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Kim HJ, Kwak N, Yoon SH, Park N, Kim YR, Lee JH, Lee JY, Park Y, Kang YA, Kim S, Mok J, Kim JY, Jeon D, Lee JK, Yim JJ. Artificial intelligence-based radiographic extent analysis to predict tuberculosis treatment outcomes: a multicenter cohort study. Sci Rep 2024; 14:13162. [PMID: 38849439 PMCID: PMC11161500 DOI: 10.1038/s41598-024-63885-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 06/03/2024] [Indexed: 06/09/2024] Open
Abstract
Predicting outcomes in pulmonary tuberculosis is challenging despite effective treatments. This study aimed to identify factors influencing treatment success and culture conversion, focusing on artificial intelligence (AI)-based chest X-ray analysis and Xpert MTB/RIF assay cycle threshold (Ct) values. In this retrospective study across six South Korean referral centers (January 1 to December 31, 2019), we included adults with rifampicin-susceptible pulmonary tuberculosis confirmed by Xpert assay from sputum samples. We analyzed patient characteristics, AI-based tuberculosis extent scores from chest X-rays, and Xpert Ct values. Of 230 patients, 206 (89.6%) achieved treatment success. The median age was 61 years, predominantly male (76.1%). AI-based radiographic tuberculosis extent scores (median 7.5) significantly correlated with treatment success (odds ratio [OR] 0.938, 95% confidence interval [CI] 0.895-0.983) and culture conversion at 8 weeks (liquid medium: OR 0.911, 95% CI 0.853-0.973; solid medium: OR 0.910, 95% CI 0.850-0.973). Sputum smear positivity was 49.6%, with a median Ct of 26.2. However, Ct values did not significantly correlate with major treatment outcomes. AI-based radiographic scoring at diagnosis is a significant predictor of treatment success and culture conversion in pulmonary tuberculosis, underscoring its potential in personalized patient management.
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Affiliation(s)
- Hyung-Jun Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Nakwon Kwak
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Soon Ho Yoon
- Department of Radiology, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Nanhee Park
- Medical Research Collaborating Center, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Young Ran Kim
- Division of Clinical Research, International Tuberculosis Research Center, Seoul, Republic of Korea
| | - Jae Ho Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ji Yeon Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, National Medical Center, Seoul, Republic of Korea
| | - Youngmok Park
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Young Ae Kang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Saerom Kim
- Division of Pulmonology, Allergy and Critical Care Medicine, Department of Internal Medicine, Pusan National University Hospital, Busan, Republic of Korea
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Republic of Korea
| | - Jeongha Mok
- Division of Pulmonology, Allergy and Critical Care Medicine, Department of Internal Medicine, Pusan National University Hospital, Busan, Republic of Korea
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Republic of Korea
| | - Joong-Yub Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Doosoo Jeon
- Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
- Department of Internal Medicine, Pusan National University School of Medicine, Yangsan, Republic of Korea
| | - Jung-Kyu Lee
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Republic of Korea
| | - Jae-Joon Yim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea.
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea.
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Shah M, Dansky Z, Nathavitharana R, Behm H, Brown S, Dov L, Fortune D, Gadon NL, Gardner Toren K, Graves S, Haley CA, Kates O, Sabuwala N, Wegener D, Yoo K, Burzynski J. NTCA Guidelines for Respiratory Isolation and Restrictions to Reduce Transmission of Pulmonary Tuberculosis in Community Settings. Clin Infect Dis 2024:ciae199. [PMID: 38632829 DOI: 10.1093/cid/ciae199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Accepted: 04/08/2024] [Indexed: 04/19/2024] Open
Affiliation(s)
- Maunank Shah
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - Zoe Dansky
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - Ruvandhi Nathavitharana
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, USA
| | - Heidi Behm
- TB Program, Oregon Health Authority, Portland, OR, USA
| | | | - Lana Dov
- Washington State Department of Health, WA, USA
| | - Diana Fortune
- National Tuberculosis Controllers Association, Smyrna, GA, USA
| | | | | | - Susannah Graves
- Department of Public Health, City and County of San Francisco, CA, USA
| | - Connie A Haley
- Department of Medicine, Division of Infectious Diseases, Vanderbilt University Medical Center, TN, USA
| | - Olivia Kates
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University, School of Medicine, Baltimore, MD, USA
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, Maryland, USA
| | | | | | - Kathryn Yoo
- Society of Epidemiologists in Tuberculosis Control (SETC); Texas Department of State Health Services, Tuberculosis and Hansen's Disease Unit (TXDSHS), TX, USA
| | - Joseph Burzynski
- New York City Department of Health and Mental Hygiene, New York, NY, USA
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MacLean ELH, Zimmer AJ, den Boon S, Gupta-Wright A, Cirillo DM, Cobelens F, Gillespie SH, Nahid P, Phillips PP, Ruhwald M, Denkinger CM. Tuberculosis treatment monitoring tests during routine practice: study design guidance. Clin Microbiol Infect 2024; 30:481-488. [PMID: 38182047 DOI: 10.1016/j.cmi.2023.12.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 12/10/2023] [Accepted: 12/25/2023] [Indexed: 01/07/2024]
Abstract
SCOPE The current tools for tuberculosis (TB) treatment monitoring, smear microscopy and culture, cannot accurately predict poor treatment outcomes. Research into new TB treatment monitoring tools (TMTs) is growing, but data are unreliable. In this article, we aim to provide guidance for studies investigating and evaluating TB TMT for use during routine clinical care. Here, a TB TMT would guide treatment during the course of therapy, rather than testing for a cure at the regimen's end. This article does not cover the use of TB TMTs as surrogate endpoints in the clinical trial context. METHODS Guidelines were initially informed by experiences during a systematic review of TB TMTs. Subsequently, a small content expert group was consulted for feedback on initial recommendations. After revision, feedback from substantive experts across sectors was sought. QUESTIONS ADDRESSED BY THE GUIDELINE AND RECOMMENDATIONS The proposed considerations and recommendations for studies evaluating TB TMTs for use during the treatment in routine clinical care fall into eight domains. We provide specific recommendations regarding study design and recruitment, outcome definitions, reference standards, participant follow-up, clinical setting, study population, treatment regimen reporting, and index tests and data presentation. Overall, TB TMTs should be evaluated in a manner similar to diagnostic tests, but TB TMT accuracy must be assessed at multiple timepoints throughout the treatment course, and TB TMTs should be evaluated in study populations who have already received a diagnosis of TB. Study design and outcome definitions must be aligned with the developmental phase of the TB TMT under evaluation. There is no reference standard for TB treatment response, so different reference standards and comparator tests have been proposed, the selection of which will vary depending on the developmental phase of the TMT under assessment. The use of comparator tests can assist in generating evidence. Clarity is required when reporting of timepoints, TMT read-outs, and analysis results. Implementing these recommendations will lead to higher quality TB TMT studies that will allow data to be meaningfully compared, thereby facilitating the development of novel tools to guide individual TB therapy and improve treatment outcomes.
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Affiliation(s)
- Emily Lai-Ho MacLean
- NHMRC Clinical Trials Centre, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Alexandra J Zimmer
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
| | - Saskia den Boon
- Global Tuberculosis Programme, World Health Organization, Geneva, Switzerland
| | | | - Daniela M Cirillo
- Emerging Bacterial Pathogens Unit, Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Frank Cobelens
- Department of Global Health and Amsterdam Institute for Global Health and Development, Amsterdam University Medical Centers Location, University of Amsterdam, Amsterdam, The Netherlands
| | - Stephen H Gillespie
- Division of Infection and Global Health, School of Medicine, University of St Andrews, St Andrews, UK
| | - Payam Nahid
- Center for Tuberculosis, University of California San Francisco, San Francisco, CA, USA
| | - Patrick P Phillips
- Center for Tuberculosis, University of California San Francisco, San Francisco, CA, USA
| | | | - Claudia M Denkinger
- Division of Clinical Tropical Medicine, Center of Infectious Diseases, Heidelberg University Hospital, Heidelberg, Germany; Center of Infection Research (DZIF), Partners Site Heidelberg, Heidelberg, Germany.
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Paradkar MS, Pradhan NN, Balaji S, Gaikwad SN, Chavan A, Dharmashale SN, Sahasrabudhe T, Lokhande R, Deshmukh SA, Barthwal M, Atre S, Raskar SS, Sawant TU, Gupte AN, Kakrani A, Golub J, Padmapriyadarsini C, Gupta A, Gupte NA, Mave V. Early Microbiologic Markers of Pulmonary Tuberculosis Treatment Outcomes. Ann Am Thorac Soc 2023; 20:1760-1768. [PMID: 38038600 PMCID: PMC10704230 DOI: 10.1513/annalsats.202302-144oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 09/26/2023] [Indexed: 12/02/2023] Open
Abstract
Rationale: Earlier biomarkers of pulmonary tuberculosis (PTB) treatment outcomes are critical to monitor shortened anti-TB treatment (ATT). Objectives: To identify early microbiologic markers of unfavorable TB treatment outcomes. Methods: We performed a subanalysis of 2 prospective TB cohort studies conducted from 2013 to 2019 in India. We included participants aged ⩾18 years who initiated 6-month ATT for clinically or microbiologically diagnosed drug-sensitive PTB and completed at least one follow-up visit. Sputum specimens were subjected to a baseline Xpert Mycobacterium tuberculosis/rifampin (MTB/RIF) assay, acid-fast bacilli (AFB) microscopy and liquid and solid cultures, and serial AFB microscopy and liquid and solid cultures at weeks 2, 4, and 8. Poisson regression was used to assess the impact of available microbiologic markers (test positivity, smear grade, time to detection, and time to conversion) on a composite outcome of failure, recurrence, or death by 18 months after the end of treatment. Models were adjusted for age, sex, nutritional status, diabetes, smoking, alcohol consumption, and regimen type. Results: Among 1,098 eligible cases, there were 251 (22%) adverse TB treatment outcomes: 127 (51%) treatment failures, 73 (29%) recurrences, and 51 (20%) deaths. The primary outcome was independently associated with the Xpert MTB/RIF assay (medium-positive adjusted incidence rate ratio [aIRR], 1.91; 95% confidence interval [CI], 1.07-3.40; high-positive aIRR, 2.51; 95% CI, 1.41-4.46), positive AFB smear (aIRR, 1.48; 95% CI, 1.06-2.06), and positive liquid culture (aIRR, 1.98; 95% CI, 1.21-3.23) at baseline; Week 2 positive liquid culture (aIRR, 1.47; 95% CI, 1.04-2.09); and Week 8 positive AFB smear (aIRR, 1.63; 95% CI, 1.06-2.50) and positive liquid culture (aIRR, 1.54; 95% CI, 1.07-2.22). There was no evidence of Mycobacterium tuberculosis growth in the Mycobacterium Growth Indicator Tube at Week 4 conferring a higher risk of adverse outcomes (aIRR, 1.25; 95% CI, 0.89-1.75). Conclusions: Our analysis identifies Week 2 respiratory mycobacterial culture as the earliest microbiologic marker of unfavorable PTB treatment outcomes.
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Affiliation(s)
- Mandar Sudhir Paradkar
- BJ Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India
- Johns Hopkins Center for Infectious Diseases in India, Pune, India
| | - Neeta Nitin Pradhan
- BJ Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India
- Johns Hopkins Center for Infectious Diseases in India, Pune, India
| | | | | | - Amol Chavan
- BJ Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India
- Johns Hopkins Center for Infectious Diseases in India, Pune, India
| | | | | | | | - Sona Anil Deshmukh
- BJ Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India
- Johns Hopkins Center for Infectious Diseases in India, Pune, India
| | | | - Sachin Atre
- Johns Hopkins Center for Infectious Diseases in India, Pune, India
- Department of Respiratory Medicine and
| | - Swapnil Suresh Raskar
- BJ Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India
- Johns Hopkins Center for Infectious Diseases in India, Pune, India
| | | | - Akshay N. Gupte
- Division of Infectious Diseases, School of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- School of Public Health, Boston University, Boston, Massachusetts
| | - ArjunLal Kakrani
- Department of Medicine, Dr. D.Y. Patil Medical College, Hospital & Research Centre, Pune, India
| | - Jonathan Golub
- Division of Infectious Diseases, School of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Amita Gupta
- Division of Infectious Diseases, School of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Nikhil Anil Gupte
- BJ Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India
- Johns Hopkins Center for Infectious Diseases in India, Pune, India
- Division of Infectious Diseases, School of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Vidya Mave
- BJ Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India
- Johns Hopkins Center for Infectious Diseases in India, Pune, India
- Division of Infectious Diseases, School of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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5
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Scott LE, Shapiro AN, Da Silva MP, Tsoka J, Jacobson KR, Emch M, Moultrie H, Jenkins HE, Moore D, Van Rie A, Stevens WS. Integrating Molecular Diagnostics and GIS Mapping: A Multidisciplinary Approach to Understanding Tuberculosis Disease Dynamics in South Africa Using Xpert MTB/RIF. Diagnostics (Basel) 2023; 13:3163. [PMID: 37891984 PMCID: PMC10606157 DOI: 10.3390/diagnostics13203163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 08/30/2023] [Accepted: 09/14/2023] [Indexed: 10/29/2023] Open
Abstract
An investigation was carried out to examine the use of national Xpert MTB/RIF data (2013-2017) and GIS technology for MTB/RIF surveillance in South Africa. The aim was to exhibit the potential of using molecular diagnostics for TB surveillance across the country. The variables analysed include Mycobacterium tuberculosis (Mtb) positivity, the mycobacterial proportion of rifampicin-resistant Mtb (RIF), and probe frequency. The summary statistics of these variables were generated and aggregated at the facility and municipal level. The spatial distribution patterns of the indicators across municipalities were determined using the Moran's I and Getis Ord (Gi) statistics. A case-control study was conducted to investigate factors associated with a high mycobacterial load. Logistic regression was used to analyse this study's results. There was striking spatial heterogeneity in the distribution of Mtb and RIF across South Africa. The median patient age, urban setting classification, and number of health care workers were found to be associated with the mycobacterial load. This study illustrates the potential of using data generated from molecular diagnostics in combination with GIS technology for Mtb surveillance in South Africa. Spatially targeted interventions can be implemented in areas where high-burden Mtb persists.
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Affiliation(s)
- Lesley Erica Scott
- Wits Diagnostic Innovation Hub, Faculty of Health Science, University of the Witwatersrand, Johannesburg 2093, South Africa; (M.P.D.S.); (J.T.); (W.S.S.)
| | - Anne Nicole Shapiro
- Department of Biostatistics, Boston University School of Public Health, Boston, MA 02118, USA; (A.N.S.); (H.E.J.)
| | - Manuel Pedro Da Silva
- Wits Diagnostic Innovation Hub, Faculty of Health Science, University of the Witwatersrand, Johannesburg 2093, South Africa; (M.P.D.S.); (J.T.); (W.S.S.)
- National Priority Program of the National Health Laboratory Services (NHLS), Johannesburg 2131, South Africa
| | - Jonathan Tsoka
- Wits Diagnostic Innovation Hub, Faculty of Health Science, University of the Witwatersrand, Johannesburg 2093, South Africa; (M.P.D.S.); (J.T.); (W.S.S.)
| | - Karen Rita Jacobson
- Division of Infectious Diseases, Boston Medical Center, Boston, MA 02118, USA;
| | - Michael Emch
- Department of Epidemiology, University of North Carolina School, Chapel Hill, NC 27127, USA;
- Department of Geography and Environment, University of North Carolina, Chapel Hill, NC 27599, USA
| | - Harry Moultrie
- National Institute for Communicable Diseases of the National Health Laboratory Service, Johannesburg 2192, South Africa;
| | - Helen Elizabeth Jenkins
- Department of Biostatistics, Boston University School of Public Health, Boston, MA 02118, USA; (A.N.S.); (H.E.J.)
| | - David Moore
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK;
| | - Annelies Van Rie
- Faculty of Medicine and Health Sciences, University of Antwerp, 2000 Antwerpen, Belgium;
| | - Wendy Susan Stevens
- Wits Diagnostic Innovation Hub, Faculty of Health Science, University of the Witwatersrand, Johannesburg 2093, South Africa; (M.P.D.S.); (J.T.); (W.S.S.)
- National Priority Program of the National Health Laboratory Services (NHLS), Johannesburg 2131, South Africa
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6
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Solans BP, Imperial MZ, Olugbosi M, Savic RM. Analysis of Dynamic Efficacy Endpoints of the Nix-TB Trial. Clin Infect Dis 2023; 76:1903-1910. [PMID: 36804834 PMCID: PMC10249992 DOI: 10.1093/cid/ciad051] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Indexed: 02/23/2023] Open
Abstract
BACKGROUND Safer, better, and shorter treatments for multidrug-resistant (MDR) and extensively drug-resistant (XDR) tuberculosis (TB) are an urgent global health need. The phase 3 clinical trial Nix-TB (NCT02333799) tested a 6-month treatment of MDR and XDR-TB consisting of high-dose linezolid, bedaquiline, and pretomanid (BPaL). In this study, we investigate the relationship between the pharmacokinetic characteristics of the drugs, patient characteristics and efficacy endpoints from Nix-TB. METHODS Pharmacokinetic data were collected at weeks 2, 8, and 16. Efficacy endpoints including treatment outcomes, time to stable culture conversion, and longitudinal time to positivity in the mycobacterial growth indicator tube assay were each characterized using nonlinear mixed-effects modeling. Relationships between patient, treatment pharmacokinetics, and disease characteristics and efficacy endpoints were evaluated. RESULTS Data from 93 (85% of the total) participants were analyzed. Higher body mass index was associated with a lower incidence of unfavorable treatment outcomes. Median time to stable culture conversion was 3 months in patients with lower baseline burden compared with 4.5 months in patients with high baseline burden. Participants with minimal disease had steeper time to positivity trajectories compared with participants with high-risk phenotypes. No relationship between any drugs' pharmacokinetics (drug concentration or exposure metrics) and any efficacy outcomes was observed. CONCLUSIONS We have successfully described efficacy endpoints of a BPaL regimen from the Nix-TB trial. Participants with high-risk phenotypes significantly delayed time to culture conversion and bacterial clearance. The lack of a relationship between pharmacokinetic exposures and pharmacodynamic biomarkers opens the possibility to use lower, safer doses, particularly for toxicity-prone linezolid. CLINICAL TRIALS REGISTRATION NCT02333799.
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Affiliation(s)
- Belén P Solans
- Department of Bioengineering and Therapeutic Sciences, University of California San Francisco Schools of Pharmacy and Medicine, San Francisco, California, USA
- UCSF Center for Tuberculosis, University of California San Francisco, San Francisco, California, USA
| | - Marjorie Z Imperial
- Department of Bioengineering and Therapeutic Sciences, University of California San Francisco Schools of Pharmacy and Medicine, San Francisco, California, USA
- UCSF Center for Tuberculosis, University of California San Francisco, San Francisco, California, USA
| | | | - Rada M Savic
- Department of Bioengineering and Therapeutic Sciences, University of California San Francisco Schools of Pharmacy and Medicine, San Francisco, California, USA
- UCSF Center for Tuberculosis, University of California San Francisco, San Francisco, California, USA
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