffenaar JWC, Nataprawira HM. Pharmacokinetics and safety/tolerability of isoniazid, rifampicin and pyrazinamide in children and adolescents treated for tuberculous meningitis. Arch Dis Child 2022; 107:70-77. [PMID: 34183327 PMCID: PMC8685623 DOI: 10.1136/archdischild-2020-321426] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 06/14/2021] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To assess the pharmacokinetics and safety/tolerability of isoniazid, rifampicin and pyrazinamide in children and adolescents with tuberculous meningitis (TBM). DESIGN Prospective observational pharmacokinetic study with an exploratory pharmacokinetic/pharmacodynamic analysis. SETTING Hasan Sadikin Hospital, Bandung, Indonesia. PATIENTS Individuals aged 0-18 years clinically diagnosed with TBM and receiving first-line anti-tuberculosis drug dosages according to revised WHO-recommended treatment guidelines. INTERVENTIONS Plasma and cerebrospinal fluid (CSF) concentrations of isoniazid, rifampicin and pyrazinamide were assessed on days 2 and 10 of treatment. MAIN OUTCOME MEASURES Plasma exposures during the daily dosing interval (AUC0-24), peak plasma concentrations (Cmax) and CSF concentrations. RESULTS Among 20 eligible patients, geometric mean AUC0-24 of isoniazid, rifampicin and pyrazinamide was 18.5, 66.9 and 315.5 hour∙mg/L on day 2; and 14.5, 71.8 and 328.4 hour∙mg/L on day 10, respectively. Large interindividual variabilities were observed in AUC0-24 and Cmax of all drugs. All patients had suboptimal rifampicin AUC0-24 for TBM treatment indication and very low rifampicin CSF concentrations. Four patients developed grade 2-3 drug-induced liver injury (DILI) within the first 4 weeks of treatment, in whom anti-tuberculosis drugs were temporarily stopped, and no DILI recurred after reintroduction of rifampicin and isoniazid. AUC0-24 of isoniazid, rifampicin and pyrazinamide along with Cmax of isoniazid and pyrazinamide on day 10 were higher in patients who developed DILI than those without DILI (p<0.05). CONCLUSION Higher rifampicin doses are strongly warranted in treatment of children and adolescents with TBM. The association between higher plasma concentrations of isoniazid, rifampicin and pyrazinamide and the development of DILI needs confirmatory studies.
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Affiliation(s)
- Rovina Ruslami
- Division of Pharmacology and Therapy, Department of Biomedical Sciences, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Fajri Gafar
- Unit of PharmacoTherapy, -Epidemiology and -Economics, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, The Netherlands
| | - Vycke Yunivita
- Division of Pharmacology and Therapy, Department of Biomedical Sciences, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Ida Parwati
- Department of Clinical Pathology, Faculty of Medicine, Universitas Padjadjaran, Hasan Sadikin Hospital, Bandung, Indonesia
| | - Ahmad R Ganiem
- Department of Neurology, Faculty of Medicine, Universitas Padjadjaran, Hasan Sadikin Hospital, Bandung, Indonesia
| | - Rob E Aarnoutse
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Bob Wilffert
- Unit of PharmacoTherapy, -Epidemiology and -Economics, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, The Netherlands,Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Jan-Willem C Alffenaar
- School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia,Westmead Hospital, Sydney, New South Wales, Australia
| | - Heda M Nataprawira
- Division of Pediatric Respirology, Department of Child Health, Faculty of Medicine, Universitas Padjadjaran, Hasan Sadikin Hospital, Bandung, Indonesia
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9
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Tuberculous Meningitis in Children: Reducing the Burden of Death and Disability. Pathogens 2021; 11:pathogens11010038. [PMID: 35055986 PMCID: PMC8778027 DOI: 10.3390/pathogens11010038] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 12/13/2021] [Accepted: 12/21/2021] [Indexed: 11/29/2022] Open
Abstract
Tuberculous meningitis disproportionately affects young children. As the most devastating form of tuberculosis, it is associated with unacceptably high rates of mortality and morbidity even if treated. Challenging to diagnose and treat, tuberculous meningitis commonly causes long-term neurodisability in those who do survive. There remains an urgent need for strengthened surveillance, improved rapid diagnostics technology, optimised anti-tuberculosis drug therapy, investigation of new host-directed therapy, and further research on long-term functional and neurodevelopmental outcomes to allow targeted intervention. This review focuses on the neglected field of paediatric tuberculous meningitis and bridges current clinical gaps with research questions to improve outcomes from this crippling disease.
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10
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Cao Y, Wang T, He K, Xue J, Wang X, Liang J. High-dose rifampicin for the treatment of tuberculous meningitis: a meta-analysis of randomized controlled trials. J Clin Pharm Ther 2021; 47:445-454. [PMID: 34897758 DOI: 10.1111/jcpt.13555] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Revised: 10/11/2021] [Accepted: 10/17/2021] [Indexed: 11/27/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Tuberculous meningitis (TBM) is one of the most serious types of extrapulmonary tuberculosis and has caused distress to human. Effective treatment is particularly important. The aim of this meta-analysis is to compare the efficacy of high-dose and standard-dose rifampicin. METHODS Databases including PubMed, Web of Science, Embase, Scopus and the Cochrane Library databases were electronically searched to identify randomized controlled trials that reported high-dose rifampicin in treatment of patients with TBM. The retrieval time is limited from inception to June 2021. Two reviewers independently screened literature, extracted data and assessed risk bias of included studies. Meta-analysis was performed by using STATA 12.0 software. RESULTS AND DISCUSSION A total of 12 studies involving 1596 patients were included. The meta-analysis results showed no significant differences in 6-month mortality, 9-month mortality, Grade I-II AE, Grade III-V AE, hepatotoxicity, hepatotoxicity Grade I-II and cardiologic events between high-dose rifampicin (or high-dose rifampicin plus moxifloxacin or levofloxacin) and standard-dose groups. The log(Cmax ) (WMD 0.69, 95%CI 0.59-0.79, p 0.001) and log(AUC0-24h ) (WMD 0.79, 95%CI 0.71-0.88, p 0.001) were higher with high-dose rifampicin. Subgroup analysis revealed the rise of log(Cmax ) in high-dose rifampicin orally was consistent with intravenous administration compared with the control (WMD 0.69, 95%CI 0.66-0.73, p 0.001). WHAT IS NEW AND CONCLUSION High-dose rifampicin was not a protective factor for 6-month mortality, despite increased plasma Cmax and AUC0-24h . However, the above conclusions are still required to be verified through more RCTs due to the limited quantity of included studies.
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Affiliation(s)
- Yan Cao
- Tuberculosis Department, The 8th Medical Center, Chinses PLA General Hospital, Beijing, China
| | - Tao Wang
- Tuberculosis Department, The 8th Medical Center, Chinses PLA General Hospital, Beijing, China
| | - Ke He
- Tuberculosis Department, The 8th Medical Center, Chinses PLA General Hospital, Beijing, China
| | - Juanmin Xue
- Tuberculosis Department, The 8th Medical Center, Chinses PLA General Hospital, Beijing, China
| | - Xinjing Wang
- Tuberculosis Department, The 8th Medical Center, Chinses PLA General Hospital, Beijing, China
| | - Jianqin Liang
- Tuberculosis Department, The 8th Medical Center, Chinses PLA General Hospital, Beijing, China
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11
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Thee S, Basu Roy R, Blázquez-Gamero D, Falcón-Neyra L, Neth O, Noguera-Julian A, Lillo C, Galli L, Venturini E, Buonsenso D, Götzinger F, Martinez-Alier N, Velizarova S, Brinkmann F, Welch SB, Tsolia M, Santiago-Garcia B, Schilling R, Tebruegge M, Krüger R. Treatment and outcome in children with tuberculous meningitis - a multi-centre Paediatric Tuberculosis Network European Trials Group study. Clin Infect Dis 2021; 75:372-381. [PMID: 34849642 DOI: 10.1093/cid/ciab982] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Currently, data on treatment, outcome, and prognostic factors in children with tuberculous meningitis (TBM) in Europe are limited. To date, most existing data on TBM originate from adult studies, or studies conducted in low-resource settings. METHODS Multicentre, retrospective study involving 27 paediatric healthcare institutions in nine European countries via an established paediatric TB research network, before and after the 2014 revision of WHO dosing recommendations. RESULTS Of 118 children, 39 (33.1%) had TBM grade 1, 68 (57.6%) grade 2 and 11 (9.3%) grade 3. Fifty-eight (49.1%) children received a standard four-drug treatment regimen; other commonly used drugs included streptomycin, prothionamide, and amikacin. Almost half of the patients (48.3%; 56/116) were admitted to intensive care unit, with a median stay of 10 (IQR 4.5-21.0) days. Of 104 children with complete outcome data, 9.6% (10/104) died, and only 47.1% (49/104) recovered fully. Main long-term sequelae included spasticity of one or more limbs and developmental delay both in 19.2% (20/104), and seizure disorder in 17.3% (18/104). Multivariate regression analyses identified microbiological confirmation of TBM, the need for neurosurgical intervention and mechanical ventilation as risk factors for unfavourable outcome. DISCUSSION There was considerable heterogeneity in the use of TB drugs in this cohort. Despite few children presenting with advanced disease and the study being conducted in a high-resource setting, morbidity and mortality were high. Several risk factors for poor outcome were identified, which may aid prognostic predictions in children with TBM in the future.
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Affiliation(s)
- Stephanie Thee
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine and Cystic Fibrosis Centre, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Robindra Basu Roy
- Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK
| | - Daniel Blázquez-Gamero
- Paediatric Infectious Diseases Unit, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Instituto de Investigación Hospital Universitario 12 de Octubre (imas12), RITIP, Madrid, Spain
| | - Lola Falcón-Neyra
- Paediatric Infectious Diseases, Rheumatology and Immunology Unit, Hospital Universitario Virgen del Rocío, Instituto de Biomedicina de Seville (IBIS), Sevilla, Spain
| | - Olaf Neth
- Paediatric Infectious Diseases, Rheumatology and Immunology Unit, Hospital Universitario Virgen del Rocío, Instituto de Biomedicina de Seville (IBIS), Sevilla, Spain
| | - Antoni Noguera-Julian
- Malalties Infeccioses i Resposta Inflamatòria Sistèmica en Pediatria, Institut de Recerca Sant Joan de Déu, Barcelona, Spain.,Departament de Pediatria, Universitat de Barcelona, Barcelona, Spain.,CIBER de Epidemiología y Salud Pública, CIBERESP, Madrid, Spain.,Red de Investigación Translacional en Infectología Pediátrica, RITIP, Madrid, Spain
| | - Cristina Lillo
- Paediatric Infectious Diseases Unit, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Instituto de Investigación Hospital Universitario 12 de Octubre (imas12), RITIP, Madrid, Spain
| | - Luisa Galli
- Department of Health Sciences, University of Florence, Florence, Italy.,Paediatric Infectious Disease Unit, Meyer Children's University Hospital, Florence, Italy
| | - Elisabetta Venturini
- Department of Health Sciences, University of Florence, Florence, Italy.,Paediatric Infectious Disease Unit, Meyer Children's University Hospital, Florence, Italy
| | - Danilo Buonsenso
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Florian Götzinger
- Department of Paediatrics and Adolescent Medicine, National Reference Centre for Childhood Tuberculosis, Klinik Ottakring, Vienna, Austria
| | - Nuria Martinez-Alier
- Department of Paediatric Infectious Diseases & Immunology, Evelina London Children's Hospital, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Svetlana Velizarova
- Department of Pulmonary Diseases, Medical University, Hospital for Lung Diseases 'St. Sofia', Sofia, Bulgaria
| | - Folke Brinkmann
- Department of Paediatric Pulmonology, Ruhr University Bochum, Bochum, Germany
| | - Steven B Welch
- Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham, UK
| | - Maria Tsolia
- Second Department or Paediatrics, National and Kapodistrian University of Athens, School of Medicine, P. and A. Kyriakou Children's Hospital, Athens, Greece
| | - Begoña Santiago-Garcia
- Department of Paediatric Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain. Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain. Red de Investigación Translacional en Infectología Pediátrica (RITIP)
| | - Ralph Schilling
- Institute of Biometry and Clinical Epidemiology, Charité - Universitätsmedizin Berlin, Germany.,Institute for Social Medicine, Epidemiology and Health Economics, Charité - Universitätsmedizin Berlin, Germany
| | - Marc Tebruegge
- Department of Paediatric Infectious Diseases & Immunology, Evelina London Children's Hospital, Guy's and St. Thomas' NHS Foundation Trust, London, UK.,Department of Paediatrics, Royal Children's Hospital Melbourne, University of Melbourne, Melbourne, Australia.,Department of Infection, Immunity & Inflammation, UCL Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Renate Krüger
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine and Cystic Fibrosis Centre, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
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12
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Huynh L, Agossah C, Lelong-Boulouard V, Marie J, Brossier D, Goyer I. Therapeutic drug monitoring of intravenous anti-tuberculous therapy: management of an 8-month-old child with tuberculous meningitis. Paediatr Int Child Health 2021; 41:285-290. [PMID: 33822698 DOI: 10.1080/20469047.2020.1855868] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Tuberculous meningitis (TBM) is now uncommon in high-income countries. It is the most severe form of extrapulmonary tuberculosis with high rates of mortality and morbidity if diagnosis and treatment are delayed. An 8-month-old girl with TBM who was treated with high-dose intravenous anti-tuberculous drugs (ATD) is reported. Therapeutic drug monitoring (TDM) of isoniazid and rifampicin was undertaken by measuring serial drug concentrations in serum and cerebrospinal fluid (CSF). There was rapid eradication of Mycobacterium tuberculosis from the CSF with a good clinical outcome and no adverse effects. Using high-dose regimens of intravenous ATD to treat TBM is an important option in order to obtain sufficient CSF diffusion. When available, TDM and a multidisciplinary approach are essential for efficient therapeutic management.
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Affiliation(s)
- Lucie Huynh
- Department of Pharmacy, Etablissement Public de Santé Mentale, Caen, France
| | - Cedric Agossah
- Department of Paediatrics, Caen University Hospital, Caen, France
| | - Véronique Lelong-Boulouard
- Department of Pharmacology, Caen University Hospital, Caen, France.,School of Medicine, Normandy University, Caen, France.,INSERM UMR, University of Normandy, Caen, France
| | - Julien Marie
- Department of Paediatrics, Caen University Hospital, Caen, France
| | - David Brossier
- School of Medicine, Normandy University, Caen, France.,Paediatric Intensive Care Unit, Caen University Hospital, Caen, France
| | - Isabelle Goyer
- Department of Pharmacy, Caen University Hospital, Caen, France
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13
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Wu X, Che X, Qiu Z, Chao J, Kong Z, Li H. Simultaneous determination of three antituberculosis drugs in the serum of patients with spinal tuberculosis by capillary electrophoresis. ANALYTICAL METHODS : ADVANCING METHODS AND APPLICATIONS 2021; 13:4307-4313. [PMID: 34473140 DOI: 10.1039/d1ay00711d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
The pharmacokinetic variations of a single drug in an antituberculosis regimen are associated with acquired drug resistance and therapy failure. This study aimed to develop a simple and effective method for monitoring the serum levels of isoniazid (INH), rifampicin (RFP), and pyrazinamide (PZA), three antibiotics used in patients with spinal tuberculosis using capillary electrophoresis (CE). A standard solution of INH, RFP, and PZA was prepared and mixed with serum to prepare the standard curve. The detection limit, quantification limit, precision, stability, repeatability, and sample recovery were determined. Then, INH, RFP, and PZA were measured from the leftover serum samples of all patients with spinal tuberculosis who were treated with 2SHRZ/2.5H2R2Z2 combined with surgery in a tertiary hospital in Qinghai from October 2015 to September 2017. A total of 107 patients with spinal tuberculosis treated using the 2SHRZ/2.5H2R2Z2 regimen combined with surgery were included in this study. All three antibiotics had linear standard curves with high correlation coefficients (R2 = 0.9997, 0.9994, and 0.9986). The recovery rates were 98.1% for INH, 96.5% for PZA, and 97.2% for RFP. The results from the serum samples showed that the plasma concentrations of INH (4.989 ± 1.692 μg mL-1) and RFP (9.400 ± 1.711 μg mL-1) reached effective therapeutic concentrations in all patients, but not PZA (33.860 ± 1.830 μg mL-1). The CE method for measuring INH, RFP, and PZA simultaneously in serum samples of patients with spinal tuberculosis is simple, rapid, and sensitive. This method is suitable for the routine monitoring of INH, RFP, and PZA concentrations in the serum of patients with spinal tuberculosis.
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Affiliation(s)
- Xuehua Wu
- Department of Pharmacy, Qinghai Provincial People's Hospital, Xining, Qinghai, China.
| | - Xiaoming Che
- Department of Orthopaedics, Qinghai Provincial People's Hospital, Xining, Qinghai, China
| | - Zhixue Qiu
- Department of Orthopaedics, Qinghai Provincial People's Hospital, Xining, Qinghai, China
| | - Jingyuan Chao
- Ganbao Section, Qinghai Provincial People's Hospital, Xining, Qinghai, China
| | - Zhanping Kong
- Department of Orthopaedics, Qinghai Provincial People's Hospital, Xining, Qinghai, China
| | - Haili Li
- College of Pharmacy, Qinghai Nationalities University, Xining, Qinghai, China
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14
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Plasma Pharmacokinetics of High-Dose Oral versus Intravenous Rifampicin in Patients with Tuberculous Meningitis: a Randomized Controlled Trial. Antimicrob Agents Chemother 2021; 65:e0014021. [PMID: 33972248 PMCID: PMC7611291 DOI: 10.1128/aac.00140-21] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Higher doses of intravenous rifampicin may improve outcomes in tuberculous meningitis but are impractical in high-burden settings. We hypothesized that plasma rifampicin exposures would be similar between oral dosing of 35 mg/kg of body weight and intravenous dosing of 20 mg/kg, which has been proposed for efficacy trials in tuberculous meningitis. We performed a randomized parallel-group pharmacokinetic study nested within a clinical trial of intensified antimicrobial therapy for tuberculous meningitis. HIV-positive participants with tuberculous meningitis were recruited from South African hospitals and randomized to one of three rifampicin dosing groups: standard (oral 10 mg/kg), high dose (oral 35 mg/kg), and intravenous (20 mg/kg). Intensive pharmacokinetic sampling was done on day 3. Data were described using noncompartmental analysis, and exposures were compared by geometric mean ratios (GMRs). Forty-six participants underwent pharmacokinetic sampling (standard dose, n = 17; high-dose oral, n = 15; intravenous, n = 14). The median CD4 count was 130 cells/mm3 (interquartile range [IQR], 66 to 253 cells/mm3). The rifampicin geometric mean area under the concentration-time curve from 0 to 24 h (AUC0-24) values were 42.9 μg · h/ml (95% confidence interval [CI], 24.5 to 75.0 μg · h/ml) for the standard dose, 295.2 μg · h/ml (95% CI, 189.9 to 458.8 μg · h/ml) for the high oral dose, and 206.5 μg · h/ml (95% CI, 154.6 to 275.8 μg · h/ml) for intravenous administration. The rifampicin AUC0-24 GMR was 1.44 (90% CI, 0.84 to 2.21) and the maximal concentration of drug in serum (Cmax) GMR was 0.89 (90% CI, 0.63 to 1.23) for high-dose oral administration with respect to intravenous dosing. The plasma rifampicin AUC0-24 was higher after an oral 35-mg/kg dose than with intravenous administration at a 20-mg/kg dose over the first few days of tuberculosis (TB) treatment. The findings support oral rifampicin dosing in future tuberculous meningitis trials.
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15
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Sartini I, Łebkowska-Wieruszewska B, Lisowski A, Poapolathep A, Giorgi M. Danofloxacin pharmacokinetics and tissue residues in Bilgorajska geese. Res Vet Sci 2021; 136:11-17. [PMID: 33556838 DOI: 10.1016/j.rvsc.2021.01.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 01/19/2021] [Accepted: 01/22/2021] [Indexed: 02/07/2023]
Abstract
Danofloxacin is a fluoroquinolone developed for veterinary medicine and used in avian species for the treatment of numerous bacterial infections. However, no pharmacokinetic data have been reported in geese. The aim of the study was three-fold: (i) to evaluate the pharmacokinetics of danofloxacin in geese after single oral (PO) and intravenous (IV) administrations; (ii) to define its residue depletion profile in different goose tissues, and (iii) to recreate a multiple-dose simulation in the practical context of large-scale breeding. Twenty-four healthy geese were randomly divided in three groups each composed of eight animals. Group 1 received danofloxacin IV (5 mg/kg) and groups 2 and 3 were treated PO with the same dose. Blood was collected until 24 h (IV; group 1) and 48 h (PO; group 2) after administration. Two animals from group 3 were sacrificed at 6, 10, 24 and 48 h to collect samples of muscle, heart, kidney, liver, and lung. Danofloxacin was quantified in each matrix using a validated high-performance liquid chromatography method with spectrofluorimetric detection and the pharmacokinetic analysis was performed using non-compartmental and compartmental approaches. Danofloxacin showed a moderate elimination half-life (6.61 h), a slow clearance (0.35 mL/g*h) and a large volume of distribution (1.46 mL/g). The peak plasma concentration after PO administration and the time to reach it were 0.96 μg/mL and 1.70 h, respectively. The oral bioavailability was moderate (58%). Higher residue concentration was found in liver and kidney, compared to the other tissues. If the AUC(0-24) value found in the present study is included in the pharmacokinetic/pharmacodynamic index (AUC(0-24)/MIC) for the prediction of fluoroquinolones' efficacy, danofloxacin seems to be effective in geese against gram-negative bacteria with a minimum inhibitory concentration (MIC) < 0.076 μg/mL and against S. pneumoniae with a MIC < 0.29 μg/mL after a single PO dose of 5 mg/kg. Liver and kidney showed the highest drug tissue penetration value, with an explorative withdrawal time of 2.6 and 3.8 days, respectively. A practical multiple-dose regimen simulation does not lead to significant plasma drug accumulation.
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Affiliation(s)
- Irene Sartini
- Department of Veterinary Medicine, University of Sassari, Sassari, Italy
| | | | - Andrzej Lisowski
- Institute of Animal Breeding and Biodiversity Conservation, University of Life Sciences, Lublin, Poland
| | - Amnart Poapolathep
- Faculty of Veterinary Medicine, Department of Pharmacology, Kasetsart University, Bangkok, Thailand
| | - Mario Giorgi
- Department of Veterinary Sciences, University of Pisa, Pisa, Italy; School of Veterinary Sciences, Department of Veterinary Medicine, University of Sassari, Sassari, Italy.
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16
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Population Pharmacokinetic Properties of Antituberculosis Drugs in Vietnamese Children with Tuberculous Meningitis. Antimicrob Agents Chemother 2020; 65:AAC.00487-20. [PMID: 33139294 PMCID: PMC7927832 DOI: 10.1128/aac.00487-20] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 10/13/2020] [Indexed: 11/20/2022] Open
Abstract
Optimal dosing of children with tuberculous meningitis (TBM) remains uncertain and is currently based on the treatment of pulmonary tuberculosis in adults. This study aimed to investigate the population pharmacokinetics of isoniazid, rifampin, pyrazinamide, and ethambutol in Vietnamese children with TBM, to propose optimal dosing in these patients, and to determine the relationship between drug exposure and treatment outcome. A total of 100 Vietnamese children with TBM were treated with an 8-month antituberculosis regimen. Optimal dosing of children with tuberculous meningitis (TBM) remains uncertain and is currently based on the treatment of pulmonary tuberculosis in adults. This study aimed to investigate the population pharmacokinetics of isoniazid, rifampin, pyrazinamide, and ethambutol in Vietnamese children with TBM, to propose optimal dosing in these patients, and to determine the relationship between drug exposure and treatment outcome. A total of 100 Vietnamese children with TBM were treated with an 8-month antituberculosis regimen. Nonlinear mixed-effects modeling was used to evaluate the pharmacokinetic properties of the four drugs and to simulate different dosing strategies. The pharmacokinetic properties of rifampin and pyrazinamide in plasma were described successfully by one-compartment disposition models, while those of isoniazid and ethambutol in plasma were described by two-compartment disposition models. All drug models included allometric scaling of body weight and enzyme maturation during the first years of life. Cerebrospinal fluid (CSF) penetration of rifampin was relatively poor and increased with increasing protein levels in CSF, a marker of CSF inflammation. Isoniazid and pyrazinamide showed good CSF penetration. Currently recommended doses of isoniazid and pyrazinamide, but not ethambutol and rifampin, were sufficient to achieve target exposures. The ethambutol dose cannot be increased because of ocular toxicity. Simulation results suggested that rifampin dosing at 50 mg/kg of body weight/day would be required to achieve the target exposure. Moreover, low rifampin plasma exposure was associated with an increased risk of neurological disability. Therefore, higher doses of rifampin could be considered, but further studies are needed to establish the safety and efficacy of increased dosing.
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Sartini I, Łebkowska-Wieruszewska B, Sitovs A, Lisowski A, Poapolathep A, Giorgi M. Levofloxacin pharmacokinetics and tissue residue concentrations after oral administration in Bilgorajska geese. Br Poult Sci 2020; 62:193-198. [PMID: 33121260 DOI: 10.1080/00071668.2020.1842855] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
1. The aim of this study was to assess the pharmacokinetics of levofloxacin, a third-generation fluoro-quinolone antimicrobial drug, in geese (n = 26) after either single intravenous or oral administration, and to evaluate the depletion profile in goose muscle, heart, liver, kidney and lung after a single oral dose.2. The pharmacokinetic study involved 16 geese which were randomly divided into two groups (n = 8/group), the first received levofloxacin (2 mg/kg) intravenously while the second was treated with orally (5 mg/kg). The tissue depletion study involved 10 geese which were dosed orally (5 mg/kg) and two animals were killed at different time-points in order to collect the selected tissues. Levofloxacin was quantified in all the matrices tested by a validated high-performance liquid chromatography (HPLC) method, using a spectrofluorimetric detector. The pharmacokinetics were analysed using a non-compartmental model.3. Plasma concentrations were quantified after up to 24 h in animals administered intravenously and up to 48 h after oral treatment. Levofloxacin was rapidly absorbed after oral administration (Tmax = 0.38 h) showing high bioavailability (95.57 ± 20.61%). The drug showed a moderate volume of distribution (1.40 ± 0.28 ml/g) and rapid clearance (0.28 ± 0.06 ml/g/h). No statistical differences in estimates were found between the two different administration methods (P > 0.05). Drug residues were highest at 6 h and decreased constantly up to 48 h in all the selected tissues. Liver and kidney had the highest levofloxacin concentrations.4. According to the pharmacokinetic/pharmacodynamic surrogate index (AUC/MIC) the levofloxacin dose regimen (after oral administration) used in the present study could be active against bacteria at a minimum inhibitory concentration (MIC) > 0.24 μg/ml in geese. In addition, drug accumulation in the liver might be controlled using an estimated preliminary withdrawal time of 90 h.
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Affiliation(s)
- I Sartini
- Department of Veterinary Medicine, University of Sassari, Sassari, Italy
| | - B Łebkowska-Wieruszewska
- Department of Pharmacology, Toxicology and Environmental Protection, University of Life Sciences, Lublin, Poland
| | - A Sitovs
- Department of Pharmacology, Riga Stradins University, Riga, Latvia
| | - A Lisowski
- Institute of Animal Breeding and Biodiversity Conservation, University of Life Sciences, Lublin, Poland
| | - A Poapolathep
- Department of Pharmacology, Faculty of Veterinary Medicine, Kasetsart University, Bangkok, Thailand
| | - M Giorgi
- Department of Veterinary Sciences, University of Pisa, Pisa, Italy
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18
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Huynh J, Thwaites G, Marais BJ, Schaaf HS. Tuberculosis treatment in children: The changing landscape. Paediatr Respir Rev 2020; 36:33-43. [PMID: 32241748 DOI: 10.1016/j.prrv.2020.02.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 02/18/2020] [Indexed: 12/15/2022]
Abstract
Traditionally children have been treated for tuberculosis (TB) based on data extrapolated from adults. However, we know that children present unique challenges that deserve special focus. New data on optimal drug selection and dosing are emerging with the inclusion of children in clinical trials and ongoing research on age-related pharmacokinetics and pharmacodynamics. We discuss the changing treatment landscape for drug-susceptible and drug-resistant paediatric tuberculosis in both the most common (intrathoracic) and most severe (central nervous system) forms of disease, and address the current knowledge gaps for improving patient outcomes.
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Affiliation(s)
- Julie Huynh
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Viet Nam; Nuffield Department of Medicine, Department of Tropical Medicine and Global Health, Oxford University, Oxford, United Kingdom.
| | - Guy Thwaites
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Viet Nam; Nuffield Department of Medicine, Department of Tropical Medicine and Global Health, Oxford University, Oxford, United Kingdom
| | - Ben J Marais
- Department of Infectious Diseases and Microbiology, The Children's Hospital Westmead, Westmead, Australia; Discipline of Child and Adolescent Health, University of Sydney, The Children's Hospital Westmead, Australia; Marie Bashir Institute for Infectious Diseases and Biosecurity, University of Sydney, Sydney, Australia
| | - H Simon Schaaf
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa; Tygerberg Hospital, Cape Town, South Africa
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19
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Rohlwink UK, Chow FC, Wasserman S, Dian S, Lai RPJ, Chaidir L, Hamers RL, Wilkinson RJ, Boulware DR, Cresswell FV, van Laarhoven A. Standardized approaches for clinical sampling and endpoint ascertainment in tuberculous meningitis studies. Wellcome Open Res 2020; 4:204. [PMID: 32399496 PMCID: PMC7194504 DOI: 10.12688/wellcomeopenres.15497.2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/20/2020] [Indexed: 01/12/2023] Open
Abstract
Tuberculous meningitis (TBM), the most severe manifestation of tuberculosis, has poorly understood immunopathology and high mortality and morbidity despite antituberculous therapy. This calls for accelerated clinical and basic science research in this field. As TBM disproportionally affects poorer communities, studies are often performed in resource-limited environments, creating challenges for data collection and harmonisation. Comparison of TBM studies has been hampered by variation in sampling strategies, study design and choice of study endpoints. Based on literature review and expert consensus, this paper provides firstly, practical recommendations to enable thorough diagnostic, pathophysiological and pharmacokinetic studies using clinical samples, and facilitates better data aggregation and comparisons across populations and settings. Secondly, we discuss clinically relevant study endpoints, including neuroimaging, functional outcome, and cause of death, with suggestions of how these could be applied in different designs for future TBM studies.
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Affiliation(s)
- Ursula K Rohlwink
- Division of Neurosurgery, Department of Surgery, Neuroscience Institute, University of Cape Town, Cape Town, 7700, South Africa
| | - Felicia C Chow
- Weill Institute for Neurosciences and Departments of Neurology and Medicine (Infectious Diseases), University of California, San Francisco, USA
| | - Sean Wasserman
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, University of Cape Town, Cape Town, South Africa,Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, Observatory, Cape Town, South Africa
| | - Sofiati Dian
- Infectious Disease Research Center, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia,Department of Neurology, Faculty of Medicine, Universitas Padjadjaran/Hasan Sadikin Hospital, Bandung, Indonesia
| | - Rachel PJ Lai
- The Francis Crick Institute, Midland Road, London, NW1 1AT, UK,Department of Infectious Diseases, Imperial College London, London, UK
| | - Lidya Chaidir
- Infectious Disease Research Center, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia,Department of Biomedical Sciences, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Raph L Hamers
- Eijkman-Oxford Clinical Research Unit, Jakarta, Indonesia,Faculty of Medicine, University of Indonesia, Jakarta, Indonesia,Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Robert J Wilkinson
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, Observatory, Cape Town, South Africa,The Francis Crick Institute, Midland Road, London, NW1 1AT, UK,Department of Infectious Diseases, Imperial College London, London, UK
| | | | - Fiona V Cresswell
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK,Infectious Disease Institute, Mulago College of Health Sciences, Kampala, Uganda,MRC-UVRI LSHTM Uganda Research Unit, Entebbe, Uganda
| | - Arjan van Laarhoven
- Department of Internal Medicine and Radboud Center of Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, The Netherlands,
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20
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Rohlwink UK, Chow FC, Wasserman S, Dian S, Lai RPJ, Chaidir L, Hamers RL, Wilkinson RJ, Boulware DR, Cresswell FV, van Laarhoven A. Standardized approaches for clinical sampling and endpoint ascertainment in tuberculous meningitis studies. Wellcome Open Res 2020; 4:204. [PMID: 32399496 PMCID: PMC7194504 DOI: 10.12688/wellcomeopenres.15497.1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/26/2019] [Indexed: 12/26/2022] Open
Abstract
Tuberculous meningitis (TBM), the most severe manifestation of tuberculosis, has poorly understood immunopathology and high mortality and morbidity despite antituberculous therapy. This calls for accelerated clinical and basic science research in this field. As TBM disproportionally affects poorer communities, studies are often performed in resource-limited environments, creating challenges for data collection and harmonisation. Comparison of TBM studies has been hampered by variation in sampling strategies, study design and choice of study endpoints. Based on literature review and expert consensus, this paper provides firstly, practical recommendations to enable thorough diagnostic, pathophysiological and pharmacokinetic studies using clinical samples, and facilitates better data aggregation and comparisons across populations and settings. Secondly, we discuss clinically relevant study endpoints, including neuroimaging, functional outcome, and cause of death, with suggestions of how these could be applied in different designs for future TBM studies.
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Affiliation(s)
- Ursula K Rohlwink
- Division of Neurosurgery, Department of Surgery, Neuroscience Institute, University of Cape Town, Cape Town, 7700, South Africa
| | - Felicia C Chow
- Weill Institute for Neurosciences and Departments of Neurology and Medicine (Infectious Diseases), University of California, San Francisco, USA
| | - Sean Wasserman
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, University of Cape Town, Cape Town, South Africa,Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, Observatory, Cape Town, South Africa
| | - Sofiati Dian
- Infectious Disease Research Center, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia,Department of Neurology, Faculty of Medicine, Universitas Padjadjaran/Hasan Sadikin Hospital, Bandung, Indonesia
| | - Rachel PJ Lai
- The Francis Crick Institute, Midland Road, London, NW1 1AT, UK,Department of Infectious Diseases, Imperial College London, London, UK
| | - Lidya Chaidir
- Infectious Disease Research Center, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia,Department of Biomedical Sciences, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Raph L Hamers
- Eijkman-Oxford Clinical Research Unit, Jakarta, Indonesia,Faculty of Medicine, University of Indonesia, Jakarta, Indonesia,Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Robert J Wilkinson
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, Observatory, Cape Town, South Africa,The Francis Crick Institute, Midland Road, London, NW1 1AT, UK,Department of Infectious Diseases, Imperial College London, London, UK
| | | | - Fiona V Cresswell
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK,Infectious Disease Institute, Mulago College of Health Sciences, Kampala, Uganda,MRC-UVRI LSHTM Uganda Research Unit, Entebbe, Uganda
| | - Arjan van Laarhoven
- Department of Internal Medicine and Radboud Center of Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, The Netherlands,
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21
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Ding J, Thuy Thuong Thuong N, Pham TV, Heemskerk D, Pouplin T, Tran CTH, Nguyen MTH, Nguyen PH, Phan LP, Nguyen CVV, Thwaites G, Tarning J. Pharmacokinetics and Pharmacodynamics of Intensive Antituberculosis Treatment of Tuberculous Meningitis. Clin Pharmacol Ther 2020; 107:1023-1033. [PMID: 31956998 PMCID: PMC7158205 DOI: 10.1002/cpt.1783] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 01/13/2020] [Indexed: 12/24/2022]
Abstract
The most effective antituberculosis drug treatment regimen for tuberculous meningitis is uncertain. We conducted a randomized controlled trial comparing standard treatment with a regimen intensified by rifampin 15 mg/kg and levofloxacin for the first 60 days. The intensified regimen did not improve survival or any other outcome. We therefore conducted a nested pharmacokinetic/pharmacodynamic study in 237 trial participants to define exposure-response relationships that might explain the trial results and improve future therapy. Rifampin 15 mg/kg increased plasma and cerebrospinal fluid (CSF) exposures compared with 10 mg/kg: day 14 exposure increased from 48.2 hour·mg/L (range 18.2-93.8) to 82.5 hour·mg/L (range 8.7-161.0) in plasma and from 3.5 hour·mg/L (range 1.2-9.6) to 6.0 hour·mg/L (range 0.7-15.1) in CSF. However, there was no relationship between rifampin exposure and survival. In contrast, we found that isoniazid exposure was associated with survival, with low exposure predictive of death, and was linked to a fast metabolizer phenotype. Higher doses of isoniazid should be investigated, especially in fast metabolizers.
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Affiliation(s)
- Junjie Ding
- Nuffield Department of Clinical Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK.,The WorldWide Antimalarial Resistance Network, Oxford, UK.,Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | | | - Toi Van Pham
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam
| | - Dorothee Heemskerk
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam
| | - Thomas Pouplin
- Nuffield Department of Clinical Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK.,Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | | | | | - Phu Hoan Nguyen
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam.,Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Loc Phu Phan
- Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | | | - Guy Thwaites
- Nuffield Department of Clinical Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK.,Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam
| | - Joel Tarning
- Nuffield Department of Clinical Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK.,The WorldWide Antimalarial Resistance Network, Oxford, UK.,Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
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22
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Butov D, Feshchenko Y, Kuzhko M, Gumenuik M, Yurko K, Grygorova A, Tkachenko A, Nekrasova N, Tlustova T, Kikinchuk V, Peshenko A, Butova T. Effectiveness of Intravenous Isoniazid and Ethambutol Administration in Patients with Tuberculosis Meningoencephalitis and HIV Infection. Tuberc Respir Dis (Seoul) 2020; 83:96-103. [PMID: 31905437 PMCID: PMC6953493 DOI: 10.4046/trd.2019.0021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 04/08/2019] [Accepted: 07/24/2019] [Indexed: 11/24/2022] Open
Abstract
Background The aim of this study was to investigate the effectiveness of intravenous isoniazid (H) and ethambutol (E) administered in patients with new sputum positive drug-susceptible pulmonary tuberculosis (TB) with tuberculous meningoencephalitis (TM) and human immunodeficiency virus (HIV) co-infection in the intensive phase of treatment. Methods Fifty-four patients with TB/TM and HIV co-infection were enrolled for this study. Group 1 comprised of 23 patients treated with E and H intravenously, while rifampicin and pyrazinamide were prescribed orally. Group 2 consisted of 31 patients treated with the first-line anti-TB drugs orally. The concentrations of H and E in blood serum were detected using a chromatographic method. Results A significant improvement in the clinical symptoms and X-ray signs in patients treated intravenously with H and E was observed and compared to group 2. The sputum Mycobacterium tuberculosis positivity was observed during the second month of the treatment in 25.0% of patients from group 1 and 76.1% of the patients from the control group (p=0.003). In addition, nine patients (39.1%) died up to 6 months when H and E were prescribed intravenously compared with 22 (70.9%) in group 2 (p=0.023). Conclusion In TB/TM with HIV, the intravenous H and E treatment was more effective than oral H and E treatment at 2 months of intensive treatment in sputum conversion as well as in clinical improvement, accompanied by significantly higher mean serum concentrations. In addition, the mortality rate was lower in intravenous H and E treatment compared to oral treatment.
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Affiliation(s)
- Dmytro Butov
- Department of Phthisiology and Pulmonology, Kharkiv National Medical University, Kharkiv, Ukraine.
| | - Yurii Feshchenko
- Department of Technologies of Treatment of Nonspecific Lung Diseases, National Institute of Phthisiology and Pulmonology named after F. G. Yanovskyi NAMS of Ukraine, Kiev, Ukraine
| | - Mykhailo Kuzhko
- Department of Resistent Tuberculosis, National Institute of Phthisiology and Pulmonology named after F. G. Yanovskyi NAMS of Ukraine, Kiev, Ukraine
| | - Mykola Gumenuik
- Department of Technologies of Treatment of Nonspecific Lung Diseases, National Institute of Phthisiology and Pulmonology named after F. G. Yanovskyi NAMS of Ukraine, Kiev, Ukraine
| | - Kateryna Yurko
- Department of Infectious Diseases, Kharkiv National Medical University, Kharkiv, Ukraine
| | - Alina Grygorova
- Department of Research, Kharkiv National Medical University, Kharkiv, Ukraine
| | - Anton Tkachenko
- Department of Biochemistry, Kharkiv National Medical University, Kharkiv, Ukraine
| | - Natalia Nekrasova
- Department of Neurology, Kharkiv National Medical University, Kharkiv, Ukraine
| | - Tetiana Tlustova
- Department of Medicine, National Institute of Phthisiology and Pulmonology named after F. G. Yanovskyi NAMS of Ukraine, Kiev, Ukraine
| | - Vasyl Kikinchuk
- Department of Criminalistics and Forensic Science, Kharkiv National University of Internal Affairs, Kharkiv, Ukraine
| | - Alexandr Peshenko
- Department of Criminalistics and Forensic Science, Kharkiv National University of Internal Affairs, Kharkiv, Ukraine
| | - Tetiana Butova
- Department of Internal Medicine, V.N. Karazin Kharkiv National University, Kharkiv, Ukraine
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23
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Deshpande D, Pasipanodya JG, Srivastava S, Bendet P, Koeuth T, Bhavnani SM, Ambrose PG, Smythe W, McIlleron H, Thwaites G, Gumusboga M, Van Deun A, Gumbo T. Gatifloxacin Pharmacokinetics/Pharmacodynamics-based Optimal Dosing for Pulmonary and Meningeal Multidrug-resistant Tuberculosis. Clin Infect Dis 2019; 67:S274-S283. [PMID: 30496459 DOI: 10.1093/cid/ciy618] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Background Gatifloxacin is used for the treatment of multidrug-resistant tuberculosis (MDR-TB). The optimal dose is unknown. Methods We performed a 28-day gatifloxacin hollow-fiber system model of tuberculosis (HFS-TB) study in order to identify the target exposures associated with optimal kill rates and resistance suppression. Monte Carlo experiments (MCE) were used to identify the dose that would achieve the target exposure in 10000 adult patients with meningeal or pulmonary MDR-TB. The optimal doses identified were validated using probit analyses of clinical data from 2 prospective clinical trials of patients with pulmonary and meningeal tuberculosis. Classification and regression-tree (CART) analyses were used to identify the gatifloxacin minimum inhibitory concentration (MIC) below which patients failed or relapsed on combination therapy. Results The target exposure associated with optimal microbial kill rates and resistance suppression in the HFS-TB was a 0-24 hour area under the concentration-time curve-to-MIC of 184. MCE identified an optimal gatifloxacin dose of 800 mg/day for pulmonary and 1200 mg/day for meningeal MDR-TB, and a clinical susceptibility breakpoint of MIC ≤ 0.5 mg/L. In clinical trials, CART identified that 79% patients failed therapy if MIC was >2 mg/L, but 98% were cured if MIC was ≤0.5 mg/L. Probit analysis of clinical data demonstrated a >90% probability of a cure in patients if treated with 800 mg/day for pulmonary tuberculosis and 1200 mg/day for meningeal tuberculosis. Doses ≤400 mg/day were suboptimal. Conclusions Gatifloxacin doses of 800 mg/day and 1200 mg/day are recommended for pulmonary and meningeal MDR-TB treatment, respectively. Gatifloxacin has a susceptible dose-dependent zone at MICs 0.5-2 mg/L.
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Affiliation(s)
- Devyani Deshpande
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, Texas
| | - Jotam G Pasipanodya
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, Texas
| | - Shashikant Srivastava
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, Texas
| | - Paula Bendet
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, Texas
| | - Thearith Koeuth
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, Texas
| | | | - Paul G Ambrose
- Institute for Clinical Pharmacodynamics, Schenectady, New York
| | - Wynand Smythe
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Observatory, South Africa
| | - Helen McIlleron
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Observatory, South Africa
| | - Guy Thwaites
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, Churchill Hospital, Oxford, United Kingdom.,Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | | | - Armand Van Deun
- Institute of Tropical Medicine, Antwerp, Belgium.,International Union Against Tuberculosis and Lung Disease, Paris, France
| | - Tawanda Gumbo
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, Texas
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24
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Daghmouri MA, Cherni I, Rebai L, Ghouibi C, Ghedira S, Houissa M. Muscular hypotonia as an onset manifestation of Tuberculosis meningitis in an HIV-negative patient. Clin Case Rep 2019; 7:2177-2180. [PMID: 31788274 PMCID: PMC6878069 DOI: 10.1002/ccr3.2474] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 06/28/2019] [Accepted: 07/13/2019] [Indexed: 11/17/2022] Open
Abstract
Muscular hypotonia is considered as one of the rarest forms of initial onset signs of TBM, in addition to aphasia and hyponatremia, the awareness of those rare onset signs, a well-conducted diagnostic approach and early treatment can improve the outcome.
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Affiliation(s)
| | - Imen Cherni
- Department of anesthesiaCharles Nicolle HospitalTunisTunisia
| | - Lotfi Rebai
- Department of anesthesiaTrauma Center of Ben ArrousBen ArrousTunisia
| | - Cheima Ghouibi
- Department of anesthesiaCharles Nicolle HospitalTunisTunisia
| | - Salma Ghedira
- Department of anesthesiaCharles Nicolle HospitalTunisTunisia
| | - Mohamed Houissa
- Department of anesthesiaCharles Nicolle HospitalTunisTunisia
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25
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Korth-Bradley JM. The Path to Perfect Pediatric Posology - Drug Development in Pediatrics. J Clin Pharmacol 2019; 58 Suppl 10:S48-S57. [PMID: 30248197 DOI: 10.1002/jcph.1081] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Accepted: 12/21/2017] [Indexed: 11/06/2022]
Abstract
Reluctance to enroll pediatric subjects in clinical trials has left gaps in information about dosing, safety, and efficacy of medications. Pharmacotherapeutic information for pediatric patients may be available for only a small range of ages and may be deficient, as children respond differently as they grow and mature from prematurity to adolescence. Current regulations, however, require early planning for the participation of children in drug development, as pediatric plans must be submitted at the end of phase 1 (European Union) or the end of phase 2 (United States). These plans are extensive, outlining planned studies, subjects to be enrolled, dose and dosage form justification, planned observations, and statistical analysis as well as planned modeling, simulation, and extrapolation analyses. The extent to which efficacy information in adults can be extrapolated to children depends on how similar the disease is in adults and each of the 5 pediatric age groups. Extrapolation may not be possible for conditions that do not occur in adults, requiring a complete development plan in adults, or extrapolation may be complete because of similar pathology and response to treatment. Pharmacokinetic and safety information cannot be extrapolated and must be collected in children of all ages, unless a waiver is granted. Physiologically based pharmacokinetic modeling, optimal design, population pharmacokinetics, and scavenged samples are all examples of new methodologies being used to study pediatric therapeutics. Clinicaltrials.gov and EU Clinical Trials registry are good sources of results of pediatric trials, although sponsors are also working toward prompt publication of study results in peer-reviewed journals.
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Affiliation(s)
- Joan M Korth-Bradley
- Clinical Pharmacology, Global Product Development, Pfizer Inc., Collegeville, PA, USA
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26
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Sartini I, Łebkowska-Wieruszewska B, Lisowski A, Poapolathep A, Owen H, Giorgi M. Concentrations in plasma and selected tissues of marbofloxacin after oral and intravenous administration in Bilgorajska geese ( Anser anser domesticus). N Z Vet J 2019; 68:31-37. [PMID: 31437418 DOI: 10.1080/00480169.2019.1658553] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Aims: To determine the pharmacokinetics and tissue depletion of 2 mg/kg marbofloxacin (MBX) in Bilgorajska geese (Anser anser domesticus) after I/V and oral administration, to calculate the daily dose from experimental data and to compare it with that calculated by allometric scaling.Methods: Eight clinically normal female Bilgorajska geese were used in a three-phase study with a 3-week wash-out period between phases. In the first phase birds received I/V administration of 2 mg/kg MBX; the same dose was given orally in the second and third phases. Blood samples were collected between 0 minutes and 48 hours in the first and second phases, and samples of liver, kidney, lung, muscle and heart were collected following slaughter of birds between 6 and 48 hours in the third phase. Concentrations of MBX in plasma and tissues were analysed using HPLC. Two additional birds served as controls. The optimal dose was calculated based on a minimal inhibitory concentration (MIC) of 0.125 μg⁄mL using the observed clearance, or using clearance calculated by allometric scaling.Results: Concentrations of MBX in plasma were detectable up to 24 hours following both I/V and oral administration. Mean oral bioavailability was 26.5 (SD 7.7)%. Concentrations of MBX in all tissues were highest at 6 hours and decreased constantly up to 34 hours. The mean optimal daily dose for oral administration of MBX, calculated using the observed clearance was 10.36 (SD 2.18) mg/kg, and using predicted clearance was 5.54 (SD 0.14) mg/kg. The preliminary withdrawal time for a maximum residue limit of 0.15 mg/kg calculated for muscle was 38.4 hours, heart 33.6 hours, kidney 48.3 hours, lung 47.7 hours and liver 49.3 hours.Conclusion and Clinical Relevance: There was insufficient evidence to recommend MBX orally administered to geese at a daily dose of 2 mg⁄kg for treatment of bacteria with an MIC of 0.125 μg/mL. Further pharmacokinetic/pharmacodynamic studies in geese are recommended to determine the MBX dose regimen and its clinical efficacy in geese.
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Affiliation(s)
- I Sartini
- Department of Veterinary Medicine, University of Sassari, Sassari, Italy
| | - B Łebkowska-Wieruszewska
- Department of Pharmacology, Toxicology and Environmental Protection, University of Life Sciences, Lublin, Poland
| | - A Lisowski
- Institute of Animal Breeding and Biodiversity Conservation, University of Life Sciences, Lublin, Poland
| | - A Poapolathep
- Faculty of Veterinary Medicine, Department of Pharmacology, Kasetsart University, Bangkok, Thailand
| | - H Owen
- School of Veterinary Science, The University of Queensland, Gatton, Australia
| | - M Giorgi
- Department of Veterinary Sciences, University of Pisa, Pisa, Italy
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Daniel BD, Grace GA, Natrajan M. Tuberculous meningitis in children: Clinical management & outcome. Indian J Med Res 2019; 150:117-130. [PMID: 31670267 PMCID: PMC6829784 DOI: 10.4103/ijmr.ijmr_786_17] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Indexed: 12/15/2022] Open
Abstract
Although the occurrence of tuberculous meningitis (TBM) in children is relatively rare, but it is associated with higher rates of mortality and severe morbidity. The peak incidence of TBM occurs in younger children who are less than five years of age, and most children present with late-stage disease. Confirmation of diagnosis is often difficult, and other infectious causes such as bacterial, viral and fungal causes must be ruled out. Bacteriological confirmation of diagnosis is ideal but is often difficult because of its paucibacillary nature as well as decreased sensitivity and specificity of diagnostic tests. Early diagnosis and management of the disease, though difficult, is essential to avoid death or neurologic disability. Hence, a high degree of suspicion and a combined battery of tests including clinical, bacteriological and neuroimaging help in diagnosis of TBM. Children diagnosed with TBM should be managed with antituberculosis therapy (ATT) and steroids. There are studies reporting low concentrations of ATT, especially of rifampicin and ethambutol in cerebrospinal fluid (CSF), and very young children are at higher risk of low ATT drug concentrations. Further studies are needed to identify appropriate regimens with adequate dosing of ATT for the management of paediatric TBM to improve treatment outcomes. This review describes the clinical presentation, investigations, management and outcome of TBM in children and also discusses various studies conducted among children with TBM.
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Affiliation(s)
- Bella Devaleenal Daniel
- Department of Clinical Research, ICMR-National Institute for Research in Tuberculosis, Chennai, India
| | - G. Angeline Grace
- Department of Clinical Research, ICMR-National Institute for Research in Tuberculosis, Chennai, India
| | - Mohan Natrajan
- Department of Clinical Research, ICMR-National Institute for Research in Tuberculosis, Chennai, India
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Mukherjee A, Lodha R, Kabra SK. Pharmacokinetics of First-Line Anti-Tubercular Drugs. Indian J Pediatr 2019; 86:468-478. [PMID: 30915644 DOI: 10.1007/s12098-019-02911-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 02/15/2019] [Indexed: 12/13/2022]
Abstract
Determining the optimal dosages of isoniazid, rifampicin, pyrazinamide and ethambutol in children is necessary to obtain therapeutic serum concentrations of these drugs. Revised dosages have improved the exposure of 1st line anti-tubercular drugs to some extent; there is still scope for modification of the dosages to achieve exposures which can lead to favourable outcome of the disease. High dose of rifampicin is being investigated in clinical trials in adults with some benefit; studies are required in children. Inter-individual pharmacokinetic variability and the effect of age, nutritional status, Human immunodeficiency virus (HIV) infection, acetylator genotype may need to be accounted for in striving for the dosages best suited for an individual.
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Affiliation(s)
- Aparna Mukherjee
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Rakesh Lodha
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India.
| | - S K Kabra
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India
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29
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Ranjalkar J, Mathew SK, Verghese VP, Bose A, Rose W, Gupta D, Fleming DH, Mathew BS. Isoniazid and rifampicin concentrations in children with tuberculosis with either a daily or intermittent regimen: implications for the revised RNTCP 2012 doses in India. Int J Antimicrob Agents 2018; 51:663-669. [DOI: 10.1016/j.ijantimicag.2017.12.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Revised: 11/26/2017] [Accepted: 12/02/2017] [Indexed: 10/18/2022]
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30
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Pharmacokinetics and pharmacodynamics of antibiotics in central nervous system infections. Curr Opin Infect Dis 2018; 31:57-68. [DOI: 10.1097/qco.0000000000000418] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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31
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Srivastava S, Deshpande D, Pasipanodya J, Nuermberger E, Swaminathan S, Gumbo T. Optimal Clinical Doses of Faropenem, Linezolid, and Moxifloxacin in Children With Disseminated Tuberculosis: Goldilocks. Clin Infect Dis 2017; 63:S102-S109. [PMID: 27742641 PMCID: PMC5064158 DOI: 10.1093/cid/ciw483] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Background. When treated with the same antibiotic dose, children achieve different 0- to 24-hour area under the concentration-time curves (AUC0–24) because of maturation and between-child physiological variability on drug clearance. Children are also infected by Mycobacterium tuberculosis isolates with different antibiotic minimum inhibitory concentrations (MICs). Thus, each child will achieve different AUC0–24/MIC ratios when treated with the same dose. Methods. We used 10 000-subject Monte Carlo experiments to identify the oral doses of linezolid, moxifloxacin, and faropenem that would achieve optimal target exposures associated with optimal efficacy in children with disseminated tuberculosis. The linezolid and moxifloxacin exposure targets were AUC0–24/MIC ratios of 62 and 122, and a faropenem percentage of time above MIC >60%, in combination therapy. A linezolid AUC0–24 of 93.4 mg × hour/L was target for toxicity. Population pharmacokinetic parameters of each drug and between-child variability, as well as MIC distribution, were used, and the cumulative fraction of response (CFR) was calculated. We also considered drug penetration indices into meninges, bone, and peritoneum. Results. The linezolid dose of 15 mg/kg in full-term neonates and infants aged up to 3 months and 10 mg/kg in toddlers, administered once daily, achieved CFR ≥ 90%, with <10% achieving linezolid AUC0–24 associated with toxicity. The moxifloxacin dose of 25 mg/kg/day achieved a CFR > 90% in infants, but the optimal dose was 20 mg/kg/day in older children. The faropenem medoxomil optimal dosage was 30 mg/kg 3–4 times daily. Conclusions. The regimen and doses of linezolid, moxifloxacin, and faropenem identified are proposed to be adequate for all disseminated tuberculosis syndromes, whether drug-resistant or -susceptible.
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Affiliation(s)
- Shashikant Srivastava
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, Texas
| | - Devyani Deshpande
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, Texas
| | - Jotam Pasipanodya
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, Texas
| | - Eric Nuermberger
- Center for Tuberculosis Research, Department of Medicine Department of International Health, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Tawanda Gumbo
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, Texas Department of Medicine, University of Cape Town, Observatory, South Africa
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32
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Török ME, Aljayyoussi G, Waterhouse D, Chau T, Mai N, Phu NH, Hien TT, Hope W, Farrar JJ, Ward SA. Suboptimal Exposure to Anti-TB Drugs in a TBM/HIV+ Population Is Not Related to Antiretroviral Therapy. Clin Pharmacol Ther 2017; 103:449-457. [PMID: 28160272 DOI: 10.1002/cpt.646] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Revised: 01/24/2017] [Accepted: 01/29/2017] [Indexed: 11/08/2022]
Abstract
A placebo-controlled trial that compares the outcomes of immediate vs. deferred initiation of antiretroviral therapy in HIV +ve tuberculous meningitis (TBM) patients was conducted in Vietnam in 2011. Here, the pharmacokinetics of rifampicin, isoniazid, pyrazinamide, and ethambutol were investigated in the presence and absence of anti-HIV treatment in 85 patients. Pharmacokinetic analyses show that HIV therapy has no significant impact on the pharmacokinetics of TB drugs in this cohort. The same population, however, displayed generally low cerebrospinal fluid (CSF) and systemic exposures to rifampicin compared to previously reported HIV -ve cohorts. Elevated CSF concentrations of pyrazinamide, on the other hand, were strongly and independently correlated with increased mortality and neurological toxicity. The findings suggest that the current standard dosing regimens may put the patient at risk of treatment failure from suboptimal rifampicin exposure, and potentially increasing the risk of adverse central nervous system events that are independently correlated with pyrazinamide CSF exposure.
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Affiliation(s)
- M E Török
- University of Cambridge, Department of Medicine, Addenbrooke's Hospital, Cambridge, UK
| | - G Aljayyoussi
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, UK
| | - D Waterhouse
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, UK
| | - Tth Chau
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Hi Chi Minh City, Vietnam
| | - Nth Mai
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Hi Chi Minh City, Vietnam
| | - N H Phu
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Hi Chi Minh City, Vietnam
| | - T T Hien
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Hi Chi Minh City, Vietnam
| | - W Hope
- University of Liverpool, Liverpool, UK
| | - J J Farrar
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Hi Chi Minh City, Vietnam
| | - S A Ward
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, UK
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Abstract
PURPOSE OF REVIEW Tuberculous meningitis is the most devastating manifestation of infection with Mycobacterium tuberculosis and represents a medical emergency. Approximately one half of tuberculous meningitis patients die or suffer severe neurologic disability. The goal of this review will be to review the pathogenic, clinical, and radiologic features of tuberculous meningitis and to highlight recent advancements in translational and clinical science. RECENT FINDINGS Pharmacologic therapy includes combination anti-tuberculosis drug regimens and adjunctive corticosteroids. It is becoming clear that a successful treatment outcome depends on an immune response that is neither too weak nor overly robust, and genetic determinants of this immune response may identify which patients will benefit from adjunctive corticosteroids. Recent clinical trials of intensified anti-tuberculosis treatment regimens conducted in Indonesia and Vietnam, motivated by the pharmacologic challenges of treating M. tuberculosis infections of the central nervous system, have yielded conflicting results regarding the survival benefit of intensified treatment regimens. More consistent findings have been observed regarding the relationship between initial anti-tuberculosis drug resistance and mortality among tuberculous meningitis patients. Prompt initiation of anti-tuberculosis treatment for all suspected cases remains a key aspect of management. Priorities for research include the improvement of diagnostic testing strategies and the optimization of host-directed and anti-tuberculosis therapies.
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The importance of clinical pharmacokinetic-pharmacodynamic studies in unraveling the determinants of early and late tuberculosis outcomes. ACTA ACUST UNITED AC 2017; 2:195-212. [PMID: 30283633 PMCID: PMC6161803 DOI: 10.4155/ipk-2017-0004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Accepted: 05/16/2017] [Indexed: 12/17/2022]
Abstract
Tuberculosis remains a major infectious cause of morbidity and mortality worldwide. Current antibiotic regimens, constructed prior to the development of modern pharmacokinetic-pharmacodynamic (PK–PD) tools, are based on incomplete understanding of exposure–response relationships in drug susceptible and multidrug resistant tuberculosis. Preclinical and population PK data suggest that clinical PK–PD studies may enable therapeutic drug monitoring for some agents and revised dosing for others. Future clinical PK–PD challenges include: incorporation of PK methods to assay free concentrations for all active metabolites; selection of appropriate early outcome measures which reflect therapeutic response; elucidation of genetic contributors to interindividual PK variability; conduct of targeted studies on special populations (including children); and measurement of PK–PD parameters at the site of disease.
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35
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Dheda K, Gumbo T, Maartens G, Dooley KE, McNerney R, Murray M, Furin J, Nardell EA, London L, Lessem E, Theron G, van Helden P, Niemann S, Merker M, Dowdy D, Van Rie A, Siu GKH, Pasipanodya JG, Rodrigues C, Clark TG, Sirgel FA, Esmail A, Lin HH, Atre SR, Schaaf HS, Chang KC, Lange C, Nahid P, Udwadia ZF, Horsburgh CR, Churchyard GJ, Menzies D, Hesseling AC, Nuermberger E, McIlleron H, Fennelly KP, Goemaere E, Jaramillo E, Low M, Jara CM, Padayatchi N, Warren RM. The epidemiology, pathogenesis, transmission, diagnosis, and management of multidrug-resistant, extensively drug-resistant, and incurable tuberculosis. THE LANCET. RESPIRATORY MEDICINE 2017; 5:S2213-2600(17)30079-6. [PMID: 28344011 DOI: 10.1016/s2213-2600(17)30079-6] [Citation(s) in RCA: 377] [Impact Index Per Article: 53.9] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 10/24/2016] [Accepted: 12/08/2016] [Indexed: 12/25/2022]
Abstract
Global tuberculosis incidence has declined marginally over the past decade, and tuberculosis remains out of control in several parts of the world including Africa and Asia. Although tuberculosis control has been effective in some regions of the world, these gains are threatened by the increasing burden of multidrug-resistant (MDR) and extensively drug-resistant (XDR) tuberculosis. XDR tuberculosis has evolved in several tuberculosis-endemic countries to drug-incurable or programmatically incurable tuberculosis (totally drug-resistant tuberculosis). This poses several challenges similar to those encountered in the pre-chemotherapy era, including the inability to cure tuberculosis, high mortality, and the need for alternative methods to prevent disease transmission. This phenomenon mirrors the worldwide increase in antimicrobial resistance and the emergence of other MDR pathogens, such as malaria, HIV, and Gram-negative bacteria. MDR and XDR tuberculosis are associated with high morbidity and substantial mortality, are a threat to health-care workers, prohibitively expensive to treat, and are therefore a serious public health problem. In this Commission, we examine several aspects of drug-resistant tuberculosis. The traditional view that acquired resistance to antituberculous drugs is driven by poor compliance and programmatic failure is now being questioned, and several lines of evidence suggest that alternative mechanisms-including pharmacokinetic variability, induction of efflux pumps that transport the drug out of cells, and suboptimal drug penetration into tuberculosis lesions-are likely crucial to the pathogenesis of drug-resistant tuberculosis. These factors have implications for the design of new interventions, drug delivery and dosing mechanisms, and public health policy. We discuss epidemiology and transmission dynamics, including new insights into the fundamental biology of transmission, and we review the utility of newer diagnostic tools, including molecular tests and next-generation whole-genome sequencing, and their potential for clinical effectiveness. Relevant research priorities are highlighted, including optimal medical and surgical management, the role of newer and repurposed drugs (including bedaquiline, delamanid, and linezolid), pharmacokinetic and pharmacodynamic considerations, preventive strategies (such as prophylaxis in MDR and XDR contacts), palliative and patient-orientated care aspects, and medicolegal and ethical issues.
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Affiliation(s)
- Keertan Dheda
- Lung Infection and Immunity Unit, Department of Medicine, Division of Pulmonology and UCT Lung Institute, University of Cape Town, Groote Schuur Hospital, Cape Town, South Africa.
| | - Tawanda Gumbo
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Kelly E Dooley
- Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ruth McNerney
- Lung Infection and Immunity Unit, Department of Medicine, Division of Pulmonology and UCT Lung Institute, University of Cape Town, Groote Schuur Hospital, Cape Town, South Africa
| | - Megan Murray
- Department of Global Health and Social Medicine, Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Jennifer Furin
- Department of Global Health and Social Medicine, Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Edward A Nardell
- TH Chan School of Public Health, Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Leslie London
- School of Public Health and Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Grant Theron
- SA MRC Centre for Tuberculosis Research/DST/NRF Centre of Excellence for Biomedical Tuberculosis Research, Division of Molecular Biology and Human Genetics, Stellenbosch University, Tygerberg, South Africa
| | - Paul van Helden
- SA MRC Centre for Tuberculosis Research/DST/NRF Centre of Excellence for Biomedical Tuberculosis Research, Division of Molecular Biology and Human Genetics, Stellenbosch University, Tygerberg, South Africa
| | - Stefan Niemann
- Molecular and Experimental Mycobacteriology, Research Center Borstel, Borstel, Schleswig-Holstein, Germany; German Centre for Infection Research (DZIF), Partner Site Borstel, Borstel, Schleswig-Holstein, Germany
| | - Matthias Merker
- Molecular and Experimental Mycobacteriology, Research Center Borstel, Borstel, Schleswig-Holstein, Germany
| | - David Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Annelies Van Rie
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; International Health Unit, Epidemiology and Social Medicine, Faculty of Medicine, University of Antwerp, Antwerp, Belgium
| | - Gilman K H Siu
- Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Hung Hom, Hong Kong SAR, China
| | - Jotam G Pasipanodya
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Camilla Rodrigues
- Department of Microbiology, P.D. Hinduja National Hospital & Medical Research Centre, Mumbai, India
| | - Taane G Clark
- Faculty of Infectious and Tropical Diseases and Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Frik A Sirgel
- SA MRC Centre for Tuberculosis Research/DST/NRF Centre of Excellence for Biomedical Tuberculosis Research, Division of Molecular Biology and Human Genetics, Stellenbosch University, Tygerberg, South Africa
| | - Aliasgar Esmail
- Lung Infection and Immunity Unit, Department of Medicine, Division of Pulmonology and UCT Lung Institute, University of Cape Town, Groote Schuur Hospital, Cape Town, South Africa
| | - Hsien-Ho Lin
- Institute of Epidemiology and Preventive Medicine, National Taiwan University, Taipei, Taiwan
| | - Sachin R Atre
- Center for Clinical Global Health Education (CCGHE), Johns Hopkins University, Baltimore, MD, USA; Medical College, Hospital and Research Centre, Pimpri, Pune, India
| | - H Simon Schaaf
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Kwok Chiu Chang
- Tuberculosis and Chest Service, Centre for Health Protection, Department of Health, Hong Kong SAR, China
| | - Christoph Lange
- Division of Clinical Infectious Diseases, German Center for Infection Research, Research Center Borstel, Borstel, Schleswig-Holstein, Germany; International Health/Infectious Diseases, University of Lübeck, Lübeck, Germany; Department of Medicine, Karolinska Institute, Stockholm, Sweden; Department of Medicine, University of Namibia School of Medicine, Windhoek, Namibia
| | - Payam Nahid
- Division of Pulmonary and Critical Care, San Francisco General Hospital, University of California, San Francisco, CA, USA
| | - Zarir F Udwadia
- Pulmonary Department, Hinduja Hospital & Research Center, Mumbai, India
| | | | - Gavin J Churchyard
- Aurum Institute, Johannesburg, South Africa; School of Public Health, University of Witwatersrand, Johannesburg, South Africa; Advancing Treatment and Care for TB/HIV, South African Medical Research Council, Johannesburg, South Africa
| | - Dick Menzies
- Montreal Chest Institute, McGill University, Montreal, QC, Canada
| | - Anneke C Hesseling
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Eric Nuermberger
- Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Helen McIlleron
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Kevin P Fennelly
- Pulmonary Clinical Medicine Section, Division of Intramural Research, National Heart, Lung, and Blood Institute (NHLBI), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Eric Goemaere
- MSF South Africa, Cape Town, South Africa; School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Marcus Low
- Treatment Action Campaign, Johannesburg, South Africa
| | | | - Nesri Padayatchi
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), MRC HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - Robin M Warren
- SA MRC Centre for Tuberculosis Research/DST/NRF Centre of Excellence for Biomedical Tuberculosis Research, Division of Molecular Biology and Human Genetics, Stellenbosch University, Tygerberg, South Africa
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