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Espinosa-Pereiro J, Alagna R, Saluzzo F, González-Moreno J, Heinrich N, Sánchez-Montalvá A, Cirillo DM. A Systematic Review of Potential Biomarkers for Bacterial Burden and Treatment Efficacy Assessment in Tuberculosis Platform-Based Clinical Trials. J Infect Dis 2024; 229:1584-1595. [PMID: 37956107 DOI: 10.1093/infdis/jiad482] [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: 06/05/2023] [Revised: 09/28/2023] [Accepted: 10/27/2023] [Indexed: 11/15/2023] Open
Abstract
Adaptive platform trials can be more efficient than classic trials for developing new treatments. Moving from culture-based to simpler- or faster-to-measure biomarkers as efficacy surrogates may enhance this advantage. We performed a systematic review of treatment efficacy biomarkers in adults with tuberculosis. Platform trials can span different development phases. We grouped biomarkers as: α, bacterial load estimates used in phase 2a trials; β, early and end-of treatment end points, phase 2b-c trials; γ, posttreatment or trial-level estimates, phase 2c-3 trials. We considered as analysis unit (biomarker entry) each combination of biomarker, predicted outcome, and their respective measurement times or intervals. Performance metrics included: sensitivity, specificity, area under the receiver-operator curve (AUC), and correlation measures, and classified as poor, promising, or good. Eighty-six studies included 22 864 participants. From 1356 biomarker entries, 318 were reported with the performance metrics of interest, with 103 promising and 41 good predictors. Group results were: α, mycobacterial RNA and lipoarabinomannan (LAM) in sputum, and host metabolites in urine; β, mycobacterial RNA and host transcriptomic or cytokine signatures for early treatment response; and γ, host transcriptomics for recurrence. A combination of biomarkers from different categories could help in designing more efficient platform trials. Efforts to develop efficacy surrogates should be better coordinated.
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Affiliation(s)
- Juan Espinosa-Pereiro
- Infectious Diseases Department, Vall d'Hebrón University Hospital, Universitat Autónoma de Barcelona, Barcelona, Spain
- International Health Program, Catalan Institute of Health, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infeccioass, Instituto de Salud Carlos III, Madrid, Spain
| | - Riccardo Alagna
- San Raffaele Scientific Institute, Milan, Italy
- Qiagen, Srl, Milan, Italy
| | | | | | - Norbert Heinrich
- Center for International Health, University Hospital, Ludwig Maximilian University Munich, Munich, Germany
- German Center for Infection Research, Munich, Germany
- Division of Infectious Diseases and Tropical Medicine, University Hospital, Ludwig Maximilian University Munich (DZIF), Partner Site Munich, Munich, Germany
| | - Adrián Sánchez-Montalvá
- Infectious Diseases Department, Vall d'Hebrón University Hospital, Universitat Autónoma de Barcelona, Barcelona, Spain
- International Health Program, Catalan Institute of Health, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infeccioass, Instituto de Salud Carlos III, Madrid, Spain
- Grupo de Estudio de Micobacterias, Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica, Madrid, Spain
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Koele SE, Dorlo TPC, Upton CM, Aarnoutse RE, Svensson EM. Power to identify exposure-response relationships in phase IIa pulmonary tuberculosis trials with multi-dimensional bacterial load modeling. CPT Pharmacometrics Syst Pharmacol 2024; 13:374-385. [PMID: 38102814 PMCID: PMC10941589 DOI: 10.1002/psp4.13089] [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: 05/25/2023] [Revised: 10/04/2023] [Accepted: 11/15/2023] [Indexed: 12/17/2023] Open
Abstract
Adequate power to identify an exposure-response relationship in a phase IIa clinical trial for pulmonary tuberculosis (TB) is important for dose selection and design of follow-up studies. Currently, it is not known what response marker provides the pharmacokinetic-pharmacodynamic (PK-PD) model more power to identify an exposure-response relationship. We simulated colony-forming units (CFU) and time-to-positivity (TTP) measurements for four hypothetical drugs with different activity profiles for 14 days. The power to identify exposure-response relationships when analyzing CFU, TTP, or combined CFU + TTP data was determined at 60 total participants, or with 25 out of 60 participants in the lowest and highest dosing groups (unbalanced design). For drugs with moderate bactericidal activity, power was low (<59%), irrespective of the data analyzed. Power was 1.9% to 29.4% higher when analyzing TTP data compared to CFU data. Combined analysis of CFU and TTP further improved the power, on average by 4.2%. For a drug with a medium-high activity, the total sample size needed to achieve 80% power was 136 for CFU, 72 for TTP, and 68 for combined CFU + TTP data. The unbalanced design improved the power by 16% over the balanced design. In conclusion, the power to identify an exposure-response relationship is low for TB drugs with moderate bactericidal activity or with a slow onset of activity. TTP provides the PK-PD model with more power to identify exposure-response relationships compared to CFU, and combined analysis or an unbalanced dosing group study design offers modest further improvement.
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Affiliation(s)
- Simon E. Koele
- Department of Pharmacy, Radboudumc Research Institute for Medical Innovation (RIMI)Radboud University Medical CenterNijmegenThe Netherlands
| | | | | | - Rob E. Aarnoutse
- Department of Pharmacy, Radboudumc Research Institute for Medical Innovation (RIMI)Radboud University Medical CenterNijmegenThe Netherlands
| | - Elin M. Svensson
- Department of Pharmacy, Radboudumc Research Institute for Medical Innovation (RIMI)Radboud University Medical CenterNijmegenThe Netherlands
- Department of PharmacyUppsala UniversityUppsalaSweden
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3
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Powell SM, Jarsberg LG, Zionce ELM, Anderson LN, Gritsenko MA, Nahid P, Jacobs JM. Longitudinal analysis of host protein serum signatures of treatment and recovery in pulmonary tuberculosis. PLoS One 2024; 19:e0294603. [PMID: 38421964 PMCID: PMC10903915 DOI: 10.1371/journal.pone.0294603] [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: 06/30/2023] [Accepted: 11/03/2023] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND A better understanding of treatment progression and recovery in pulmonary tuberculosis (TB) infectious disease is crucial. This study analyzed longitudinal serum samples from pulmonary TB patients undergoing interventional treatment to identify surrogate markers for TB-related outcomes. METHODS Serum that was collected at baseline and 8, 17, 26, and 52 weeks from 30 TB patients experiencing durable cure were evaluated and compared using a sensitive LC-MS/MS proteomic platform for the detection and quantification of differential host protein signatures relative to timepoint. The global proteome signature was analyzed for statistical differences across the time course and between disease severity and treatment groups. RESULTS A total of 676 proteins showed differential expression in the serum over these timepoints relative to baseline. Comparisons to understand serum protein dynamics at 8 weeks, treatment endpoints at 17 and 26 weeks, and post-treatment at 52 weeks were performed. The largest protein abundance changes were observed at 8 weeks as the initial effects of antibiotic treatment strongly impacted inflammatory and immune modulated responses. However, the largest number of proteome changes was observed at the end of treatment time points 17 and 26 weeks respectively. Post-treatment 52-week results showed an abatement of differential proteome signatures from end of treatment, though interestingly those proteins uniquely significant at post-treatment were almost exclusively downregulated. Patients were additionally stratified based upon disease severity and compared across all timepoints, identifying 461 discriminating proteome signatures. These proteome signatures collapsed into discrete expression profiles with distinct pathways across immune activation and signaling, hemostasis, and metabolism annotations. Insulin-like growth factor (IGF) and Integrin signaling maintained a severity signature through 52 weeks, implying an intrinsic disease severity signature well into the post-treatment timeframe. CONCLUSION Previous proteome studies have primarily focused on the 8-week timepoint in relation to culture conversion status. While this study confirms previous observations, it also highlights some differences. The inclusion of additional end of treatment and post-treatment time points offers a more comprehensive assessment of treatment progression within the serum proteome. Examining the expression dynamics at these later time periods will help in the investigation of relapse patients and has provided indicative markers of response and recovery.
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Affiliation(s)
- Samantha M. Powell
- Biologcal Sciences Division, Pacific Northwest National Laboratory, Richland, Washington, United States of America
| | - Leah G. Jarsberg
- Division of Pulmonary and Critical Care Medicine, University of California, San Francisco, San Francisco, California, United States of America
| | - Erin L. M. Zionce
- Earth Systems Science Division, Pacific Northwest National Laboratory, Richland, Washington, United States of America
| | - Lindsey N. Anderson
- Biologcal Sciences Division, Pacific Northwest National Laboratory, Richland, Washington, United States of America
| | - Marina A. Gritsenko
- Biologcal Sciences Division, Pacific Northwest National Laboratory, Richland, Washington, United States of America
| | - Payam Nahid
- Division of Pulmonary and Critical Care Medicine, University of California, San Francisco, San Francisco, California, United States of America
| | - Jon M. Jacobs
- Environmental Molecular Sciences Laboratory, Pacific Northwest National Laboratory, Richland, Washington, United States of America
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Dufault SM, Crook AM, Rolfe K, Phillips PPJ. A flexible multi-metric Bayesian framework for decision-making in Phase II multi-arm multi-stage studies. Stat Med 2024; 43:501-513. [PMID: 38038137 DOI: 10.1002/sim.9961] [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] [Revised: 09/19/2023] [Accepted: 10/30/2023] [Indexed: 12/02/2023]
Abstract
We propose a multi-metric flexible Bayesian framework to support efficient interim decision-making in multi-arm multi-stage phase II clinical trials. Multi-arm multi-stage phase II studies increase the efficiency of drug development, but early decisions regarding the futility or desirability of a given arm carry considerable risk since sample sizes are often low and follow-up periods may be short. Further, since intermediate outcomes based on biomarkers of treatment response are rarely perfect surrogates for the primary outcome and different trial stakeholders may have different levels of risk tolerance, a single hypothesis test is insufficient for comprehensively summarizing the state of the collected evidence. We present a Bayesian framework comprised of multiple metrics based on point estimates, uncertainty, and evidence towards desired thresholds (a Target Product Profile) for (1) ranking of arms and (2) comparison of each arm against an internal control. Using a large public-private partnership targeting novel TB arms as a motivating example, we find via simulation study that our multi-metric framework provides sufficient confidence for decision-making with sample sizes as low as 30 patients per arm, even when intermediate outcomes have only moderate correlation with the primary outcome. Our reframing of trial design and the decision-making procedure has been well-received by research partners and is a practical approach to more efficient assessment of novel therapeutics.
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Affiliation(s)
- Suzanne M Dufault
- Division of Biostatistics, Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
- UCSF Center for Tuberculosis, University of California, San Francisco, CA, USA
| | - Angela M Crook
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology, London, UK
| | | | - Patrick P J Phillips
- UCSF Center for Tuberculosis, University of California, San Francisco, CA, USA
- Division of Pulmonary and Critical Care Medicine, University of California, San Francisco, San Francisco, CA, USA
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Zhang F, Zhang F, Dong Y, Li L, Pang Y. New Insights into Biomarkers for Evaluating Therapy Efficacy in Pulmonary Tuberculosis: A Narrative Review. Infect Dis Ther 2023; 12:2665-2689. [PMID: 37938418 PMCID: PMC10746651 DOI: 10.1007/s40121-023-00887-x] [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: 09/21/2023] [Accepted: 10/20/2023] [Indexed: 11/09/2023] Open
Abstract
Evaluating therapy efficacy is crucial for patients with tuberculosis (TB), especially those with drug-resistant tuberculosis (DR-TB). The World Health Organization currently recommends sputum smear and culture as the standard methods for evaluating pulmonary tuberculosis (PTB) therapy efficacy. However, these approaches have limitations including low sensitivity, lengthy culture periods, and susceptibility to contamination. There is an urgent need for dependable biomarkers to evaluate therapy efficacy in patients with PTB. Numerous new biomarkers of Mycobacterium tuberculosis (MTB) and the host have been used in recent studies to evaluate PTB therapy efficacy. A systematic review and update of these biomarkers can facilitate the discovery of novel biomarkers and assessment models, as well as provide a solid scientific basis for alternative indicators of evaluating therapy efficacy. In this review we summarize the recent advancements and limitations of biomarkers used to monitor therapy efficacy, highlighting the importance of utilizing a combination of biomarkers. Although some biomarkers have potential in evaluating the efficacy of therapy in patients with PTB, they also have some limitations. Further research, validation, and optimization are required to identify the most reliable and effective alternative biomarkers and apply them to clinical practice.
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Affiliation(s)
- Fuzhen Zhang
- Department of Bacteriology and Immunology, Beijing Chest Hospital, Capital Medical University/Beijing Tuberculosis & Thoracic Tumor Research Institute, No. 97, Machang, Tongzhou District, Beijing, 101149, People's Republic of China
- Department of Epidemiology, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, 250012, People's Republic of China
| | - Fan Zhang
- Department of Epidemiology, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, 250012, People's Republic of China
| | - Yu Dong
- Department of Bacteriology and Immunology, Beijing Chest Hospital, Capital Medical University/Beijing Tuberculosis & Thoracic Tumor Research Institute, No. 97, Machang, Tongzhou District, Beijing, 101149, People's Republic of China
| | - Liang Li
- Department of Bacteriology and Immunology, Beijing Chest Hospital, Capital Medical University/Beijing Tuberculosis & Thoracic Tumor Research Institute, No. 97, Machang, Tongzhou District, Beijing, 101149, People's Republic of China.
- Department of Epidemiology, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, 250012, People's Republic of China.
| | - Yu Pang
- Department of Bacteriology and Immunology, Beijing Chest Hospital, Capital Medical University/Beijing Tuberculosis & Thoracic Tumor Research Institute, No. 97, Machang, Tongzhou District, Beijing, 101149, People's Republic of China.
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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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Lawal IO, Abubakar S, Ankrah AO, Sathekge MM. Molecular Imaging of Tuberculosis. Semin Nucl Med 2023; 53:37-56. [PMID: 35882621 DOI: 10.1053/j.semnuclmed.2022.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 07/05/2022] [Indexed: 01/28/2023]
Abstract
Despite the introduction of many novel diagnostic techniques and newer treatment agents, tuberculosis (TB) remains a major cause of death from an infectious disease worldwide. With about a quarter of humanity harboring Mycobacterium tuberculosis, the causative agent of TB, the current efforts geared towards reducing the scourge due to TB must be sustained. At the same time, newer alternative modalities for diagnosis and treatment response assessment are considered. Molecular imaging entails the use of radioactive probes that exploit molecular targets expressed by microbes or human cells for imaging using hybrid scanners that provide both anatomic and functional features of the disease being imaged. Fluorine-18 fluorodeoxyglucose (FDG) is the most investigated radioactive probe for TB imaging in research and clinical practice. When imaged with positron emission tomography interphase with computed tomography (PET/CT), FDG PET/CT performs better than sputum conversion for predicting treatment outcome. At the end of treatment, FDG PET/CT has demonstrated the unique ability to identify a subset of patients declared cured based on the current standard of care but who still harbor live bacilli capable of causing disease relapse after therapy discontinuation. Our understanding of the pathogenesis and evolution of TB has improved significantly in the last decade, owing to the introduction of FDG PET/CT in TB research. FDG is a non-specific probe as it targets the host inflammatory response to Mycobacterium tuberculosis, which is not specifically different in TB compared with other infectious conditions. Ongoing efforts are geared towards evaluating the utility of newer probes targeting different components of the TB granuloma, the hallmark of TB lesions, including hypoxia, neovascularization, and fibrosis, in TB management. The most exciting category of non-FDG PET probes developed for molecular imaging of TB appears to be radiolabeled anti-tuberculous drugs for use in studying the pharmacokinetic characteristics of the drugs. This allows for the non-invasive study of drug kinetics in different body compartments concurrently, providing an insight into the spatial heterogeneity of drug exposure in different TB lesions. The ability to repeat molecular imaging using radiolabeled anti-tuberculous agents also offers an opportunity to study the temporal changes in drug kinetics within the different lesions during treatment.
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Affiliation(s)
- Ismaheel O Lawal
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology and Imaging Sciences, Emory University, Atlanta, GA; Department of Nuclear Medicine, University of Pretoria, Pretoria, Gauteng, South Africa.
| | - Sofiullah Abubakar
- Department of Radiology and Nuclear Medicine, Sultan Qaboos Comprehensive Cancer Care and Research Center, Muscat, Oman
| | - Alfred O Ankrah
- Department of Nuclear Medicine, University of Pretoria, Pretoria, Gauteng, South Africa; National Center for Radiotherapy Oncology and Nuclear Medicine, Korle Bu Teaching Hospital, Accra, Ghana; Medical Imaging Center, Department of Nuclear Medicine and Molecular Imaging, University Medical Center Groningen, Groningen, The Netherlands
| | - Mike M Sathekge
- Department of Nuclear Medicine, University of Pretoria, Pretoria, Gauteng, South Africa; Nuclear Medicine Research Infrastructure (NuMeRI), Steve Biko Academic Hospital, Pretoria, South Africa
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Malatesta S, Weir IR, Weber SE, Bouton TC, Carney T, Theron D, Myers B, Horsburgh CR, Warren RM, Jacobson KR, White LF. Methods for handling missing data in serially sampled sputum specimens for mycobacterial culture conversion calculation. BMC Med Res Methodol 2022; 22:297. [PMID: 36402979 PMCID: PMC9675206 DOI: 10.1186/s12874-022-01782-8] [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: 07/14/2022] [Accepted: 11/02/2022] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND The occurrence and timing of mycobacterial culture conversion is used as a proxy for tuberculosis treatment response. When researchers serially sample sputum during tuberculosis studies, contamination or missed visits leads to missing data points. Traditionally, this is managed by ignoring missing data or simple carry-forward techniques. Statistically advanced multiple imputation methods potentially decrease bias and retain sample size and statistical power. METHODS We analyzed data from 261 participants who provided weekly sputa for the first 12 weeks of tuberculosis treatment. We compared methods for handling missing data points in a longitudinal study with a time-to-event outcome. Our primary outcome was time to culture conversion, defined as two consecutive weeks with no Mycobacterium tuberculosis growth. Methods used to address missing data included: 1) available case analysis, 2) last observation carried forward, and 3) multiple imputation by fully conditional specification. For each method, we calculated the proportion culture converted and used survival analysis to estimate Kaplan-Meier curves, hazard ratios, and restricted mean survival times. We compared methods based on point estimates, confidence intervals, and conclusions to specific research questions. RESULTS The three missing data methods lead to differences in the number of participants achieving conversion; 78 (32.8%) participants converted with available case analysis, 154 (64.7%) converted with last observation carried forward, and 184 (77.1%) converted with multiple imputation. Multiple imputation resulted in smaller point estimates than simple approaches with narrower confidence intervals. The adjusted hazard ratio for smear negative participants was 3.4 (95% CI 2.3, 5.1) using multiple imputation compared to 5.2 (95% CI 3.1, 8.7) using last observation carried forward and 5.0 (95% CI 2.4, 10.6) using available case analysis. CONCLUSION We showed that accounting for missing sputum data through multiple imputation, a statistically valid approach under certain conditions, can lead to different conclusions than naïve methods. Careful consideration for how to handle missing data must be taken and be pre-specified prior to analysis. We used data from a TB study to demonstrate these concepts, however, the methods we described are broadly applicable to longitudinal missing data. We provide valuable statistical guidance and code for researchers to appropriately handle missing data in longitudinal studies.
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Affiliation(s)
- Samantha Malatesta
- Department of Biostatistics, Boston University School of Public Health, 801 Massachusetts Ave, 3rd Floor, Boston, MA, 02119, USA.
| | - Isabelle R Weir
- Center for Biostatistics in AIDS Research in the Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Sarah E Weber
- Section of Infectious Diseases, Boston Medical Center, Boston, MA, USA
| | - Tara C Bouton
- Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Tara Carney
- Alcohol, Tobacco and Other Drug Research Unit, South African Medical Research Council, Tygerberg, South Africa
- Department of Psychiatry and Mental Health, University of Cape Town, Groote Schuur Hospital, Observatory, Cape Town, South Africa
| | | | - Bronwyn Myers
- Alcohol, Tobacco and Other Drug Research Unit, South African Medical Research Council, Tygerberg, South Africa
- Department of Psychiatry and Mental Health, University of Cape Town, Groote Schuur Hospital, Observatory, Cape Town, South Africa
- Curtin enAble Institute, Faculty of Health Sciences, Curtin University, Perth, Australia
| | - C Robert Horsburgh
- Department of Biostatistics, Boston University School of Public Health, 801 Massachusetts Ave, 3rd Floor, Boston, MA, 02119, USA
- Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, Boston, MA, USA
- Departments of Epidemiology and Global Health, Boston University School of Public Health, Boston, MA, USA
| | - Robin M Warren
- DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research and South African Medical Research Council Centre for Tuberculosis Research, Cape Town, South Africa
- Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Karen R Jacobson
- Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Laura F White
- Department of Biostatistics, Boston University School of Public Health, 801 Massachusetts Ave, 3rd Floor, Boston, MA, 02119, USA
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Thakur C, Tripathi A, Ravichandran S, Shivananjaiah A, Chakraborty A, Varadappa S, Chikkavenkatappa N, Nagarajan D, Lakshminarasimhaiah S, Singh A, Chandra N. A new blood-based RNA signature (R 9), for monitoring effectiveness of tuberculosis treatment in a South Indian longitudinal cohort. iScience 2022; 25:103745. [PMID: 35118358 PMCID: PMC8800112 DOI: 10.1016/j.isci.2022.103745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 03/31/2021] [Accepted: 01/06/2022] [Indexed: 11/17/2022] Open
Abstract
Tuberculosis (TB) treatment involves a multidrug regimen for six months, and until two months, it is unclear if treatment is effective. This delay can lead to the evolution of drug resistance, lung damage, disease spread, and transmission. We identify a blood-based 9-gene signature using a computational pipeline that constructs and interrogates a genome-wide transcriptome-integrated protein-interaction network. The identified signature is able to determine treatment response at week 1-2 in three independent public datasets. Signature-based R9-score correctly detected treatment response at individual timepoints (204 samples) from a newly developed South Indian longitudinal cohort involving 32 patients with pulmonary TB. These results are consistent with conventional clinical metrics and can discriminate good from poor treatment responders at week 2 (AUC 0.93(0.81-1.00)). In this work, we provide proof of concept that the R9-score can determine treatment effectiveness, making a case for designing a larger clinical study.
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Affiliation(s)
- Chandrani Thakur
- Department of Biochemistry, Indian Institute of Science, Bangalore, India
| | - Ashutosh Tripathi
- Department of Microbiology and Cell Biology, Indian Institute of Science, Bangalore, India
- Centre for Infectious Disease Research, Indian Institute of Science, Bangalore, India
| | | | - Akshatha Shivananjaiah
- SDS Tuberculosis Research Centre and Rajiv Gandhi Institute of Chest Diseases, Bangalore, India
| | - Anushree Chakraborty
- SDS Tuberculosis Research Centre and Rajiv Gandhi Institute of Chest Diseases, Bangalore, India
| | - Sreekala Varadappa
- SDS Tuberculosis Research Centre and Rajiv Gandhi Institute of Chest Diseases, Bangalore, India
| | | | - Deepesh Nagarajan
- Department of Biochemistry, Indian Institute of Science, Bangalore, India
| | | | - Amit Singh
- Department of Microbiology and Cell Biology, Indian Institute of Science, Bangalore, India
- Centre for Infectious Disease Research, Indian Institute of Science, Bangalore, India
| | - Nagasuma Chandra
- Department of Biochemistry, Indian Institute of Science, Bangalore, India
- National Mathematics Initiative, Indian Institute of Science, Bangalore, India
- Centre for Biosystems Science and Engineering, Indian Institute of Science, Bangalore, India
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10
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Imperial MZ, Phillips PPJ, Nahid P, Savic RM. Precision-Enhancing Risk Stratification Tools for Selecting Optimal Treatment Durations in Tuberculosis Clinical Trials. Am J Respir Crit Care Med 2021; 204:1086-1096. [PMID: 34346856 PMCID: PMC8663006 DOI: 10.1164/rccm.202101-0117oc] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 07/28/2021] [Indexed: 12/04/2022] Open
Abstract
Rationale: No evidence-based tools exist to enhance precision in the selection of patient-specific optimal treatment durations to study in tuberculosis clinical trials. Objectives: To develop risk stratification tools that assign patients with tuberculosis into risk groups of unfavorable outcome and inform selection of optimal treatment duration for each patient strata to study in clinical trials. Methods: Publicly available data from four phase 3 trials, each evaluating treatment duration shortening from 6 to 4 months, were used to develop parametric time-to-event models that describe unfavorable outcomes. Regimen, baseline, and on-treatment characteristics were evaluated as predictors of outcomes. Exact regression coefficients of predictors were used to assign risk groups and predict optimal treatment durations. Measurements and Main Results: The parametric model had an area under the receiver operating characteristic curve of 0.72. A six-item risk score (HIV status, smear grade, sex, cavitary disease status, body mass index, and Month 2 culture status) successfully grouped participants into low (1,060/3,791; 28%), moderate (1,740/3,791; 46%), and high (991/3,791; 26%) risk, requiring treatment durations of 4, 6, and greater than 6 months, respectively, to reach a target cure rate of 93% when receiving standard-dose rifamycin-containing regimens. With current one-duration-fits-all approaches, high-risk groups have a 3.7-fold (95% confidence interval, 2.7-5.1) and 2.4-fold (1.9-2.9) higher hazard risk of unfavorable outcomes compared with low- and moderate-risk groups, respectively. Four-month regimens were noninferior to the standard 6-month regimen in the low-risk group. Conclusions: Our model discrimination was modest but consistent with current models of unfavorable outcomes. Our results showed that stratified medicine approaches are feasible and may achieve high cure rates in all patients with tuberculosis. An interactive risk stratification tool is provided to facilitate decision-making in the regimen development pathway.
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Affiliation(s)
- Marjorie Z. Imperial
- Department of Bioengineering and Therapeutic Sciences
- University of California, San Francisco, Center for Tuberculosis, and
| | - Patrick P. J. Phillips
- University of California, San Francisco, Center for Tuberculosis, and
- Division of Pulmonary and Critical Care Medicine, San Francisco General Hospital, University of California, San Francisco, San Francisco, California
| | - Payam Nahid
- University of California, San Francisco, Center for Tuberculosis, and
- Division of Pulmonary and Critical Care Medicine, San Francisco General Hospital, University of California, San Francisco, San Francisco, California
| | - Radojka M. Savic
- Department of Bioengineering and Therapeutic Sciences
- University of California, San Francisco, Center for Tuberculosis, and
- Division of Pulmonary and Critical Care Medicine, San Francisco General Hospital, University of California, San Francisco, San Francisco, California
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11
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Musisi E, Dide-Agossou C, Al Mubarak R, Rossmassler K, Ssesolo AW, Kaswabuli S, Byanyima P, Sanyu I, Zawedde J, Worodria W, Voskuil MI, Savic RM, Nahid P, Davis JL, Huang L, Moore CM, Walter ND. Reproducibility of the Ribosomal RNA Synthesis Ratio in Sputum and Association with Markers of Mycobacterium tuberculosis Burden. Microbiol Spectr 2021; 9:e0048121. [PMID: 34494858 PMCID: PMC8557932 DOI: 10.1128/spectrum.00481-21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 08/09/2021] [Indexed: 11/21/2022] Open
Abstract
There is a critical need for improved pharmacodynamic markers for use in human tuberculosis (TB) drug trials. Pharmacodynamic monitoring in TB has conventionally used culture or molecular methods to enumerate the burden of Mycobacterium tuberculosis organisms in sputum. A recently proposed assay called the rRNA synthesis (RS) ratio measures a fundamentally novel property, how drugs impact ongoing bacterial rRNA synthesis. Here, we evaluated RS ratio as a potential pharmacodynamic monitoring tool by testing pretreatment sputa from 38 Ugandan adults with drug-susceptible pulmonary TB. We quantified the RS ratio in paired pretreatment sputa and evaluated the relationship between the RS ratio and microbiologic and molecular markers of M. tuberculosis burden. We found that the RS ratio was highly repeatable and reproducible in sputum samples. The RS ratio was independent of M. tuberculosis burden, confirming that it measures a distinct new property. In contrast, markers of M. tuberculosis burden were strongly associated with each other. These results indicate that the RS ratio is repeatable and reproducible and provides a distinct type of information from markers of M. tuberculosis burden. IMPORTANCE This study takes a major next step toward practical application of a novel pharmacodynamic marker that we believe will have transformative implications for tuberculosis. This article follows our recent report in Nature Communications that an assay called the rRNA synthesis (RS) ratio indicates the treatment-shortening of drugs and regimens. Distinct from traditional measures of bacterial burden, the RS ratio measures a fundamentally novel property, how drugs impact ongoing bacterial rRNA synthesis.
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Affiliation(s)
- Emmanuel Musisi
- Infectious Disease Research Collaboration, Kampala, Uganda
- Department of Biochemistry, Makerere University, Kampala, Uganda
- Department of Medical and Biological Sciences, Infection and Global Health Division, University of St. Andrews, St. Andrews, United Kingdom
| | | | - Reem Al Mubarak
- Rocky Mountain Regional VA Medical Center, Aurora, Colorado, USA
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Karen Rossmassler
- Rocky Mountain Regional VA Medical Center, Aurora, Colorado, USA
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | | | | | | | - Ingvar Sanyu
- Infectious Disease Research Collaboration, Kampala, Uganda
| | | | | | - Martin I. Voskuil
- Department of Immunology and Microbiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Consortium for Applied Microbial Metrics, Aurora, Colorado, USA
| | - Rada M. Savic
- Consortium for Applied Microbial Metrics, Aurora, Colorado, USA
- Department of Bioengineering and Therapeutic Sciences, University of California San Francisco, San Francisco, California, USA
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco, San Francisco, California, USA
- Division of HIV, Infectious Diseases, and Global Medicine, University of California San Francisco, San Francisco, California, USA
| | - Payam Nahid
- Consortium for Applied Microbial Metrics, Aurora, Colorado, USA
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco, San Francisco, California, USA
- Division of HIV, Infectious Diseases, and Global Medicine, University of California San Francisco, San Francisco, California, USA
- UCSF Center for Tuberculosis, San Francisco, California, USA
| | - J. Lucian Davis
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, USA
- Pulmonary, Critical Care, and Sleep Medicine Section, Yale School of Medicine, New Haven, Connecticut, USA
| | - Laurence Huang
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco, San Francisco, California, USA
- Division of HIV, Infectious Diseases, and Global Medicine, University of California San Francisco, San Francisco, California, USA
- Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Camille M. Moore
- Division of Biostatistics and Bioinformatics, National Jewish Health, Denver, Colorado, USA
| | - Nicholas D. Walter
- Rocky Mountain Regional VA Medical Center, Aurora, Colorado, USA
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Consortium for Applied Microbial Metrics, Aurora, Colorado, USA
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12
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Gupte AN, Kumar P, Araújo-Pereira M, Kulkarni V, Paradkar M, Pradhan N, Menon P, Chandrasekaran PD, Hanna LE, Yogendra Shivakumar SVB, Rockwood N, Du Bruyn E, Karyakarte R, Gaikwad S, Bollinger R, Golub J, Gupte N, Viswanathan V, Wilkinson RJ, Mave V, Babu S, Kornfeld H, Andrade BB, Gupta A. Baseline IL-6 is a biomarker for unfavorable tuberculosis treatment outcomes: a multi-site discovery and validation study. Eur Respir J 2021; 59:13993003.00905-2021. [PMID: 34711538 PMCID: PMC7612881 DOI: 10.1183/13993003.00905-2021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 08/18/2021] [Indexed: 11/24/2022]
Abstract
Background Biomarkers of unfavorable tuberculosis treatment outcomes are needed to accelerate new drug and regimen development. Whether plasma cytokine levels can predict unfavorable tuberculosis treatment outcomes is unclear. Methods We identified and internally validated the association between 20 a-priori selected plasma inflammatory markers and unfavorable treatment outcomes of failure, recurrence and all-cause mortality among adults with drug-sensitive pulmonary tuberculosis in India. We externally validated these findings in two independent cohorts of predominantly diabetic and HIV coinfected tuberculosis patients in India and South Africa, respectively. Results Pre-treatment IFN-γ, IL-13 and IL-6 were associated with treatment failure in the discovery analysis. Internal validation confirmed higher pre-treatment IL-6 concentrations among failure cases compared to controls. External validation among predominantly diabetic tuberculosis patients found an association between pre-treatment IL-6 concentrations and subsequent recurrence and death. Similarly, external validation among predominantly HIV coinfected tuberculosis patients found an association between pre-treatment IL-6 concentrations and subsequent treatment failure and death. In a pooled analysis of 363 tuberculosis cases from the Indian and South African validation cohorts, high pre-treatment IL-6 concentrations were associated with higher risk of failure (adjusted odds ratio [aOR]=2.16, 95%CI 1.08-4.33, p=0.02), recurrence (aOR=5.36, 95%CI 2.48-11.57, p<0.001) and death (aOR=4.62, 95%CI 1.95-10.95, p<0.001). Adding baseline IL-6 to a risk-prediction model comprising of low BMI, high smear grade and cavitation improved model performance by 15 percent (C-statistic of 0.66 versus 0.76, p=0.02). Conclusion Pre-treatment IL-6 is a biomarker for unfavorable tuberculosis treatment outcomes. Future studies should identify optimal IL-6 concentrations for point-of-care risk prediction.
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Affiliation(s)
- Akshay N Gupte
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, USA .,Center for Clinical Global Health Education, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Pavan Kumar
- National Institute for Research in Tuberculosis, Chennai, India
| | - Mariana Araújo-Pereira
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz (FIOCRUZ), Salvador, Brazil.,Multinational Organization Network Sponsoring Translational and Epidemiological Research, Salvador, Brazil.,Faculdade de Medicina, Universidade Federal da Bahia, Salvador, Brazil
| | - Vandana Kulkarni
- Center for Clinical Global Health Education, Johns Hopkins University School of Medicine, Baltimore, USA.,Byramjee-Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India.,Johns Hopkins India Private Limited, Pune, India
| | - Mandar Paradkar
- Center for Clinical Global Health Education, Johns Hopkins University School of Medicine, Baltimore, USA.,Byramjee-Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India.,Johns Hopkins India Private Limited, Pune, India
| | - Neeta Pradhan
- Center for Clinical Global Health Education, Johns Hopkins University School of Medicine, Baltimore, USA.,Byramjee-Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India.,Johns Hopkins India Private Limited, Pune, India
| | - Pradeep Menon
- National Institute for Research in Tuberculosis, Chennai, India
| | | | | | | | - Neesha Rockwood
- Wellcome Centre for Infectious Disease Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, South Africa.,Department of Microbiology, Faculty of Medicine, University of Colombo, Colombo 8, Sri Lanka.,Department of Infectious Diseases, Imperial College London, United Kingdom
| | - Elsa Du Bruyn
- Wellcome Centre for Infectious Disease Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, South Africa.,Department of Infectious Diseases, University of Cape Town, Observatory, South Africa
| | - Rajesh Karyakarte
- Department of Microbiology, Byramjee-Jeejeebhoy Government Medical College, Pune, India
| | - Sanjay Gaikwad
- Department of Pulmonary Medicine, Byramjee-Jeejeebhoy Government Medical College, Pune, India
| | - Robert Bollinger
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, USA.,Center for Clinical Global Health Education, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Jonathan Golub
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, USA.,Center for Tuberculosis Research, Johns Hopkins University, Baltimore, USA
| | - Nikhil Gupte
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, USA.,Center for Clinical Global Health Education, Johns Hopkins University School of Medicine, Baltimore, USA
| | | | - Robert J Wilkinson
- Wellcome Centre for Infectious Disease Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, South Africa.,Department of Infectious Diseases, Imperial College London, United Kingdom.,Department of Infectious Diseases, University of Cape Town, Observatory, South Africa.,The Francis Crick Institute, London, UK
| | - Vidya Mave
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, USA.,Center for Clinical Global Health Education, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Subash Babu
- National Institutes of Health - National Institute for Research in Tuberculosis - International Center for Excellence in Research, Chennai, India
| | - Hardy Kornfeld
- Division of Pulmonary Medicine, University of Massachusetts Medical School, Worcester, USA
| | - Bruno B Andrade
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz (FIOCRUZ), Salvador, Brazil.,Multinational Organization Network Sponsoring Translational and Epidemiological Research, Salvador, Brazil.,Faculdade de Medicina, Universidade Federal da Bahia, Salvador, Brazil
| | - Amita Gupta
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, USA.,Center for Clinical Global Health Education, Johns Hopkins University School of Medicine, Baltimore, USA
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13
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Zhang N, Savic RM, Boeree MJ, Peloquin CA, Weiner M, Heinrich N, Bliven-Sizemore E, Phillips PPJ, Hoelscher M, Whitworth W, Morlock G, Posey J, Stout JE, Mac Kenzie W, Aarnoutse R, Dooley KE. Optimising pyrazinamide for the treatment of tuberculosis. Eur Respir J 2021; 58:13993003.02013-2020. [PMID: 33542052 DOI: 10.1183/13993003.02013-2020] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 12/11/2020] [Indexed: 11/05/2022]
Abstract
Pyrazinamide is a potent sterilising agent that shortens the treatment duration needed to cure tuberculosis. It is synergistic with novel and existing drugs for tuberculosis. The dose of pyrazinamide that optimises efficacy while remaining safe is uncertain, as is its potential role in shortening treatment duration further.Pharmacokinetic data, sputum culture, and safety laboratory results were compiled from Tuberculosis Trials Consortium (TBTC) studies 27 and 28 and Pan-African Consortium for the Evaluation of Antituberculosis Antibiotics (PanACEA) multi-arm multi-stage tuberculosis (MAMS-TB), multi-centre phase 2 trials in which participants received rifampicin (range 10-35 mg·kg-1), pyrazinamide (range 20-30 mg·kg-1), plus two companion drugs. Pyrazinamide pharmacokinetic-pharmacodynamic (PK-PD) and pharmacokinetic-toxicity analyses were performed.In TBTC studies (n=77), higher pyrazinamide maximum concentration (Cmax) was associated with shorter time to culture conversion (TTCC) and higher probability of 2-month culture conversion (p-value<0.001). Parametric survival analyses showed that relationships varied geographically, with steeper PK-PD relationships seen among non-African than African participants. In PanACEA MAMS-TB (n=363), TTCC decreased as pyrazinamide Cmax increased and varied by rifampicin area under the curve (p-value<0.01). Modelling and simulation suggested that very high doses of pyrazinamide (>4500 mg) or increasing both pyrazinamide and rifampicin would be required to reach targets associated with treatment shortening. Combining all trials, liver toxicity was rare (3.9% with grade 3 or higher liver function tests (LFT)), and no relationship was seen between pyrazinamide Cmax and LFT levels.Pyrazinamide's microbiological efficacy increases with increasing drug concentrations. Optimising pyrazinamide alone, though, is unlikely to be sufficient to allow tuberculosis treatment shortening; rather, rifampicin dose would need to be increased in parallel.
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Affiliation(s)
- Nan Zhang
- University of California, San Francisco, School of Pharmacy, San Francisco, CA, USA
| | - Radojka M Savic
- University of California, San Francisco, School of Pharmacy, San Francisco, CA, USA
| | - Martin J Boeree
- Depts of Lung Diseases and Pharmacy, Radboud Institute for Health Sciences, Radboud university medical center, Nijmegen, The Netherlands
| | - Charles A Peloquin
- College of Pharmacy and Emerging Pathogens Institute, University of Florida, Gainesville, FL, USA
| | - Marc Weiner
- Veterans Administration Medical Center, San Antonio, TX, USA
| | - Norbert Heinrich
- Division of Infectious Diseases and Tropical Medicine, Medical Center of the University of Munich, and German Center for Infection Research (DZIF), Munich Partner site, Munich, Germany
| | | | - Patrick P J Phillips
- Center for Tuberculosis, University of California San Francisco, San Francisco, CA, USA
| | - Michael Hoelscher
- Division of Infectious Diseases and Tropical Medicine, Medical Center of the University of Munich, and German Center for Infection Research (DZIF), Munich Partner site, Munich, Germany
| | | | - Glenn Morlock
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - James Posey
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Jason E Stout
- UCSF Center for Tuberculosis, University of California San Francisco, San Francisco, CA, USA
| | | | - Robert Aarnoutse
- Depts of Lung Diseases and Pharmacy, Radboud Institute for Health Sciences, Radboud university medical center, Nijmegen, The Netherlands
| | - Kelly E Dooley
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
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14
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Weir IR, Wasserman S. Treatment effect measures for culture conversion endpoints in phase IIb tuberculosis treatment trials. Clin Infect Dis 2021; 73:2131-2139. [PMID: 34254635 DOI: 10.1093/cid/ciab576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Indexed: 11/12/2022] Open
Abstract
Phase IIb trials of tuberculosis therapy rely on early biomarkers of treatment effect. Despite limited predictive ability for clinical outcomes, culture conversion, the event in which an individual previously culture positive for Mycobacterium tuberculosis yields a negative culture after initiating treatment, is a commonly used endpoint. Lack of consensus on how to define the outcome and corresponding measure of treatment effect complicates interpretation and limits between-trial comparisons. We review common analytic approaches to measuring treatment effect and introduce difference in restricted mean survival times as an alternative to identify faster times to culture conversion and express magnitude of effect on the time scale. Findings from the PanACEA MAMSTB trial are reanalyzed as an illustrative example. In a systematic review we demonstrate variability in analytic approaches, sampling strategies, and outcome definitions in phase IIb tuberculosis trials. Harmonization would allow for larger meta-analyses, and may help expedite advancement of new TB therapeutics.
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Affiliation(s)
- Isabelle R Weir
- Center for Biostatistics in AIDS Research in the Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Sean Wasserman
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa.,Division of Infectious Diseases and HIV Medicine, Department of Medicine, University of Cape Town, Cape Town, South Africa
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15
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A Longitudinal Model-Based Biomarker Analysis of Exposure Response in Adults with Pulmonary Tuberculosis. Antimicrob Agents Chemother 2021; 65:e0179420. [PMID: 34252302 PMCID: PMC8448095 DOI: 10.1128/aac.01794-20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
The identification of sensitive, specific, and reliable biomarkers that can be quantified in the early phases of tuberculosis treatment and predictive of long-term outcome is key for the development of an effective short-course treatment regimen. Time to positivity (TTP), a biomarker of treatment outcome against Mycobacterium tuberculosis, measures longitudinal bacterial growth in mycobacterial growth indicator tube broth culture and may be predictive of standard time to stable culture conversion (TSCC). In two randomized phase 2b trials investigating dose-ranging rifapentine (Studies 29 and 29X), 662 participants had sputum collected over 6 months where TTP, TSCC, and time to culture conversion were quantified. The goals of this post hoc study were to characterize longitudinal TTP profiles and to identify individual patient characteristics associated with delayed time to culture conversion. In order to do so, a nonlinear mixed-effects model describing longitudinal TTP was built. Independent variables associated with increased bacterial clearance (increased TTP), assessed by subject-specific and population-level trajectories, were higher rifapentine exposure, lower baseline grade of sputum acid-fast bacillus smear, absence of productive cough, and lower extent of lung infiltrates on radiographs. Importantly, sensitivity analysis revealed that major learning milestones in phase 2b trials, such as significant exposure-response and covariate relationships, could be detected using truncated TTP data as early as 6 weeks from start of treatment, suggesting alternative phase 2b study designs. The TTP model built depicts a novel phase 2b surrogate endpoint that can inform early assessment of experimental treatment efficacy and treatment failure or relapse in patients treated with shorter and novel TB treatment regimens, improving efficiency of phase 2 clinical trials. (The studies discussed in this paper have been registered at ClinicalTrials.gov under identifiers NCT00694629 and NCT01043575.)
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16
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Kloprogge F, Abubakar I, Esmail H, Hack V, Kunst H, McHugh TD, Noursadeghi M, Surey J, Tiberi S, Lipman M. Exploring a combined biomarker for tuberculosis treatment response: protocol for a prospective observational cohort study. BMJ Open 2021; 11:e052885. [PMID: 34244287 PMCID: PMC8268918 DOI: 10.1136/bmjopen-2021-052885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 06/21/2021] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION An improved understanding of factors explaining tuberculosis (TB) treatment response is urgently needed to help clinicians optimise and personalise treatment and assist scientists undertaking novel treatment regimen trials. Promising outcome proxy measures, including sputum bacillary load and host immune response, are widely reported with variable results. However, they have not been studied together in combination with antibiotic exposure. The aim of this observational cohort study is to investigate which antibiotic exposures correlate with sputum bacillary load and which with the host immune response. Subsequently, we will explore if these correlations can be used to inform a candidate combined biomarker predicting cure. METHODS AND ANALYSIS All patients aged ≥ 18, diagnosed with drug-sensitive pulmonary TB (culture or molecular test), eligible for standard anti-TB treatment, at selected London, UK TB Services, will be invited to participate in this observational cohort study (target sample size=210). Patients will be asked to give blood for host transcriptomics and antibiotic plasma exposure, in addition to standard of care sputum samples for bacillary load. Antibiotic plasma concentrations will be quantified using a validated liquid chromatograph triple quadrupole mass spectrometer (LC-MS/MS) assay and sputum bacillary load by mycobacterial growth incubator tube time to positivity. Expression from a total of 35 prespecified host blood genes will be quantified using NanoString®. Antibiotic exposure, sputum bacillary load and host blood transcriptomic time series data will be analysed using nonlinear mixed-effects models. Correlations between combinations of longitudinal biomarkers and microbiological cure at the end of treatment and remaining relapse free for 1 year thereafter will be analysed using logistic regression and Cox proportional hazard models. ETHICS AND DISSEMINATION The observational cohort study has been approved by the UK's HRA REC (20/SW/0007). Written informed consent will be obtained. Results will be disseminated via publication, presentation and through engagement with institutes/companies developing novel anti-TB treatment combinations.
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Affiliation(s)
- Frank Kloprogge
- Institute for Global Health, University College London, London, UK
| | - Ibrahim Abubakar
- Institute for Global Health, University College London, London, UK
| | - Hanif Esmail
- Institute for Global Health, University College London, London, UK
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - Vanessa Hack
- Institute for Global Health, University College London, London, UK
| | - Heinke Kunst
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Timothy D McHugh
- UCL Centre for Clinical Microbiology, Division of Infection & Immunity, University College London, London, UK
| | - Mahdad Noursadeghi
- Division of Infection and Immunity, University College London, London, London, UK
| | - Julian Surey
- Institute for Global Health, University College London, London, UK
| | - Simon Tiberi
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
- Division of Infection, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Marc Lipman
- Respiratory medicine, Royal Free London NHS Foundation Trust, London, UK
- UCL Respiratory, Division of Medicine, University College London, London, UK
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17
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Bacterial load slopes represent biomarkers of tuberculosis therapy success, failure, and relapse. Commun Biol 2021; 4:664. [PMID: 34079045 PMCID: PMC8172544 DOI: 10.1038/s42003-021-02184-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 05/03/2021] [Indexed: 02/04/2023] Open
Abstract
There is an urgent need to discover biomarkers that are predictive of long-term TB treatment outcomes, since treatment is expense and prolonged to document relapse. We used mathematical modeling and machine learning to characterize a predictive biomarker for TB treatment outcomes. We computed bacterial kill rates, γf for fast- and γs for slow/non-replicating bacteria, using patient sputum data to determine treatment duration by computing time-to-extinction of all bacterial subpopulations. We then derived a γs-slope-based rule using first 8 weeks sputum data, that demonstrated a sensitivity of 92% and a specificity of 89% at predicting relapse-free cure for 2, 3, 4, and 6 months TB regimens. In comparison, current methods (two-month sputum culture conversion and the Extended-EBA) methods performed poorly, with sensitivities less than 34%. These biomarkers will accelerate evaluation of novel TB regimens, aid better clinical trial designs and will allow personalization of therapy duration in routine treatment programs.
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18
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Nikolayevskyy V, Balabanova Y, Kontsevaya I, Ignatyeva O, Skenders G, Vasiliauskiene E, Bockel DV, Drobniewski F. Biomarkers of treatment success in fully sensitive pulmonary tuberculosis patients: a multicenter longitudinal study. Biomark Med 2020; 14:1439-1452. [PMID: 33140661 DOI: 10.2217/bmm-2020-0246] [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: 11/21/2022] Open
Abstract
Aim: Novel biomarkers that are able to accurately monitor tuberculosis (TB) treatment effectiveness are needed to adjust therapy and identify a need for a regimen change. Materials & methods: In our study, conducted on a cohort comprising 100 pulmonary TB patients, we analyzed the role of plasma cytokines and Toll-like receptors expression as biomarkers of treatment response. Results: Changes in toll-interacting protein (TOLLIP) and lymphocyte antigen 96 (LY96) gene expression as well as nine cytokine levels over the first 2 months were significantly associated with successful treatment outcome. Successful treatment was associated with higher serum concentration of Toll-like receptor-2. Conclusion: Our results suggest that differential expression of specific effector molecules and dynamics of selected cytokines may help to identify those responding to TB treatment early.
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Affiliation(s)
- Vladyslav Nikolayevskyy
- Imperial College London, Du Cane Road, London W12 0NN, UK.,Public Health England, 61 Colindale Ave, London NW9 5EQ, UK
| | - Yanina Balabanova
- Imperial College London, Du Cane Road, London W12 0NN, UK.,Bayer AG, 178 Muelerstrasse, Berlin D-13353, Germany
| | - Irina Kontsevaya
- Imperial College London, Du Cane Road, London W12 0NN, UK.,Research Center Borstel, Parkallee 1-40, Borstel D-23845, Germany.,N.V. Postnikov Samara Region Clinical Tuberculosis Dispensary, 154 Novo-Sadovaya Street, Samara 443068, Russian Federation
| | - Olga Ignatyeva
- N.V. Postnikov Samara Region Clinical Tuberculosis Dispensary, 154 Novo-Sadovaya Street, Samara 443068, Russian Federation.,Medical University Reaviz, 100v Chkalova Street, Samara 443030, Russian Federation
| | - Girts Skenders
- Riga East University Hospital, Centre of Tuberculosis & Lung Diseases, 68 Lielvardes Street, Riga LV-1006, Latvia
| | - Edita Vasiliauskiene
- Department of Physiology, Biochemistry, Microbiology & Laboratory Medicine, Faculty of Medicine, Institute of Biomedical Sciences, Vilnius University, 21/27 M. K. Ciurlionio, Vilnius LT-03101, Lithuania.,Centre of Laboratory Medicine, Tuberculosis Laboratory, Vilnius University Hospital Santaros Klinikos, Santariskiu Street 2, Vilnius LT-08661, Lithuania
| | - David van Bockel
- The Kirby Institute for Infection & Immunity in Society, University of New South Wales, High Street, NSW 2052 Sydney, Australia
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Hayford FEA, Dolman RC, Blaauw R, Nienaber A, Smuts CM, Malan L, Ricci C. The effects of anti-inflammatory agents as host-directed adjunct treatment of tuberculosis in humans: a systematic review and meta-analysis. Respir Res 2020; 21:223. [PMID: 32847532 PMCID: PMC7448999 DOI: 10.1186/s12931-020-01488-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 08/17/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The potential role of adjunctive anti-inflammatory therapy to enhance tuberculosis (TB) treatment has recently received increasing interest. There is, therefore, a need to broadly examine current host-directed therapies (HDTs) that could accelerate treatment response and improve TB outcomes. METHODS This systematic review and meta-analysis included randomised controlled trials of vitamin D and other HDT agents in patients receiving antibiotic treatment for pulmonary TB. Sputum smear conversion rate at 4-8 weeks was the primary outcome. Secondary outcomes included blood indices associated with infectivity and inflammation, chest radiology and incidence of adverse events. RESULTS Fifty-five studies were screened for eligibility after the initial search, which yielded more than 1000 records. Of the 2540 participants in the 15 trials included in the meta-analysis, 1898 (74.7%) were male, and the age at entry ranged from 18 to 70 years. There was a 38% significantly (RR 1.38, 95% CI = 1.03-1.84) increased sputum smear negativity in patients administered with vitamin D in addition to standard TB treatment than those receiving only the TB treatment. Patients treated with other HDT anti-inflammatory agents in addition to TB treatment also had a 29% significantly increased sputum smear conversion rate (RR 1.29, 95% CI = 1.09-1.563). Lymphocyte to monocyte ratio was significantly higher in the vitamin D treatment groups compared to the controls (3.52 vs 2.70, 95% CI for difference 0.16-1.11, p = 0.009) and (adjusted mean difference 0.4, 95% CI 0.2 -- 0.6; p = 0.001); whilst tumour necrosis factor-alpha (TNF-α) showed a trend towards a reduction in prednisolone (p < 0.001) and pentoxifylline (p = 0.27) treatment groups. Vitamin D and N-acetylcysteine also accelerated radiographic resolution in treatment compared to placebo at 8 weeks. No differences were observed in the occurrence of adverse events among all HDT treatments. CONCLUSIONS Vitamin D and other anti-inflammatory HDT medications used as adjunct TB treatment may be well tolerated and effective. They significantly improved sputum smear conversion rate and chest radiological appearance, and also exhibited an inflammation resolution effect.
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Affiliation(s)
- Frank Ekow Atta Hayford
- Centre of Excellence for Nutrition, Faculty of Health Sciences, Building G16, North- West University, Potchefstroom Campus, Potchefstroom, South Africa. .,Department of Nutrition and Dietetics, School of Biomedical and Allied Health Sciences, College of Health Sciences, University of Ghana, Accra, Ghana.
| | - Robin Claire Dolman
- Centre of Excellence for Nutrition, Faculty of Health Sciences, Building G16, North- West University, Potchefstroom Campus, Potchefstroom, South Africa
| | - Renee Blaauw
- Division of Human Nutrition, Stellenbosch University, Cape Town, South Africa
| | - Arista Nienaber
- Centre of Excellence for Nutrition, Faculty of Health Sciences, Building G16, North- West University, Potchefstroom Campus, Potchefstroom, South Africa
| | - Cornelius Mattheus Smuts
- Centre of Excellence for Nutrition, Faculty of Health Sciences, Building G16, North- West University, Potchefstroom Campus, Potchefstroom, South Africa
| | - Linda Malan
- Centre of Excellence for Nutrition, Faculty of Health Sciences, Building G16, North- West University, Potchefstroom Campus, Potchefstroom, South Africa
| | - Cristian Ricci
- Centre of Excellence for Nutrition, Faculty of Health Sciences, Building G16, North- West University, Potchefstroom Campus, Potchefstroom, South Africa.,Department of Pediatric Epidemiology, Department of Pediatrics, Medical Faculty , University/Institution: Leipzig University, Leipzig, Germany
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20
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The role of volatile organic compounds as predictors of treatment response in drug susceptible TB patients: An initial proof of concept study. J Infect 2020; 81:e25-e27. [PMID: 32610109 DOI: 10.1016/j.jinf.2020.06.071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 06/26/2020] [Indexed: 11/21/2022]
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21
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Kloprogge F, Mwandumba HC, Banda G, Kamdolozi M, Shani D, Corbett EL, Kontogianni N, Ward S, Khoo SH, Davies GR, Sloan DJ. Longitudinal Pharmacokinetic-Pharmacodynamic Biomarkers Correlate With Treatment Outcome in Drug-Sensitive Pulmonary Tuberculosis: A Population Pharmacokinetic-Pharmacodynamic Analysis. Open Forum Infect Dis 2020; 7:ofaa218. [PMID: 32733976 PMCID: PMC7378673 DOI: 10.1093/ofid/ofaa218] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 06/03/2020] [Indexed: 11/13/2022] Open
Abstract
Background This study aims to explore relationships between baseline demographic covariates, plasma antibiotic exposure, sputum bacillary load, and clinical outcome data to help improve future tuberculosis (TB) treatment response predictions. Methods Data were available from a longitudinal cohort study in Malawian drug-sensitive TB patients on standard therapy, including steady-state plasma antibiotic exposure (154 patients), sputum bacillary load (102 patients), final outcome (95 patients), and clinical details. Population pharmacokinetic and pharmacokinetic-pharmacodynamic models were developed in the software package NONMEM. Outcome data were analyzed using univariate logistic regression and Cox proportional hazard models in R, a free software for statistical computing. Results Higher isoniazid exposure correlated with increased bacillary killing in sputum (P < .01). Bacillary killing in sputum remained fast, with later progression to biphasic decline, in patients with higher rifampicin area under the curve (AUC)0-24 (P < .01). Serial sputum colony counting negativity at month 2 (P < .05), isoniazid CMAX (P < .05), isoniazid CMAX/minimum inhibitory concentration ([MIC] P < .01), and isoniazid AUC0-24/MIC (P < .01) correlated with treatment success but not with remaining free of TB. Slower bacillary killing (P < .05) and earlier progression to biphasic bacillary decline (P < .01) both correlate with treatment failure. Posttreatment recurrence only correlated with slower bacillary killing (P < .05). Conclusions Patterns of early bacillary clearance matter. Static measurements such as month 2 sputum conversion and pharmacokinetic parameters such as CMAX/MIC and AUC0-24/MIC were predictive of treatment failure, but modeling of quantitative longitudinal data was required to assess the risk of recurrence. Pooled individual patient data analyses from larger datasets are needed to confirm these findings.
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Affiliation(s)
- Frank Kloprogge
- Institute for Global Health, University College London, London, United Kingdom
| | - Henry C Mwandumba
- Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi.,Liverpool School of Tropical Medicine, Liverpool, United Kingdom.,Department of Microbiology, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Gertrude Banda
- Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Mercy Kamdolozi
- Department of Microbiology, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Doris Shani
- Department of Microbiology, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Elizabeth L Corbett
- Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi.,Department of Microbiology, College of Medicine, University of Malawi, Blantyre, Malawi.,London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Steve Ward
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Saye H Khoo
- Department of Pharmacology, University of Liverpool, Liverpool, United Kingdom
| | - Geraint R Davies
- Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi.,Liverpool School of Tropical Medicine, Liverpool, United Kingdom.,Institute of Global Health, University of Liverpool, Liverpool, United Kingdom
| | - Derek J Sloan
- Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi.,Liverpool School of Tropical Medicine, Liverpool, United Kingdom.,Department of Microbiology, College of Medicine, University of Malawi, Blantyre, Malawi.,Institute of Global Health, University of Liverpool, Liverpool, United Kingdom.,School of Medicine, University of St Andrews, St Andrews, United Kingdom
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22
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Accelerating the transition of new tuberculosis drug combinations from Phase II to Phase III trials: New technologies and innovative designs. PLoS Med 2019; 16:e1002851. [PMID: 31287813 PMCID: PMC6615592 DOI: 10.1371/journal.pmed.1002851] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Geraint Davies and colleagues discuss the potential for innovative early-phase clinical trial methods and technologies to reduce risk and speed up drug development for tuberculosis.
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23
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Jolliffe DA, Ganmaa D, Wejse C, Raqib R, Haq MA, Salahuddin N, Daley PK, Ralph AP, Ziegler TR, Martineau AR. Adjunctive vitamin D in tuberculosis treatment: meta-analysis of individual participant data. Eur Respir J 2019; 53:13993003.02003-2018. [DOI: 10.1183/13993003.02003-2018] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Accepted: 12/12/2018] [Indexed: 01/12/2023]
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24
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Goletti D, Lindestam Arlehamn CS, Scriba TJ, Anthony R, Cirillo DM, Alonzi T, Denkinger CM, Cobelens F. Can we predict tuberculosis cure? What tools are available? Eur Respir J 2018; 52:13993003.01089-2018. [PMID: 30361242 DOI: 10.1183/13993003.01089-2018] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 09/24/2018] [Indexed: 01/08/2023]
Abstract
Antibiotic treatment of tuberculosis takes ≥6 months, putting a major burden on patients and health systems in large parts of the world. Treatment beyond 2 months is needed to prevent tuberculosis relapse by clearing remaining, drug-tolerant Mycobacterium tuberculosis bacilli. However, the majority of patients treated for only 2-3 months will cure without relapse and do not need prolonged treatment. Assays that can identify these patients at an early stage of treatment may significantly help reduce the treatment burden, while a test to identify those patients who will fail treatment may help target host-directed therapies.In this review we summarise the state of the art with regard to discovery of biomarkers that predict relapse-free cure for pulmonary tuberculosis. Positron emission tomography/computed tomography scanning to measure pulmonary inflammation enhances our understanding of "cure". Several microbiological and immunological markers seem promising; however, they still need a formal validation. In parallel, new research strategies are needed to generate reliable tests.
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Affiliation(s)
- Delia Goletti
- Translational Research Unit, National Institute for Infectious Diseases "L. Spallanzani" IRCCS, Dept of Epidemiology and Preclinical Research, Rome, Italy
| | | | - Thomas J Scriba
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease and Molecular Medicine, and Division of Immunology, Dept of Pathology, University of Cape Town, Cape Town, South Africa
| | - Richard Anthony
- National Institute for Public Health and the Environment (RIVM), Utrecht, The Netherlands
| | - Daniela Maria Cirillo
- Emerging Bacterial Pathogens Unit, San Raffaele Scientific Institute, HSR, Division of Immunology and Infectious Diseases Milan, Milan, Italy
| | - Tonino Alonzi
- Translational Research Unit, National Institute for Infectious Diseases "L. Spallanzani" IRCCS, Dept of Epidemiology and Preclinical Research, Rome, Italy
| | | | - Frank Cobelens
- Dept of Global Health and Amsterdam Institute for Global Health and Development, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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25
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Meyvisch P, Kambili C, Andries K, Lounis N, Theeuwes M, Dannemann B, Vandebosch A, Van der Elst W, Molenberghs G, Alonso A. Evaluation of six months sputum culture conversion as a surrogate endpoint in a multidrug resistant-tuberculosis trial. PLoS One 2018; 13:e0200539. [PMID: 30024924 PMCID: PMC6053142 DOI: 10.1371/journal.pone.0200539] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Accepted: 06/27/2018] [Indexed: 11/18/2022] Open
Abstract
The emergence of multidrug resistant-tuberculosis (MDR-TB), defined as Mycobacterium tuberculosis strains with in vitro resistance to at least isoniazid and rifampicin, has necessitated evaluation and validation of appropriate surrogate endpoints for treatment response in drug trials for MDR-TB. The trial that has demonstrated efficacy of bedaquiline, a diarylquinoline that inhibits mycobacterial ATP synthase, possesses the requisite features to conduct this evaluation. Approval of bedaquiline for use in MDR-TB was based primarily on the results of the controlled C208 Stage II study (ClinicalTrials.gov number, NCT00449644) including 160 patients randomized 1:1 to receive bedaquiline or placebo for 24 weeks when added to an 18-24-month preferred five-drug background regimen. Since randomization in C208 Stage II was preserved until study end, the trial results allow for the investigation of the complex relationship between sustained durable outcome with either Week 8 or Week 24 culture conversion as putative surrogate endpoints. The relationship between Week 120 outcome with Week 8 or Week 24 culture conversion was investigated using a descriptive analysis and with a recently developed statistical methodology for surrogate endpoint evaluation using methods of causal inference. The results demonstrate that sputum culture conversion at 24 weeks is more reliable than sputum culture conversion at 8 weeks when assessing the outcome of adding one new drug to a MDR-TB regimen.
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Affiliation(s)
- Paul Meyvisch
- Janssen Pharmaceutica, Beerse, Belgium
- I-BioStat, Universiteit Hasselt, Diepenbeek, Belgium
- * E-mail:
| | - Chrispin Kambili
- Johnson & Johnson Global Services, Raritan, NJ, United States of America
| | | | | | | | - Brian Dannemann
- Janssen Research & Development, Titusville, NJ, United States of America
| | | | | | - Geert Molenberghs
- I-BioStat, Universiteit Hasselt, Diepenbeek, Belgium
- I-BioStat, KU Leuven, Leuven, Belgium
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26
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Wu HX, Xiong XF, Zhu M, Wei J, Zhuo KQ, Cheng DY. Effects of vitamin D supplementation on the outcomes of patients with pulmonary tuberculosis: a systematic review and meta-analysis. BMC Pulm Med 2018; 18:108. [PMID: 29954353 PMCID: PMC6025740 DOI: 10.1186/s12890-018-0677-6] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Accepted: 06/19/2018] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Vitamin D is involved in the host immune response toward Mycobacterium tuberculosis. However, the efficacy of vitamin D supplementation on sputum conversion, clinical response to treatment, adverse events, and mortality in patients with pulmonary tuberculosis (PTB) remains controversial. We aimed to clarify the efficacy and safety of vitamin D supplementation in PTB treatment. METHODS We searched Medline, Embase, Cochrane Central Register of Controlled Trials, Web of Science for double-blind, randomized controlled trials of vitamin D supplementation in patients with PTB that reported sputum conversion, clinical response to treatment, adverse events, or mortality, published from database inception to November 26, 2017. This study was registered with PROSPERO, number CRD42018081236. RESULTS A total of 1787 patients with active PTB receiving vitamin D supplementation along with standard anti-tuberculosis regimen were included in the eight trials with different doses of vitamin D ranging from 1000 IU/day to 600,000 IU/month at different intervals. Primary analysis revealed that vitamin D supplementation increased the proportion of sputum smear and culture conversions (OR 1.21, 95%CI 1.05~ 1.39, z = 2.69, P = 0.007; OR 1.22, 95%CI 1.04~ 1.43, z = 2.41, P = 0.02), but did not improve the time to sputum smear and culture conversions (HR 1.07, 95%CI 0.83~ 1.37, z = 0.50, P = 0.62; HR 0.97, 95%CI 0.76~ 1.23, z = 0.29, P = 0.77). In the secondary analysis, vitamin D improved serum 25(OH)D, plasma calcium concentration, lymphocyte count, and chest radiograph (MD 103.36, 95%CI 84.20~ 122.53, z = 10.57, P < 0.00001; SMD 0.26, 95%CI 0.15~ 0.37, z = 4.61, P < 0.00001; MD 0.09, 95%CI 0.03~ 0.14, z = 2.94, P = 0.003); MD -0.33, 95% CI -0.57~ - 0.08 z = 2.57, P = 0.01), but had no impact on adverse events, mortality and other indicators(TB score, BMI, mean mid-upper arm circumference, weight gain, CRP, ESR, and other blood cells) (P > 0.05). CONCLUSIONS Vitamin D supplementation can be considered as a combination therapy in patients with PTB.
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Affiliation(s)
- Hong-xia Wu
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, NO.37 Guoxue Alley, Chengdu, 610041 Sichuan China
| | - Xiao-feng Xiong
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, NO.37 Guoxue Alley, Chengdu, 610041 Sichuan China
| | - Min Zhu
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, NO.37 Guoxue Alley, Chengdu, 610041 Sichuan China
| | - Jia Wei
- Department of Respiratory Medicine, Chengdu Second People’s Hospital, Chengdu, China
| | - Kai-quan Zhuo
- Department of Neurosurgery, Suining Municipal Hospital of TCM, Suining, China
| | - De-yun Cheng
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, NO.37 Guoxue Alley, Chengdu, 610041 Sichuan China
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27
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Bonnett LJ, Ken-Dror G, Koh GCKW, Davies GR. Comparing the Efficacy of Drug Regimens for Pulmonary Tuberculosis: Meta-analysis of Endpoints in Early-Phase Clinical Trials. Clin Infect Dis 2018; 65:46-54. [PMID: 28402396 PMCID: PMC5850317 DOI: 10.1093/cid/cix247] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2016] [Accepted: 01/30/2017] [Indexed: 11/13/2022] Open
Abstract
Background A systematic review of early clinical outcomes in tuberculosis was undertaken to determine ranking of efficacy of drugs and combinations, define variability of these measures on different endpoints, and to establish the relationships between them. Methods Studies were identified by searching PubMed, Medline, Embase, LILACS (Latin American and Caribbean Health Sciences Literature), and reference lists of included studies. Outcomes were early bactericidal activity results over 2, 7, and 14 days, and the proportion of patients with negative culture at 8 weeks. Results One hundred thirty-three trials reporting phase 2A (early bactericidal activity) and phase 2B (culture conversion at 2 months) outcomes were identified. Only 9 drug combinations were assessed on >1 phase 2A endpoint and only 3 were assessed in both phase 2A and 2B trials. Conclusions The existing evidence base supporting phase 2 methodology in tuberculosis is highly incomplete. In future, a broader range of drugs and combinations should be more consistently studied across a greater range of phase 2 endpoints.
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Affiliation(s)
- Laura J Bonnett
- Department of Biostatistics, University of Liverpool, Liverpool, UK
| | - Gie Ken-Dror
- Department of Biostatistics, University of Liverpool, Liverpool, UK
| | - Gavin C K W Koh
- Diseases of the Developing World, GlaxoSmithKline, Uxbridge, UK
| | - Geraint R Davies
- Department of Clinical Infection, Microbiology and Immunology, University of Liverpool, United Kingdom
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28
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Mourik BC, Svensson RJ, de Knegt GJ, Bax HI, Verbon A, Simonsson USH, de Steenwinkel JEM. Improving treatment outcome assessment in a mouse tuberculosis model. Sci Rep 2018; 8:5714. [PMID: 29632372 PMCID: PMC5890284 DOI: 10.1038/s41598-018-24067-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Accepted: 03/19/2018] [Indexed: 12/12/2022] Open
Abstract
Preclinical treatment outcome evaluation of tuberculosis (TB) occurs primarily in mice. Current designs compare relapse rates of different regimens at selected time points, but lack information about the correlation between treatment length and treatment outcome, which is required to efficiently estimate a regimens’ treatment-shortening potential. Therefore we developed a new approach. BALB/c mice were infected with a Mycobacterium tuberculosis Beijing genotype strain and were treated with rifapentine-pyrazinamide-isoniazid-ethambutol (RpZHE), rifampicin-pyrazinamide-moxifloxacin-ethambutol (RZME) or rifampicin-pyrazinamide-moxifloxacin-isoniazid (RZMH). Treatment outcome was assessed in n = 3 mice after 9 different treatment lengths between 2–6 months. Next, we created a mathematical model that best fitted the observational data and used this for inter-regimen comparison. The observed data were best described by a sigmoidal Emax model in favor over linear or conventional Emax models. Estimating regimen-specific parameters showed significantly higher curative potentials for RZME and RpZHE compared to RZMH. In conclusion, we provide a new design for treatment outcome evaluation in a mouse TB model, which (i) provides accurate tools for assessment of the relationship between treatment length and predicted cure, (ii) allows for efficient comparison between regimens and (iii) adheres to the reduction and refinement principles of laboratory animal use.
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Affiliation(s)
- Bas C Mourik
- Department of Medical Microbiology & Infectious Diseases, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Robin J Svensson
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | - Gerjo J de Knegt
- Department of Medical Microbiology & Infectious Diseases, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Hannelore I Bax
- Department of Internal Medicine, Section of Infectious Diseases, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Annelies Verbon
- Department of Internal Medicine, Section of Infectious Diseases, Erasmus University Medical Center, Rotterdam, The Netherlands
| | | | - Jurriaan E M de Steenwinkel
- Department of Medical Microbiology & Infectious Diseases, Erasmus University Medical Center, Rotterdam, The Netherlands.
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Nahid P, Dorman SE, Alipanah N, Barry PM, Brozek JL, Cattamanchi A, Chaisson LH, Chaisson RE, Daley CL, Grzemska M, Higashi JM, Ho CS, Hopewell PC, Keshavjee SA, Lienhardt C, Menzies R, Merrifield C, Narita M, O'Brien R, Peloquin CA, Raftery A, Saukkonen J, Schaaf HS, Sotgiu G, Starke JR, Migliori GB, Vernon A. Executive Summary: Official American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America Clinical Practice Guidelines: Treatment of Drug-Susceptible Tuberculosis. Clin Infect Dis 2017; 63:853-67. [PMID: 27621353 DOI: 10.1093/cid/ciw566] [Citation(s) in RCA: 174] [Impact Index Per Article: 24.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2016] [Accepted: 06/06/2016] [Indexed: 01/02/2023] Open
Abstract
The American Thoracic Society, Centers for Disease Control and Prevention, and Infectious Diseases Society of America jointly sponsored the development of this guideline for the treatment of drug-susceptible tuberculosis, which is also endorsed by the European Respiratory Society and the US National Tuberculosis Controllers Association. Representatives from the American Academy of Pediatrics, the Canadian Thoracic Society, the International Union Against Tuberculosis and Lung Disease, and the World Health Organization also participated in the development of the guideline. This guideline provides recommendations on the clinical and public health management of tuberculosis in children and adults in settings in which mycobacterial cultures, molecular and phenotypic drug susceptibility tests, and radiographic studies, among other diagnostic tools, are available on a routine basis. For all recommendations, literature reviews were performed, followed by discussion by an expert committee according to the Grading of Recommendations, Assessment, Development and Evaluation methodology. Given the public health implications of prompt diagnosis and effective management of tuberculosis, empiric multidrug treatment is initiated in almost all situations in which active tuberculosis is suspected. Additional characteristics such as presence of comorbidities, severity of disease, and response to treatment influence management decisions. Specific recommendations on the use of case management strategies (including directly observed therapy), regimen and dosing selection in adults and children (daily vs intermittent), treatment of tuberculosis in the presence of HIV infection (duration of tuberculosis treatment and timing of initiation of antiretroviral therapy), as well as treatment of extrapulmonary disease (central nervous system, pericardial among other sites) are provided. The development of more potent and better-tolerated drug regimens, optimization of drug exposure for the component drugs, optimal management of tuberculosis in special populations, identification of accurate biomarkers of treatment effect, and the assessment of new strategies for implementing regimens in the field remain key priority areas for research. See the full-text online version of the document for detailed discussion of the management of tuberculosis and recommendations for practice.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Julie M Higashi
- Tuberculosis Control Section, San Francisco Department of Public Health, California
| | - Christine S Ho
- Division of Tuberculosis Elimination, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | | | | | | | | | - Masahiro Narita
- Tuberculosis Control Program, Seattle and King County Public Health, and University of Washington, Seattle
| | - Rick O'Brien
- Ethics Advisory Group, International Union Against TB and Lung Disease, Paris, France
| | | | | | | | - H Simon Schaaf
- Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | | | | | - Giovanni Battista Migliori
- WHO Collaborating Centre for TB and Lung Diseases, Fondazione S. Maugeri Care and Research Institute, Tradate, Italy
| | - Andrew Vernon
- Division of Tuberculosis Elimination, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
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30
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Chen RY, Via LE, Dodd LE, Walzl G, Malherbe ST, Loxton AG, Dawson R, Wilkinson RJ, Thienemann F, Tameris M, Hatherill M, Diacon AH, Liu X, Xing J, Jin X, Ma Z, Pan S, Zhang G, Gao Q, Jiang Q, Zhu H, Liang L, Duan H, Song T, Alland D, Tartakovsky M, Rosenthal A, Whalen C, Duvenhage M, Cai Y, Goldfeder LC, Arora K, Smith B, Winter J, Barry Iii CE. Using biomarkers to predict TB treatment duration (Predict TB): a prospective, randomized, noninferiority, treatment shortening clinical trial. Gates Open Res 2017. [PMID: 29528048 PMCID: PMC5841574 DOI: 10.12688/gatesopenres.12750.1] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: By the early 1980s, tuberculosis treatment was shortened from 24 to 6 months, maintaining relapse rates of 1-2%. Subsequent trials attempting shorter durations have failed, with 4-month arms consistently having relapse rates of 15-20%. One trial shortened treatment only among those without baseline cavity on chest x-ray and whose month 2 sputum culture converted to negative. The 4-month arm relapse rate decreased to 7% but was still significantly worse than the 6-month arm (1.6%, P<0.01). We hypothesize that PET/CT characteristics at baseline, PET/CT changes at one month, and markers of residual bacterial load will identify patients with tuberculosis who can be cured with 4 months (16 weeks) of standard treatment. Methods: This is a prospective, multicenter, randomized, phase 2b, noninferiority clinical trial of pulmonary tuberculosis participants. Those eligible start standard of care treatment. PET/CT scans are done at weeks 0, 4, and 16 or 24. Participants who do not meet early treatment completion criteria (baseline radiologic severity, radiologic response at one month, and GeneXpert-detectable bacilli at four months) are placed in Arm A (24 weeks of standard therapy). Those who meet the early treatment completion criteria are randomized at week 16 to continue treatment to week 24 (Arm B) or complete treatment at week 16 (Arm C). The primary endpoint compares the treatment success rate at 18 months between Arms B and C. Discussion: Multiple biomarkers have been assessed to predict TB treatment outcomes. This study uses PET/CT scans and GeneXpert (Xpert) cycle threshold to risk stratify participants. PET/CT scans are not applicable to global public health but could be used in clinical trials to stratify participants and possibly become a surrogate endpoint. If the Predict TB trial is successful, other immunological biomarkers or transcriptional signatures that correlate with treatment outcome may be identified. Trial Registration: NCT02821832
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Affiliation(s)
- Ray Y Chen
- Tuberculosis Research Section, Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Laura E Via
- Tuberculosis Research Section, Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD, USA.,Wellcome Centre for Infectious Diseases Research in Africa,Institute of Infectious Disease and Molecular Medicine, University of Cape Town (UCT), Cape Town, South Africa
| | - Lori E Dodd
- Biostatistics Research Branch, Division of Clinical Research, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Gerhard Walzl
- South Africa Department of Science and Technology - National Research Foundation Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Stephanus T Malherbe
- South Africa Department of Science and Technology - National Research Foundation Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - André G Loxton
- South Africa Department of Science and Technology - National Research Foundation Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Rodney Dawson
- Division of Pulmonology, Department of Medicine, University Of Cape Town Lung Institute, University of Cape Town (UCT), Cape Town, South Africa
| | - Robert J Wilkinson
- Wellcome Centre for Infectious Diseases Research in Africa,Institute of Infectious Disease and Molecular Medicine, University of Cape Town (UCT), Cape Town, South Africa.,Francis Crick Institute, London, NW1 2AT, UK.,Department of Medicine, Imperial College London, London, W2 1PG, UK
| | - Friedrich Thienemann
- Wellcome Centre for Infectious Diseases Research in Africa,Institute of Infectious Disease and Molecular Medicine, University of Cape Town (UCT), Cape Town, South Africa.,Department of Internal Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Michele Tameris
- South African Tuberculosis Vaccine Initiative, University of Cape Town (UCT), Cape Town, South Africa
| | - Mark Hatherill
- South African Tuberculosis Vaccine Initiative, University of Cape Town (UCT), Cape Town, South Africa
| | - Andreas H Diacon
- TASK Applied Science and Stellenbosch University, Cape Town, South Africa
| | - Xin Liu
- Henan Provincial Chest Hospital, Zhengzhou, Henan, China
| | - Jin Xing
- Henan Provincial Institute of Tuberculosis and Prevention, Henan Center for Disease Control, Zhengzhou, Henan, China
| | - Xiaowei Jin
- Xinmi City Institute of Tuberculosis Prevention and Control, Xinmi, Henan, China
| | - Zhenya Ma
- Kaifeng City Institute of Tuberculosis Prevention and Control, Kaifeng, Henan, China
| | - Shouguo Pan
- Zhongmu County Health and Epidemic Prevention Station, Zhongmu, Henan, China
| | - Guolong Zhang
- Henan Provincial Institute of Tuberculosis and Prevention, Henan Center for Disease Control, Zhengzhou, Henan, China
| | - Qian Gao
- Fudan University, Shanghai, China
| | - Qi Jiang
- Fudan University, Shanghai, China
| | - Hong Zhu
- Sino-US Tuberculosis Collaborative Research Program, Zhengzhou, Henan, China
| | - Lili Liang
- TASK Applied Science and Stellenbosch University, Cape Town, South Africa
| | | | - Taeksun Song
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town (UCT), Cape Town, South Africa
| | - David Alland
- Division of Infectious Diseases, Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Michael Tartakovsky
- Office of Cyber Infrastructure and Computational Biology, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Alex Rosenthal
- Office of Cyber Infrastructure and Computational Biology, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Christopher Whalen
- Office of Cyber Infrastructure and Computational Biology, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Michael Duvenhage
- Office of Cyber Infrastructure and Computational Biology, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Ying Cai
- Tuberculosis Research Section, Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Lisa C Goldfeder
- Tuberculosis Research Section, Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Kriti Arora
- Tuberculosis Research Section, Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Bronwyn Smith
- South Africa Department of Science and Technology - National Research Foundation Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Jill Winter
- Catalysis Foundation for Health, Emeryville, CA, USA
| | - Clifton E Barry Iii
- Tuberculosis Research Section, Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD, USA.,Wellcome Centre for Infectious Diseases Research in Africa,Institute of Infectious Disease and Molecular Medicine, University of Cape Town (UCT), Cape Town, South Africa
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31
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Sigal GB, Segal MR, Mathew A, Jarlsberg L, Wang M, Barbero S, Small N, Haynesworth K, Davis JL, Weiner M, Whitworth WC, Jacobs J, Schorey J, Lewinsohn DM, Nahid P. Biomarkers of Tuberculosis Severity and Treatment Effect: A Directed Screen of 70 Host Markers in a Randomized Clinical Trial. EBioMedicine 2017; 25:112-121. [PMID: 29100778 PMCID: PMC5704068 DOI: 10.1016/j.ebiom.2017.10.018] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Revised: 10/15/2017] [Accepted: 10/19/2017] [Indexed: 01/19/2023] Open
Abstract
More efficacious treatment regimens are needed for tuberculosis, however, drug development is impeded by a lack of reliable biomarkers of disease severity and of treatment effect. We conducted a directed screen of host biomarkers in participants enrolled in a tuberculosis clinical trial to address this need. Serum samples from 319 protocol-correct, culture-confirmed pulmonary tuberculosis patients treated under direct observation as part of an international, phase 2 trial were screened for 70 markers of infection, inflammation, and metabolism. Biomarker assays were specifically developed for this study and quantified using a novel, multiplexed electrochemiluminescence assay. We evaluated the association of biomarkers with baseline characteristics, as well as with detailed microbiologic data, using Bonferroni-adjusted, linear regression models. Across numerous analyses, seven proteins, SAA1, PCT, IL-1β, IL-6, CRP, PTX-3 and MMP-8, showed recurring strong associations with markers of baseline disease severity, smear grade and cavitation; were strongly modulated by tuberculosis treatment; and had responses that were greater for patients who culture-converted at 8weeks. With treatment, all proteins decreased, except for osteocalcin, MCP-1 and MCP-4, which significantly increased. Several previously reported putative tuberculosis-associated biomarkers (HOMX1, neopterin, and cathelicidin) were not significantly associated with treatment response. In conclusion, across a geographically diverse and large population of tuberculosis patients enrolled in a clinical trial, several previously reported putative biomarkers were not significantly associated with treatment response, however, seven proteins had recurring strong associations with baseline radiographic and microbiologic measures of disease severity, as well as with early treatment response, deserving additional study.
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Affiliation(s)
- G B Sigal
- Meso Scale Diagnostics, LLC, Rockville, MD, USA.
| | - M R Segal
- University of California, San Francisco, CA, USA
| | - A Mathew
- Meso Scale Diagnostics, LLC, Rockville, MD, USA
| | - L Jarlsberg
- University of California, San Francisco, CA, USA
| | - M Wang
- Meso Scale Diagnostics, LLC, Rockville, MD, USA
| | - S Barbero
- Meso Scale Diagnostics, LLC, Rockville, MD, USA
| | - N Small
- Meso Scale Diagnostics, LLC, Rockville, MD, USA
| | | | - J L Davis
- Yale School of Public Health and Yale School of Medicine, New Haven, CT, USA
| | - M Weiner
- San Antonio VA Medical Center, San Antonio, TX, USA
| | - W C Whitworth
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - J Jacobs
- Pacific Northwest National Laboratory, Richland, WA, USA
| | - J Schorey
- University of Notre Dame, Notre Dame, IN, USA
| | - D M Lewinsohn
- Oregon Health and Science University, Portland, OR, USA
| | - P Nahid
- University of California, San Francisco, CA, USA.
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32
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Ganmaa D, Munkhzul B, Fawzi W, Spiegelman D, Willett WC, Bayasgalan P, Baasansuren E, Buyankhishig B, Oyun-Erdene S, Jolliffe DA, Xenakis T, Bromage S, Bloom BR, Martineau AR. High-Dose Vitamin D 3 during Tuberculosis Treatment in Mongolia. A Randomized Controlled Trial. Am J Respir Crit Care Med 2017; 196:628-637. [PMID: 28692301 DOI: 10.1164/rccm.201705-0936oc] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Existing trials of adjunctive vitamin D in the treatment of pulmonary tuberculosis (PTB) are variously limited by small sample sizes, inadequate dosing regimens, and high baseline vitamin D status among participants. Comprehensive analyses of the effects of genetic variation in the vitamin D pathway on response to vitamin D supplementation are lacking. OBJECTIVES To determine the effect of high-dose vitamin D3 on response to antimicrobial therapy for PTB and to evaluate the influence of single-nucleotide polymorphisms (SNPs) in vitamin D pathway genes on response to adjunctive vitamin D3. METHODS We conducted a clinical trial in 390 adults with PTB in Ulaanbaatar, Mongolia, who were randomized to receive four biweekly doses of 3.5 mg (140,000 IU) vitamin D3 (n = 190) or placebo (n = 200) during intensive-phase antituberculosis treatment. MEASUREMENTS AND MAIN RESULTS The intervention elevated 8-week serum 25-hydroxyvitamin D concentrations (154.5 nmol/L vs. 15.2 nmol/L in active vs. placebo arms, respectively; 95% confidence interval for difference, 125.9-154.7 nmol/L; P < 0.001) but did not influence time to sputum culture conversion overall (adjusted hazard ratio, 1.09; 95% confidence interval, 0.86-1.36; P = 0.48). Adjunctive vitamin D3 accelerated sputum culture conversion in patients with one or more minor alleles for SNPs in genes encoding the vitamin D receptor (rs4334089, rs11568820) and 25-hydroxyvitamin D 1α-hydroxylase (CYP27B1: rs4646536) (adjusted hazard ratio ≥ 1.47; P for interaction ≤ 0.02). CONCLUSIONS Vitamin D3 did not influence time to sputum culture conversion in the study population overall. Effects of the intervention were modified by SNPs in VDR and CYP27B1. Clinical trial registered with www.clinicaltrials.gov (NCT01657656).
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Affiliation(s)
- Davaasambuu Ganmaa
- 1 Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,2 Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Baatar Munkhzul
- 3 National Center for Communicable Diseases, Ministry of Health, Mongolia National Center for Communicable Diseases Campus, Ulaanbaatar, Mongolia; and
| | - Wafaie Fawzi
- 2 Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Donna Spiegelman
- 1 Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,2 Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Walter C Willett
- 1 Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,2 Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Purev Bayasgalan
- 3 National Center for Communicable Diseases, Ministry of Health, Mongolia National Center for Communicable Diseases Campus, Ulaanbaatar, Mongolia; and
| | - Erkhembayar Baasansuren
- 3 National Center for Communicable Diseases, Ministry of Health, Mongolia National Center for Communicable Diseases Campus, Ulaanbaatar, Mongolia; and
| | - Burneebaatar Buyankhishig
- 3 National Center for Communicable Diseases, Ministry of Health, Mongolia National Center for Communicable Diseases Campus, Ulaanbaatar, Mongolia; and
| | - Sereeter Oyun-Erdene
- 3 National Center for Communicable Diseases, Ministry of Health, Mongolia National Center for Communicable Diseases Campus, Ulaanbaatar, Mongolia; and
| | - David A Jolliffe
- 4 Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Theodoros Xenakis
- 4 Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Sabri Bromage
- 2 Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Barry R Bloom
- 2 Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Adrian R Martineau
- 4 Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
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33
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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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34
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Rockwood N, Pasipanodya JG, Denti P, Sirgel F, Lesosky M, Gumbo T, Meintjes G, McIlleron H, Wilkinson RJ. Concentration-Dependent Antagonism and Culture Conversion in Pulmonary Tuberculosis. Clin Infect Dis 2017; 64:1350-1359. [PMID: 28205671 PMCID: PMC5411399 DOI: 10.1093/cid/cix158] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2016] [Accepted: 02/15/2017] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND There is scant evidence to support target drug exposures for optimal tuberculosis outcomes. We therefore assessed whether pharmacokinetic/pharmacodynamic (PK/PD) parameters could predict 2-month culture conversion. METHODS One hundred patients with pulmonary tuberculosis (65% human immunodeficiency virus coinfected) were intensively sampled to determine rifampicin, isoniazid, and pyrazinamide plasma concentrations after 7-8 weeks of therapy, and PK parameters determined using nonlinear mixed-effects models. Detailed clinical data and sputum for culture were collected at baseline, 2 months, and 5-6 months. Minimum inhibitory concentrations (MICs) were determined on baseline isolates. Multivariate logistic regression and the assumption-free multivariate adaptive regression splines (MARS) were used to identify clinical and PK/PD predictors of 2-month culture conversion. Potential PK/PD predictors included 0- to 24-hour area under the curve (AUC0-24), maximum concentration (Cmax), AUC0-24/MIC, Cmax/MIC, and percentage of time that concentrations persisted above the MIC (%TMIC). RESULTS Twenty-six percent of patients had Cmax of rifampicin <8 mg/L, pyrazinamide <35 mg/L, and isoniazid <3 mg/L. No relationship was found between PK exposures and 2-month culture conversion using multivariate logistic regression after adjusting for MIC. However, MARS identified negative interactions between isoniazid Cmax and rifampicin Cmax/MIC ratio on 2-month culture conversion. If isoniazid Cmax was <4.6 mg/L and rifampicin Cmax/MIC <28, the isoniazid concentration had an antagonistic effect on culture conversion. For patients with isoniazid Cmax >4.6 mg/L, higher isoniazid exposures were associated with improved rates of culture conversion. CONCLUSIONS PK/PD analyses using MARS identified isoniazid Cmax and rifampicin Cmax/MIC thresholds below which there is concentration-dependent antagonism that reduces 2-month sputum culture conversion.
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Affiliation(s)
- Neesha Rockwood
- Department of Medicine, Imperial College London, United Kingdom
- Wellcome Center for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, South Africa
| | - Jotam G Pasipanodya
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, Texas
| | - Paolo Denti
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town
| | - Frederick Sirgel
- Department of Science and Technology/National Research Foundation Centre of Excellence for Biomedical Tuberculosis Research/ South African Medical Research Foundation Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Health Sciences, Stellenbosch University, Tygerberg
| | - Maia Lesosky
- Wellcome Center for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, South Africa
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, and
| | - 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, South Africa; and
| | - Graeme Meintjes
- Department of Medicine, Imperial College London, United Kingdom
- Department of Medicine, University of Cape Town, South Africa; and
| | - Helen McIlleron
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town
| | - Robert J Wilkinson
- Department of Medicine, Imperial College London, United Kingdom
- Wellcome Center for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, South Africa
- Department of Medicine, University of Cape Town, South Africa; and
- Francis Crick Institute, London, United Kingdom
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Atwine D, Orikiriza P, Taremwa I, Ayebare A, Logoose S, Mwanga-Amumpaire J, Jindani A, Bonnet M. Predictors of delayed culture conversion among Ugandan patients. BMC Infect Dis 2017; 17:299. [PMID: 28438118 PMCID: PMC5402635 DOI: 10.1186/s12879-017-2335-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 03/22/2017] [Indexed: 01/10/2023] Open
Abstract
Background Estimates of month-2 culture conversion, a proxy indicator of tuberculosis (TB) treatment efficacy in phase-2 trials can vary by culture-type and geographically with lower rates reported among African sites. The sub-study aimed at comparing TB detection rates of different culture media, within and across rifampicin-based regimens (R10, 15 and 20 mg/Kg) over a 6-month treatment follow-up period, and to establish predictors of month-2 culture non-conversion among HIV-negative TB patients enrolled at RIFATOX trial site in Uganda. Methods Unlike in other Rifatox Trial sites, it is only in Uganda were Lowenstein-Jensen (LJ) and Mycobacteria growth indicator tube (MGIT) were used throughout 6-months for treatment monitoring. Conversion rates were compared at month-2, 4 and 6 across cultures and treatment-type. Binomial regression analysis performed for predictors of month-2 non-conversion. Results Of the 100 enrolled patients, 45% had converted based on combined LJ and MGIT by month-2, with no significant differences across treatment arms, p = 0.721. LJ exhibited higher conversion rates than MGIT at month-2 (58.4% vs 56.0%, p = 0.0707) and month-4 (98.9% vs 88.4%, p = 0.0391) respectively, more so within the high-dose rifampicin arms. All patients had converted by month-6. Time-to-TB detection (TTD) on MGIT and social service jobs independently predict month-2 non-conversion. Conclusion The month-2 culture conversion used in phase 2 clinical trials as surrogate marker of treatment efficacy is influenced by the culture method used for monitoring mycobacterial response to TB treatment. Therefore, multi-centric TB therapeutic trials using early efficacy endpoint should use the same culture method across sites. The Time-to-detection of MTB on MGIT prior to treatment and working in Social service jobs bear an increased risk of culture non-conversion at month-2. Trial registration ISRCTN ISRCTN55670677. Registered 09th November 2010. Retrospectively registered. Electronic supplementary material The online version of this article (doi:10.1186/s12879-017-2335-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Daniel Atwine
- Epicentre Mbarara Research Centre, PO box 1956, Mbarara, Uganda. .,Mbarara University of Science and Technology, Mbarara, Uganda. .,University of Montpellier 1, Montpellier, France.
| | - Patrick Orikiriza
- Epicentre Mbarara Research Centre, PO box 1956, Mbarara, Uganda.,Mbarara University of Science and Technology, Mbarara, Uganda
| | - Ivan Taremwa
- Epicentre Mbarara Research Centre, PO box 1956, Mbarara, Uganda
| | - Arnold Ayebare
- Epicentre Mbarara Research Centre, PO box 1956, Mbarara, Uganda
| | - Suzan Logoose
- Epicentre Mbarara Research Centre, PO box 1956, Mbarara, Uganda
| | - Juliet Mwanga-Amumpaire
- Epicentre Mbarara Research Centre, PO box 1956, Mbarara, Uganda.,Mbarara University of Science and Technology, Mbarara, Uganda
| | | | - Maryline Bonnet
- Epicentre Mbarara Research Centre, PO box 1956, Mbarara, Uganda.,IRD UMI233 TransVIHMI-UM-INSERM U1175, Montpellier, France
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36
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Lu P, Liu Q, Martinez L, Yang H, Lu W, Ding X, Zhu L. Time to sputum culture conversion and treatment outcome of patients with multidrug-resistant tuberculosis: a prospective cohort study from urban China. Eur Respir J 2017; 49:49/3/1601558. [PMID: 28331033 PMCID: PMC5380874 DOI: 10.1183/13993003.01558-2016] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Accepted: 12/11/2016] [Indexed: 11/05/2022]
Abstract
Sputum culture plays an important role in monitoring treatment response in patients with multidrug-resistant tuberculosis (MDR-TB), and sputum culture conversion is a clinical tool used to predict therapeutic efficacy [1]. Monthly culture monitoring is essential for earlier detection of treatment failure in patients with MDR-TB. More sensitive signals of nonresponse would further avoid adverse outcomes [2]. The timing of testing for culture conversion has potential as a marker of MDR-TB treatment successhttp://ow.ly/borO308pPXg
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Affiliation(s)
- Peng Lu
- Dept of Epidemiology and Biostatistics, School of Public Health, Nanjing Medical University, Nanjing, PR China.,These authors contributed equally to this work
| | - Qiao Liu
- Dept of Chronic Communicable Disease, Center for Disease Control and Prevention of Jiangsu Province, Nanjing, PR China.,These authors contributed equally to this work
| | - Leonardo Martinez
- Dept of Epidemiology and Biostatistics, University of Georgia School of Public Health, Athens, GA, USA.,These authors contributed equally to this work
| | - Haitao Yang
- Dept of Epidemiology and Biostatistics, School of Public Health, Nanjing Medical University, Nanjing, PR China.,Institute of Parasitic Disease of Jiangsu Province, Wuxi, PR China
| | - Wei Lu
- Dept of Chronic Communicable Disease, Center for Disease Control and Prevention of Jiangsu Province, Nanjing, PR China
| | - Xiaoyan Ding
- Dept of Chronic Communicable Disease, Center for Disease Control and Prevention of Jiangsu Province, Nanjing, PR China
| | - Limei Zhu
- Dept of Chronic Communicable Disease, Center for Disease Control and Prevention of Jiangsu Province, Nanjing, PR China
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Dheda K, Gumbo T, Maartens G, Dooley KE, McNerney R, Murray M, Furin J, Nardell EA, London L, Lessem E, Theron G, van Helden P, Niemann S, Merker M, Dowdy D, Van Rie A, Siu GKH, Pasipanodya JG, Rodrigues C, Clark TG, Sirgel FA, Esmail A, Lin HH, Atre SR, Schaaf HS, Chang KC, Lange C, Nahid P, Udwadia ZF, Horsburgh CR, Churchyard GJ, Menzies D, Hesseling AC, Nuermberger E, McIlleron H, Fennelly KP, Goemaere E, Jaramillo E, Low M, Jara CM, Padayatchi N, Warren RM. The epidemiology, pathogenesis, transmission, diagnosis, and management of multidrug-resistant, extensively drug-resistant, and incurable tuberculosis. THE LANCET. RESPIRATORY MEDICINE 2017; 5:S2213-2600(17)30079-6. [PMID: 28344011 DOI: 10.1016/s2213-2600(17)30079-6] [Citation(s) in RCA: 382] [Impact Index Per Article: 54.6] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 10/24/2016] [Accepted: 12/08/2016] [Indexed: 12/25/2022]
Abstract
Global tuberculosis incidence has declined marginally over the past decade, and tuberculosis remains out of control in several parts of the world including Africa and Asia. Although tuberculosis control has been effective in some regions of the world, these gains are threatened by the increasing burden of multidrug-resistant (MDR) and extensively drug-resistant (XDR) tuberculosis. XDR tuberculosis has evolved in several tuberculosis-endemic countries to drug-incurable or programmatically incurable tuberculosis (totally drug-resistant tuberculosis). This poses several challenges similar to those encountered in the pre-chemotherapy era, including the inability to cure tuberculosis, high mortality, and the need for alternative methods to prevent disease transmission. This phenomenon mirrors the worldwide increase in antimicrobial resistance and the emergence of other MDR pathogens, such as malaria, HIV, and Gram-negative bacteria. MDR and XDR tuberculosis are associated with high morbidity and substantial mortality, are a threat to health-care workers, prohibitively expensive to treat, and are therefore a serious public health problem. In this Commission, we examine several aspects of drug-resistant tuberculosis. The traditional view that acquired resistance to antituberculous drugs is driven by poor compliance and programmatic failure is now being questioned, and several lines of evidence suggest that alternative mechanisms-including pharmacokinetic variability, induction of efflux pumps that transport the drug out of cells, and suboptimal drug penetration into tuberculosis lesions-are likely crucial to the pathogenesis of drug-resistant tuberculosis. These factors have implications for the design of new interventions, drug delivery and dosing mechanisms, and public health policy. We discuss epidemiology and transmission dynamics, including new insights into the fundamental biology of transmission, and we review the utility of newer diagnostic tools, including molecular tests and next-generation whole-genome sequencing, and their potential for clinical effectiveness. Relevant research priorities are highlighted, including optimal medical and surgical management, the role of newer and repurposed drugs (including bedaquiline, delamanid, and linezolid), pharmacokinetic and pharmacodynamic considerations, preventive strategies (such as prophylaxis in MDR and XDR contacts), palliative and patient-orientated care aspects, and medicolegal and ethical issues.
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Affiliation(s)
- Keertan Dheda
- Lung Infection and Immunity Unit, Department of Medicine, Division of Pulmonology and UCT Lung Institute, University of Cape Town, Groote Schuur Hospital, Cape Town, South Africa.
| | - Tawanda Gumbo
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Kelly E Dooley
- Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ruth McNerney
- Lung Infection and Immunity Unit, Department of Medicine, Division of Pulmonology and UCT Lung Institute, University of Cape Town, Groote Schuur Hospital, Cape Town, South Africa
| | - Megan Murray
- Department of Global Health and Social Medicine, Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Jennifer Furin
- Department of Global Health and Social Medicine, Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Edward A Nardell
- TH Chan School of Public Health, Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Leslie London
- School of Public Health and Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Grant Theron
- SA MRC Centre for Tuberculosis Research/DST/NRF Centre of Excellence for Biomedical Tuberculosis Research, Division of Molecular Biology and Human Genetics, Stellenbosch University, Tygerberg, South Africa
| | - Paul van Helden
- SA MRC Centre for Tuberculosis Research/DST/NRF Centre of Excellence for Biomedical Tuberculosis Research, Division of Molecular Biology and Human Genetics, Stellenbosch University, Tygerberg, South Africa
| | - Stefan Niemann
- Molecular and Experimental Mycobacteriology, Research Center Borstel, Borstel, Schleswig-Holstein, Germany; German Centre for Infection Research (DZIF), Partner Site Borstel, Borstel, Schleswig-Holstein, Germany
| | - Matthias Merker
- Molecular and Experimental Mycobacteriology, Research Center Borstel, Borstel, Schleswig-Holstein, Germany
| | - David Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Annelies Van Rie
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; International Health Unit, Epidemiology and Social Medicine, Faculty of Medicine, University of Antwerp, Antwerp, Belgium
| | - Gilman K H Siu
- Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Hung Hom, Hong Kong SAR, China
| | - Jotam G Pasipanodya
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Camilla Rodrigues
- Department of Microbiology, P.D. Hinduja National Hospital & Medical Research Centre, Mumbai, India
| | - Taane G Clark
- Faculty of Infectious and Tropical Diseases and Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Frik A Sirgel
- SA MRC Centre for Tuberculosis Research/DST/NRF Centre of Excellence for Biomedical Tuberculosis Research, Division of Molecular Biology and Human Genetics, Stellenbosch University, Tygerberg, South Africa
| | - Aliasgar Esmail
- Lung Infection and Immunity Unit, Department of Medicine, Division of Pulmonology and UCT Lung Institute, University of Cape Town, Groote Schuur Hospital, Cape Town, South Africa
| | - Hsien-Ho Lin
- Institute of Epidemiology and Preventive Medicine, National Taiwan University, Taipei, Taiwan
| | - Sachin R Atre
- Center for Clinical Global Health Education (CCGHE), Johns Hopkins University, Baltimore, MD, USA; Medical College, Hospital and Research Centre, Pimpri, Pune, India
| | - H Simon Schaaf
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Kwok Chiu Chang
- Tuberculosis and Chest Service, Centre for Health Protection, Department of Health, Hong Kong SAR, China
| | - Christoph Lange
- Division of Clinical Infectious Diseases, German Center for Infection Research, Research Center Borstel, Borstel, Schleswig-Holstein, Germany; International Health/Infectious Diseases, University of Lübeck, Lübeck, Germany; Department of Medicine, Karolinska Institute, Stockholm, Sweden; Department of Medicine, University of Namibia School of Medicine, Windhoek, Namibia
| | - Payam Nahid
- Division of Pulmonary and Critical Care, San Francisco General Hospital, University of California, San Francisco, CA, USA
| | - Zarir F Udwadia
- Pulmonary Department, Hinduja Hospital & Research Center, Mumbai, India
| | | | - Gavin J Churchyard
- Aurum Institute, Johannesburg, South Africa; School of Public Health, University of Witwatersrand, Johannesburg, South Africa; Advancing Treatment and Care for TB/HIV, South African Medical Research Council, Johannesburg, South Africa
| | - Dick Menzies
- Montreal Chest Institute, McGill University, Montreal, QC, Canada
| | - Anneke C Hesseling
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Eric Nuermberger
- Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Helen McIlleron
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Kevin P Fennelly
- Pulmonary Clinical Medicine Section, Division of Intramural Research, National Heart, Lung, and Blood Institute (NHLBI), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Eric Goemaere
- MSF South Africa, Cape Town, South Africa; School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Marcus Low
- Treatment Action Campaign, Johannesburg, South Africa
| | | | - Nesri Padayatchi
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), MRC HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - Robin M Warren
- SA MRC Centre for Tuberculosis Research/DST/NRF Centre of Excellence for Biomedical Tuberculosis Research, Division of Molecular Biology and Human Genetics, Stellenbosch University, Tygerberg, South Africa
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Ciani O, Buyse M, Drummond M, Rasi G, Saad ED, Taylor RS. Time to Review the Role of Surrogate End Points in Health Policy: State of the Art and the Way Forward. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2017; 20:487-495. [PMID: 28292495 DOI: 10.1016/j.jval.2016.10.011] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Revised: 10/08/2016] [Accepted: 10/20/2016] [Indexed: 05/25/2023]
Abstract
The efficacy of medicines, medical devices, and other health technologies should be proved in trials that assess final patient-relevant outcomes such as survival or morbidity. Market access and coverage decisions are, however, often based on surrogate end points, biomarkers, or intermediate end points, which aim to substitute and predict patient-relevant outcomes that are unavailable because of methodological, financial, or practical constraints. We provide a summary of the present use of surrogate end points in health care policy, discussing the case for and against their adoption and reviewing validation methods. We introduce a three-step framework for policymakers to handle surrogates, which involves establishing the level of evidence, assessing the strength of the association, and quantifying relations between surrogates and final outcomes. Although the use of surrogates can be problematic, they can, when selected and validated appropriately, offer important opportunities for more efficient clinical trials and faster access to new health technologies that benefit patients and health care systems.
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Affiliation(s)
- Oriana Ciani
- Evidence Synthesis and Modelling for Health Improvement, Institute of Health Research, University of Exeter Medical School, Exeter, UK; Centre for Research on Health and Social Care Management, Bocconi University, Milan, Italy.
| | - Marc Buyse
- International Drug Development Institute, Louvain-la-Neuve, Belgium; CluePoints, Inc., Cambridge, MA, USA
| | | | - Guido Rasi
- European Medicines Agency, London, UK; University "Tor Vergata," Rome, Italy
| | | | - Rod S Taylor
- Evidence Synthesis and Modelling for Health Improvement, Institute of Health Research, University of Exeter Medical School, Exeter, UK
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Tiberi S, Carvalho ACC, Sulis G, Vaghela D, Rendon A, Mello FCDQ, Rahman A, Matin N, Zumla A, Pontali E. The cursed duet today: Tuberculosis and HIV-coinfection. Presse Med 2017; 46:e23-e39. [PMID: 28256380 DOI: 10.1016/j.lpm.2017.01.017] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Revised: 12/23/2016] [Accepted: 01/17/2017] [Indexed: 01/22/2023] Open
Abstract
The tuberculosis (TB) and HIV syndemic continues to rage and are a major public health concern worldwide. This deadly association raises complexity and represent a significant barrier towards TB elimination. TB continues to be the leading cause of death amongst HIV-infected people. This paper reports the challenges that lay ahead and outlines some of the current and future strategies that may be able to address this co-epidemic efficiently. Improved diagnostics, cheaper and more effective drugs, shorter treatment regimens for both drug-sensitive and drug-resistant TB are discussed. Also, special topics on drug interactions, TB-IRIS and TB relapse are also described. Notwithstanding the defeats and meagre investments, diagnosis and management of the two diseases have seen significant and unexpected improvements of late. On the HIV side, expansion of ART coverage, development of new updated guidelines aimed at the universal treatment of those infected, and the increasing availability of newer, more efficacious and less toxic drugs are an essential element to controlling the two epidemics. On the TB side, diagnosis of MDR-TB is becoming easier and faster thanks to the new PCR-based technologies, new anti-TB drugs active against both sensitive and resistant strains (i.e. bedaquiline and delamanid) have been developed and a few more are in the pipeline, new regimens (cheaper, shorter and/or more effective) have been introduced (such as the "Bangladesh regimen") or are being tested for MDR-TB and drug-sensitive-TB. However, still more resources will be required to implement an integrated approach, install new diagnostic tests, and develop simpler and shorter treatment regimens.
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Affiliation(s)
- Simon Tiberi
- Barts health NHS trust, Royal London hospital, division of infection, 80, Newark street, E1 2ES London, United Kingdom.
| | - Anna Cristina C Carvalho
- Oswaldo Cruz institute (IOC), laboratory of innovations in therapies, education and bioproducts, (LITEB), Fiocruz, Rio de Janeiro, Brazil.
| | - Giorgia Sulis
- University of Brescia, university department of infectious and tropical diseases, World health organization collaborating centre for TB/HIV co-infection and TB elimination, Brescia, Italy.
| | - Devan Vaghela
- Barts Health NHS Trust, Royal London hospital, department of respiratory medicine, 80, Newark street, E1 2ES London, United Kingdom.
| | - Adrian Rendon
- Hospital universitario de Monterrey, centro de investigación, prevención y tratamiento de infecciones respiratorias, Monterrey, Nuevo León UANL, Mexico.
| | - Fernanda C de Q Mello
- Federal university of Rio de Janeiro, instituto de Doenças do Tórax (IDT)/Clementino Fraga Filho hospital (CFFH), rua Professor Rodolpho Paulo Rocco, n° 255 - 1° Andar - Cidade Universitária - Ilha do Fundão, 21941-913, Rio De Janeiro, Brazil.
| | - Ananna Rahman
- Papworth hospital NHS foundation trust, department of respiratory medicine, Papworth Everard, Cambridge, United Kingdom.
| | - Nashaba Matin
- Barts Health NHS Trust, Royal London hospital, HIV medicine, infection and immunity, London, United Kingdom.
| | - Ali Zumla
- UCL hospitals NHS Foundation Trust, university college London, NIHR biomedical research centre, division of infection and immunity, London, United Kingdom.
| | - Emanuele Pontali
- Galliera hospital, department of infectious diseases, Genoa, Italy.
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40
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Nahid P, Dorman SE, Alipanah N, Barry PM, Brozek JL, Cattamanchi A, Chaisson LH, Chaisson RE, Daley CL, Grzemska M, Higashi JM, Ho CS, Hopewell PC, Keshavjee SA, Lienhardt C, Menzies R, Merrifield C, Narita M, O'Brien R, Peloquin CA, Raftery A, Saukkonen J, Schaaf HS, Sotgiu G, Starke JR, Migliori GB, Vernon A. Official American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America Clinical Practice Guidelines: Treatment of Drug-Susceptible Tuberculosis. Clin Infect Dis 2016; 63:e147-e195. [PMID: 27516382 PMCID: PMC6590850 DOI: 10.1093/cid/ciw376] [Citation(s) in RCA: 672] [Impact Index Per Article: 84.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2016] [Accepted: 06/06/2016] [Indexed: 02/06/2023] Open
Abstract
The American Thoracic Society, Centers for Disease Control and Prevention, and Infectious Diseases Society of America jointly sponsored the development of this guideline for the treatment of drug-susceptible tuberculosis, which is also endorsed by the European Respiratory Society and the US National Tuberculosis Controllers Association. Representatives from the American Academy of Pediatrics, the Canadian Thoracic Society, the International Union Against Tuberculosis and Lung Disease, and the World Health Organization also participated in the development of the guideline. This guideline provides recommendations on the clinical and public health management of tuberculosis in children and adults in settings in which mycobacterial cultures, molecular and phenotypic drug susceptibility tests, and radiographic studies, among other diagnostic tools, are available on a routine basis. For all recommendations, literature reviews were performed, followed by discussion by an expert committee according to the Grading of Recommendations, Assessment, Development and Evaluation methodology. Given the public health implications of prompt diagnosis and effective management of tuberculosis, empiric multidrug treatment is initiated in almost all situations in which active tuberculosis is suspected. Additional characteristics such as presence of comorbidities, severity of disease, and response to treatment influence management decisions. Specific recommendations on the use of case management strategies (including directly observed therapy), regimen and dosing selection in adults and children (daily vs intermittent), treatment of tuberculosis in the presence of HIV infection (duration of tuberculosis treatment and timing of initiation of antiretroviral therapy), as well as treatment of extrapulmonary disease (central nervous system, pericardial among other sites) are provided. The development of more potent and better-tolerated drug regimens, optimization of drug exposure for the component drugs, optimal management of tuberculosis in special populations, identification of accurate biomarkers of treatment effect, and the assessment of new strategies for implementing regimens in the field remain key priority areas for research. See the full-text online version of the document for detailed discussion of the management of tuberculosis and recommendations for practice.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Julie M. Higashi
- Tuberculosis Control Section, San Francisco Department
of Public Health, California
| | - Christine S. Ho
- Division of Tuberculosis Elimination, National Center
for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and
Prevention, Atlanta, Georgia
| | | | | | | | | | | | - Masahiro Narita
- Tuberculosis Control Program, Seattle and King County Public Health, and
University of Washington, Seattle
| | - Rick O'Brien
- Ethics Advisory Group, International Union Against TB
and Lung Disease, Paris,
France
| | | | | | | | - H. Simon Schaaf
- Department of Paediatrics and Child Health, Stellenbosch University, Cape
Town, South Africa
| | | | | | - Giovanni Battista Migliori
- WHO Collaborating Centre for TB and Lung Diseases, Fondazione S. Maugeri Care and
Research Institute, Tradate, Italy
| | - Andrew Vernon
- Division of Tuberculosis Elimination, National Center
for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and
Prevention, Atlanta, Georgia
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Sotgiu G, Nahid P, Loddenkemper R, Abubakar I, Miravitlles M, Migliori GB. The ERS-endorsed official ATS/CDC/IDSA clinical practice guidelines on treatment of drug-susceptible tuberculosis. Eur Respir J 2016; 48:963-971. [DOI: 10.1183/13993003.01356-2016] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Accepted: 07/14/2016] [Indexed: 11/05/2022]
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Wallis RS, Peppard T. Early Biomarkers and Regulatory Innovation in Multidrug-Resistant Tuberculosis. Clin Infect Dis 2016; 61Suppl 3:S160-3. [PMID: 26409278 DOI: 10.1093/cid/civ612] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Biomarkers play an essential role in accelerating drug development. Sputum culture conversion using solid medium is the best-characterized tuberculosis biomarker, having been examined at the patient and trial levels in studies with thousands of subjects, and having recently been validated using data from 3 unsuccessful phase 3 trials. We presently are poised at the threshold of regulatory innovation for antibacterials to treat drug-resistant infections, in which Special Medical Use authorization restricted to patients with limited options could be based on the results of small clinical trials. Patients worldwide would be well served by licensing of new regimens for multidrug-resistant tuberculosis based on biomarker evidence commensurate with the urgency of the current global crisis.
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Polverino E, Bothamley GH, Goletti D, Heyckendorf J, Sotgiu G, Aliberti S. The best of respiratory infections from the 2015 European Respiratory Society International Congress. ERJ Open Res 2016; 2:00049-2016. [PMID: 27730203 PMCID: PMC5034596 DOI: 10.1183/23120541.00049-2016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Accepted: 05/27/2016] [Indexed: 12/01/2022] Open
Abstract
The breadth and quality of scientific presentations on clinical and translational research into respiratory infections at the 2015 European Respiratory Society (ERS) International Congress in Amsterdam, the Netherlands, establishes this area as one of the leadings fields in pulmonology. The host-pathogen relationship in chronic obstructive pulmonary disease, and the impact of comorbidities and chronic treatment on clinical outcomes in patients with pneumonia were studied. Various communications were dedicated to bronchiectasis and, in particular, to different prognostic and clinical aspects of this disease, including chronic infection with Pseudomonas and inhaled antibiotic therapy. Recent data from the World Health Organization showed that Europe has the highest number of multidrug-resistant tuberculosis cases and the poorest countries have the least access to suitable treatments. Latent tuberculosis and different screening programmes were also discussed with particular attention to risk factors such as HIV infection and diabetes. Several biomarkers were proposed to distinguish between active tuberculosis and latent infection. Major treatment trials were discussed (REMOX, RIFQUIN and STREAM). The possibility of once-weekly treatment in the continuation phase (RIAQUIN) was especially exciting. The continuing rise of Mycobacterium abscessus as a significant pathogen was noted. This article reviews some of the best contributions from the Respiratory Infections Assembly to the 2015 ERS International Congress.
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Affiliation(s)
- Eva Polverino
- Fundació Clinic, Hospital Clinic of Barcelona – Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Ciber de Enfermedades Respiratorias, Barcelona, Spain
- These authors contributed equally
| | - Graham H. Bothamley
- Dept of Respiratory Medicine, Homerton University Hospital, London, UK
- These authors contributed equally
| | - Delia Goletti
- Translational Research Unit, Dept of Epidemiology and Preclinical Research, National Institute for Infectious Diseases, Rome, Italy
| | - Jan Heyckendorf
- Division of Clinical Infectious Diseases, German Center for Infection Research, Research Center, Borstel, Germany
| | - Giovanni Sotgiu
- Clinical Epidemiology and Medical Statistics Unit, Dept of Biomedical Sciences, University of Sassari, Medical Education and Professional Development Unit, Sassari, Italy
| | - Stefano Aliberti
- Dept of Pathophysiology and Transplantation, University of Milan, Cardio-Thoracic Unit and Cystic Fibrosis Adult Center, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
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Phillips PPJ, Dooley KE, Gillespie SH, Heinrich N, Stout JE, Nahid P, Diacon AH, Aarnoutse RE, Kibiki GS, Boeree MJ, Hoelscher M. A new trial design to accelerate tuberculosis drug development: the Phase IIC Selection Trial with Extended Post-treatment follow-up (STEP). BMC Med 2016; 14:51. [PMID: 27004726 PMCID: PMC4804526 DOI: 10.1186/s12916-016-0597-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2015] [Accepted: 03/11/2016] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND The standard 6-month four-drug regimen for the treatment of drug-sensitive tuberculosis has remained unchanged for decades and is inadequate to control the epidemic. Shorter, simpler regimens are urgently needed to defeat what is now the world's greatest infectious disease killer. METHODS We describe the Phase IIC Selection Trial with Extended Post-treatment follow-up (STEP) as a novel hybrid phase II/III trial design to accelerate regimen development. In the Phase IIC STEP trial, the experimental regimen is given for the duration for which it will be studied in phase III (presently 3 or 4 months) and patients are followed for clinical outcomes of treatment failure and relapse for a total of 12 months from randomisation. Operating characteristics of the trial design are explored assuming a classical frequentist framework as well as a Bayesian framework with flat and sceptical priors. A simulation study is conducted using data from the RIFAQUIN phase III trial to illustrate how such a design could be used in practice. RESULTS With 80 patients per arm, and two (2.5 %) unfavourable outcomes in the STEP trial, there is a probability of 0.99 that the proportion of unfavourable outcomes in a potential phase III trial would be less than 12 % and a probability of 0.91 that the proportion of unfavourable outcomes would be less than 8 %. With six (7.5 %) unfavourable outcomes, there is a probability of 0.82 that the proportion of unfavourable outcomes in a potential phase III trial would be less than 12 % and a probability of 0.41 that it would be less than 8 %. Simulations using data from the RIFAQUIN trial show that a STEP trial with 80 patients per arm would have correctly shown that the Inferior Regimen should not proceed to phase III and would have had a high chance (0.88) of either showing that the Successful Regimen could proceed to phase III or that it might require further optimisation. CONCLUSIONS Collection of definitive clinical outcome data in a relatively small number of participants over only 12 months provides valuable information about the likelihood of success in a future phase III trial. We strongly believe that the STEP trial design described herein is an important tool that would allow for more informed decision-making and accelerate regimen development.
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Affiliation(s)
- Patrick P. J. Phillips
- />MRC Clinical Trials Unit at University College London, Aviation House, 125 Kingsway, London, WC2B 6NH UK
| | - Kelly E. Dooley
- />School of Medicine, Johns Hopkins University, Baltimore, Maryland USA
| | | | - Norbert Heinrich
- />Division of Infectious Diseases and Tropical Medicine, Medical Center of the Ludwig-Maximilians-University (LMU), Munich, Germany
- />German Center for Infection Research (DZIF), Munich Partner Site, Munich, Germany
| | - Jason E. Stout
- />School of Medicine, Duke University, Durham, North Carolina USA
| | - Payam Nahid
- />University of California San Francisco, San Francisco, California USA
| | - Andreas H. Diacon
- />Division of Physiology, Department of Medical Biochemistry, Stellenbosch University, Tygerberg, South Africa
- />TASK Applied Science, Bellville, South Africa
| | - Rob E. Aarnoutse
- />Department of Pharmacy, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Gibson S. Kibiki
- />East African Health Research Commission (EAHRC), East African Community, Arusha, Tanzania
| | - Martin J. Boeree
- />Department of Lung Diseases, Radboud University Medical Center, UCCZ Dekkerswald, Nijmegen, The Netherlands
| | - Michael Hoelscher
- />Division of Infectious Diseases and Tropical Medicine, Medical Center of the Ludwig-Maximilians-University (LMU), Munich, Germany
- />German Center for Infection Research (DZIF), Munich Partner Site, Munich, Germany
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45
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Phillips PPJ, Mendel CM, Burger DA, Crook AM, Nunn AJ, Dawson R, Diacon AH, Gillespie SH, Gillespie SH. Limited role of culture conversion for decision-making in individual patient care and for advancing novel regimens to confirmatory clinical trials. BMC Med 2016; 14:19. [PMID: 26847437 PMCID: PMC4743210 DOI: 10.1186/s12916-016-0565-y] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Accepted: 01/23/2016] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Despite recent increased clinical trials activity, no regimen has proved able to replace the standard 6-month regimen for drug-sensitive tuberculosis. Understanding the relationship between microbiological markers measured during treatment and long-term clinical outcomes is critical to evaluate their usefulness for decision-making for both individual patient care and for advancing novel regimens into time-consuming and expensive pivotal phase III trials. METHODS Using data from the randomized controlled phase III trial REMoxTB, we evaluated sputum-based markers of speed of clearance of bacilli: time to smear negative status; time to culture negative status on LJ or in MGIT; daily rate of change of log10(TTP) to day 56; and smear or culture results at weeks 6, 8 or 12; as individual- and trial-level surrogate endpoints for long-term clinical outcome. RESULTS Time to culture negative status on LJ or in MGIT, time to smear negative status and daily rate of change in log10(TTP) were each independent predictors of clinical outcome, adjusted for treatment (p <0.001). However, discrimination between low and high risk patients, as measured by the c-statistic, was modest and not much higher than the reference model adjusted for BMI, history of smoking, HIV status, cavitation, gender and MGIT TTP. CONCLUSIONS Culture conversion during treatment for tuberculosis, however measured, has only a limited role in decision-making for advancing regimens into phase III trials or in predicting the outcome of treatment for individual patients. REMoxTB ClinicalTrials.gov number: NCT00864383.
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Affiliation(s)
- Patrick P J Phillips
- MRC Clinical Trials Unit at UCL, Aviation House, 125 Kingsway, London, WC2B 6NH, UK.
| | - Carl M Mendel
- Global Alliance for TB Drug Development, New York, NY, USA
| | - Divan A Burger
- Department of Mathematical Statistics and Actuarial Science, University of the Free State, Bloemfontein, South Africa
| | | | - Andrew J Nunn
- MRC Clinical Trials Unit at UCL, Aviation House, 125 Kingsway, London, WC2B 6NH, UK
| | - Rodney Dawson
- Division of Pulmonology and Department of Medicine, University of Cape Town Lung Institute, Mowbray, Cape Town, South Africa
| | - Andreas H Diacon
- Division of Physiology, Department of Medical Biochemistry, Stellenbosch University, Tygerberg, Cape Town, South Africa.,TASK Applied Science, Bellville, Cape Town, South Africa
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46
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Validation of surrogate end points for overall survival in advanced colorectal cancer: A harmonized approach is needed. J Clin Epidemiol 2016; 70:277-8. [DOI: 10.1016/j.jclinepi.2015.08.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2015] [Accepted: 08/31/2015] [Indexed: 11/22/2022]
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Bonnett LJ, Davies GR. Quality of outcome reporting in phase II studies in pulmonary tuberculosis. Trials 2015; 16:518. [PMID: 26566930 PMCID: PMC4644328 DOI: 10.1186/s13063-015-1050-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 11/10/2015] [Indexed: 11/29/2022] Open
Abstract
Tuberculosis (TB) remains a major killer amongst the infectious diseases. Current treatment involves a four-drug regimen for at least 6 months. New drugs and regimens are required to shorten treatment duration, reduce toxicity and combat drug resistance, but the optimal methodology to define the critical path for novel regimens is not well defined. We undertook a systematic review to summarise outcomes reported in Phase II trials of patients with newly diagnosed pulmonary TB to assess the need for a core outcome set. A systematic search of databases (PubMed, MEDLINE, EMBASE and LILACs) was conducted on 1 May 2015 to retrieve relevant peer-reviewed articles. Reference lists of included studies were also searched. This systematic review considered all reported outcomes. Risk of bias was considered via sequence generation, allocation concealment, blinding, reasons for exclusions, and selective reporting. Of 55 included studies, 20 were Phase IIB studies based on culture conversion, 32 were Phase IIA studies based on quantitative bacteriology, and three considered alternative outcomes. Large variation in reported outcomes and trial characteristics was observed across the included studies. Bacteriological results were as often expressed in terms of positivity as negativity, with varying definitions of culture conversion. Variation in reporting was particularly marked for Phase IIA studies, where multiple time intervals were typically selected for analysis and sometimes resulted in differing interpretations of the efficacy of drugs or regimens. Within both Phase IIA and IIB studies, there was variation in the time points at which the study participants were sampled, as well as in the bacteriological media and methods used. For successful future meta-analysis of early-phase studies, the findings of this review suggest that development of a core outcome set would be desirable. This would enable trial results to be more easily compared and combined, potentially leading to more effective development of new treatment strategies for patients with TB. Pending development of, and agreement on, such a core outcome set, we suggest some interim recommendations for reporting of future phase II studies of pulmonary tuberculosis.
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Affiliation(s)
- Laura Jayne Bonnett
- Department of Biostatistics & Department of Clinical Infection, Microbiology & Immunology, University of Liverpool, Waterhouse Building, Block F, 1-5 Brownlow Street, Liverpool, L69 3GL, UK. .,Department of Clinical Infection, Microbiology, & Immunology, University of Liverpool, Ronald Ross Building, 8 West Derby Street, Liverpool, L69 7BE, UK.
| | - Geraint Rhys Davies
- Department of Clinical Infection, Microbiology, & Immunology, University of Liverpool, Ronald Ross Building, 8 West Derby Street, Liverpool, L69 7BE, UK.
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48
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Mitnick CD, Rusen ID, Bain LJ, Horsburgh CR. Issues in design and interpretation of MDR-TB clinical trials: report of the first Global MDR-TB Clinical Trials Landscape Meeting. BMC Proc 2015. [PMCID: PMC4652574 DOI: 10.1186/1753-6561-9-s8-s1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Recognizing that the current MDR-TB regimen is suboptimal and based on low-quality evidence, the Global MDR-TB Clinical Trials Landscape Meeting was held in December, 2014 to strategize about coordination of research and development of new treatment regimens for this disease that affects millions of people worldwide every year. Sixty international experts on multidrug-resistant tuberculosis (MDR-TB) met in Washington D.C. and Cape Town, South Africa to consider key MDR-TB trial-related issues, including: standardization of definitions; clinical trial capacity building and; regimens optimized to foster compliance, avoid the emergence of resistance and have clinical relevance for special populations, including children and those co-infected with HIV. Underpinning all of this is the generation of a sufficient evidence base to facilitate regulatory approval and improved normative guidance. Participants discussed treatment combinations currently being studied in Phase 2B and Phase 3 trials as well as other promising new regimens and combinations that may be evaluated in the near future. These include regimens designed specifically to enable shorter duration and all-oral treatment as a means of maximizing treatment completion. It is hoped that clear definition of these challenges will facilitate the process of identifying solutions that accelerate progress towards effective, non-toxic treatments that can be programmatically implemented.
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49
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Lanoix JP, Chaisson RE, Nuermberger EL. Shortening Tuberculosis Treatment With Fluoroquinolones: Lost in Translation? Clin Infect Dis 2015; 62:484-90. [PMID: 26527614 DOI: 10.1093/cid/civ911] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Accepted: 10/16/2015] [Indexed: 11/12/2022] Open
Abstract
The disappointing recent failure of fluoroquinolone-containing regimens to shorten the duration of tuberculosis treatment in costly phase 3 trials has raised serious questions about the reliability of preclinical tuberculosis models, especially mice, and the current paradigm of regimen development. Therefore we re-examined data from murine models and early-stage clinical trials on which the pivotal trials were based, concluding that phase 3 trial results were in line with preceding studies. Finally, we offer suggestions for a more efficient and integrated preclinical and clinical regimen development program where quantitative pharmacokinetic and pharmacodynamic models more predictive of curative treatment durations are set forth.
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Affiliation(s)
- Jean-Philippe Lanoix
- Department of Medicine, Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, Maryland INSERM U1088, Amiens, France
| | - Richard E Chaisson
- Department of Medicine, Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Eric L Nuermberger
- Department of Medicine, Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, Maryland
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50
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Wang C, Wei LL, Shi LY, Pan ZF, Yu XM, Li TY, Liu CM, Ping ZP, Jiang TT, Chen ZL, Mao LG, Li ZJ, Li JC. Screening and identification of five serum proteins as novel potential biomarkers for cured pulmonary tuberculosis. Sci Rep 2015; 5:15615. [PMID: 26499913 PMCID: PMC4620482 DOI: 10.1038/srep15615] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2015] [Accepted: 09/29/2015] [Indexed: 01/14/2023] Open
Abstract
Rapid and efficient methods for the determination of cured tuberculosis (TB) are lacking. A total of 85 differentially expressed serum proteins were identified by iTRAQ labeling coupled with two-dimensional liquid chromatography-tandem mass spectrometry (2D LC-MS/MS) analysis (fold change >1.50 or <0.60, P < 0.05). We validated albumin (ALB), Rho GDP-dissociation inhibitor 2 (ARHGDIB), complement 3 (C3), ficolin-2 (FCN2), and apolipoprotein (a) (LPA) using the enzyme-linked immunosorbent assay (ELISA) method. Significantly increased ALB and LPA levels (P = 0.036 and P = 0.012, respectively) and significantly reduced ARHGDIB, C3, and FCN2 levels (P < 0.001, P = 0.035, and P = 0.018, respectively) were observed in cured TB patients compared with untreated TB patients. In addition, changes in ALB and FCN2 levels occurred after 2 months of treatment (P < 0.001 and P = 0.030, respectively). We established a cured TB model with 87.10% sensitivity, 79.49% specificity, and an area under the curve (AUC) of 0.876. The results indicated that ALB, ARHGDIB, C3, FCN2, and LPA levels might serve as potential biomarkers for cured TB. Our study provides experimental data for establishing objective indicators of cured TB and also proposes potential markers for evaluating the efficacy of anti-TB drugs.
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Affiliation(s)
- Chong Wang
- Institute of Cell Biology, Zhejiang University, Hangzhou 310058, P.R. China
| | - Li-Liang Wei
- Department of Respiratory Medicine, The Sixth Hospital of Shaoxing, Shaoxing 312000, P.R. China
| | - Li-Ying Shi
- Department of Clinical Laboratory, Zhejiang Hospital, Hangzhou 310013, P.R. China
| | - Zhi-Fen Pan
- Department of Tuberculosis, The First Hospital of Jiaxing, Jiaxing 314001, P.R. China
| | - Xiao-Mei Yu
- Department of Clinical Laboratory, Zhejiang Hospital, Hangzhou 310013, P.R. China
| | - Tian-Yu Li
- Institute of Cell Biology, Zhejiang University, Hangzhou 310058, P.R. China
| | - Chang-Ming Liu
- Institute of Cell Biology, Zhejiang University, Hangzhou 310058, P.R. China
| | - Ze-Peng Ping
- Institute of Cell Biology, Zhejiang University, Hangzhou 310058, P.R. China
| | - Ting-Ting Jiang
- Institute of Cell Biology, Zhejiang University, Hangzhou 310058, P.R. China
| | - Zhong-Liang Chen
- Institute of Cell Biology, Zhejiang University, Hangzhou 310058, P.R. China
| | - Lian-Gen Mao
- Institute of Cell Biology, Zhejiang University, Hangzhou 310058, P.R. China
| | - Zhong-Jie Li
- Institute of Cell Biology, Zhejiang University, Hangzhou 310058, P.R. China
| | - Ji-Cheng Li
- Institute of Cell Biology, Zhejiang University, Hangzhou 310058, P.R. China
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